ACAMALARIA News and Editorial

Remembering the past, charting the future

February 15, 2012

ACAM’s Editorial for 2011

Larry Casazza, MD MPH, Director for African Communities Against Malaria (ACAM)

 

Another year has quickly passed; it’s time once again to pause, give thanks, and sort out what we’ve learned in the interim. This facility is uniquely given to us humans alone with the responsibility to apply that learned wisdom to where we want to go in the future. And even among the human race, it is not given to many to be so fortunate!

The past year has seen technical and programmatic advances in global health, especially related to the remarkable drop in malaria mortality and morbidity in sub-Sahara Africa. For example, a recent analysis of malaria prevention in 34 African countries estimates that over 730,000 lives were saved between 2000 and 2010, nearly three quarters of them since 2006, when the use of both insecticides treated mosquito nets and artemisinin-based combination therapies (ACTs) became more widespread. Furthermore, according to 2011 statistics, only one out of ten people in the city of Dar es Salaam have malaria parasites. Research scientists from the Ifakara Health Institute (IHI) Dr Stefan Dongus and Prosper Chaki stated that there is also a dramatic drop in infections among households. Dr Chaki explained that in 2009/2010 malaria prevalence was 13 percent, attributing the situation to a decrease in mosquito density by 90 percent. This decrease in mosquito density is due to implementation of various projects over the last five years, including larvicide-spraying.[1] Certainly this is a cause for celebration!

But before we get carried away with today’s advances, it behooves us to pause for a moment and look back on history not to miss the lessons so carefully learned from those heroes upon which our current advances are built. This reminder came home to me on a recent assignment undertaken with the AMREF Kenya country office, which is deliberately cataloging their rich 55-year-old accumulation of documents, reports, films and slides using today’s digitalization technologies. Fortunately, much of this has been carefully preserved, creating a priceless historical picture of not only the organization’s work, but in reality, a rich history of the medical developments in Africa itself. This is an enviable legacy for the relatively young Foundations in my adopted hometown of Seattle, Washington.

Dr. Michael Wood, the Director General of AMREF since its inception, in November 1981 described the early years when resources were extremely lean, but the organization survived on the remarkable generosity and the voluntary spirit of the growing band of committed staff. The pioneering work included establishing a flourishing radio communications network that eventually linked numerous rural health facilities with AMREF’s central office in Nairobi. Local Africans in the bush built air strips for nothing and the first Flying Doctors aircraft arrived in 1960.[2]

Just as today, the Great Debate between curative and preventive medicine went on fiercely. It was obvious that clinical medicine had no chance of catching up with disease unless other efforts were put in at the other end of the problem— namely, increasing preventive medicine and spreading health education. But as occurs today, talk about it was endless and governments and donors paid lip service to the idea. As occurs in many African countries even today, when there’s a squeeze on the national health budget it is the Health Education Department that is the first to be cut back.

Even back in 1980s, Dr. Wood noted the emphasis for health services began to be directed to the right place, namely, at the community level. ACAM continues to champion this same focus today and it is still an uphill battle. Discussions among donors and governments in the comfortable capital cities design programs with little regard for input from the communities themselves. Sustainability is a common buzzword, but the steps necessary to make it happen at the community level are never carefully considered and funded in the budget. The task of developing healthcare is a colossal one, but it can be solved on the spot by the community itself with the help of those who are prepared to go into these uncomfortable places to teach, persuade, immunize, and deal with the medical needs where they exist.

This past year has seen remarkable credit being attributed to the role of community-based health officers and workers for the encouraging success of national eradication of trachoma, malaria, and polio. It is upon this level of care provider that perhaps 90% of the patients present for treatment, and can be adequately attended provided the workers are trained to dispense available medications that are highly effective. A most encouraging example are efforts to address the neglected tropical diseases that sap so much health and energy, especially from young growing children, thus setting the stage for their later demise. Ever true today, taking water as a case in point, as Dr. Mahler, former Director General of WHO, said it was more important to know how many water taps there are per 1000 population, rather than the number of hospital beds. The old dictum persists today, “You get action depending “on what you count”.

