Stories from the Field: Necessary Angels

Within the public health community, Community-Based Primary Health Care (CBPHC) is a common point of discussion. But rarely has the story been told by a Pulitzer Prize-winning author or captured in pictures for the National Geographic Magazine. The December 2008 edition shared with the world the story of The Comprehensive Rural Health Project (CRHP) in Jamkhed, India. “Necessary Angels” was the fitting title to a story of history and hope for village health workers who have healed communities, saved lives and transformed the place of the untouchable caste in the process.

The Comprehensive Rural Health Project, Jamkhed was created by Dr’s Mabelle and Rajanikant (Raj) S. Arole. Graduating top in their class in medical school, they continued their studies in public health at Johns Hopkins University. It is there as students, they met their mentor and lifelong friend, Dr. Carl Taylor. In 1970 they returned to the state of Maharashtra in Western India, and began to transform health care at the community level.

Over 39 years later, CRHP is still going strong and its fundamental principles have been used within the Indian Government’s National Rural Health Mission (NRHM). CRHP has trained over 100,000 community health and development (grassroots) workers and receives 2,000 trainees per year from NGOs, Indian government agencies and 100 other countries. Although Dr. Mabelle Arole passed away in 1999, her spirit lives on as a central part of the organization and in the fundamentals of CRHP work. Their daughter, Dr. Shobha Arole is the Associate Director of CRHP and is board president of Oikocredit, an international microfinance NGO. Their efforts have earned Dr. Raj Arole and Dr. Shobha Arole recognition as Schwab Foundation Social Entrepreneurs.

You can learn more from Dr. Raj and Mabelle Arole’s 1994 book Jamkhed: A  Comprehensive Rural Health Projectand in Carl Taylor and Daniel Talyor-Ide’s book Just and Lasting Change . You can read the National Geographic article “Necessary Angels” and watch the related video on-line by following the hyperlinks provided. Photographs by Lynn Johnson.

Dr. Sanjay Gupta for Surgeon General: a Smart Communications Choice

I was surprised when I first heard about Dr. Sanjay Gupta’s possible appointment to US Surgeon General by president elect Barack Obama.  What type of message did it send to young people in the field of public health that the pathway to leadership was through the lens of a TV camera rather than toiling in the trenches of public health programs?  The guy’s a neurosurgeon and TV reporter, not your typical public health leader.  But as I thought further, I realized that the main role of the Surgeon General is communication to the US public.  Dr. Gupta has incredible communications skills to translate public health message to the American people.  He has years of experience in media and health policy, including a series on global health.  In addition, Dr. Gupta can also benefit from his own version of the “Koop Effect”.  One of the reasons that Dr. C. Everett Koop was so effective as Surgeon General was that his unique beard made him highly recognizable and his grandfatherly appearance made people comfortable with him.   Having worked for years as the chief health correspondent for CNN, Dr. Gupta is already recognizable to most Americans (arguably one of the most recognizable physicians in the US) and his familiarity will bring a large measure of comfort. 

The US is facing numerous domestic and international public health challenges, including healthcare reform, spiraling costs, the obesity epidemic, the aging of America, the rise of autism, environmental health challenges, emerging diseases, and bio-terrorism threats.  We need a Surgeon General who people will listen to and whose advice they will act on; someone who can translate public health statistics into messages people understand and that resonate with their values and lives.  The most recent Surgeon General, Dr. Richard Carmona, though a good communicator and public health practitioner, was unfortunately constrained from expressing his opinion, including the blocking of the publication of his global health report.  The US needs a Surgeon General who has the trust and the ear of the President and the people.

Dr. Gupta will have to reach out to the medical and public health communities in order to gain their respect–but this won’t be difficult.   Not only is Dr. Gupta an excellent communicator and respected practicing physician, but he has also done high level health policy work as a White House Fellow and is familiar with how health legislation gets made. Through reaching out to the public health community including the APHA and valuing our input, he can gain our trust and we can work with the next Surgeon General to help Americans to live healthier lives.

