Rick Brennan, an Australian emergency and humanitarian health official, joins Robin Davies to reflect on a career spanning some of the world's most challenging crises — from the Democratic Republic of the Congo and Liberia to the West African Ebola outbreak, Afghanistan under the Taliban and the ongoing conflict in Gaza.
Rick Brennan, an Australian emergency physician appointed a Member of the Order of Australia in 2025, recounts the pivotal early decision that shaped his professional life — choosing public health and humanitarian work over clinical medicine after being offered a full-time role with the US Centers for Disease Control. He describes the emotional weight of that moment, knowing it meant the end of his clinical career, but reflects that he never looked back. He also discusses the countrywide mortality surveys he led in the Democratic Republic of the Congo during his decade at the International Rescue Committee, which documented over five million excess deaths — the vast majority caused not by direct violence but by the collapse of the health system.
A substantial portion of the conversation covers Brennan's work in Liberia under President Ellen Johnson Sirleaf, where strong national leadership from a Nobel Peace Prize–winning president and a transparent, dedicated minister of health helped the country meet the Millennium Development Goals for child mortality — a remarkable achievement for the seventh poorest country in the world, which reduced child mortality faster than any other country in Africa. Brennan highlights the role of well-designed transition funding from the US Office of Foreign Disaster Assistance in averting the closure of health facilities as humanitarian funding declined and development funding was slow to materialise.
The discussion turns to the 2014 West Africa Ebola outbreak, where Brennan candidly acknowledges the World Health Organization's early failures, its slow scale-up across country office, regional and headquarters levels, and the organisation's struggle to communicate its subsequent course corrections — including then-Director-General Margaret Chan's concern that doing so would sound defensive. He reflects on the importance of community engagement and working through local NGOs with established field presence, rather than arriving with a top-down expert approach. The crisis ultimately catalysed WHO's shift toward an all-hazards emergency management framework and the establishment of the WHO Health Emergencies Programme under Pete Salama in 2016, bringing preparedness, detection, response and recovery work under a single program.
Brennan details his experience covering Afghanistan following the Taliban takeover, including the pragmatic diplomacy required to convene meetings in Doha that brought Taliban health officials together with major donors who were officially prohibited from engaging with the new government. He describes the development of an interim health strategy with buy-in from UNICEF, the World Bank and USAID that became the basis for continued donor funding through UN agencies rather than the government. The conversation also touches on the impact of recent US aid cuts, what Australia can do to help fill emerging gaps in the region, and the unfinished business of the grand bargain — particularly on unearmarked funding, cash transfers, pooled funding and the localisation agenda, where funding through local partners reached only four and a half per cent by 2023 against a 25 per cent target.
The episode's most confronting segment addresses Gaza, where Brennan outlines the scale of devastation: over 70,000 deaths, 170,000 injured, 42,000 facing lifetime disabilities, and 92 per cent of dwellings damaged or destroyed. He discusses the systematic obstruction of humanitarian access negotiated through COGAT, with well over 50 per cent of mission requests denied at times, and WHO's documentation of more than 840 attacks on healthcare in Gaza and over 900 in the West Bank since the conflict began. Brennan notes that WHO's global surveillance system has recorded over 9,200 attacks on healthcare since 2018, resulting in more than 4,000 deaths — averaging three attacks and one and a half deaths per day — with not a single person held to account. He points to the polio vaccination campaign, which achieved 95 per cent coverage during a ceasefire, as evidence of what can be accomplished when access and resources are provided, and calls for a global alliance for the protection of healthcare grounded in the political will of member states.
"I knew that I wanted to learn about public health. As a medical student in Australia, and certainly as an emergency physician in training, you learn very little about public health. When I was in Bosnia, I was exposed to a lot of public health practitioners, and I thought that's a big gap in my knowledge. The toughest decision came after that. After about a year with the CDC, they offered me a full-time job, and I had to decide whether I was going to pursue public health and humanitarian work or clinical work. That was an extremely difficult decision. I remember I made the decision and I broke down and cried, because I knew it was the end of my clinical career. But it was the right decision, and I never looked back." — Rick Brennan
We wish to acknowledge the Indigenous people of Australia, the wider Asia-Pacific region and other parts of the world, and express our respect for their traditional knowledge and practices, which stem from a deep connection to the lands and waters they have inhabited for millennia.
Welcome to Devpolicy Talks, the podcast of the Development Policy Centre. We’re part of the Crawford School of Public Policy at the Australian National University, on Ngunnawal and Ngambri country in Canberra.
I’m Robin Davies.
This is our thirteenth season, and we’re bringing you a mix of interviews, event recordings, and in-depth features on topics central to our research — Australia’s overseas aid, development in Papua New Guinea and the Pacific, and other regional and global development issues.
My guest today is Rick Brennan, an Australian emergency physician who spent much of his career at the World Health Organization and was appointed a Member of the Order of Australia in 2025. He started out at Westmead Hospital in Sydney before three volunteer missions to Bosnia in the 1990s convinced him to leave clinical medicine for humanitarian work — a decision he says brought him to tears at the time.
