“If We Don't Do It Then Who?”
Africa is developing its greatest resource—its people—to face its greatest challenge
What's the best way to improve the health of 900 million Africans? Researchers can drop into remote villages, gather data and fill international journals with their discoveries. Though these scientific breakthroughs are critical to the advancement of public health, they will not by themselves solve Africa's ills. Too many African children still lack safe water to drink, nutritious food to eat and immunizations to protect them against disease. And sick adults still need treatments that are either unavailable or prohibitively expensive. Life expectancy for children born today in sub-Saharan Africa is 46 years. However well-funded and well-intentioned, foreign researchers and programs can only do so much. Most African public health experts will tell you the only real solution to the continent's health problems lies with Africans themselves.
As Easmon Otupiri, a researcher at Kwame Nkrumah University of Science and Technology (KNUST) in Kumasi, Ghana, says, "If we don't do it, then who? You have to be able to do it yourself. And it can be done."
Otupiri should know. A Romanian-trained veterinarian who learned about public health while working in rural villages of his native Ghana, he became enamored with public health after witnessing its ability to reduce high infant mortality. He changed careers, earned advanced public health degrees and took part in programs that halved child mortality rates in areas of northern Ghana. Adding some specialized training to his natural smarts and passion for hard work, Otupiri now heads the Department of Community Health at KNUST.
In the public health world, Otupiri's transformation exemplifies "capacity building," an unwieldy bit of policyspeak that simply means educating people to do their own research and intervention programs. It follows the old adage: Teach people to fish, rather than give them fish.
Long before the term "capacity building" came into vogue, the Bloomberg School was educating generations of African public health researchers and leaders. The School has almost 300 African alumni and 50 current African graduate students. And two new programs are extending that commitment. With a $2 million USAID grant, the Bloomberg School is strengthening public health curricula at Makerere University in Uganda and Muhimbili University College of Health Sciences in Tanzania. And for each of the next three years, the new De Beers African Health Scholars Program will support two African MPH students. (See story, page 59.)
An exemplar of the School's commitment to capacity building, the Johns Hopkins Fogarty AIDS International Training & Research Program (AITRP) was founded 18 years ago. It has trained hundreds of investigators, technicians and others in HIV research and prevention, developing on-the-ground expertise needed to battle the AIDS epidemic. With Fogarty support, for example, 14 Ugandan investigators from the Rakai Health Sciences Program have earned master's or doctoral degrees at the Bloomberg School, as have 18 Malawian researchers. More than 1,400 others have benefited from short-term training in Baltimore or their home country. The educational investment continues to deliver unexpected benefits, says Chris Beyrer, director of the Johns Hopkins Fogarty AITRP, the oldest and largest of 25 such programs at U.S. universities. When antiretroviral medications became available through the President's Emergency Plan for AIDS Relief (PEPFAR), Fogarty-trained HIV researchers and managers had the best skills to establish an infrastructure that could distribute the medications and monitor and care for patients. "So many of the people we've trained to do HIV research have become leaders in the antiretroviral rollout," says Beyrer, MD, MPH '90.
"From the perspective of a slowly unfolding disaster like AIDS, the long-term investment over time becomes absolutely critical," says Beyrer. "Protocols come and go, but building this longer term capacity is really the lasting contribution. If you care about Africa, that is the most important thing."
While more than 94 percent of Johns Hopkins Fogarty alumni are still working in their home countries, other African professionals have left for more stable and better-funded work in industrialized countries. The only risk of capacity building: the brain drain. Fully 12 percent of Africa-educated physicians have emigrated to the United States, United Kingdom and Canada alone, according to a 2004 study published in Human Resources for Health. Almost one-third of Ghana's medical school graduates practice in the United States.
"At the grass roots level, it is a big problem," says Gloria Quansah Asare, DrPH '95, MPH '90, an adjunct faculty member at the University of Ghana School of Public Health (UGSPH). "You find two nurses at the bedside in the morning, and at the end of the day, one is on a flight to the UK. The rapture, they call it."