VIDEO about Community-led Total Sanitation in Indonesia – PCI

Solihin asks the crowd whether anyone wants to drink a cup of feces-contaminated water.

Project Concern International (PCI) is the first NGO in Indonesia to fully implement Community-led Total Sanitation (CLTS) and offer no subsidies to communities. Watch the video here (and listen to some cool music):

View or download VIDEO here (MPEG4)
Download high-quality video (MPEG2, 700MB)

This video is about 18 minutes in length and shows how CLTS gets started in a community. The CLTS method emphasizes the importance of “natural leaders,” community members who emerge during the triggering session and demonstrate strong motivation and resolve to help their village become “open defecation free.”

Although the process is still new, the initial figures look promising. In only ten months, 53 villages have been triggered, and nearly 1000 latrines have been built. Six of these villages have declared themselves “100% open defecation free,” while the rest are on their way. All this has been done with a project staff of less than 40 people, and no water and sanitation budget. Though this method may prove the death of huge and costly rural sanitation schemes, it may also spur the reevaluation of the old saying “less is more” and its application to aid and development programs.

CLTS was implemented under the Child Health Opportunities Integrated with Community Empowerment program, or CHOICE, which PCI begun in 2003. With USAID support, this four-year maternal and child health project spans four sub-districts in Pandeglang, an economically and socially depressed region approximately two hours west of Jakarta. Read a full description in this PDF document or visit Livelihoods Connect for more information about CLTS and other programs. You might also like the Handbook on community-led total sanitation and check out Sociolingo’s Africa Blog.

Transdisciplinarity: global health workers breaking down walls

Message from Miriam (Section Chair)

As a lifelong international MCH professional, as a faculty member, and as citizen of the world, I am so excited about chairing IH Section this year. To me, what is so special about international health is that it is a transdisciplinary field. The term “transdisciplinary” may be new to some of you, so here’s the definition, developed by Piaget (yes, the same Piaget), translated by yours truly: “concerning interdisciplinary discourse, we hope to see a higher level emerge, “transdisciplinarity,” which would not settle for interactions or reciprocities between specializations, but which would internalize such interaction within an overall construct, and break down the walls between disciplines.”

While section members present themselves with interests such as “community-based health” or “MCH” or “health systems,” as international health workers we all recognize that enabling health for all will demand comprehensive, multi-level, and transdisciplinary thinking.

My goals for the next few years are 1) to enhance our student-professional networking, 2) to continue to strengthen our voice in APHA advocacy for support and funding for our important work, and 3) to work with the committees and members to develop a simple but effective strategic plan to help ensure continuity of effort.

Wishing you all much success in all your transdisciplinary endeavors.

Best of the Best

There was much to appreciate about the APHA 2008 meeting in San Diego, but two sessions that started off the meeting will stand out in my mind for a long time.

On Saturday we were supposed to have a Trade and Health tour of Tijuana, but because of increased violence there the trip was called off.  Instead, Tijuana came to us.  Over the course of three hours we heard from some inspiring environmental health efforts (a successful community effort to clean up a disgusting toxic waste dump) and occupational health work (a maquila worker-turned-activist).  The last hour was a fantastic film that I highly recommend to anyone interested in either or these topics:

Maquilopolis

How effective is our work towards reaching the MDGs?

By Elvira Beracochea, MIDEGO

Are we really making a difference? Should we account for our work and present transparent results, good and bad to our peers, host country partners and funding agencies?

This year the IH section hosted the second panel on “Aid Effectiveness and Accountability.” This panel is a follow on to the one we had last year. I am happy that the topic of Aid Effectiveness is raising more attention. I want to thank two guest presenters: Michael Hammer, Executive Director of the One World Trust, who came from the UK for this panel and Elisabeth Sandor of the OECD, who came from Paris for this panel.