From there, Rick worked with the US Centres for Disease Control, spent a decade at the International Rescue Committee in New York, and helped lead the countrywide mortality surveys in the Democratic Republic of the Congo that documented more than five million excess deaths. He later ran a post-conflict health reconstruction project in Liberia under President Ellen Johnson Sirleaf, before joining WHO — where he directed the Ebola response in 2014 and eventually became Regional Emergency Director for the Eastern Mediterranean, covering 22 countries including Afghanistan, Syria, Yemen and Sudan.
In our conversation, Rick talks candidly about WHO's early stumbles on Ebola and the reforms that followed, the shift to an all-hazards approach to emergencies, and the pragmatic diplomacy he used in Doha to keep donor money flowing into Afghanistan's health system after the Taliban takeover — including arranging side meetings between Taliban officials and donors who were officially forbidden from speaking with them.
We spend a good part of the interview on Gaza. Rick walks through the scale of the devastation — over 70,000 deaths, 92 per cent of dwellings damaged or destroyed, hospitals barely functioning, and access requests denied by Israeli authorities well over half the time. He sets this alongside the global picture from WHO's surveillance system: more than 9,200 attacks on health care since 2018, over 4,000 deaths, and not a single person held to account. But he also points to the polio vaccination campaign in Gaza itself, which hit 95 per cent coverage during a brief ceasefire, as proof of what's possible when access and resources are there.
We finish with his thoughts on health as a bridge to peace, what Australia can do as US aid retreats, and the unfinished business of the grand bargain on humanitarian reform.
Rick Brennan:
My name is Rick Brennan. I'm a Sydney boy. I trained as an emergency physician in Sydney and the United States, and then started my humanitarian career in about 1993. I decided that was the direction of travel I wanted to go. I resigned my job at Westmead Hospital in 1995, went to the US and obtained a Master's of Public Health degree, and I've been working in humanitarian assistance for US CDC, international NGOs, and most recently with the World Health Organization ever since. I reached the compulsory retirement age in the last twelve months, so I'm now doing some consultancy and academic work.
Robin Davies:
So when you started at the University of Sydney and trained as an emergency physician, that was a new specialty at the time, wasn't it?
Rick Brennan:
Yeah. In fact, when I graduated from medical school, I didn't even realise emergency medicine was a specialty. I started my training in the mid-nineties, and when I qualified as an emergency physician, the Australian government still hadn't recognised emergency medicine as a formal specialty. That came a couple of years later. But it soon became one of the fastest growing specialties in the world, including in Australia.
Robin Davies:
So what kind of work were you doing at Westmead?
Rick Brennan:
Working in the emergency department. At that time, Westmead was the largest and busiest trauma centre in Australia, and most of the trauma was motor vehicle accidents, but it wasn't just that. More of our cases were exacerbations of heart disease or respiratory disease, people coming in with abdominal pain, back pain, coughs and colds. It was what we would call a high-acuity emergency department, and I loved it. I loved the clinical work, and we had a very diverse population. It was a real privilege to work there.
Robin Davies:
And then your first international work was undertaken in Bosnia, I believe. You were doing voluntary work there?
Rick Brennan:
Yeah. I went as a volunteer for the first time for about four weeks. I was working for an American NGO called International Medical Corps. Between 1993 and 1995, I did three missions there, each varying between four and six weeks. We established a professional emergency department in the main referral hospital in central Bosnia, and we established an emergency medicine residency — the first one in Bosnia, which as I understand still continues today.
Again, it was like any emergency department; it wasn't just trauma. About twenty percent of the cases we saw were war trauma, but we saw a lot of people with exacerbations of their chronic diseases because they didn't have access to their regular medications — people coming in with strokes because they couldn't treat their high blood pressure, bad asthma because they couldn't treat their asthma, and so on. That was a formative experience. Those three missions led me to decide that I wanted to pursue humanitarian work more full-time. I resigned my job at Westmead as a staff specialist and went and got a public health degree in the US, and from there embarked on my humanitarian career more full-time.
Robin Davies:
So how hard was that decision for you at the time to resign your position at Westmead?
Rick Brennan:
That wasn't the toughest decision, because I knew that I wanted to learn about public health. As a medical student in Australia, and certainly as an emergency physician in training, you learn very little about public health. When I was in Bosnia, I was exposed to a lot of public health practitioners, and I thought that was a big gap in my knowledge.
The toughest decision came after that, when, after about a year with the CDC, they offered me a full-time job. I had to decide then whether I was going to pursue public health and humanitarian work or clinical work. That was an extremely difficult decision. I remember I made the decision and I broke down and cried, because I knew it was the end of my clinical career. But it was the right decision.
Robin Davies:
And I never looked back. After the CDC, you actually worked for the International Rescue Committee for ten years. What were some of the highlights of that? That was ten years in New York. What was your role there, and what sort of changes did you bring about in the organisation?
