We Have Changed Film News

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.

2008-02-27T19:08:00.000-08:00

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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.

The Human Element

2007-12-08T13:06:00.000-08:00

A recent speech at Boston University by Dr. Jim Kim of Partners in Health, as well as the recent illness of my parents, has made me realize how much of health care delivery is about people. This may sound ridiculously obvious, naive, or just plain obtuse. But often when we think of health care we think of drugs, technology, and highly skilled doctors and nurses. All of those things are necessary but not sufficient. When it comes down to it, taking care of the sick is about spending time with someone who is sick. It may just involve checking on someone to see if they are taking their medicines, or having their meals prepared, or just talking. This is not high tech stuff. It does take time, and it does take lots of willing and concerned people. Community health workers, friends, family and other non-physicians can provide much of this care. But medical care does get complicated, and does require referral to more highly skilled providers. As Dr. Kim pointed out, community health worker programs are vital, but left alone, without doctors and nurses to back them up, they can be disastrous. Any discussion of the future of global health care must include the question of health care delivery, and any discussion of health care delivery must include the question of creating such a network of both physicians and non physicians. One without the other is unrealistic.

Film Production Begins

2007-11-20T11:52:00.000-08:00

Film production of "A Year in the Life: Healing Africa" begins in January. The initial shoots will focus on interviews with leading global health experts on human resource problems in the developing world. On-location filming- the heart of the documentary- then takes off in Zambia in February. Both a US and Zambian film crew will be involved. While the US film crew will be filming in stages, the Zambian crew will allow continued coverage of the principal characters over the next year. As the writer and documentary filmmaker Alan Rosenthal puts it "this ability to portray change is one of the gifts of documentary." As video becomes available, it will be posted on this website.
It's good to start.

Better

2007-11-03T17:18:00.000-07:00

In Atul Gawande's book Better, the author places current surgical treatment of the wounded in Iraq in the context of military history. He notes how military medical teams in the current war have drastically reduced mortality from trauma- compared to the Vietnam war, or even the more recent Gulf War- without any new technologies. He also notes how this has been done without an increase in medical personnel. The vast improvements have been achieved with a better system. Forward Surgical Teams (FSTs) that literally follow troops on missions, can assemble surgical care units at the scene of injury- ultimate M*A*S*H units. Such units temporize and stabilize the wounded. These are then linked to Combat Support Hospitals (CSHs; like much about the military, acronyms abound). More advanced hospitals, primarily in Germany, can then perform technically involved, and time-consuming, surgeries. The FSTs are thus part of a network of support.
Better systems may also be a key to health in the developing world. A recent article in The Lancet (Vol 370, Sept 29, pg 1115) shows how a health program in the Democratic Republic of Congo has effectively addressed the problem of river blindness. The African Programme for Oncocerciasis Control (APOC; public health is not without its acronyms, either) enlists volunteers in villages to deliver and monitor treatment for this nasty parasite. These volunteers are linked to local health workers, thus creating a network of health care. The system, dubbed community-directed treatment has reduced the prevalence of onchocerciasis infection by 73% before implementation of the program- this all in a war-torn country. This network system of voluntary workers are now extending their care to Vitamin A distribution and other types of deworming. Better.

Documentary, Film

2007-10-08T18:12:00.000-07:00

Is documentary film reportage, or cinema? Obviously, the answer is both. Some films have been pure reportage (much of the excellent Frontline series), some pure cinema ('Koyaanisqatsi:Life Out of Balance'), and often the best have been both (most recently, 'Grizzly Man' and 'Iraq in Fragments'). Since many documentary films have a social advocacy bent, the film as witness, reportage and documentation are important dimensions. But a documentary film as cinema is not without merit. And I think that this cinematic quality is vital for a good film, documentary or otherwise. The director Akira Kurowsawa said it best in his Something Like an Autobiography: "There is something that might be called cinematic beauty. It can only be expressed in a film, and it must be present in a film for that film to be a moving work. When it is very well expressed, one experiences a particularly deep emotion while watching that film. I believe it is this quality that draws people to come and see a film, and that is the hope of attaining this quality that inspires the filmmaker to make his film in the first place. In other words, I believe that the essence of the cinema lies in cinematic beauty."
No matter how grim or important or vital a documentary film, and no matter how urgent and pressing its cause, documentary film is ultimately, well, film, and can only be enriched by this cinematic undercurrent.

Certainty and Uncertainty

2007-09-25T07:20:00.000-07:00

One of the most difficult aspects to practicing medicine (anywhere in the world) is uncertainty. The new mantra in medicine, and appropriately so, is "evidenced-based medicine". For some areas of medicine, such as cardiology, there are large randomized controlled studies that guide decision making. Even so, these studies generate statistical averages, and it is always hard to say if an individual patient will experience the statistical benefit, or the statistical harm. Many areas of medicine do not have these evidenced-based tools, and that is where experience and the art of medicine come to play. But imagine working as a doctor where even in areas of medicine where scientific knowledge exists, you don't have the means to bring the fruits of this knowledge to your patients. And so with some certainty you know your patient could have lived, only if they had the proper medicines. With more marginal cases, uncertainty still hovers, but much of that doubt is whether more effective tools would have made a difference. Then imagine you have doubts about being able to properly raise a family, providing an education for your children, or- in worn-torn countries- having basic security. But you are certain that a better life exists somewhere else. So you leave.

