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date: 26 September 2022

Ten Lessons From a Career in Global Health: Guidance to Those Considering a Life Working With the Poor Countries of the Worldfree

Ten Lessons From a Career in Global Health: Guidance to Those Considering a Life Working With the Poor Countries of the Worldfree

  • Jon RohdeJon RohdeT. H. Chan School of Public Health, Harvard University

Summary

Global health, defined by the World Health Organization as “priority on improving health and achieving equity in health for all people worldwide,” is an expanded view of traditional public health. While utilizing many of the tools widely taught in schools of public health, its emphasis is both on reaching the poorest and most isolated populations and transferring knowledge and skills for their benefit. Extensive and continuous field interactions and collaboration with the populations for whom health interventions are intended to benefit are very important. Thus, immersion in local culture and society, language skills, and active listening are key attributes for a global health professional to acquire. These apply to local health workers as well as expatriates. A broad array of disciplinary insights, ranging from clinical medicine to social sciences, communication strategies, and team building, are often more valuable than a single technocentric expertise, enabling a more holistic approach to health problems. The ability to simplify suggested techniques and interventions and especially the ability to create a culturally understood logic behind biomedical explanations go a long way to establishing acceptance of health messages and advice. Introducing new ideas, habits, and procedures incrementally rather than in one large dose of instructions or training has more lasting impact on both trainees and the targeted population. Invariably, delegating both authority and responsibility to “lower-level” workers—that is, those closer to the people through tradition, familiarity, and geographic access—results in greater acceptability and uptake of desired behaviors. Learning in the field is best accomplished from observing and emulating mentor figures—those who best exemplify the attributes of a widely accepted and respected health leader. In time, one’s own role as a mentor for new recruits facilitates the transfer of attitudes and approaches that embody these important principles of global health work. In the end, one’s impact on communities will be measured by the people and institutions that one inspires and leaves to carry on the work into the future.

Subjects

  • Global Health

Preface

With the requirement to join a government service after completing Harvard Medical School in 1967, I joined the U.S. Public Health Service, National Institute of Allergy and Infectious Diseases, in order to pursue my interest in the pathophysiology of cholera, a classical scourge still prevalent in South and East Asia. Located in Dhaka (then Dacca, East Pakistan), the Cholera Research Laboratory (CRL) was well equipped to both manage hundreds of patients with severe diarrhea and research the underlying pathophysiology of the disease and develop improved methods of treatment. While I conducted radioisotope studies to define the aberrations in the intestine that lead to massive fluid losses and to treat them by oral methods, it soon became clear to me that the real answers to this, the major killer of children in poor countries, lay in a better understanding of pediatrics and life in poor rural settings. I retailored my career to live and work in countries of the South and to develop systems of health care that would embrace large populations.

I first qualified in pediatrics, spending my senior residency year in 1972 as a volunteer pediatrician at the Hôpital Albert Schweitzer in rural Haiti. The Rockefeller Foundation sent me to Gaja Mada University in Yogyakarta, Indonesia, in 1973 to teach pediatrics and encourage community-relevant research and teaching. Then in Haiti again in 1980, I headed up a project to strengthen the entire rural health system. In India in 1986, I became the UNICEF regional advisor for health and nutrition and later, as Global Health Advisor to Executive Director James P. Grant, traveled the world with Grant promoting Child Survival. In 1993, Grant appointed me Representative of UNICEF in India, with the entire country of 125 million children younger than age 5 years to care for. I met Nelson Mandela soon after his inauguration in 1994 and 3 years later moved to South Africa to head up the Equity Project, tasked with restructuring the health services. In 2021, more than 50 years after I arrived in Dhaka, in retirement, I reflect on that journey and what lessons it may have for a younger generation of professionals interested in spending their careers contributing to health among the poor.