Rick Brennan:
The International Rescue Committee was typical of a lot of NGOs in the 1990s. They were not particularly professionalised, so they brought in new leadership and wanted to elevate the standards of their work. They had been doing a lot of public health work, but with no strategy, no system, and no technical support in their headquarters.
I was working for the CDC. The CDC was asked to send someone to develop that strategy, and CDC sent me. I spent three months with them looking at their programs, developed the strategy, and proposed it to them. They accepted it, and I thought it was a great organisation. So I applied for the job. I essentially wrote my own job description, and then we set up this technical health unit at IRC.
IRC's mission and mandate was to provide humanitarian assistance and protection services to refugees and populations affected by conflict. They also had a big resettlement program in the US, resettling about 10,000 refugees per year, but I was on the humanitarian side. We worked in around 25 countries, all conflict-affected or refugee settings. We rapidly expanded. We had, I think, three staff at the start, and 22 staff at the end, and we expanded our programs by a factor of ten.
Some of the highlights: I think we really advanced the professionalisation of humanitarian health within that organisation. I led the revision of the health services chapter of the Sphere standards and expanded those, helping to establish international standards for non-communicable diseases, trauma care, and mental health within Sphere. One of the other big highlights was the countrywide mortality surveys we did in the DRC, which documented over five million excess deaths due to the conflict there, the vast majority of which were not related to direct violence but due to the collapse of the health system.
It was a good time to be in humanitarian assistance over those years. In 2005, there was the humanitarian reform. There were standards being developed, and training courses. We worked very closely with Columbia University in putting together a well-established program on responding to humanitarian health needs, which we partnered on with AUB in Lebanon, Makerere University in Uganda, and Mahidol University in Thailand. That program went out to train people in all those different areas. It was a wonderful experience, a great organisation, and those were just some of the highlights.
Robin Davies:
One of the things you did was your work in Liberia under President Ellen Johnson Sirleaf. You had, what, two and a half years there, managing a post-conflict health system reconstruction project. I understand it was quite successful. What made that work, and what sort of lessons would you draw from that for other places like Syria or Yemen?
Rick Brennan:
Yeah, I went to Liberia, and I think the stars were aligned for that project. It was the post-conflict period. You had a president who was widely regarded as a superstar and subsequently won the Nobel Peace Prize, who had a lot of support and trust from the international donors. You had a Minister of Health who was very transparent and very dedicated, and again very much trusted by the donors and the operational partners. He took the position that "we need your help, but we're in charge."
There were a couple of other things that worked very well. There was tremendous transition planning, perhaps the best example I've ever seen, and credit to OFDA, the Office of Foreign Disaster Assistance, and the US government at that time. They did a mapping of how, as the humanitarian funding declined, it was going to take a long time for the development funding to kick in. You could see that as humanitarian funding declined, progressively more and more clinics and hospitals were going to close. So they made a pitch to Washington, and Washington put in tremendous transition funding until the development funding ramped up.
Then you had a very participatory process of designing the project — again, with government right out in front, and a couple of very competent people within the government leading that process and bringing in experts who were not taking a top-down approach. It was a very consultative process. One of my colleagues said about the Minister of Health that he was a genius at making public policy. He brought in all the stakeholders, including, in Liberia, the 15 counties. So the county health officers would all come in, and they would decide things jointly, and then he would hold them to account.
In that environment, it engendered a lot of trust and confidence amongst the donors, so they sustained the funding. It was a very well designed project. We had service delivery, health policy and health systems, and a behaviour change and communication arm. The health service delivery was implemented through performance-based contracts. We had a tremendous team, and we managed those contracts to run about 120-odd health facilities. We were able to document tremendous progress in scaling up — from a very low level, I might add — the coverage of essential services.
Based on that, and again the great leadership of the Ministry of Health and the government itself, Liberia met the Millennium Development Goals for child mortality, which was unbelievable, because they were the seventh poorest country in the world, and reduced child mortality faster than any other country in Africa. It was because of that national leadership that I think we were a success.
Robin Davies:
So how did you then move to WHO?
Rick Brennan:
After ten years at IRC, I thought it was time to move on, and then the opportunity came up for Liberia. So I went there and ran that program for JSI for two and a half years.
Towards the end of that, at WHO, their emergency work was divided. The health security and outbreak work was done very separately from the humanitarian work. They were under two different divisions, if you like — two different assistant directors-general. On the humanitarian side, they were overexpanded, and they did a big reform. They fired five of the directors and then advertised for a director. I applied for the job and came in. There was blood on the floor. They went from 95 staff down to 36 staff, and then I came in to run the humanitarian side of the house.
When Ebola blew up in 2014, the initial response wasn't going well. They asked my boss at the time, Bruce Aylward, to come in and run it, and he appointed me as the Director of the Ebola Response. After that, history shows that those two parts of the house came together under the WHO Health Emergencies Programme under Pete Salama in 2016.
