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"If We Don't Do It Then Who?"

"If We Don't Do It, Then Who?" Page 1

Africa is developing its greatest resource—its people—to face its greatest challenge

Guarded optimism: Children play in the village of Lupata, Zambia. A healthier future for all Africans requires well-educated public health researchers and practitioners. Through its graduate education curriculum and programs like the Bill and Melinda Gates Institute for Population and Reproductive Health, the Bloomberg School has long invested in such "capacity building."

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...


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.

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