In 2013, Alfred Sommer, previously Dean of Johns Hopkins School of Public Health and a friend since our years together at Harvard Medical School, at Dhaka’s CRL and later in Indonesia, published a compelling guide, Ten Lessons in Public Health, which illustrated the principles that had guided his career. Although we share many of the lessons, I felt my experience over 50 plus years living in poor countries provided some alternative insights that could be of value to young professionals looking for a career of service in the Global South. Many readers may, in fact, be citizens of these countries and will return there to serve their compatriots. Others may travel to countries new to them and, as I experienced, will learn from new colleagues and new cultures. These 10 lessons should hold relevance for all seeking to participate in the search for global health.

In addition to living for decades in settings that provided these experiences, I must here acknowledge I could never have done so without the enthusiastic support of my wife and guide Cornelia, without whom I would frequently have lost my way. May you be so fortunate to have such a partner.

Get Out of the Comfortable Space and Go Live Where the Problems Are—and Stay There!!

You cannot do global health from an office or academic ivory tower. The skills you need to develop are not those found in a classroom but, rather, the experience of living and interacting in a setting of the Global South. Although you need to have a base from which to operate, it must allow you to respond to situations as they are thrown at you. Fortunately for me, when I graduated from Harvard Medical School in 1967, mandatory government service was required of all new doctors, so I opted to join the U.S. Public Health Service, posted in East Pakistan to conduct research on cholera. In Dhaka, while the job of a clinician and researcher in a well-funded hospital offered me a platform, the daily interaction with villagers coming for care and the forays out to the most isolated villages, often by boat (Figure 1), provided insights into the determinants of health: preferred water sources; defecation; purdah and the seclusion of women; the value of education; and the unpredictable and seemingly capricious whims of nature with droughts, floods, and cyclones. The plight of the landless becomes apparent as one witnesses the efforts to eke out a living on mudbanks emerging from a meandering river that can claim a homestead overnight. To this add the plight of money lenders charging usurious rates to those with no capital, the crippling customs of tradition that make the birth of a daughter a fiscal calamity, and the trade-off between a hospitalization for a woman in obstructed labor versus the family cow with a similar problem. Witnessing the tragedy of yet another child death underscores the reluctance to accept family planning. The realities of a life in poverty are everywhere the key determinants of health—the contingencies protean and threats seemingly infinite. These may be listed in a course, but experiencing them first-hand is the real education in public health.

Figure 1. Speedboat ambulance to transport patients and staff to remote areas in Matlab, Bangladesh.

Source: International Centre for Diarrheoal Disease Research, Bangladesh; used with permission.

The Great Bhola Cyclone of November 1970 in East Pakistan opened a door to a whole range of insights and experiences that called for innovation and rapid responsiveness to a vast health challenge. Overnight a tidal wave swept away entire villages and some 500,000 people drowned; many times that number of animals were lost. Rapid assessment of the tragic situation surprisingly revealed the relative lack of need for clinical medical response, for only the strong had survived. The need for immediate food aid and the urgency of mobilizing survivors to put their lives together in a new model of community living became the priorities. Along with local colleagues who could navigate the bureaucracy, several of us from the Cholera Hospital, encouraged and led by our wives, undertook to provide relief and redevelopment of a remote island in the Ganges Delta, where two-thirds of its population of 30,000 had been swept away (Figure 2). Underneath it all, the influence of corrupt local power structures undermining every effort to organize a response tore at every initiative. The failures were as instructive as the successes. Experience was our only teacher because nothing in our education except a will to help prepared us. I lived on that remote tide-swept island for several weeks organizing its rehabilitation that eventually spanned over 4 years and millions of donor dollars (C. Rohde, 2014).

Figure 2. Author and wife in cyclone relief work in Bangladesh, November 1970.

Source: Jon Rohde.