Administratively, AMREF eventually needed to address major issues as its reputation and skills in advising governments and other international organizations grew. For example: how to design practical research projects of immediate value to healthcare providers; how to include health behavior techniques as an essential component of health programming; how to scale up and disseminate the ideas and practices that proved worthwhile in practice; what was the correct mixture of medicine and management? These were just a few of the issues confronting AMREF’s Leadership. The Board of AMREF was not shy about calling in management consultants to assist them in revising their management structure as needed. This prevented them from going after too many enticing opportunities, but rather to concentrate its efforts within a defined and agreed strategy. AMREF learned to say “no” when suggested projects did not fit into its program.

The institution evolved, determined to keep bureaucracy at bay— a task that today’s senior staff still resist with skill. The management continues to be participatory, rather than authoritative; it remains flexible, human, and analytic; they are a hard-working dedicated professional group of people who try to remain both consistent and yet innovative. It has continued to maintain a common purpose, a loyalty, and an esprit de corps that holds together the various parts of the organization. Indeed, this “soul” of the organization has recently become identified into a new unit called Heritage. It is responsible for consolidating and cataloging the 55 years of AMREF’s documentation for posterity’s use and “lessons learned”.

Remarkably throughout the early growth years, Michael Wood, as AMREF’s first CEO, never showed signs of a negative attitude toward governments in Africa; rather he recognized that they had been put into an impossible situation, namely, administering health services to mushrooming populations with minimal resources. In fact, he recognized that certain aspects of public health should not be run by governments at all. Dr. Wood back in 1981 was not afraid to ask, “Where are we going?”; “Can we justify our existence?”

Today AMREF continues to use ingenuity to keep going, to change when necessary, and to devise new policies and approaches as needed. Their innovations in the field of healthcare include research, behavioral sciences, and training in both curative and preventive medicine. But the overriding emphasis is on implementation—for them, that’s the only way to find out what is practical, appropriate and possible. Meanwhile today’s major health program implementers/contractors devote considerable budgets for Advocacy activities as they compete for financial resources. But in the words of Dr. Wood, “Exhortation and advice is no substitute for implementation”.

In conclusion, today’s leading Global Health institutions have much to learn from those who forged historical changes in the past. Go forward to address the new challenges, but don’t repeat old mistakes. Rather, make original ones and openly share the wisdom with others as you go. Do as AMREF’s Dr. Wood has done.

ACAM Applauds new USAID Administrator

February 8, 2011

Editorial Update 2011
ACAM applauds new USAID Administrator’s Comments
On January 19, 2011, Dr. Rajiv Shah, the youthful, newly appointed Administrator for USAID programming gave a noteworthy performance to a packed audience at the Center for Global Development in Washington, DC. He titled it, “A Modern Development Enterprise”.
In the shadow of the upcoming 50th anniversary of the Agency (USAID), Dr. Shah quickly and decisively challenged the organization to return to its former reputation as the “Premier Development Organization in the World”. He noted it had slipped considerably from its earlier standards. Making reference to Pres. Eisenhower’s coining of the phrase, “the Military-Industrial Complex “, he queried that perhaps now at USAID, we had created a “Development-Government Complex”.
Many of his comments revolved around the issue of improving monitoring and evaluation standards of USAID-funded activities. He lampooned the type of evaluation often employed by contractors known as 2-2-2, namely, two consultants, both coming from the organization originally awarded the contract, to conduct an evaluation for two weeks in the field, interviewing two dozen key respondents. Furthermore, he added, “And nobody reads the report”.
As the new standard for future evaluations, he called for new evaluation guidelines including collection of baseline data against the evaluation indicators to be measured. He challenged the outcome of the final evaluation data to include an estimation of what would have been these values were it not for the inputs from the USAID-funded activity. These evaluation performance standards are well known among NGOs who have successfully executed USAID-funded Child Survival projects for years. Yet regrettably, the Agency has not made much note of these contributions and the invaluable lessons learned over the years. These NGOs consistently work with trusted local partners in poor communities globally, often incorporating private sector investments, and aiming for with Dr. Shah called for, “sustainable and durable results”.
Much aligned with ACAM’s focus was the fact that Dr. Shah designated sub-Saharan Africa to be the “epi-center of our work”. It was this same recognition that this region is the most neglected, that prompted ACAM to focus its efforts in the same continent. He recounted that when he came on board at USAID, over 40% of the positions in that region of the world were vacant. This void he promised would change quickly.
Finally, Dr. Shah emphasized the fact that USAID-funded work should thrive on an emphasis on Learning, covering all aspects of project activity. These would include: logistics, governance issues, integrated program management, and cost efficiencies measured by unit cost/impact improvement. Included was his emphasis on two important contributing factors– involvement with the local public-sector and the local private sector to create truly transformational development.
Dr. Shah’s formal presentation was followed by a lively question and answer session from the participating audience. Their insightful perspectives and pointed questions resulted in remarkably clear responses, all without the presence of staged preparation on the part of the speaker. What a refreshing, encouraging experience to get to know this new leader at USAID!