Kampala Forum- The World Takes Notice

2007-09-11T06:39:00.000-07:00

With the announcement of the first Global Forum on Human Resources for Health, the world is finally awakening to the crisis in human resources in health care. Until now, the vast majority of the energy and money spent on health in the developing world has not been in this direction. Maybe because the remedies are so complex, or it isn't a sexy enough topic, or it is linked to such an elaborate web of social, cultural and economic factors. As a recent commentary in The Lancet put it: "That the workforce was the engine of health work- obvious to practitioners and leaders on the ground in affected countries- was simply invisible to global leaders."
The Joint Learning Initiative has been one of the organizations at the forefront of bringing this issue to light. The WHO has also launched the Global Health Workforce Alliance (GHWA), which announced the upcoming Global Forum on Human Resources to be held in Kampala, Uganda on March 4-7. As The Lancet article points out, GHWA is launching four global task forces to address human resource problems: 1)Fast-tracking training and education 2)Ameliorating harmful aspects of migration 3)Harmonizing HIV efforts with health systems (so 'vertical' programs don't steal from Peter to pay Paul, i.e., drain health workers from public health to specialized NGO programs) and 4)Develop feasible financing options.
No easy task. 'A Year in the Life: Healing Africa' has one simple goal: to humanize these often abstract concepts. Just one part of a changing tide.

Outreach News

2007-08-31T17:21:00.000-07:00

The film project "A Year in the Life: Healing Africa" has just been awarded a grant for educational outreach from Harvard University's Office of the Provost. This is a grant to help develop educational content, and will be used to edit video segments from the film for online and classroom teaching. This material will be piloted at two Harvard Medical School first year classes, 'Patient-Doctor I', which introduces interview techniques and basic patient/doctor skills, as well as 'Introduction to Social Medicine', which is meant to introduce cross-cultural concepts as well as issues involving disparities in health care. The documentary footage should serve as a powerful teaching method in both classes, with the immediacy of film a way to bridge the great gaps in distance and social conditions that exist between the US and sub-Saharan Africa. This grant will ensure an educational audience for the film, and will hopefully act a springboard for further outreach.
This grant fits one of the underlying concepts of the film, namely, that improvement in health care in the developing world doesn't involve a one way street from the rich world to the poor. Rather, the developed world has much to learn from the developing world. The film will portray African agents of change in health care: that is, African doctors, nurses, and community health workers who are addressing crises like AIDS in their own unique ways. There has been a general shift in attitude in much of the public health world, which has gone from a top-down to a ground-up approach to problem solving. Preconceived notions and dogma can cause much harm, both to health care and development (and not to mention good documentary films that hope to achieve some truth and objectivity).

Talk Is Cheap, and Effective

2007-08-19T16:37:00.000-07:00

Reading the excellent new book on HIV/AIDS in Africa by Helen Epstein "The Invisible Cure" you are reminded of the power of frank talk. While President Museveni of Uganda deserves much credit for the drop in HIV rates in that country through the promotion of both an open national discussion of HIV/AIDS and promotion of the 'ABCs' (despite an overemphasis on the 'A'), the real story is the openness of the Ugandan people. One of the key points of Epstein's narrative is how Ugandans, from the early days of the AIDS crisis, were able to discuss the problem. This may be in part from the cohesive nature of Ugandan society, one that, despite years of brutal dictatorship under Idi Amin, survived into modern times. This is in stark contrast to other countries, particularly South Africa, where society and families were uprooted by both apartheid and economic forces (especially in regard to the mining industry). In a less cohesive, more fragmented society, such open talk was rare. Add to this the unfortunate denial of all things HIV/AIDS related (from the science to prevention to treatment) by President Mbeki, and a time bomb exploded with tragic effect.
Another interesting thread in the book is the story of loveLife, a nationwide media campaign meant to promote healthy lifestyles for the youth of South Africa. While the program enjoyed some popularity, often employing the methods of Western glitzy advertising and American self-help gurus, HIV/AIDS prevention, the nominal goal of the campaign, was rarely discussed in a frank manner. Donors such as the Global Fund to Fight AIDS, Tuberculosis and Malaria lost interest as well, and it is still not clear how positive an impact loveLife has had in South Africa. What is clear is that real discussions about HIV/AIDS are an effective preventative measure. Media projects that deal with the reality of HIV/AIDS, rather than a preconceived notion of the facts, are more likely to add to this open discussion. This is true of documentary films as well.
And what of an open discussion when it comes to distributing funding for health care? Much of the truth in terms of absorptive capacity and sustainability is on the ground, in places like the clinics and hospitals of Zambia and elsewhere. There is nothing inherently wrong with grand designs for improving the life of millions suffering from HIV/AIDS and other plagues. In fact, such goals are an admirable change from the extremes of the past, either outright neglect or funding with ulterior motives of a geopolitical bent. But an open discussion with those who know best, those in individual countries each with their own culture and unique set of hurdles, is a good place to start.