Four years later in Java, Indonesia, after months of trying to respond to village women’s requests to guide them to better child nutrition with lectures and modern child scales, I happened to notice that in every open market women sold produce by weight using a simple locally made scale (Figure 3). From rice to firewood and jewelry, the measure was accurately made with a traditional bar scale. We quickly gave up the modern baby scale and found that weighing a child suspended in a basket from a traditional hanging scale was immediately understood and weight gain from month to month was viewed by mothers as a measure of good health. Child weighing by village women became a monthly activity in villages throughout the country. Our printed nutrition education tools were replaced by women coaching each other and sharing tips on feeding. We found the way to a powerful program to influence child-rearing behavior only by repeated interaction and observation of village women in their homes (Oendari & Rohde, 2020).

Figure 3. Use of traditional weighing scale for village child weight monthly in Indonesia.

Source: Jon Rohde.

In Haiti, the government mandated that medicines were free of charge in health facilities—if they were available at all, which due to financial constraints and corruption they rarely were. We tried to improve supply through government stores and improved regulations but failed. In time, we noticed that outside many clinics were medicine stores that made a huge profit. We arranged to offer communities a set of essential drugs prepackaged in recommended doses at a price only 10% above costs at a small secure room run by volunteers near each clinic. This led to a network of several hundred community “pharmacies” supplied from a central unit that purchased generic drugs internationally. Most villages used the 10% profits to subsidize the poorer households needing medicines (Rohde, 1985)

In India, despite a vast network of free government health services, I came to realize that an even larger number of unqualified medicine sellers [often called rural medical practitioners (RMPs)] provided the first medical advice to 70% or more of rural residents (Rohde & Viswanathan, 1995; Figure 4). Interviews with hundreds of these providers and thousands of their clients showed that their proximity to the community, the familiarity of their treatments, and the flexible reimbursement arrangements ensured the trust of the consumers. Finding that almost all RMPs had mobile phones, we linked 10,000 of them to qualified doctors in a call center to solve more difficult problems and trained them in the treatment of diarrhea and pneumonia in children, as well as to suspect and refer adults with symptoms of tuberculosis (TB) (World Health Partners, 2021). By 2010, thousands of RMPs had been brought in to support national programs achieving high coverage of essential services such as family planning, TB, and child illness.

Figure 4. Rural practitioners in India treat the majority of patients.

Source: Jon Rohde.

Viable solutions to health problems require insights that can only be derived from living and observing in communities. That is the real education in global health. Take any opportunity offered to experience life in a community other than your own.

Learn the Language and Culture—Immerse Yourself

Language is key to insight, understanding, and acceptance. Ideally, one has a good grounding in a new language prior to landing in a country, for the process of getting settled and learning the many aspects of a new culture and surroundings is facilitated by understanding at least a bit of the local language. One is immediately accepted and encouraged to learn more when it is seen you are trying to learn and communicate, even if your skills are limited. In Bengal, I had daily lessons to get started, but I did not begin to make real progress until I started spending days at a time in the village. I attained fluency only when I lived on the cyclone-affected island for weeks at a time. It is difficult to get into a language when colleagues are already fluent in your native tongue, in my case English. The best strategy is to find people who do not speak English and interact regularly with them. Better still, live in a village where English is unknown. Additional benefits accrue as one gains unique insights to the culture and realities of rural life. Not understanding Indian classical music, I decided to take sitar lessons and came to love Indian raga traditions. Musicians visiting from India would play for an evening in our home for gathered Bengali friends, strengthening relationships and establishing enduring friendships.

Fortunately, the Rockefeller Foundation gave me 3 months of intensive language training in Indonesian before I first arrived there in 1973. That I gave a small and somewhat stumbling speech at my welcoming party set me off on a convivial relationship with colleagues. As many wished to learn English, I spent a few hours each week teaching English to the provincial health department staff, learning many medical terms and exploring the technical and organizational intricacies of that bureaucracy. Because the language of instruction at the university was, and is, Bahasa Indonesia, learning came fast. I studied a draft manual for community health workers (CHWs) that gave me far more useful terms than standard Indonesian language courses. Teaching was arduous at first, for me and my students as well, but in a short time my efforts yielded friendships and cultural insights otherwise unavailable. I lectured and eventually wrote textbooks in Bahasa Indonesia. Dance, puppet shows, and palace parades became our family entertainment, and my children grew up speaking Javanese as well—a far more complex tongue with many subtleties that came naturally to the very young (Figure 5).

