Year 25+: Healing Africa News

The Power of Idea(l)s

2009-08-27T08:00:00.000-07:00

"Rights are not something handed down from above, but are fought for from below."

Author Unknown

Idea(l)s can kill. There was nothing fuzzy or woolly about the machine guns and bayonets and bombs and living graves of totalitarianism and anti-Semitism during World War II. Yet from the ashes of that horrific century sprung the concept of human rights and health. The Nuremberg Code was created during the 1946 and 1947 trials of Nazi doctors. Other types of rights infringements during this century, such as Tuskegee, demonstrated the necessity and relevance of these simple codes and ideals in more recent times. The AIDS movement borrowed much from these concepts- along with important ideas from the civil rights movement- to eventually ensure treatment for HIV patients in the developed world. Now the developing world is beginning to reap the rewards of such activism. The story of this ideal, the idea of health as a human right, remains alive and controversial and pertinent to issues ranging from child and maternal health, to passive and active health care allocation, to the United States' debate about universal health care.

Can idea(l)s heal? Stay tuned.

Development That Works

2009-05-13T13:42:00.000-07:00

I did a thought experiment the other day, imagining I had 100 million dollars to spend on development in Zambia. While there has been much recent criticism of aid from the West to developing countries (some of it well taken- see William Easterly's 'White Man's Burden') there is good data that certain forms of aid do work. Health projects (where outcomes- like deaths and disease rates- are relatively easy to measure) are one area with good data. So as part of my experiment, I tried to conceive of ways to give 100 million dollars directly to health care in Zambia. It's not easy to donate well. For example, giving directly to the Zambian government runs into problems with fungibility, where 100 million dollars donated to health might mean the government spends 100 million dollars less on health, with no net gain. Donating to local community projects has its own problems. The Bamako Initiative, which is a community managed health program piloted in Benin, Guinea and Mali, had success in those countries, allowing local communities to use donations to purchase drugs directly, and empowered to hire their own staff for health clinics. But the success of this type of program hasn't translated to countries like Zambia, where human resource limitations mean no real choice for communities. This lack of 'soft' infrastructure is a major hurdle to donating well in the health sector.

So the next step in my thought experiment was to imagine a way to improve both this 'soft' infrastructure and health. There is very good data that female education reduces under five mortality and reduces birthrates. In addition, increased life spans are associated with increased education. Maybe giving to education would not only improve health, but create an educated workforce that would be able to improve economic growth in Zambia? Maybe such an educated workforce would also create a new pool of health care professionals?

Is there any data that donation to education works? Yes. African governments, with donations, have increased literacy rates dramatically over the past few decades- Zambia now has a literacy rate of 70%. Getting to that last 30% might involve projects like the PROGESA program in Mexico, which has had success in increasing enrollment by paying families to keep their kids in school. But the quality of education is still an issue. There is also data that providing instructional materials, as well as involving community members in running schools (as has been done in El Salvador; a 'self-care' model akin to community health workers for HIV) can increase school quality.

It might be a thought experiment, but it's not all pie in the sky. Not all developmental goals are warm and fuzzy ideas that make donors feel good and have no real impact. Just as critics of aid are correct to highlight wasteful aid- misallocation of money can kill- we are all obliged to continue aid that does work and save lives.

So if I ever do get a 100 million dollars, it's going to education.

A Window of Opportunity

2009-04-04T18:54:00.000-07:00

The following is from a paper I'm currently working on. I apologize if it is dry in places, but it does make a few key points about the whole idea of "AIDS Exceptionalism."

Final3.25Paper.doc

Two Quick Thoughts- The New Face of AIDS

2009-02-18T17:35:00.000-08:00

A few developments in the past few years have come to light in the world of HIV/AIDS. One is that people on anti-retroviral therapy for a decade or so- which we're beginning to see now in the United States- develop chronic conditions like cardiovascular disease, kidney disease, diabetes and cancer at a premature age. This wave of chronic disease is just beginning to hit the developed world, and it will be a tremendous challenge to Africa and the rest of the developing world in the near future. The other development, which is an offshoot of the AIDS activist movement from the early days of the AIDS pandemic, is the shaping of AIDS policies and the creation of HIV care systems by people living with HIV. While those with HIV have always been the midwives of HIV care, the remarkably rapid expansion of HIV care in Africa over the past few years is a unique testament to this movement. Furthermore, when people are both patients and providers in a health care system, in their own communities, they are a powerful engine for transparent, accountable health care systems built from the ground-up. The future will tell whether the systems they've helped build can broaden to manage the new face of AIDS- which really means whether these systems can provide comprehensive care for all health, given the multiple dimensions of chronic HIV infection.

