Ebola has focused the world’s attention on the challenges of health care in Africa. The continent has 11% of the world’s population but 25% of the world’s disease burden. It also has just 1.3% of the global health workforce.
Yet African health leaders have shown enormous creativity, innovation and leadership in tackling global health challenges.
University of Melbourne Professor of Public Health Rob Moodie spoke with Lord Nigel Crisp about his new book – African Health Leaders: Making Change and Claiming the Future – and the lessons Australia and the world can learn from African health leaders.
Nigel Crisp is an independent crossbench member of the House of Lords, where he co-chairs the All Party Parliamentary Group on Global Health. Lord Crisp was chief executive of the National Health Service in England and permanent secretary of the UK Department of Health between 2000 and 2006.
Rob Moodie: If I could start out by setting the scene from your latest book, African Health Leaders: Making Change and Reclaiming the Future. In it, your co-editor, Ugandan doctor Francis Omaswa, writes that over the past 30 to 40 years, the relationship between donors and African countries has been pretty mixed. As he says, donors have helped improve things but it’s been done at a price.
He talks about a loss of core values, the loss of self-respect, self-confidence and self-determination. What do you think has gone wrong?
Nigel Crisp: Well, I think there was a certain inevitability about it. The quotation he uses is:
we went begging for help and we got it in return for some of our core values.
I suppose they were in the position of being weak in terms of their negotiating position, they were looking for help, and I suppose we came in from the west (and I associate the UK and the US and Australia and elsewhere) and tried to do our best.
You’ll know that very often you can come into a country and you can think you know the solutions because actually you’ve seen something similar in your own country. What, of course, you often forget and it takes you some time to remember and recognise, is that there are big cultural issues about how you do things and it’s not just as simple as applying our knowledge in another country.
Now, a lot of what was actually done by the west has been terrific, obviously things like the development of antiretovirals and so on. So there’s western science and all sorts of very good things.
But we’ve slightly steamrolled it, and there’s also been political issues. If I take the American example of PEPFAR, they had to report to [the US] Congress very clearly on results and what they were doing, and that political tie pulls them back into Americans doing things, rather than Americans supporting other people to do things.
Rob Moodie: The other argument that you spell out are the huge challenges for Africa. It has 11% of the world’s population, but 25% of the world’s disease burden, 65% of the HIV burden and a huge cut of the malaria burden, yet such a tiny proportion of the global health workforce.
You note that there have been some real successes out of this sort of adversity – task substitution is one. Your book is telling us what can we learn from African leaders in this regard.
Nigel Crisp: Yes, well I think there’s a lot of hidden stories, unsung heroes, because inevitably in the UK and America and around the world the stories you hear are the stories about your own people. We hear about the great successes of the Bob Geldolf sort of mission and we don’t hear these stories from people actually within the situation, the leaders who are there all the time.
Within the book you’ll have noticed they’re always very respectful of the help that others give them, they’re welcoming of the help that others give them. But they want more space for themselves. You do have these fantastic leaders.
Let me start with Miriam Were in Kenya, 1976. Top medical student of the year, she did her PhD then on patient participation. And she did it on patient participation in 1976 because she’d recognised that actually the biggest issues about health were about hygiene and how patients behaved and how villages behaved. She was going to have the biggest impact by doing that.
So she set up these programs, which are really the forerunners of many community health worker programs all across Africa. And it’s a really interesting set of issues about not just patient involvement, but community involvement – how you get people involved.
Some of that has now been taken and copied and is being used in New York, working with a different sort of community but using the same sort of principles. So here you have a really important point about how you use a community to help itself, or how you help a community to help itself.
Or the other one that was also in 1976 was a young doctor called Pascoal Moccumbi who, like a lot of these leaders, had been in exile fighting a revolution. The Portuguese left after independence in 1974. By 1976 he found himself the Minister of Health, and he found he had no doctors because the Portuguese had left and they were basically the doctors.
His biggest pressing problem was pregnant women and how to care for them. So he set up a program of training, essentially nurses, to be able to do obstetric surgery, including Cesarean sections. They did it so well that it was being done at the same complication rate as it would be with physicians, at about a third of the price. And, of course, the nurses stayed in the country.
Now, 37 or 38 years later, it’s still continuing as successfully as it was then, and it’s peer-reviewed and so on. It has been a really interesting success story and I think that whilst I’m not suggesting that here in Australia that cesareans should be done by nurses – others may wish to suggest that – it’s a point about the principles.
It’s about opening your mind so you don’t have to think in terms of the boundaries of doctors and nurses that have essentially been negotiated through trade agreements and that there are some principles which show how you can actually do that sort of task-shifting successfully.