Robin Davies:
Yes, the Australian Pete Salama. I wanted to ask about the Ebola response. You've acknowledged that initially it was slower than it could have been for structural reasons in WHO. But what did you learn from that response about the organisation of a major health emergency response?
Rick Brennan:
On the WHO side, it's almost like a federated agency, and I think everyone acknowledges that the country office and the regional office were too slow to respond, and at headquarters we didn't get behind them fast enough. Our processes and systems for detection, for triggering response, for scaling up our resources — the organisation always had an operational role but downplayed that relative to its technical, normative role.
I was in a meeting with the Director-General and the regional directors at the end of 2014 where she said, "Does anyone disagree that we have to be operational?" No one said no. She said, "Okay, we've just got to scale up our operational capacity." What do I mean by that? It means having people who are trained as emergency managers. It means having systems and processes that allow you to move people and resources quickly. Having funds — so we set up an emergency response fund. We expanded our stockpiles and revised our systems and processes.
One of my jobs when I became the Director of Emergency Operations after the establishment of the WHE in 2016 was to revise our emergency response framework, using emergency management best practices to guide our response to crises, our detection of crises, and our response. That was a game changer. We introduced the incident management system at WHO, and that really did change the way that we operated.
I think one of the other big lessons was that we really did not do well in engaging communities well enough. And it wasn't just engaging communities — it was engaging other partners who had an operational presence on the ground: NGOs who'd been on the ground for years, who knew communities, and we didn't work enough through them. Taking advantage of all the capacities that exist, and not just coming in as "we're the experts and we know how to control an outbreak" — I mean, that's important, having good public health processes and systems, but you need those entry points into communities. It's the locals themselves, and it's the operational NGOs that have a field presence, that provide you with that entrance.
Robin Davies:
You talked about that internal discussion about whether WHO should be taking on an operational role in emergency response. How much of a debate was that inside WHO — moving from normative to operational?
Rick Brennan:
There was always a little bit of schizophrenia within WHO. It's in the WHO constitution that we should be responding to emergencies. There was always operational work — polio, the Global Outbreak Alert and Response Network, GOARN — responding to disease outbreaks but also conflicts. WHO was the health cluster lead agency within the humanitarian system as well as managing the Global Outbreak Alert and Response Network. So there were two very operational partnerships for different types of emergencies. But there was this kind of denial that we were doing that.
After Ebola, there was a recognition that we have to have an all-hazards approach. So we brought all our emergency work — our preparedness work, our mitigation work, our detection work, our response and recovery work — under one program, regardless of whether it was for a disease outbreak, a natural disaster, a technological disaster, or a conflict. I think that was absolutely the right thing to do. Ironically, some elements within WHO still say we've gone too far on this. But the record shows disasters, humanitarian needs and outbreaks are increasing globally, and I think WHO has to play that role.
Robin Davies:
A huge barrier for WHO in playing that role has been financing, and it's always a flood or drought situation. You referred to the Health Emergencies Response Fund, I think it was called. Outside the Ebola crisis itself, WHO was never very generously funded by donors through that mechanism. I think it was meant to support immediate responses and then be replenished. Beyond that, WHO had to go to the Central Emergency Response Fund competing with other UN agencies for those resources. So the financing side of it was always pretty tough. How do you think that could have been run better?
Rick Brennan:
Internally, we did establish the Contingency Fund for Emergencies, the CFE. In the early days that was reasonably well funded, but I think donors have fallen off there. One of the challenges has been just the expanding needs. There are four times as many people needing humanitarian assistance today as there were ten years ago. And there's more and more complexity with the convergence of state fragility, conflict, disease outbreaks, and natural disasters, including climate-related ones. So needs are increasing, and the complexity of emergencies has also increased. And we're losing a lot of the political support as well.
Fundraising is always a challenge in development or emergency settings. Accountability, being data-driven, demonstrating your impact and effectiveness — that's the focus we tried to take, particularly when I was in the Eastern Mediterranean region. But the pie is only so big, so oftentimes you just have to prioritise. Well, you're always prioritising your priorities, as Ellen Johnson Sirleaf used to say. Being accountable, being efficient, prioritisation — these are the ways to manage your constrained resources.
Robin Davies:
But in the context of the whole WHO budget, do you think that there could have been a more determined effort to quarantine resources for the Contingency Fund for Emergencies, rather than going out begging to donors year by year?
Rick Brennan:
Yes, I do. But again, the pie was so small. A lot of people would say in WHO that after Ebola and after COVID, the emergency program expanded dramatically. Others would contend that WHO deprioritised other important areas. One that comes to mind, and I would acknowledge this, is non-communicable diseases. I don't think we did enough. I don't think that has been a big enough priority for the organisation over recent years. There is still the focus on infectious diseases, a big focus on emergencies, and increasingly on health systems and health promotion.
Relative to other departments, I think we did reasonably well with the donors. But you're right, within the core funding we weren't protected enough. We had to go out and raise our own money. So I would agree that within the core funding, we've seen the results of that, because the emergency program has been so dramatic.