One World Trus (www.oneworldtrust.org) is a fifty-year old non-profit organization in the UK evaluating and holding accountable organizations such as DfID, Aga Khan Foundation, etc. Their accountability report is a must for those working in IH. Last year the OECD decided to include health as its tracer sector and is monitoring progress towards the MDGs and the commitments made in Paris Declaration.  

Sun, Sea and Sanitation – APHA 2008 in San Diego

By Isobel Hoskins

A visiting UK editor’s impressions of the APHA conference….

I didn’t attend that many scientific sessions at APHA this year, being preoccupied with meetings about Global Health database and visiting exhibitors in the vast exhibition but those I did go to seemed to keep bringing up sanitation and hygiene as the key to so much disease prevention. Its really part of next years’ theme, Water and Health.

First, the speech by the US Assistant Secretary for Health Joxel Garcia reminded us that the major impacts on public health last century in the developed world were achieved by vaccines and sanitation. I was thinking- is enough effort now being applied to doing this for the developing world? Or are more glamorous projects getting the money. The Millenium Development Goal for sanitation is apparently behind where it should be.

Health Care as a Means to Peace

By Courtney Cawthon

Attending the Community-Based Primary Health Care (CBPHC) workshop on Saturday, October 25 at the 136th annual APHA conference, I was reminded of how there truly can be “power in numbers”.

Having worked in domestically in tertiary care at a well-funded institution (basically the opposite of CBPHC) for almost a year now, I searched for common ground with the international community-based primary care group, relying on my relatively brief but highly educative experiences in international public health. I of course am still interested in community health and primary care, but as others noted in an earlier blog entry from this conference, the funding for positions in that field is minimal.
 
At the workshop on Saturday, I realized just how many dedicated people there are focused on this area, and that our strength is in combining efforts to accomplish our goals. I often witnessed how a group’s synergy can greatly improve its effectiveness and creativity. At the workshop, we split into 3 groups, each one discussing the major actions needed to further the field of CBPHC, including, documentation and dissemination, raising awareness, and finding funding. My group was charged with discussing how to create or find more resources to implement programs in CBPHC.

Failed Leadership of the Health Sector in Addressing the 2008 World Food Crisis

By Charles Teller

Where have international nutrition and health sector leaders been during this serious 2008 crisis of spiraling food crises that are worsening food and nutrition insecurity among the most vulnerable in the world?

At a lively, standing room only session (#3302) on the 2008 Global Food Crisis Monday at the APHA meetings, the 4 panelists and moderator agreed that it was much more than a crisis. It reflected a longer term structural and systems issue related to food poverty, international trade, climate change, energy and environment. Case studies on India and Ethiopia helped to contextualize the intra-country discrepancies in undernourishment, stunting and wasting.

On my Ethiopian case, I contrasted the apocalyptic press statements in September 2008 of the UN ( FAO, WFP,Humanitarian Affairs) with my Oct. 20th interview with the well-informed Minister of Health of Ethiopia who felt that overall high inflation and energy costs, as well as drought, were more serious shocks  to health and nutrition of his people.  In presenting the long and short-term trends in food access and malnutrition in Ethiopia, I found that this discrepancy in information reflects the lack of representative and reliable data on the evolution of the situation, causes and immediate effects.

Community-Based PHC: So What’s New??

Participants Trying to keep up with the flow of ideas

By Janine Schooley

Sometimes I get the question, “So what’s new and innovative in CBPHC?”  The answer is that there isn’t anything new, and that’s the point!  We already know what we need to do.  We have the bullets, as someone said, but the gun seems to be elsewhere or malfunctioning.  I think it isn’t that we don’t have the gun.  I just think we have misplaced it, or it needs some tinkering to get to work, or we need to remind ourselves how to pull the trigger.  I really dislike this analogy for it’s militaristic and violent connotations, but I couldn’t come up with anything better….So, to continue this horrible analogy, we have several bullets and they are inexpensive, tried and true.  We know the power of exclusive breastfeeding, good antenatal care, immunizations, long lasting insecticidal nets, good nutrition, and other low cost, low tech interventions in terms of saving lives and improving quality of life.  We’ve been talking about this for decades, not just amongst ourselves, the practitioners in the field, but at the highest policy levels.  As the September 13-19, 2008 Lancet reminds us, a major milestone, the Alma-Ata Declaration, was issued 30 years ago.  So what’s new isn’t the need for what the Alma-Ata Declaration so eloquently calls for, but perhaps it’s the realization that we still haven’t gotten there.  In other words, we don’t need innovation.  What we need is inspiration and, as Nike so aptly puts it “Just do it!”. 