Rob Moodie: In fact, in the UK, and certainly in Australia, we could learn from that in terms of practice nurses and nurse practitioners. It seems to be an ongoing demarcation dispute with the doctors, can’t we learn from that?
Nigel Crisp: Exactly, and I gather you have an issue about nurses and endoscopists at the moment in Sydney or somewhere, I was told.
Well we’ve gone past that in the UK; we’ve actually got nurses and endoscopists and they’re just normal; and we’ve got nurses prescribing and so on. But it’s the same set of principles.
There are basically five principles we pull out in the book, which are:
- Make sure you’ve got a plan.
- Make sure you’re recruiting the right people because it’s not just any nurse.
- Make sure they’re properly trained.
- Make sure they’ve got access to supervision and the ability to refer. Because quite a lot of these schemes – and there have been lots of them around the world as you’ll know – have failed because when people got out of their depth there wasn’t someone to refer on to.
- Then, finally, make sure that this is seen as part of a bigger plan of teamwork and teams.
By and large, when you see those five things applied, you see these things working successfully – whether they’re in the UK or Australia or indeed in Malawi or Mozambique.
Rob Moodie: If I could also ask you about the question or the issue of the day, which is obviously Ebola. It has focused so much international attention on health systems in West Africa.
But also, it really does bring this up as a global issue: what’s our international response? What’s the capacity of the local workforce? And what might we have done better, both there and internationally, to have responded to the challenge of Ebola?
Nigel Crisp: Well, what I think is interesting about Ebola – and you’ll know this better than I – is that it’s not that easy to transmit. You’ve actually got to have contact with body fluids, unlike something like SARS, which is therefore much more frightening.
In the 38 years since Ebola was identified, we’ve had 25 outbreaks and they’ve all been contained fairly quickly. So what’s different this time?
What’s different is it’s in some of the poorest countries whose infrastructure has been almost destroyed, and the international response was too slow. Again, you’ll be aware that in Nigeria, for example, and in Congo even, DRC even more interestingly, they had outbreaks as part of this which they controlled. So the Congolese doctors dealt with it by themselves without any international help.
But in these three areas [Guinea, Sierra Leone and Liberia], I think the international help was late. Amongst other things, one of the reasons was when H1N1 was thought to be a pandemic, about two years ago, the WHO was considered to have overreacted: stockpiled drugs that weren’t necessarily the right ones and generally overreacted.
I think on this occasion they’ve under-reacted, or slowly reacted, in part because they overreacted last time. They got heavily criticised. So there’s sort of no win here. So, anyway, they got it wrong, so people have gone in later.
What is needed now is a massive input because the thing has got big and it’s massively important that it’s got on top of, partly – again, you’d know better than me – because there is the possibility of it mutating the longer it carries on and therefore it could become more dangerous.
And, secondly, the impact, which is not just the impact of the deaths of Ebola. It’s the impact of the deaths on society, from everyone avoiding hospitals and dying of other things. It’s the impact of the farmers not planting their crops. It’s the impact on the economy and so on. So there’s a real need.
I think two of the lessons that come out of this are, firstly, this is very connected with communities. It’s very connected with communal practices and cultural practices of washing bodies after death and these sort of things. This takes us back to the point that actually in a health system it needs to be built bottom-up. It needs to be built from community workers upwards. It needs to be about the paitent-empowerment type stuff Miriam Were was doing in 1976.
And our support in the future for countries like Sierra Leone needs to recognise that health systems need to be strengthened in that way. And that means building local leadership and supporting local leadership.
When it comes to the international response – and there needs to be international response – I think clearly there needs to be a rethink about what happened on that and particularly on a public health issue. I think we’re better at natural disasters – though this is a national disaster, I suppose – I think we’re better at earthquakes and things.
We need to have better ways of responding to public health crises. But I suspect there’s also need for an African response so that it is people with at least some potential local knowledge and so on who can work with local communities.
Rob Moodie: I think you’ve raised a terrific point there. Colleagues have mentioned to me about the sort of response to date which has been a very medical, very military response to Ebola and has not really yet involved the community as we did with HIV. And I think we learnt a lot about the involvement of communities in HIV.
Do you think that’s what we should be doing here? That sense of making sure the community is actually involved in the fight against Ebola?
Nigel Crisp: I think so. I’m going to quote again a wonderful expression in the book from Miriam Were:
If it doesn’t happen in the community, it doesn’t happen in the nation.
That’s where you’ve got to start. There’s another great African quotation:
Health is made at home, hospitals are for repairs.
So both of them make the point that you’ve got to start where the people are. Start with their culture. Start with their understanding and work up from there. I think we need to do that.