Robin Davies:
Just one last question on Ebola. Do you feel like WHO gets enough credit for what was done in West Africa? My perception is that there was global panic about the situation, and some very exaggerated fears about what would happen if one doctor came back from West Africa and entered a Western country. At the same time, I don't think people really understand how the epidemic ended. They just think it fizzled out somehow. Was that story well told?
Rick Brennan:
No, I don't think it was. I don't think we were ever forgiven for our earlier failures. But I do believe that we made huge course corrections, and I do believe that we helped turn it around. Not just us, of course — these things always start at community level and so on — but the resources that we were able to coordinate and mobilise: 30 mobile labs, 50 emergency medical teams. We had 72 operational bases across three countries, with over 1,200 staff doing the contact tracing.
If you went out with those teams day in and day out, going out into the remote villages doing the contact tracing, doing the promotion — of course, mixed performance on those teams — and then starting to do the vaccine trials and so on. I think there was a good story to tell about how WHO acknowledged its shortcomings and made a dramatic shift, and I think with partners, as part of a broader response, we did make a significant contribution. But that story is not well told.
I remember saying to Margaret Chan, who was the Director-General at the time, "Look, we've got to communicate our course corrections better, and our effectiveness in several areas." She said, "No, that would make WHO sound defensive." So the story was never particularly well communicated.
Robin Davies:
Moving on to COVID, how did the Ebola response set WHO up to respond to COVID four years later, when it emerged?
Rick Brennan:
The first thing is that we had an emergency program with a lot more capacities, and it was clearly a priority right from the start. We had very good leadership from senior people like Mike Ryan. In the emergency program, we had dedicated resources at regional level with professional emergency managers. Of course, there were always gaps. That was one thing.
The second thing was the systems and processes. Our emergency response framework and our approach to structuring and managing our response was much more efficient than it used to be. A lot of the investments we'd made in detection, surveillance, and event-based surveillance had also paid off, and some of our work on the lab side.
Areas where we didn't capitalise enough were in risk communications and community engagement. We didn't build that capacity enough after Ebola. Again, I think we were playing catch-up in that area.
And as an organisation, I think we were more confident in emergency response based on the changes that we'd made. Of course, it's never a perfect response in something as complex as that. But I feel proud of the way the organisation handled it. In the region that I worked in, the Eastern Mediterranean region, where we covered 22 countries, we did have an external review which reflected quite positively on the response.
Robin Davies:
So you moved to Cairo as Regional Emergency Director in 2019, so not that long before the pandemic. I know you've said something like seventy percent of your job was COVID, but at the same time you were managing, I think, five other major existing health emergencies across the Eastern Mediterranean. I read somewhere that the region had about ten percent of the world's population and almost half of the people who were affected by health emergencies at that time. So how on earth did you manage all of that?
Rick Brennan:
Yeah, we had close to forty percent of people impacted by health emergencies and six or seven percent of the world's population — actually, that's right, it was nine percent. So it was huge, and they were complex emergencies: Afghanistan, Syria, Yemen, Sudan, Somalia, Libya. And it wasn't just that there was conflict and displacement — we had ongoing disease outbreaks, and earthquakes and floods and so on.
I had a tremendous boss, the Regional Director, Dr Al-Mandhari, a wonderful man from Oman. He was incredibly supportive. I had a strong team of four managers responsible for the health security side, the preparedness side, the health information and surveillance side, and the response side. We were able to pull on the resources from other departments.
Of course, what matters most in any response is who's on the ground closest to the emergency. We had some very good country reps in some countries and some very good emergency managers on the ground. The regional office and headquarters are in a support role to the people who are delivering day in and day out. So the most important thing is having the right people on the ground. In many instances we did well. There were gaps in others, of course — it's always a mixed performance. But again, it's part of this theme about professionalising our approach to managing emergencies and having sufficient resources to do so.
Robin Davies:
The composition of WHO's regions is sometimes a bit surprising. The Eastern Mediterranean encompasses Afghanistan. I'm interested in your experience dealing with the Taliban during your time in that role. You had to engage, including on very sensitive issues — sensitive for them — around women's health care. How did you manage that engagement while avoiding the crossing of any major red lines?
Rick Brennan:
When the Taliban took over, there had been a well-established health program run by a program management unit in the Ministry of Health to support service delivery across around 2,200 primary health care facilities across the country. It was called the Sehatmandi project, and it consisted of performance-based contracts that were almost entirely funded by international donors.
When the Taliban came in, the donors withdrew that funding. So we were looking at a scenario where there was going to be a precipitous decline in the availability of health services. What we did was speak with the donors. We sent in a team to rapidly develop contracts with the implementing partners who'd been delivering the performance-based contracts, to sustain those with some bridge funding until the World Bank was able to get through its internal processes to free up money for a broader, longer-term project. So we had this stop-gap measure to continue funding the existing partners.
Then we needed to come up with an interim health strategy that would run for eighteen months to two years, and we got buy-in from UNICEF, the World Bank and USAID to convene relevant partners to develop that strategy. That would form the basis of the funding coming through the big donors like the World Bank and USAID.