The Fierce Urgency of Now

2009-01-25T15:51:00.000-08:00

About this time last year I was sitting in the office of Dr. Cassius Banda, the spokesperson for the Zambian Ministry of Health. While the purpose of my visit was to obtain a letter of permission for filming at government-run clinics, the conversation inevitably turned to the American presidential campaign that played on TVs broadcasting CNN throughout the building. Dr. Banda spoke of the great psychological impact of Barack Obama as president, and how much that would mean throughout the world- especially in Africa. I have not spoken to Dr. Banda since our meeting, but I'm sure he's very happy, like much of the world.

President Obama speaks of "the fierce urgency of now" and no more is that true than in a part of the world where people die by the thousands every day for very treatable medical conditions. The work of CIDRZ (Center for Infectious Disease Research in Zambia) as portrayed in our film is all about that urgency. A recent case study of their work at the Harvard School of Public Health remarked on how fast they are increasing the numbers of patients receiving effective anti-retroviral therapy. Really fast- from zero to nearly a 100,000 patients in a matter of a few years. And the numbers keep increasing day by day. Yet they are still treating less than a half of the people who need treatment in Zambia (although not due to a lack of effort); and Zambia is only one country in sub-Saharan Africa. [It is hard to imagine the suffering in places like Zimbabwe or the Congo, where political instability makes health care delivery nearly impossible.] As CIDRZ deputy director Iris Mwanza describes her work and that of her colleagues, some days they can pat themselves on the back, and other days they realize how much more needs to be done.

Some have written and spoken of AIDS exceptionalism, and there may be some truth to that, when children die of diarrhea while others receive cutting edge HIV care. But no one can deny the suffering from AIDS, and PEPFAR and other money being spent is a fact. It's happened. There is so much to learn about health care delivery from what has been accomplished in Zambia, and so much potential use for that knowledge. Urgently, and now.

Against Complaceny

2008-12-01T17:16:00.000-08:00

The great thing about World AIDS Day is the way that the press and governments focus on this critical health and human rights issue. The bad thing is that it's only one day. A great number of wonderful and dedicated people have devoted their lives to dealing with the AIDS crisis, but there is always a concern that the rest of the world will develop a fatal complacency. Things are much better, but we all know there is still a long way to go. Even if there was a halt to new infections from this moment, there are millions already infected that need care for decades to come. But new infections still do occur. And AIDS is a long wave event. Inertia is a mighty force, and the job of filmmakers, artists, journalists, doctors, nurses and all those who fight this scourge is to also fight the inertia and complacency that can settle in so easily.

Two Trains

2008-11-26T13:33:00.000-08:00

In the 1980s, two trains collided in Africa. One was carrying the AIDS pandemic, the other, a broken health care system. Africa has been suffering from that train wreck ever since. The film "Year 25+: Healing Africa" returns to the scene twenty-five years later.
The AIDS pandemic strained an already strained health care system. Doctors and nurses fled abroad, or succumbed to the disease themselves. Fewer doctors meant little care for AIDS patients, let alone all the other ills of Arica, from TB to malaria. This worsening disease burden led to a vicious cycle- a greater patient load for doctors, more brain drain, more disease, more poverty.
To understand the enormity of this crisis in human resources, you need to understand the humans behind it- the providers. And to understand possible solutions, you need to understand what once seemed impossible. Not only has a network of AIDS care providers arisen in parts of Africa, but this network is now at the vanguard of health provision.
This story looks at the three acts in this drama- the haunting past of millions of deaths, the promising present of AIDS care, and the challenging future to deliver this promise to not only AIDS patients, but to the child with malaria in a rural village, or the shantytown barber with multi-drug resistant TB. The film personalizes the drama by telling it through the eyes of six compelling characters at the frontlines of health care. It is a vital story, not just for Africa, but for health care everywhere in the developing world.

The Return

2008-10-13T18:38:00.000-07:00

One of the great strains on the already strained health systems in sub-Saharan Africa is 'brain drain'. Brain Drain- the exodus of the most talented and educated from poor countries- is a relentless force. It bleeds parts of the world like Africa that can least afford it. While development money is pouring in, those most able to ensure sustainable development pour out. Poverty, poor working conditions- the reasons people leave- are understood. Why people stay- or come back- is more of a mystery. The main characters in our film in production have all returned to Africa- some after living and working overseas, others from near-death after struggling with AIDS. But they have all come back. Our film seeks to find out how the tide of brain drain can be reversed. Understanding this story of why people stay and how they have created a remarkable health system offers creative possibilities to improving the lot of millions.