Figure 5. Wayang Kulit (shadow puppets) carry messages most widely into villages in Indonesia.

Source: Elsa Ruiz and Asia Society; used with permission.

Although the official language of Haiti is French, and although I took an intensive immersion course with Berlitz before landing there, the language of the people is Creole. It is a simplified French and laced with witty proverbs and sayings. I memorized much of a small book, Sayings My Grandfather Said (Jeanty & Brown, 1976), and found the aphorisms not only gained me acceptance even with the more sophisticated French speakers but also provided more convincing arguments in support of a case than the more formal French. For instance, arguing with others during a policy discussion in which I believed that a committee should not take charge, I exclaimed, “A goat with many masters dies in the noonday sun,” and won the decision to let one person take charge. Calling up an alternative position in different situations by exclaiming that “A dog has four legs but can only go in one direction” won other discussions. In contrast to some settings in which francophone folks belittle flawed French, in Haiti colleagues took it as a compliment when I tried to express my ideas in their language.

In India, Hindi is the widest spoken of 22 official languages. Correcting my mistake with Bengali, I studied from the Devanagari script, rather than a Romanized version, thus enabling me to read signs and eventually parts of the newspaper. However, because English is universally spoken by the educated classes, and even those not well educated such as taxi drivers and shop keepers, and I never lived in a village where English is less widely known, I never became even partially fluent in the national language. Although not an impediment to my work in UNICEF within government offices, I missed out on news broadcasts, cultural events, songs, and the rich history and written traditions of India. I did, however, immerse myself in the arts and culture, attending Indian dance, music soirees, and frequenting galleries and museums. I also dressed in Khadi, the homespun cotton of Gandhi, finding it far more comfortable than the suits and ties of foreigners and bureaucrats, a holdover from colonial times. Many expressed appreciation that a foreigner could enjoy their culture and adapt their apparel.

In South Africa, I lived first in the area where Xhosa is the spoken tongue. A remarkably complex language, its numerous tongue-twisting clicks and 10 different declensions for nouns baffled me, and though I tried for several months of daily lessons, I never even began to master the simplest phrases. Fortunately, English is widely spoken and government is conducted in English, so I took the easy way and never used a local language. Perhaps I was getting too old to start again!

Language and culture reveal the true inner workings of a society, and when one is seen to actively embrace these, attempting to assimilate them into one’s own life, acceptance and credibility as a true colleague and friend are greatly facilitated. You will learn to enjoy new ways of thinking, drama, music, and art never before imagined while at the same time making lasting friendships.

Learn in the Field—Observe, Listen

Perhaps the most perceptive foreigners in countries of the South are Peace Corps volunteers or similar young people who live and work in the villages. By and large, they are not experts in anything, and yet their presence is seen as a testimony to their commitment and dedication to others. The experience provides them with insights generally lacking in the organizations in which they subsequently will be employed and provides a significant advantage toward promotion. Although it is unlikely that many can avail of this valuable education, some exposure to realities of village life can make a huge difference in ones’ effectiveness in public health.

I once asked a very successful young doctor in rural Java how he decided to initiate training health volunteers in one village and not another. He responded, “When they start planting flowers around their houses and along the paths they are ready to take up village health.” His health programs were remarkably long-lived and successful, in contrast to the blanket approach recommended by government.