The brain drain has weakened Africa's already overstressed clinical environment. Sub-Saharan Africa averages fewer than 13 physicians per 100,000 people. (By comparison, the United States has 279 physicians per 100,000.) The departure of physicians and nurses—mainstays of public health's professional ranks—necessarily limits future leadership in public health.
Stopping the brain drain requires better pay, more resources and greater stability for health workers. Isabella Quakyi, UGSPH director, believes that training and educating professionals in-country can help as well. A malaria parasitologist and former scientist at the National Institutes of Health, Quakyi returned home with the goal of improving the public health education there and retaining skilled researchers and practitioners in Ghana. A partnership with the Bill and Melinda Gates Institute for Population and Reproductive Health at the Bloomberg School has provided Quakyi with the opportunity. "We've made our training more meaningful and strengthened our facilities so students find it more difficult to go away," says Quakyi. "When you train them here, you train them to associate with problems and problem solving in this country."
In universities, cities, villages and health ministries, capacity building is reshaping African approaches to health policy, health care systems, research and other programs and priorities. The following stories offer glimpses of the promise and peril in public health capacity building in Africa today. A generous gift. A star is born. An idea that saves mothers' lives...
A WONDERFUL PROBLEM
Just a few months into her tenure as Gates Institute director, Amy Tsui had a wonderful problem: how do you most effectively spend $60 million in 14 years?
The gifts from the Bill and Melinda Gates Foundation—$20 million in 1999 and another $40 million in 2003—were for improving population and reproductive health in the developing world. "You don't have that kind of opportunity very often," says Tsui. "If you do it right, it will always be there."
Tsui (pronounced choy) and her Gates Institute colleagues ruled out establishing clinical services. They also rejected a massive research effort because U.S. salaries for 20 or more reproductive health experts would have soon eaten up the funds. Besides, Tsui recalled an unsatisfying conclusion to research she'd done in Malawi. "I had done a brief cohort study there. But when we were gone, that was it. The people were still in the village. They were still getting HIV, and there were still unintended pregnancies," she says. Tsui and her team concluded that their strength lay in peer-to-peer collaborations. "We thought, let's see if we can develop a working collaboration with partner institutions so they will have an enduring program," she says.
In 2002, the Gates Institute launched an ambitious program of partnerships with six academic institutions in four African countries: Ethiopia, Ghana, Nigeria and Malawi. (Three other partnerships in Egypt, Jamaica and Pakistan are being developed.) With $1 million support over five years, each university has hired new faculty, launched or expanded graduate degree programs in reproductive health and public health, and built computer facilities that link them to the latest in research worldwide. The support has also brought two dozen visiting faculty to the Bloomberg School to help them develop or revise the courses they teach. In 2005, the Gates Institute academic partners were training nearly 200 graduate students.
The Gates Institute encourages its partners to link up with ministries of health, other universities and even other departments within their own university. At Nigeria's Obafemi Awolowo University, for example, sociology Professor Olabisi I. Aina has brought her discipline's perspective to the health sciences curriculum. "What we're saying is, you're not just treating the physical. You're also treating the emotional, and you're also treating the cultural," she says. "You become a part of the life of the patient, and you can't do that without the skills of the social sciences." As an example, she cites the emphasis that Nigeria's Hausa people place on vaginal delivery in childbirth. "If you're able to deliver naturally, that is like a man who has gone to war and got a medal," says Aina, director of the Center for Gender and Social Policy Studies at OAU. "If your wife delivers through a surgical operation, that devalues the man." A physician who understands the culture can discuss delivery options for a problematic pregnancy weeks or months in advance with the husband and wife—giving the woman a better chance for a safe delivery, she says.
Gratified by such collaborative education, Tsui hopes the Gates Institute's "seed money" helps the partner universities gain sufficient critical mass to establish long-term programs. One way they can do this is by collaborating with ministries of health so they can produce public health leaders with the skills the ministries need to solve their countries' health problems.
The partnership's ultimate goal is to educate cadres of public health researchers and practitioners, health ministry officials and even future political leaders who will make lasting improvements in the public health arena.
In essence, teaching fishermen to teach others how to fish.