Push and Pull

2008-08-12T11:19:00.000-07:00

An editorial in the August 7th New England Journal of Medicine talks about "push" and "pull" factors in improving health care in the developing world. The editorial (The President's Emergency Plan for AIDS Relief- Is the Emergency Over?) is a look at the past and future of PEPFAR (the President's Emergency Plan for AIDS Relief), which has provided much of the funding for HIV/AIDS care in sub-Saharan Africa. Despite my misgivings about every other aspect of the Bush administration, and despite some limitations of the original program in terms of prevention, it has been a remarkable success, saving thousands of lives. Fortunately, Congress has reauthorized the program this July. The work of CIDRZ portrayed in our documentary film could not have happened without this funding. CIDRZ has been able to translate this money into an effective network of health providers for HIV care. The question now is whether such a network can be broadened to other areas of health care. As the editorial notes:
"In a sense, then, the key choice for PEPFAR at this crossroads is between a "pull" strategy and a "push" strategy: Will a continued singular focus on HIV "pull" other components of national health care systems forward, so that they become more responsive to other health threats and can catalyze the necessary changes in social norms and policy? Or will a "push" strategy that is focused primarily on strengthening health care systems and tackling fundamental issues that define societal vulnerabilities to disease be more effective in achieving both HIV-specific and broader health and social goals?"

Plastics

2008-07-23T14:48:00.000-07:00

In the film "The Graduate" there was that one word- 'plastics'. The word has a great deal of meaning for documentary film, and Zambia, as well. Bear with the extended metaphor...
After my first trip to Zambia in 2005, I returned with thoughts of a documentary film exploring human resource issues in the developing world with Zambia as the case study, and the University Teaching Hospital as the place to film. In addition, a hospice I had visited seemed a place of great hope, as its program for HIV treatment was successfully reaching scores of people in a desperately poor community. To be honest, I expected a film to show how dire things are on the ground in sub-Saharan Africa. But returning to film this past February, a very different film came to be, and it continues to evolve in the editing. My preconceptions about the Zambian health care system were misguided. First, the University Teaching Hospital is only a small part of the health system; the vast majority of Zambians get their care in urban clinics or rural health centres (or community health workers). It made sense to extend the reach of the film to these other health settings. Second, things change quickly. The promising hospice program had shut down. But in the few short years CIDRZ (the Center for Infectious Disease Research in Zambia) had significantly ramped up treatment for HIV. This success also led to a degree of optimism in the film. I had gone to Zambia to show how bad things were in the human resource realm for health care. I returned to show how many good things have happened. My thinking had to be plastic, the film had to be plastic, and the editing- to properly tell the story-had to be plastic. Fixed ideas are the death to any kind of truth and reality ( I won't extend this point to any US government personalities, but....).
The other need for plasticity is in thinking about the improvement in health care in the developing world. As pointed out in the documentary film, one of the reasons anti-retrovirals have been so successfully rolled-out in Zambia is fluid thinking. The Zambian government has had a laissez-faire attitude in terms of the use of the public sector clinics in this regard. Clinics and communities could devise their own methods and protocols for treating and following AIDS patients. It has worked remarkably well. It is also an important lesson for those of us in both the developed and developing world trying to improve health care delivery. Top down money is not such a bad thing, but top down policy (with a few caveats on accountability) may not be such a good idea.
While plastics may have seemed like a horrible future for a graduate in the 1960s, plastics may not be such a bad thing now.