APHA San Diego: A passion for Primary Health Care

By Monica Dyer

WHO World Health Report 2008

Attending the Community-Based Primary Health Care workshop yesterday was one of the most invigorating experiences I have had in quite a long time. It was so fantastic to meet people carrying out work that I have been constantly thinking and talking about the need for. As my colleagues and I struggle to establish a comprehensive community health center in Gatineau, Haiti we are constantly trying to figure out whether or not we are actually implementing best practices. While we all value the importance of making decisions based on evidence and learning from others’ mistakes, it is incredibly challenging to find detailed information. Through this process and past research, I have been made especially aware of the need for more accessible and thorough documentation of both effective and ineffective practices and implementation experiences in global health.

This is not to be unexpected as organizations carrying out this work are usually so over-extended and resource constrained that documenting their processes and practices often becomes low-priority unless it is to meet the requirements of funders. However, when this is the purpose of such documentation the tone changes from factual reporting of successes and failures to trying to demonstrate efficacy so that a donors will keep sending money, so financial survival is not the best motivating factor for the objective documentation needed. In my own experience so far, although we have said that documenting and sharing the entire process of establishing a community health center would be a very useful activity that we would like to do, we have thus far been unable to follow through while dealing with all of the day-to-day logistics of running a clinic, seeking/maintaining funding and the planning of future programs and community organizing. If we had a volunteer historian or could work with students to take the documentation process on as a project for course credit, it might be much more feasible. However, with limited time to coordinate such efforts and so many critical activities competing for our resources, this honestly falls relatively low on our hierarchy of needs. 

I was encouraged when I recently heard about the Global Health Delivery Online www.ghdonline.org but somewhat disappointed that it thus far only includes HIV, TB and Technology discussion communities. Understandably, these are in the scope of the founding collaborators’ chief interests but I hope they will continue to expand this venue into other important realms in need of increased attention.

APHA San Diego: notes from a CBPHC workshop

By Corinne Cohen

TB can be fatal. It is a worldwide epidemic that knows no borders.

I am a resident in Family and Preventive Medicine, concurrently working towards getting my MPH.  I attended the Community Based Primary Health Care (CBPHC) workshop at the American Public Health Association National Conference, which was organized by APHA’s International Health Section on October 25, 2008. Project Concern International (PCI) facilitated the workshop. 

We opened by discussing the principles of the 1978 Alma-Ata Conference, which include health as a fundamental human right, equity, and the emphasis on community participation. 

We engaged in several spirited group discussions about the role of CBPHC in our own work and ideas for effective behavior change.  A highlight was a presentation on the use of TB-Photovoice (http://tbphotovoice.org/tbpv2/index.php?option=com_frontpage&Itemid=1), a powerful means for creating effective messages of change from those who are most affected by the disease.  At the end of the workshop we broke into groups to discuss either the documentation and dissemination of work, how to increase funding, and how to advance knowledge of CBPHC.  My group was comprised of documenters and disseminatorsand we discussed starting a new journal that is a forum for talking about projects that are in the works or have been completed — this would allow newcomers to avoid reinventing the wheel, would serve as a forum for old hats to bounce ideas off each other around what did and didn’t work in their projects, and would also provide powerful individual stories, photos, videos, etc. that would assist with funding.  The forum would be online, open access and free.  Start up funding for such a new journal  is actively pursued and hopefully we can capitalize on that.  Wikipedia sounded like an option as well.  Also, we want to try to connect students and young professionals with project managers so that we can recruit writers!  Community-Campus listserv may be the way to go for that connection.
 