Preparing for COLLABORATION seminars in East Africa

February 7, 2011

At the Global level, among those discussing planning Health\Development strategies, there is growing realization that unless there is a major re-thinking among those who working in Global Health, it will be impossible to achieve MDG’s on time due to disabling internal competition among individual organizations and governments, despite major resource shifts to achieve this end.

In 2006, as a result of a meeting held at the Carter Center, these issues were identified among major donor organizations and global program implementers together with recommendations set forth to improve the situation. Unfortunately there has been no opportunity for these recommendations to be reviewed and revised from the perspective of organizations working “closer to the ground”, , namely, NGOs, CBO’s, and FBOs who for decades have worked with communities in well-established, trusting relationships.

ACAM will share the results of the 2006 meeting with collaborative groups working at national level in Kenya and Tanzania to discuss with them suggestions for improving the draft list of recommendations that came from the 2006 session.

In addition, ACAM will probe beyond these recommendations to provide candid feedback regarding the complexities that exist well below African national levels of collaboration. ACAM will present a description of current in-country organizational efforts to close the gap between those national organizational consortia already functioning at the community level, but in need of additional resources — organizational, communication, managerial and financial, to truly deliver the effective Global Health interventions to these communities who in turn take responsibility for achieving their sustainable availability for the poor residing there.

Editorial January 2011 – Am I Truly My Brother’s Keeper?

January 22, 2011

At the close of an old year, what better time to stop intentionally, to step away from all the noise and negotiations, and take an honest look at what we have done, where we are going, and how we are getting there.

For ACAM, 2010 has been a major year of change. Our Headquarters has shifted from Washington, DC to the “other Washington”—-Seattle WA, situated in the verdant Northwest. Venturing far beyond the Beltway is a challenge, but a healthy one in order to define a new perspective, within a new environment, with new partners influencing new technologies and strategies.

In 2010, encouraging advances in Global Health achievements continued despite significant economic downturns, especially in the United States and some of our European partners. Yet commitment to Global Health remains solid as evidenced by the following words of Pres. Barack Obama issued on May 5, 2009. He said. “We will not be successful in our efforts to end deaths from AIDS, malaria, and tuberculosis unless we do more to improve health systems around the world, focus our efforts on child and maternal health, and ensure that the best practices drive the funding for these programs.” [1]At last, there is realization that all the emphasis on technical advances becomes relatively unproductive without a major re-thinking around the health systems themselves– so vital to deliver these life-saving improvements. This notion is further reinforced in the recent Global Fund proposals outlines calling for clearly defined plans for planning, implementing, and evaluating sustainable community-based health delivery plans.

More specifically, malaria funding has increased from $400 million in the year 2000 to over $1.4 billion in 2009.[2] And malaria program strategies have moved from “Scaling up”, now to “Elimination”. This is cause for celebration except for the uneven results seen across countries, particularly in Africa. Nonetheless, there is now a well-established evidence-base for widespread scale-up and universal coverage. Furthermore, continued progress in scale-up and elimination will require improved tools for malaria control and surveillance. Hopefully these will evolve over time as efforts to monitor antimalarial resistance and track coverage with RBM interventions mature. Lastly, currently the Phase III malaria vaccine trial in Kenya promises a future in which this disease can be prevented through application of a vaccine program to those at risk.[3]

So what can be holding us back?