Now where Ebola is, you’ve got to involve the military, you’ve got to involve the clinical interventions, because it has gotten big and it’s out of control. Well, not necessarily out of control, it’s sort of coming into control and it will take some time to do that sort of response.
The tragedy would be if we came away from this thinking that’s the sort of response we have to build up for the future. What you’ve got to build for the future is the resilience of the communities and an ability to respond as close to them as possible.
Rob Moodie: Nigel, if I could get you to look at the future and the big challenges of health and health care in Africa. In your view, how are African nations going to balance this need to boost local health-care systems, their prevention systems, fight infectious disease and now pick up the battle against non-communicable diseases, like cancer and cardiovascular diseases and diabetes. How do they manage these challenges?
Nigel Crisp: Well, what we say in the book, and I defer here to the Africans and particularly my co-editor, Francis Omaswa, is the first thing the Africans need to get their act together, they need to be more confident. He’s got a wonderful quotation in the beginning of the book which is something like:
when we Africans feel the sense of shame of our position, we will act.
I think there is a big thing about Africans being self-confident enough to make things happen and not to be too dependent on the international community. So he sees that as a real starting point, and he can say that as an African and I can’t say it as a European.
The second thing is that there will still need to be very substantial support from the west and the east, the richer countries of the world, and that needs to be done on the basis of what we call co-development: a recognition that it’s in my interests too to help you develop your health system and that I will learn stuff from you and you will learn stuff from me.
Another great quotation is:
everyone’s got something to teach and everyone’s got something to learn.
I think there are all kinds of opportunities for us to be much more creative in the way in which we work in these countries.
Just to take one is around staffing. You know the brain-drain issue of people having some level of health training and then leaving Africa and coming and living elsewhere (and this applies in other countries around the world). This is an important issue, but the even more important issue is that simply not enough people are being trained.
If every African who had ever left, having had some health training, went back, it would deal with about 10% of the problem. The numbers are roughly about 150,000 have left and you need about 1.5 million. Roughly speaking, that’s the shape of the figures.
So that tells me two things. One is that we need to do much more to train more people, so I think part of our support can be that. But I would also put forward the proposition that maybe we should be training some of our people there. What would it be like if we actually had a year out of our training and had training in Africa?
It would be a damn sight cheaper for us and what would be interesting is we would pay the university, you know you’d twin the university between Melbourne and Blantyre and you from Melbourne would get the cheaper deal for that second year and you’d be paying Blantyre.
Rob Moodie: You might study in Malawi, that’s a great idea.
Nigel Crisp: So there’s that sort of stuff that can change the nature of the relationship and then the third thing is actually what’s the vision here, because we’ve got the wrong vision in our country.
From what I’ve read I think you and I probably have a similar vision. The future is about mobilising society to improve health. The great stuff in the UK of creating the NHS in 1948 was bringing together all the health systems – the private, public and everything – into a goal to improve health. What we’ve got to do now is to bring together all sectors of society that have an impact on health in order to improve health.
I think the Africans can be a bit ahead of us and that’s why, again in that book, we talk about health being made at home and in the community. I think I read that you’ve written something similar to that, about having to counteract the forces in society that currently make people unhealthy.
Rob Moodie: Yes, you’ve particularly got to watch what the tobacco companies, alcohol companies and junk food companies are doing in Africa as well, because they will somehow be driving these non-communicable diseases.
Nigel Crisp: Well, they will do indeed. I think Africans can be ahead if they’re confident enough about not trying to copy us.
Rob Moodie: Finally, if I can just mention we’ve been teaching and training hundreds of young African doctors here in our school of public health. A couple of young Ugandan doctors, who topped the subject I teach, have gone back to Kampala and there are 20 of them back there, a young generation. I have enormous confidence, I must admit, in the new generation of doctors and health leaders there. Is that what you sense as well?
Nigel Crisp: I think so. Our book is about three generations. It’s the 80-year-olds who were there at the beginning of independence. It’s the three current ministers, well actually two - one’s lost her job - current leaders writing about stuff. And then we took the views of six younger future leaders. I think they’re all terrific, but this last group is the sort of people you’re talking about; they’re world citizens.
But it’s patchy, Africa is 53 countries. I don’t know Malawi particularly well, but there’s not a huge strength in depth, I suspect, and I think one of the things we should be doing with our training is starting to build sufficient capacity. So if you’ve got 20 young doctors in Uganda who want to change the world, well they can do it. If you’ve only got two it’s a lot harder.
So I think there is something about a minimum number, a critical mass is what I’m thinking of, and some countries are there or nearer there, I think. Uganda is interesting; they’ve got a doctor now who is prime minister and he’s very interested in all this, which I think is very encouraging. I’m moderately hopeful.
African Health Leaders: Making Change and Claiming the Future is published by Oxford University Press.