We convened a meeting in Doha, and we invited the Taliban. We invited the Minister of Health, who was a reasonable guy, to be honest, and four of his staff — one or two of whom had been in the previous Ministry of Health and knew the drill. They came in with their own priorities, which were not unreasonable. They'd thought them through pretty well.
Of course, the big donors were not going to put any money through the government. All the money had previously gone through the government to support these performance-based contracts. Now it was going to have to go through UNICEF. The World Bank and USAID reps who turned up were officially not allowed to speak with the Taliban. So that forum allowed them to have side meetings with the Taliban officials, and to explain that they had constraints from their capitals where they couldn't put money through the government, but that they would try to work alongside them as much as possible.
That was the process. We developed the strategy, we got buy-in, and the funding came. Then it was really the guys on the ground who had to manage that relationship moving forward. There were weekly meetings with the Taliban officials. Of course, they were very frustrated — they always wanted money going through them. They were worried about the effectiveness of the contracting partners and the service delivery. They were worried about corruption and so on. But the team met with them on a regular basis, including with UNICEF. There were always tensions, but I think they were able to manage that as well as possible under the circumstances and continue the delivery of the services.
I went there a couple of times. I liked the Minister of Health. He wasn't an extreme example — he was from the more moderate wing of the Taliban, and he would call us to account. He was very clear about his expectations, and we tried to meet them. In the end, we had a two-year follow-up from that initial meeting, and the World Bank was able to invite him. He spoke very well, again holding us to account, and I think collectively we were able to meet most of his demands.
Robin Davies:
The last couple of years of your time with WHO were obviously dominated by the crisis in Gaza. Could you tell me a bit about how WHO worked, or didn't work, in Gaza in that period, and some of your reflections on the impact of the crisis on the health system, which I understand was pretty good pre-conflict in terms of immunisation coverage and surveillance and so forth?
Rick Brennan:
Yeah. A lot has happened in Gaza, a lot in Sudan, Syria — everything over the last few years. In Gaza, as you said, prior to the most recent conflict, under enormous constraints, the Ministry of Health delivered pretty well for the people of Gaza. Many of their health outcomes and coverage indicators compared favourably with other countries across the region.
You're familiar with the situation. Very high levels of violence: over 70,000 deaths, 170,000 injured, 42,000 of those 170,000 will have lifetime disabilities. Destruction of the health system: until relatively recently, only 14 out of 36 hospitals were working, and they were only partially functioning. We've got about 18 partially functioning right now. Still today, less than 40 percent of primary health care facilities are functioning. And there's destruction of infrastructure — water and sanitation, roads and so on. Ninety-two percent of dwellings are damaged or destroyed.
On top of that, you've got the huge levels of displacement — 1.9 million people displaced in overcrowded, unsanitary conditions. So you've got everything. You've got trauma. You've got infectious diseases. You've got a collapse of a health system, with people not getting treated for their chronic diseases. You've got women who need to be able to deliver — about 180 deliveries per month. Trying to provide health services in that context was very difficult. Mental health issues, of course. Trying to set up disease surveillance systems, because we were very worried about disease outbreaks. Then the insecurity, the constraints on access provided by the IDF, the Israel Defence Forces, and constantly trying to negotiate access.
So what did WHO do? Early on, there was a lot to support hospital services: running missions to hospitals to deliver medicines, supplies, equipment, fuel, food, water — bringing tankers in, working very closely with OCHA and UNICEF on that. Medically evacuating people who needed to be evacuated. Bringing in emergency medical teams and coordinating them. Trying to identify where the gaps were, and bringing in teams from outside Gaza who could provide clinical services — in some instances surgical teams, putting them in the hospitals, in some instances field hospitals, in others mobile clinics and primary health care.
That service delivery element was key. Bringing in the supplies, working with UNRWA — for example, they weren't allowed to bring supplies in. Today, WHO is bringing in all the supplies for UNRWA and for many of the other agencies. Then there was the infectious disease component, trying to put in surveillance systems and some sort of diagnostic capacity on the ground, and that's been a real challenge. We worked closely with UNRWA on that because they had the biggest presence on the ground, along with the Ministry of Health, in terms of primary health care facilities.
When we had that first — well, the only case to date — of the vaccine-derived case of polio, we ran the vaccination campaigns. Again, it shows what can be achieved when you have resources and you have access to people, even in the toughest circumstances. The vaccination coverage rate for polio was ninety-five percent. There have been no more cases of polio. They're not finding polio in the sewage anymore, in the environmental samples. Then there was scaling up vaccination more broadly — there's a catch-up campaign right now ongoing for vaccines in Gaza.
Then there's the coordination function. There are about 80 members of the health cluster doing various elements of health care. There are the EMTs — over 20 EMTs operational now, supporting 35 different health facilities. That coordination function has been vital.