Alongside the “good news” with its promising opportunities for the future, there is a dark side, an unseemly aspect in the quest to eliminate malaria as a threat to health, particularly for the poor of Africa. It is not discussed openly in “polite company”, but hangs over the eventual dream of “universal coverage” as a continual threat to achieving that dream. Namely, it is the rampant corruption that exists within the ranks of the public health officials who are responsible for discharging the respective national malaria programs.

Thanks to the vigilance of the Global Fund hierarchy in Geneva, there have been instances when Global Fund operations in some countries have been suspended due to corruption, with those responsible eventually brought to justice. In addition to these extreme cases, such practices are unfortunately the modus operandi in many countries, although operating at lower levels of responsibility and magnitude. The result is erosion of trust in these public health negotiations between key implementing parties such as, the private corporate sector— essential partners to address the logistics, procurement and distribution of RBM interventions. The invaluable voices of the community, even when organized in well-established collaborative groups nationally, are routinely disregarded when governments are discussing issues related to malaria program strategy, especially with the global donors.

Even more detrimental is the growing realization among the common citizens that their elected government officials are not reliable to carry out their tasks for the sake of the common good. In today’s world of rapidly expanding means for social networking, this climate of mistrust among these predominately youthful populations found throughout all the African countries can sow seeds for future violence erupting on the Continent; Kenya, for example, is slowly recovering from the post-Election Clashes of 2008. On the other hand, this same population is rapidly gaining skills using updated communication technology and with their demographic advantage (over 80% are youths in many African countries), if inspired by the hope of a better future, can usher in a generation of prosperity previously unknown.

What is needed now is an understanding that indeed we all are “our brother’s keeper”. Away with tribal divisions, rigid religious dogmas, and racial and economic segmentation. Enough of “Business as Usual”. Time is short; the time is now for more Community-directed program involvement, along with integrated program surveillance, monitoring and evaluation. Resources are urgently needed to strengthen the “Bottom Up” partners’ contribution in order to compliment and sustain the advances made so far by the current predominantly “Top Down” achievements.

---

[1] Presentation by John R. Mac Arthur, MD MPH,  CDC,  Division of Parasitic Disease and Malaria Center for Global Health on Nov.25, 2010 for PHGR Malaria titled, “A Commitment to Malaria Control and Prevention: The First Steps toward Elimination”.

[2] IBID

[3] Presentation by S. Patrick Kuchur, MD MPH, CDC –Div. of Parasitic Disease and the Malaria Center for Global Health on Nov. 25, 2010 at PHGR Malaria session titled, “ CDC’s Scientific Evidence for Scale –up and Positioning for Malaria Elimination”.

Dr. Larry Casazza, director of African Communities Against Malaria (ACAM), donated a generous gift…

June 15, 2010

 

Dr. Larry Casazza, director of African Communities Against Malaria (ACAM), donated a generous gift of books, training materials, CDs and reports about malaria to our Tony Wilmot Library.

This collection reflects the life- long passion of Dr. Casazza, MD, MPH. For 25 years, Dr. Casazza has dedicated himself to implementing community-based activities to improve the health and welfare of women and children. He has also worked for the World Bank and World Vision, and is a faculty member at Johns Hopkins University in the US. Larry has often resided on campus at the Hoenecker Centre and has built lasting friendships with members of the NEGST family.

A large portion of the resources donated are specific to eradicating malaria, the number one killer of Africa’s children. The materials in the library range from technical reports to very practical training materials for use in African villages.

Another portion focuses on designing and delivering community health initiatives on a grass-roots level, including the classic book “Just and Lasting Change: When Communities Own Their Future”, by David Taylor Ide and Carl Taylor. We now have many manuals for training trainers and for assessing the impact of health initiatives applicable to a wide range of issues beyond malaria eradication.

AIU’s Institute for the Study of African Realities Director Dr. George Renner welcomed the gift. The “reality” of malaria and other killer diseases are having devastating effects on rural Africa. Renner sees the collection being used to increase the church’s capacity to make a difference in people’s lives and to explore and benefit from the vast wisdom already present in rural communities. He sees churches being empowered to become centers of shalom in a comprehensive sense. Christian leaders can be trained to nurture sustainable community development initiatives.

The NEGST community says a big “Asante Sana” to Dr. Larry Casazza for blessing us with these valuable resources.

Next Page »