In a very rural district of central Java, Boyolali, with a population of nearly 500,000, there was but one government doctor when an outbreak of plague in several mountain hamlets sent frightened villagers fleeing the area. Realizing that such dispersion of possibly infected persons could result in a district-wide epidemic, Dr. Gunawan gathered up all the antibiotics he could commandeer from the hospital pharmacy and medicine shops and publicly announced he could be found only in the villages where the disease was found. He set up his clinic on the porch of a villager high on the slopes of the mountain and treated anyone with symptoms. The dispersed population returned home to seek care, and spread of the disease was halted. Gunawan laughingly explained to me, “I was the only doctor for many miles. They had to come back to me.”

I spent my first year in Indonesia on the medical faculty of Gaja Mada University in Jogjakarta, visiting each of the 75 rural health centers in the province, asking the young doctors posted there about their challenges and particularly about the relevance of their medical education to their work (Figure 6). Invariably they listed numerous skills that they lacked in the areas of sociology, understanding customs, assessing objective needs, communication and organizational abilities, and team building. When, with colleagues, we designed the 6-year medical curriculum in community health (Rohde, 1980), we focused on these and related abilities and provided on-the-ground experience in each cognitive–behavioral category to learn and practice these skills. Fortunately, our students all boarded in local homes spread through the less affluent communities surrounding the university. We expected them to participate in community activities, celebrating holidays and supporting mobilization for local actions in support of the environment, education, home food production, and the like. Community leaders were asked to evaluate the contribution of our students to the welfare of their neighborhood. In the third year, each class was assigned an entire community in which to work during the next 3 years applying skills they learned in class to their “own village.” Each student visited five or six families two or three times each month to weigh and immunize children, encourage family planning, build latrines, find cases of TB and ensure continuity of treatment, eliminate insect vectors, and even study improved management of community assets and stimulate wide participation in health activities. They held an annual village pameran (health fair) demonstrating with posters and graphs their survey findings, measuring blood pressure, showing with a transparent plastic model how intrauterine devices are inserted, and displaying sections of preserved lungs with tuberculous cavities. In their fifth year, they trained volunteers to take over their work as health aides, nutrition counselors, environmental motivators, and even home gardening specialists. In their final year, they were posted to rural clinics tasked with applying the full package of skills they had learned and training clinic staff to work as a team. Within a few years, our graduates captured the majority of the national department of health annual commendations for the functioning of the rural clinics they led. Years later, they became directors of provincial health services, directors of national programs, and even health ministers. Many later told me the experience had given them insights, skills, and motivation that few colleagues from other medical schools had been able to attain.

Figure 6. Author with students visiting nearby villages in Indonesia.

Source: Jon Rohde.

BRAC (originally the Bangladesh Rural Advancement Committee), under the leadership of its charismatic and remarkably capable founder F. H. Abed, has become one of the world’s leading nongovernmental organizations (NGOs) (A. Chowdhury & Perry, 2020). Following the death of James Grant, who served as the Executive Director of UNICEF from 1980 until his death in 1995, Abed wanted to perpetuate the work of Grant through establishing a School of Public Health in his name at BRAC University in Dhaka. I was invited to head a curriculum committee to develop an innovative Master of Public Health (MPH) program that the school has offered to 30 students annually since 2004. Drawn from countries throughout the world, students follow what appears to be a standard curriculum except that each of the 15 courses requires fieldwork in Bangladeshi communities to enable experiencing the substance and context of each subject in poor settings (Figure 7). The school is unique in providing hands-on experience in the many disciplines of global health work. The nearly 600 graduates have taken positions of substantial responsibility in their home countries, applying lessons learned and implemented in the field. Many have received recognition for outstanding innovations and effective response to public health disasters. Subsequent feedback showed that the most salient influence on their careers was the experience gained in the field work at the BRAC James Grant School of Public Health.

Figure 7. Students at the BRAC School of Public Health in Bangladesh have community-based (top) as well as hospital-based (bottom) experiences.

Source: BRAC James P. Grant School of Public Health, BRAC University; used with permission.