Then there's the advocacy function. WHO has documented over 840 attacks on health care since the start of the conflict. There have been more attacks, frankly, in the West Bank over the same period — over 900. Most of those attacks in the West Bank involve restricting access to health care, whereas a lot of the attacks in Gaza were direct physical, violent attacks on infrastructure.
It's been very difficult. We've had staff members killed. The psychological strain on the Gazan people themselves, and on the frontline workers, including those working for WHO, has been enormous. The other aspect I didn't mention, of course, was nutrition and setting up the stabilisation centres. There are huge levels of food insecurity and famine now in Gaza City, and the psychological strain has been incredible. The testimonials of aid workers coming out about what they've seen have been incredible.
We haven't had the political will to bring the appropriate approach to ending the conflict. We've got some hope now with the recent ceasefire. But moving forward, there's a very strong sense that this peace plan doesn't include sufficient consultation with the Gazan people themselves, or the UN, or the operational agencies.
Robin Davies:
Obviously, there are huge constraints involved in operating in a war zone, but how much further constrained was WHO by active blocking by the IDF of access to Gaza?
Rick Brennan:
When we tried to run these missions — we're based more in the south, and then we would try to run missions to hospitals, to clinics and so on, often with partners — this isn't just about WHO. UNRWA, OCHA, UNICEF: we all worked collectively on this. I can't remember the exact figures, but a very high proportion of requests for those missions was denied — well over 50 percent at times. You had to coordinate with COGAT, which was negotiating for the Israeli government, and that's been very difficult. There was often insufficient access, and you can see that. Just the fact that we have such high rates of acute malnutrition, and the fact that we've got famine, gives you a sense of what access the international community has had for delivery.
Robin Davies:
And were those access denials justified in some way? Were reasons given, or was it arbitrary?
Rick Brennan:
Not always, certainly. What was always implied or conveyed was security. Our people got very close to some pretty awful incidents. But again, you can see, when there was the ceasefire for the polio vaccination campaign, what can be achieved if you're given access.
Robin Davies:
You talked about attacks on health care workers and humanitarian workers in Gaza. I think you were the principal author of a report for WHO, *In the Line of Fire*, about the protection of health care workers globally. Can you talk a bit about what you found and what you recommended?
Rick Brennan:
This is a terrible emerging trend in humanitarian action today: a decline in respect for international humanitarian law, the laws of war, the Geneva Conventions, international human rights law, and international norms.
In 2018, we set up a surveillance system to document attacks on health care in conflict settings. I looked up the data — you can go on the dashboards online, accessible to everyone. Since January 2018, we've documented over 9,200 attacks on health care. That's resulted in over 4,000 deaths — three attacks per day, every day, and one and a half deaths per day, every day, through attacks on health care, which has special protection under international humanitarian law. These attacks are increasing, as are attacks on humanitarian workers more generally. Last year, there were four times as many attacks on humanitarian workers worldwide as there were ten years ago.
This is a terrible development. It's attacks on humanitarians and health workers, and that reduces people's access to health care. You can see this in increasing rates of disease outbreaks. As I mentioned before, up until relatively recently, only 14 of 36 hospitals were functional in Gaza. In October last year, only 12 percent of health facilities in Khartoum, out of over 800 or 900, were functional, and they were only partially functional. This is largely due to attacks on health care.
The other dimension is that not only are the attacks increasing, and not only are they reducing access to health care at a time when people need it most, but there's no accountability. Even though these can constitute war crimes, of the 9,200 attacks that WHO has documented, not one person has been held to account. This is proceeding with impunity.
Robin Davies:
In the context of that report, you called for the creation of a Global Alliance for the Protection of Health Care. How would that work? What would it do, particularly in the context that there really is a broader breakdown in international humanitarian law at the moment, which is not confined to the health care sector?
Rick Brennan:
We've got to put an alliance like that together, and the timing's not right yet. We've got a core group that's working on this. We believe politically it's probably not the appropriate time, but we're looking at perhaps sometime next year.
You need governments. This is all about political will. You need the political will to reaffirm our respect and our commitment to international humanitarian law, and the ICRC is leading a process on that. And then you need political will to hold people accountable. Any such alliance would have to have member states — have governments as core members — and to lead that political drive to achieve the accountability that we're looking for. Of course, like-minded organisations, NGOs, civil society organisations, and academic institutions would all be welcome to join that alliance. But without core commitments from member states, we're not going to get the accountability that we need.
Robin Davies:
And what would be the mechanism for holding states or other armed actors to account?
Rick Brennan:
There are mechanisms. The International Criminal Court, the International Court of Justice, and there's the concept of universal jurisdiction. Someone who's been charged with a war crime — if Putin arrived tomorrow in a Western country, that government is within their rights to arrest him. So there are mechanisms available under domestic law and international law to apprehend people suspected or charged with war crimes, but there has been a reluctance to do so.
Robin Davies:
And is it partly about visibility and transparency of these crimes? You've done a one-off report, but would you see scope for a mechanism that really shines a continuous light on this problem?
