Remembering the past, charting the future
Another year has quickly passed; it’s time once again to pause, give thanks, and sort out what we’ve learned in the interim. This facility is uniquely given to us humans alone with the responsibility to apply that learned wisdom to where we want to go in the future. And even among the human race, it is not given to many to be so fortunate!
The past year has seen technical and programmatic advances in global health, especially related to the remarkable drop in malaria mortality and morbidity in sub-Sahara Africa. For example, a recent analysis of malaria prevention in 34 African countries estimates that over 730,000 lives were saved between 2000 and 2010, nearly three quarters of them since 2006, when the use of both insecticides treated mosquito nets and artemisinin-based combination therapies (ACTs) became more widespread. Furthermore, according to 2011 statistics, only one out of ten people in the city of Dar es Salaam have malaria parasites. Research scientists from the Ifakara Health Institute (IHI) Dr Stefan Dongus and Prosper Chaki stated that there is also a dramatic drop in infections among households. Dr Chaki explained that in 2009/2010 malaria prevalence was 13 percent, attributing the situation to a decrease in mosquito density by 90 percent. This decrease in mosquito density is due to implementation of various projects over the last five years, including larvicide-spraying. Certainly this is a cause for celebration!
But before we get carried away with today’s advances, it behooves us to pause for a moment and look back on history not to miss the lessons so carefully learned from those heroes upon which our current advances are built. This reminder came home to me on a recent assignment undertaken with the AMREF Kenya country office, which is deliberately cataloging their rich 55-year-old accumulation of documents, reports, films and slides using today’s digitalization technologies. Fortunately, much of this has been carefully preserved, creating a priceless historical picture of not only the organization’s work, but in reality, a rich history of the medical developments in Africa itself. This is an enviable legacy for the relatively young Foundations in my adopted hometown of Seattle, Washington.
Dr. Michael Wood, the Director General of AMREF since its inception, in November 1981 described the early years when resources were extremely lean, but the organization survived on the remarkable generosity and the voluntary spirit of the growing band of committed staff. The pioneering work included establishing a flourishing radio communications network that eventually linked numerous rural health facilities with AMREF’s central office in Nairobi. Local Africans in the bush built air strips for nothing and the first Flying Doctors aircraft arrived in 1960.
Just as today, the Great Debate between curative and preventive medicine went on fiercely. It was obvious that clinical medicine had no chance of catching up with disease unless other efforts were put in at the other end of the problem— namely, increasing preventive medicine and spreading health education. But as occurs today, talk about it was endless and governments and donors paid lip service to the idea. As occurs in many African countries even today, when there’s a squeeze on the national health budget it is the Health Education Department that is the first to be cut back.
Even back in 1980s, Dr. Wood noted the emphasis for health services began to be directed to the right place, namely, at the community level. ACAM continues to champion this same focus today and it is still an uphill battle. Discussions among donors and governments in the comfortable capital cities design programs with little regard for input from the communities themselves. Sustainability is a common buzzword, but the steps necessary to make it happen at the community level are never carefully considered and funded in the budget. The task of developing healthcare is a colossal one, but it can be solved on the spot by the community itself with the help of those who are prepared to go into these uncomfortable places to teach, persuade, immunize, and deal with the medical needs where they exist.
This past year has seen remarkable credit being attributed to the role of community-based health officers and workers for the encouraging success of national eradication of trachoma, malaria, and polio. It is upon this level of care provider that perhaps 90% of the patients present for treatment, and can be adequately attended provided the workers are trained to dispense available medications that are highly effective. A most encouraging example are efforts to address the neglected tropical diseases that sap so much health and energy, especially from young growing children, thus setting the stage for their later demise. Ever true today, taking water as a case in point, as Dr. Mahler, former Director General of WHO, said it was more important to know how many water taps there are per 1000 population, rather than the number of hospital beds. The old dictum persists today, “You get action depending “on what you count”.
Administratively, AMREF eventually needed to address major issues as its reputation and skills in advising governments and other international organizations grew. For example: how to design practical research projects of immediate value to healthcare providers; how to include health behavior techniques as an essential component of health programming; how to scale up and disseminate the ideas and practices that proved worthwhile in practice; what was the correct mixture of medicine and management? These were just a few of the issues confronting AMREF’s Leadership. The Board of AMREF was not shy about calling in management consultants to assist them in revising their management structure as needed. This prevented them from going after too many enticing opportunities, but rather to concentrate its efforts within a defined and agreed strategy. AMREF learned to say “no” when suggested projects did not fit into its program.
The institution evolved, determined to keep bureaucracy at bay— a task that today’s senior staff still resist with skill. The management continues to be participatory, rather than authoritative; it remains flexible, human, and analytic; they are a hard-working dedicated professional group of people who try to remain both consistent and yet innovative. It has continued to maintain a common purpose, a loyalty, and an esprit de corps that holds together the various parts of the organization. Indeed, this “soul” of the organization has recently become identified into a new unit called Heritage. It is responsible for consolidating and cataloging the 55 years of AMREF’s documentation for posterity’s use and “lessons learned”.
Remarkably throughout the early growth years, Michael Wood, as AMREF’s first CEO, never showed signs of a negative attitude toward governments in Africa; rather he recognized that they had been put into an impossible situation, namely, administering health services to mushrooming populations with minimal resources. In fact, he recognized that certain aspects of public health should not be run by governments at all. Dr. Wood back in 1981 was not afraid to ask, “Where are we going?”; “Can we justify our existence?”
Today AMREF continues to use ingenuity to keep going, to change when necessary, and to devise new policies and approaches as needed. Their innovations in the field of healthcare include research, behavioral sciences, and training in both curative and preventive medicine. But the overriding emphasis is on implementation—for them, that’s the only way to find out what is practical, appropriate and possible. Meanwhile today’s major health program implementers/contractors devote considerable budgets for Advocacy activities as they compete for financial resources. But in the words of Dr. Wood, “Exhortation and advice is no substitute for implementation”.
In conclusion, today’s leading Global Health institutions have much to learn from those who forged historical changes in the past. Go forward to address the new challenges, but don’t repeat old mistakes. Rather, make original ones and openly share the wisdom with others as you go. Do as AMREF’s Dr. Wood has done.
Many thanks to Dr. Casazza for allowing us to republish this post. The original can be found on the African Communities against Malaria website.