The Moral Equivalent of War

2008-06-07T09:33:00.000-07:00

From William James' essay 'The Moral Equivalent of War' (1910):
"Let me illustrate my idea more concretely. There is nothing to make one indignant in the mere fact that life is hard, that men should toil and suffer in pain. The planetary conditions once for all are such, and we can stand it. But that so many men, by mere accidents of birth and opportunity, should have a life of nothing else but toil and pain and hardness and inferiority imposed upon them, should have no vacation, while others natively no more deserving never get any taste of this campaigning life at all,- this is capable of arousing indignation in reflective minds. It may end by seeming shameful to all of us that some of us have nothing but campaigning, and others nothing but unmanly ease. If now- and this is my idea- there were, instead of military conscription a conscription of the whole youthful population to form for a certain number of years a part of the army enlisted against Nature, the injustice would tend to be evened out, and numerous other goods to the commonwealth would follow. The military ideals of hardihood and discipline would be wrought into the growing fibre of the people; no one would remain blind as the luxurious classes are now blind, to man's real relations to the globe he lives on, and to the permanently sour and hard foundations of his higher life. To coal and iron mines, to freight trains, to fishing fleets in December, to dish-washing, clothes-washing, and window-washing, to road-building and tunnel-making, to foundries and stoke-holes, and to the frames of skyscrapers, would our gilded youths be drafted off, according to their choice, to get the childishness knocked out of them, and to come back into society with healthier sympathies and soberer ideas. They would have paid their blood-tax, done their own part in the immemorial human warfare against nature, they would tread the earth more proudly, the women would value them more highly, they would be better fathers and teachers of the following generation."

Big Changes

2008-05-12T19:36:00.000-07:00

When I first travelled to Zambia three years ago, big money was just beginning to flow in for health care. Still, treatment for HIV/AIDS seemed a pipe dream for many. Infrastructure is not exactly a sexy word, but that seemed to be the secret. And the real story of limits in infrastructure came down to the human element. Not enough doctors or nurses to provide health care: a simple enough problem with no real solution in sight. I didn't know that in 2005 a group of Zambians and researchers from the University of Alabama were finding the solution while I was just beginning to perceive the problem.
The Center for Infectious Disease Research in Zambia (CIDRZ) began as a group of researchers from the University of Alabama Medical School. Dr. Moses Sinkala from Zambia had been studying in Birmingham when he met Dr. Jeffrey Stringer. Both obstetricians with a keen interest in HIV- particularly prevention of mother to child transmission- they struck up a friendship that eventually led to Dr. Stringer's involvement in CIDRZ. In a relatively short time, Dr. Stringer was given the challenge of putting a thousand Zambians on antiretroviral therapy. This seemed an impossible task. A combination of factors came into play, which can serve as an important lesson for scaling up health care in developing countries.
First, the Zambian government did allow a laissez-faire, even entrepreneurial approach, to increasing access to antiretroviral drugs. There were not universal protocols mandated by the Ministry of Health; rather a ground-up approach for the many clinics involved. Second, nonphysician health care providers played a key role: from nurses, to clinical officers, to community health workers. Third, some top-rate logistics and organization allowed a pipe dream to become a reality. Fourth, the money and CIDRZ came together at an opportune time in the history of the AIDS epidemic in Zambia. An openness about HIV was beginning to push back against stigma. So many had been directly or indirectly affected by AIDS that the truth could no longer hide.
Dr. Stringer and CIDRZ published a landmark paper in the Journal of the American Medical Association in the summer of 2006, in which they documented their initial success at rolling out antiretroviral treatment for 16,000 Zambians. What many had thought impossible had been done. Currently, there are over 100,000 on antiretroviral therapy in Zambia.
When I returned to Zambia this year, three years from my first visit to film 'A Year in the Life', much had changed. I think I was somewhat naive in my preconceptions for the film. I didn't want to make a film about outsiders 'saving Africa'; I wanted to tell an African story, about Africans taking charge. I think that is the story we filmed, for the most part. But it is naive to think that the enormity of the problem of HIV and other health care issues is a problem that can't be solved with out multiple partnerships between NGOs (both Zambian and international), governments, and individuals. And the vast majority of the health care for CIDRZ and others in Zambia is provided by Zambians. But maybe the best way to remind ourselves on how to solve these problems is to remember an important step in saving those 100,000 lives. The first step was a friendship struck up between a Zambian doctor and a US doctor in Birmingham, Alabama.

2008-04-01T17:22:00.000-07:00

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New Thinking

2008-03-29T17:14:00.000-07:00

The shortage of doctors is not just an African phenomenon, it is a worldwide phenomenon. In the United States, for example, new physicians avoid primary care medicine like the plague. Older physicians burn out quickly, and retire at a relatively young age. Medical students clamor for dermatology residencies like the world truly needed a disproportinate number of skin doctors. And yet waiting rooms are teaming with the uninsured and forgotten. And these needs pale in comparison to the developing world. Why?
While doctors and other health care professionals cannot complain about salary in the developed world (but do, nonetheless), there is much more to job satisfaction than money. Long hours can preclude family time, personal growth, sanity. While caring for the sick is a privledge, it's not easy, and it has its toll.
So what about a new model for health care provision? Maybe the majority of health care doesn't need to be provided by doctors and nurses. Maybe those who begin at one level- say an entry level medical assistant- could earn time towards nursing or medical school, and that doctors could move from clinical years to teaching years or innovation/research time or foreign development or medical business or public health or whatever. Maybe a lifetime in just one medical clinic for a doctor is not a realistic expectation anymore. Neither is a clinic staffed by mostly doctors. Medical technicians, physicians assistants (all with the incentives of moving up the ladder of medical professionals) may make more staffing sense. In Zambia, much of the care is provided by nonphysicans. But they're under tremendous stress, without the possibility of promotion. That needs to change. Something needs to change.