Rick Brennan:
Yes, I think we do need better investigations. That's not the mandate of WHO. We need other organisations that have the mandate to do those investigations and to bring the charges through the appropriate bodies and processes.
Robin Davies:
We talked about the impacts of conflict on health, but you've also looked at this the other way around. You wrote in *The Lancet* a couple of years ago that health can be a factor in achieving peace, particularly in the Middle East. Can you talk a bit more about that?
Rick Brennan:
In our conceptualisation of this idea of health as a bridge for peace, or health for peace, we talk about peace with a big P and peace with a small p. Peace with a big P is ceasefires and political resolutions to conflicts. We don't pretend that health can achieve that — that's a political channel. But health can, through providing access to health services impartially, expanding the coverage of health, and listening to populations, help advance some of the underlying factors that promote peace: social cohesion, trust, and confidence-building measures such as vaccination campaigns. But they can't be just one-off exercises. It's got to be part of sustained support for health.
When there are divided communities, health interventions are often seen as neutral, and they're an opportunity to bring divided communities together. So it's really the small-p dividends that we're looking at with health as a bridge to peace.
Robin Davies:
Earlier this year, you published an article on our blog, the Development Policy Centre's blog, about the impact of US aid funding cuts and related cuts to the work of the Centers for Disease Control. Clearly, these cuts create additional risk of cross-border disease transmission — signals will be missed. What do you think a donor country like Australia can do, at least in part, to fill that gap, maybe in our region, whether through its aid program or through the work of the new CDC, which starts up in early 2026?
Rick Brennan:
I think Australia is committed to a lot of the principles that seem to be under attack right now: good public health principles, multilateralism, humanitarianism. A country like Australia has to hold the line and continue to advocate and assert the importance of those principles and processes.
Australia punches above its weight on many fronts, perhaps not so much in overseas development assistance. But the good news is that Australia has committed to hold the line and not cut its funding on humanitarian work and development assistance, and that sends an important signal.
I think it's also important for Australia to look to fill some of the gaps that have been left by other donors, particularly the US, in the region. Australia is proud of its position — we're here within the Western Pacific and have certain responsibilities. So I think it's important for it to continue to provide those resources, and it's important for Australia to continue to reaffirm the important principles of public health, of multilateralism, and of humanitarianism.
Robin Davies:
I wanted to finish with a question about the multilateral architecture for managing global health risks and responding to global health emergencies. The UN system periodically embarks on an ambitiously named, nebulous initiative of one sort or another. We've had the Transformative Agenda, the Grand Bargain, and I know you've been involved from a WHO perspective in many of those exercises. In light of everything that's happened through the pandemic and beyond, fundamentally, what do you think needs to happen to make the global health emergency ecosystem function better?
Rick Brennan:
Those previous episodes of reform had mixed success. I think the Transformative Agenda did lead to improved processes and systems for collective action. The Grand Bargain has not delivered on some of the really important issues — the way that we fund humanitarian assistance. There's a commitment for unearmarked funding and longer-term funding, particularly for the protracted crises. We haven't delivered on that; that's poor. The cash transfers and pooled funding — we haven't delivered on those at sufficient scale. It's probably not the right time politically to push for those, but we have to really look at how we fund humanitarian assistance, pool funding to make funding more flexible, and scale up cash assistance. The evidence base exists for both of those.
The localisation agenda — we haven't advanced that. Under the Grand Bargain, you may recall, there was a target of 25 percent of funding going through local partners. That came out of the Grand Bargain in 2016; by 2023, it was only four and a half percent. We've fallen well short of our commitments there, and again I think donors need to look at themselves in that regard. I fully agree with the localisation agenda, but I don't think we've been very clear about, concretely, what that looks like at the different levels. Local and national agencies — we need to advance that and empower local actors more.
Then there's accountability — again, an area of commitment that I just don't think we delivered on. There's a lot of thinking now, with reduced resources, about hyper-prioritising. Perhaps there might be one single humanitarian agency for the UN. Revising our coordination structures — these are all issues on the table. But we have to complete the unfinished work, in my view, of the Grand Bargain, and take on some of these other themes — working more with regional authorities. Look what's happened here in the Asia-Pacific: regional institutions are stepping forward in a way that they haven't in other parts of the world, and the UN can start stepping back as regional institutions provide more of the support that's required by countries when they're overwhelmed.
Robin Davies:
Alright, well, thank you very much. Welcome back to Australia after thirty years away — although I know you've still got one foot in the US as well. I really appreciate your giving your time to us.
Rick Brennan:
Thank you. Pleasure.
Devpolicy Talks is the podcast of the Australian National University’s Development Policy Centre. Our producers are Robin Davies, Amita Monterola and Finn Clark. You can read and subscribe to our daily blogs on aid, international development, and the Pacific at devpolicy.org, and find the transcript and show notes for this episode on our website. Follow us on Facebook, LinkedIn, Instagram, and Twitter. Send us feedback or ideas for episodes to devpolicy@anu.edu.au. Join us in a fortnight for the next episode of Devpolicy Talks.