PUBLIC HEALTH "VET"
A Ghanaian fireball of energy and enthusiasm, Easmon Otupiri spent the mid-1980s teaching poultry management to women in poor villages in northern Ghana. Otupiri delighted the village women with his sweet talk and easy manner. "I know every corner of the northern regions," he says. "And it gives me a lot of joy when the women recognize me and are happy to see me."
When a family planning campaign was launched in the area, the women balked at taking such personal advice from strangers. They wanted to hear the news from someone they trusted. So Otupiri took on the job, learned about public health and embarked on a new career.
Saddened by the fact that more than two out of ten children there do not make it to their fifth birthday, Otupiri soon focused on child survival and began educating the women about basic steps they could take to improve their children's health. In some villages, colostrum—initial breast milk rich in proteins and antibodies—was traditionally discarded because of its color. Otupiri persuaded them to abandon the practice. He also counseled the women about malnutrition (an underlying cause of many common illnesses), diarrheal diseases, malaria and respiratory infections. "When you help them, it makes a big difference in the whole family," says Otupiri. "When you teach them to manage uncomplicated malaria, it's a big input you make. If she can recognize it early then she can prevent it from becoming a more complicated case and even death. She can pass along that information to family and friends.
"If somebody has a lot of kids and I can help make a difference in that person's life, why not?" says Otupiri.
After earning graduate degrees in public health, Otupiri joined KNUST's School of Medical Sciences faculty. He's now earning a doctoral degree through a program that allows him to study at KNUST and the Bloomberg School, with Gates Institute support.
As a faculty member, Otupiri finds his greatest satisfaction in the MPH program's second semester when his graduate students visit district health centers (where many had worked before entering the program). "They come back and tell you, 'Wow, there's a lot going on that's wrong, that needs to be changed. We didn't see this before,'" he says. "When you get a few skills and competencies, you go back with a different eye."
Otupiri now shares his passionate inspiration with his graduate students and demands the same in return. He tells them, "We want managers who lead and not just manage. Take us somewhere. Take us to the Promised Land! Lead us there!"
A NEW BABY
In a breezy classroom at the University of Ghana's School of Public Health, the benefits of its partnership with the Gates Institute are already manifest. More than 30 new MPH students crowd Professor Fred Binka's course on the history of tropical diseases. Most are taking time from their jobs with the Ghana Health Service or other organizations. The students sit behind flat-screen monitors attached to new PCs linked to the Internet. (Previously, the UGSPH master's program had just a dozen students and 10 computers.)
Binka's booming voice fills the room as he announces the course will be interactive, and students are expected to contribute. He asks them to tell him the earliest reported instances of communicable diseases. One student says, "Edward Jenner and smallpox."
"No, Edward Jenner was recent," Binka says, adding that some of the classic stories of communicable disease are found in the Bible. He asks for the name of the Biblical general cured of leprosy. The students pause and think. "What? Are there no Christians here?" he asks, laughing. When a student raises his hand, Binka says, "Okay, there's a cardinal here. We can make you Pope, if you get it right."
The student correctly answers "Naaman." Binka discusses the dread disease for a moment or two, how lepers walked with a bell to warn healthy people away, how some lost limbs to the disease. Then he fires up his PowerPoint presentation and begins a discourse on the history of cholera by noting a recent outbreak in Ghana. (Binka is not only concerned about the history of disease, but the future. He's executive director of a non-profit research group called the INDEPTH Network. In April, the Bill and Melinda Gates Foundation awarded the group $17 million to assist with malaria drug and vaccine clinical trials.)
Traditionally, UGSPH and the other partner institutions offered a staid environment in which faculty lectured to students who dutifully took notes. That's largely changed now that faculty have visited the Bloomberg School. In Baltimore, the Ghanaians watched students question and challenge professors, make presentations, participate in group projects and meet individually with faculty. Back in Africa, courses that used to be heavy on theory now emphasize real-world problem-solving, practical solutions and collaborative work.
Course offerings have been expanded as well. Fifteen new courses on population and reproductive health alone were added in 2006 at UGSPH. And 12 new full-time faculty have been recruited to teach the graduate courses. Similar gains have been made at the other partner institutions.