Overall, the workshop was stimulating and exciting – an opportunity to gather a collection of dedicated and passionate professionals to share ideas and projects that serve a common goal.

Stories from the Field: Realities of field work at 14,000 feet.

High in China’s western Qinghai province is a small village where project DROLMA is based. The population consists of 2,800 nomadic people who move twice a year, to and from their summer encampments which reach 15,420 feet into the sky. The conditions are harsh with short growing seasons; their traditional diet consists of roasted barley flour mixed with yak butter and salted tea. A centrally located monastery with 52 monks in residence provides the spiritual guidance for this community. It was the wisdom of one of their spiritual leaders that made the project a reality. He reached out for assistance, seeking new ideas for problems that have challenged his people for decades.

Stories from the Field: Blowing whistles for change.

According to the UN, 2.6 billion people around the world do not have access to what we take for granted, a clean and safe latrine. The UN General Assembly declared the year 2008 the International Year of Sanitation, the goal is to raise awareness and to accelerate progress towards the Millennium Development Goal (MDG) target to reduce by half the proportion of the 2.6 billion people without access to basic sanitation by 2015.

According to the WHO, about 2 million people die every year due to diarrheal diseases caused by poor sanitation and hygiene; most of them are children less than 5 years of age.To help combat this, Plan is pioneering new approach in Asia and East and Southern Africa – Community-Led Total Sanitation (CLTS), which educates communities about the importance of sanitation and helps them to construct and maintain their own latrines. Dr. Selina Amin brought to our attention the work of the Jaldhaka Program Unit of Plan Bangladesh.

The Jaldhaka Program Unit is situated at the northern part of Bangladesh. Their target population included 100,000 children and adults in rural communities where lack of appropriate facilities led to open defecation. CLTS was introduced, and a creative approach was added – active involvement of children. They call it the Child-to-Child (CtC) approach, where children became active participants in changing community behaviors. Armed with knowledge, flags and a whistle, children were empowered to participate by alerting the community with whistles when someone was caught not using a latrine.

Stories from the Field: One individual at a time

Public-private partnerships are transforming public health, creating new opportunities to broaden our reach with new partners and ideas. Some of the terminology or business methodology used on the private side is new to those on the public sector. But over time, these differences add to the creative spirit behind such partnerships. Such differences help drive transformations for both public and private organizations, offering new ideas that are tested in one venue and become transferable to another.

Dr. Elvira Beracochea has worked in both the private and public sector, and combined these experiences to create MIDEGO. The model she developed takes basic principles of business management and tailors them to meet the needs of NGO’s. Coaching, mentoring and training are standard development tools offered in the private sector, often used to reinforce a positive culture of growth and development. For NGO’s this is a luxury, where every dollar is scrutinized and valued against the larger needs they serve. Yet for NGO’s, these development needs are just as great or even greater than in the private sector.

Stories from the Field: Just and Lasting Change

On May 28^th, Prof. Carl Taylor was honored as the inaugural recipient of the Global Health Council Lifetime Achievement Award for his dedication to improving the health care of the world’s most marginalized people through innovative and sustainable community-based interventions. During his acceptance speech, Dr Taylor discussed the future of global health and that new directions will be required to meet the challenges as globalization takes over. He talked about the need to focus on “peoples self reliant social change” and that the greatest problem is going to be the issue of the “worlds total health ecology”. This is when the “3-way partnership” is important; where in addition to the top down officials and programs, and bottom-up self reliant communities, a new generation of health professionals must emerge that specialize in bringing the top and bottom together to find new patterns for collaboration. When this is accomplished, Dr Taylor believes that health for all will be possible and mutual empowerment will begin. (Photo by Medora Hebert, Global Health Council)

Stories from the Field: What is your vision 200 years from now?