Daily Stresses

2008-03-26T13:46:00.000-07:00

Aka Kalema (pictured on the right) is a clinical officer at the Nansenga Rural Health Centre, about two hours drive from Lusaka. As rural outposts go, it is not in a remote area, but far enough removed from the city to mean no physicians are available. Clinical officers are the equivalent of physician's assistants in the United States, but given the lack of doctors in Zambia, their role is greatly expanded. Aka is the highest level of health care provider available in a large network of rural villages surrounding the clinic. He sees children, adults, and assists with deliveries when birth attendants are not available. Except for two weeks out of the year, he is essentially on-call 24 hours a day. Officially the clinic is open 8 am to 5pm, but once or twice a night Aka may be awoken from his nearby living quarters to see patients. Medications can be in short supply. Aka has an impressive knowledge of medicine- but then again, he must, where there are no doctors. In addition to his clinic duties, he is also administrator, statistician and public relations for the small but busy clinic. While he describes satisfaction with helping the people of his community, he admits to fatigue and stress. Like anyone, he yearns for growth, and would like to go to medical school and be a doctor some day. But his three years of training for work as a clinical officer, as well as his years of experience, count for nothing when applying to the few competitive spots for medical school in Zambia. In addition, the financial burdens of medical school are great. And yet, realistically, he cannot leave- his training is not recognized in neighboring African countries or overseas in the UK or US.
A great deal of care in Zambia and the rest of Africa is provided by such hard-working non-physician providers. "Task-shifting", that is, the shifting of tasks in the health field from physicians to non-physicians such as Aka, is a key element of providing health care where there are not enough doctors and nurses. But this shifting means a heavy burden is placed on their shoulders. In some remote rural areas, in fact, the "sweeper"- the janitor, is the only one available to provide care.

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Thoughts on Return

2008-02-22T12:20:00.000-08:00

Despite the enormity of the AIDS crisis in sub-Saharan Africa, as well as the onslaught of other diseases, poverty, failed infrastructure , etc..., you can't help but have a feeling of optimism after being there- however cautious and guarded that optimism might be. For one thing, there has been a sea change in HIV care since I visited there three years ago. Due in large part to PEPFAR, the Global Fund and others, drugs in Lusaka are widely available, and making their way to rural areas. The fantastic work of CIDRZ ( Center for Infectious Disease Research in Zambia, from the Univeristy of Alabama)- portrayed in the film- has also played a major role. And you can't help but be struck by the energy and commitment of the Zambian health care providers. The film footage captures this energy, but you can still see there's a long way to go, and many more are needed to tackle the enormous challenges ahead. Much has been gained; much left to achieve.
As we continue post-production for this first stage of shooting, more photos and video and thoughts to follow...

Filming in Zambia

2008-02-15T07:58:00.000-08:00

It's been at times challenging, intense, frustrating but always interesting as we film in Zambia. Today we filmed Dr. Jeffrey Stringer in Matero clinic in Lusaka, as well as Kalingalinga clinic. Footage should be appearing on the website soon! More to follow.....

Headed for Zambia

2008-01-09T16:41:00.000-08:00

Film production in Zambia begins at the end of this month. Most of the interim time will be spent assembling equipment, reconfirming locations, characters, etc..., and checking and rechecking lists.
A few thoughts and hopes before filming begins. The goals of the project are many, not the least of which is to make a good film. Good people are involved on both sides of the camera, which will be necessary but not sufficient. Telling a compelling story is also necessary but not sufficient. And while the film will have an important advocacy role, the film in a sense should not be about advocacy. It is ultimately a story about people, and people can never be put in boxes. (A favorite quote of the political philosopher Isaiah Berlin is that "out of the crooked timber of humanity, nothing straight was ever made.") So we'll do our best to keep our eyes open and let the characters and fate- tragic, comic, and otherwise- tell the story.
Good luck to all involved.