The transformation has been dramatic and gratifying, says Kofi Asante, chair of the Department of Population, Family and Reproductive Health at UGSPH. "The collaboration definitely has made all the difference between barely existing and having a viable and active department," says Asante. "It's like having a newborn baby in your hands and watching it grow and develop. That's the excitement you have."
A COUNTRYWIDE DIFFERENCE
Nigeria has one of the highest rates of maternal mortality in the world—800 annual deaths from pregnancy-related causes per 100,000 live births, according to WHO and UNICEF estimates. (Among industrialized countries, the average is 13.)
As an obstetrician, Oladosu Ojengbede has fought to save mothers' lives for 20 years. In 2002, Ojengbede, director of the Center for Population and Reproductive Health at Nigeria's University of Ibadan, added a new dimension to his work. That summer, he came to the Bloomberg School for a Gates Institute-sponsored strategic leadership training course taught by Henry Mosley, MD, MPH '65, professor of Population and Family Health Sciences, and Ben Lozare, PhD, associate director of the Center for Communication Programs. The course is designed to help leaders in government, academia and the private sector develop strategies to make their organizations deal more effectively with reproductive health and public health issues.
Easmon Otupiri tells students: We want managers who lead and not just manage. Take us somewhere. Take us to the Promised Land!
The training emboldened Ojengbede to confront Nigeria's maternal mortality from a new perspective. One of the main causes of maternal death in Nigeria is eclampsia—seizures caused by severe hypertension during pregnancy. The condition can be effectively treated with magnesium sulfate, but in Nigeria the drug is expensive and difficult to obtain. In the past, "everyone was just gaping and looking and not doing much," says Ojengbede.
Ojengbede hit on a solution: manufacture it in Nigeria for one-fifth the cost. Ojengbede persuaded a hospital pharmacy to produce some magnesium sulfate and used it in a small trial. It worked. He is now securing grants to manufacture the drug and distribute it nationwide. "We're hoping that once it's made available nationally, deaths from eclampsia will just come crashing down," he says. "We're just trying to create stylish ideas to confront simple problems."
While Ojengbede was tackling these logistical barriers, the Gates Institute was working on another track. In 2004, it hosted 11 parliament members from five countries at the Bloomberg School. The intent was to raise the profile of reproductive health among government policy makers in developing countries. After returning from Baltimore, the two Nigerian parliament members managed to earmark funds for reproductive health in the Ministry of Health's budget. The money,
among other things, pays for monitoring reproductive health outreach programs like Safe Motherhood and other projects to ensure they are efficient and effective. "Before, they never saw they had a role in health. They thought, I'm not a doctor. I'm not a nurse," says Ojengbede of the two Nigerian parliament members. "After they came back they knew they could make a positive change. Reproductive health is now on the priority list at the Ministry of Health. It's become a regular budget line."
SAVE A MOTHER, SAVE A CHILD
For many people living in isolated parts of Nigeria's far northern reaches, few health care facilities exist and maternal mortality rates are very high.
Worse still, the death of a mother in childbirth is sometimes a tragedy compounded.
"The baby is blamed for the mother's death. They think a baby who kills the mother should not be allowed to live," says Oladoyinbo Olatunde, an MPH student at the University of Ibadan who worked in the region for a missionary health organization. "When the mother dies, the child is buried alive with the mother. It seems to be a communal death sentence on those children. There were seven instances in the last year that we got there late and they had [already] done the burials."
The custom represents a constellation of complex challenges: What are the origins of these deeply held cultural traditions? How can the people be persuaded to spare the children? What is causing the appalling rates of maternal mortality? What interventions need to be brought to the region and how will they be paid for?
"Many people, even decision makers, don't have the kind of comprehensive background needed," says Olatunde. "This course has helped us to begin to see ourselves play a more active role. It's changed the mental models we're operating in. We think outside the box. We are ready to take risks. I feel our organization is set for a very big leap forward."
Olatunde hopes his MPH coursework and leadership training will help him save mothers' and children's lives. "If we can stop the mothers from dying, then there will be no babies to be buried," he says.