It’s impossible not to be moved by William Foege, MD, MPH, a leader in public health who continues to educate, motivate and challenge those who are searching for new solutions to complex global issues.  Last week at the Global Health Council’s annual meeting, Dr Foege spoke to individuals interested in pursuing careers in global health.  He chose to share lessons from his years of experience…. lessons we can all learn from.

1. Preparation:  You cannot know everything in advance, public health combines multiple disciplines. Become a generalist and find a specialty that interests you.
2. Possibilities: 10 years ago the options were few, now the possibilities are endless.

Which Top Family Planning Research Findings should be put into Practice? Vote!

Which are the most important family planning research findings that should be put into practice? Authors for an upcoming Population Reports issue on the topic invite you to vote for the top three findings from a list of seven. For example, WHO recommends that family planning clients receive up to a year’s supply of pills, or as many pill packs as feasible, at the first visit. Research finds that women who get a full year’s supply of pills are more likely to use the method effectively, without interruption. This practice is rare in many countries, however. Have a more urgent finding that should become a practice? Vote and then write a comment on INFO’s Blog.

Are Millennium Development Goals (MDGs) Unfair to Africa?

“At the midway point between their adoption in 2000 and the 2015 target date for achieving the Millennium Development Goals, sub-Saharan Africa is not on track to achieve any of the Goals”. http://www.un.org/millenniumgoals/docs/MDGafrica07.pdf

Yes, according to William Easterly, author of “The White Man’s Burden”, at a February 6 event, Africa was set up to fail by the way MDG targets were set and indicators defined (http://www.brookings.edu/events/2008/0206_africa.aspx). With wit and by taking occasional cheap shots at those who developed the MDG goals and targets, Easterly held the attention of a large audience. Using data and trends, he made a compelling case why MDGs did not give sub-Saharan Africa credit for its considerable progress, thus contributing to the stereotype of “Africa’s failure”. In his response, Danny Leipziger of the World Bank took issue with many of Easterly’s claims pointing out, for example, that Tanzania was treated no different from Nepal for most MDG goals. Here is the question: Do you believe that MDGs are fair or unfair to Africa?

Who decides what to evaluate, how and when?

A systematic review of the United Nations Children’s Fund (UNICEF) estimated that 15 percent of all its reports included impact assessments, but noted that “many evaluations were unable to properly assess impact because of methodological shortcomings” (Victora 1995). A review of 127 studies of 258 community health financing programs found that only two studies were able to derive robust conclusions about the impact on access to health services (ILO 2002).

International consensus is growing that more and better impact evaluations are needed. Only by applying scientific rigor can development programs show that they produce results and offer a good return on the investment. The World Bank has made considerable investments in evaluating the impact of many of its development programs. Other donors like the UK and the Netherlands are joining forces. However, impact evaluations are expensive and not all programs need them. Here is the question: How to decide which programs should have an impact evaluation, who should decide and when? Let us know what you think!

Are you interested in the APHA Trade and Health Forum?

The APHA Trade and Health Forum was formed last April.  Some of you have asked for an update as to what the forum is, what it has done, and plans for the coming year.   

This past year’s APHA conference in Washington DC included the first face-to-face business meeting of the new Forum on Trade and Health. Over 25 people from a variety of sections gathered to discuss how global trade affects public health, and what we can do about it. The Forum sponsored three oral sessions and one poster session, and co-sponsored several other events. The Forum welcomes new participants from any section!

Hello APHA International Health Section Members and Friends!

It is a New Year and a new beginning for communicating among members of the International Health Section of the American Public Health Association. What is new?

• Our website has a new look. Please check it out at http://www.apha.org/membergroups/sections/aphasections/intlhealth/
• This “IH Blog”. It is a new tool (for us) to hear members about their concerns and issues related to global health.

 I would like to invite you to write for the IH Blog. If you have any suggestions concerning topics that you would like to discuss, feel free to comment.