In India, I slowly realized that most qualified doctors practiced in urban settings yet the vast majority of people lived far from modern health care. The census indicated that 3 million or more called themselves “doctors,” yet only approximately 350,000 were licensed (Figure 8). I commissioned a study of nonqualified RMPs, termed by many as “quacks,” to learn of their medical practices, where they obtained their knowledge, and what the perceptions of their clients were (Rohde & Viswanathan, 1995). Seventy percent of rural respondents indicated their preference for these RMPs over licensed physicians because they lived nearby, accepted payment in kind, spoke the local dialect, and used a mixture of modern and traditional medicines. A colleague established a network of 10,000 RMPs who were trained in a short course of key child and adult treatments and were then provided with a call center for advice from academically trained doctors. Greatly improved treatment procedures were followed. This previously ignored resource has become a major support to national health programs, especially for TB and child survival.

Figure 8. Practitioners in rural Bihar, India, are widely consulted and trusted; patients waiting to consult with a private rural medical practitioner.

Source: World Health Partners; used with permission.

Be open to new ideas from field observations to expand health activities and influence other medical workers to go beyond the bounds of hospitals and clinics. Traditional healers, community workers, and volunteers often understand better which factors determine behavior and how to influence them. Lecturing is usually ineffective and can be counterproductive, whereas entertainers such as puppeteers and village comedians can get even new ideas across faster and with more acceptance. Different cultures learn in remarkably different ways—but for all, experience is the best teacher.

Be a Generalist, Be Open to a Wide Range of Knowledge, Don’t Get Buttonholed

Expertise in a single skill is an immensely valuable resource, but it takes a generalist to define the need and guide the experts in a given setting. No doubt, clinical skills are respected and gain acceptance in a public health setting. For me, my training in pediatrics provided the best foot in the door because child mortality and malnutrition were very high in poor countries in the second half of the 20th century. While health information systems gathered extensive data on illnesses, careful analysis showed me that half of all deaths were among children, and a close look showed only a few common causes: diarrhea, pneumonia, and immunizable diseases such as measles or polio. Underlying more than half of deaths was undernutrition. All these conditions could be prevented or readily treated. Realizing that mothers are the critical actors in the lives of the very young, effective communication was key to gaining acceptance of actions they would have to take in their daily lives.

Working with village mothers’ groups, we demonstrated how monthly weighing of children revealed, long before any obvious changes, how well each child was growing. Noticing that in village markets run by women virtually every item was sold by weight using traditional scales, we encouraged women to weigh children themselves, using their scales and baskets to hold the children. Gathering each month to share advice on food preparation and tips on child-rearing—especially for those not gaining weight—the monthly village weighing became the occasion for motivating specific actions in gardening, child-rearing, family planning, and treatment of common illness. Any child with diarrhea was rehydrated orally, and all could see and appreciate the rapid recovery. The local clinic nurse came to immunize at these gatherings (reaching far more infants than came to the clinic), and family planning supplies were distributed. The tradition of breastfeeding was widely encouraged in opposition to commercial promotion of infant formula. Household gardens proliferated, and diets became measurably diversified. Child malnutrition decreased by half in a few years. Within a decade, these monthly weighing clubs spread throughout the country, gradually adding to their activities to embrace common ailments, detecting diabetes and high blood pressure among the mothers and, in some cases, providing mental health support for those depressed or grieving (Rohde et al., 1975). Villages posted the results of their activities in simple graphs or figures: the percentage of children gaining weight, the percentage fully immunized, the number of cases treated, and the percentage of couples regulating fertility (Rohde et al., 1993). Targets were set locally and celebrated when met. There were so many different skills and disciplines needed to guide and modify these activities that only a generalist could appreciate the wide range of knowledge that was required to make the contributions.

In both Haiti and South Africa, our team was asked to scrutinize the health budgets and make concrete suggestions on reallocation to meet the needs of more people. We had to justify changes to skeptical political leaders, which required both economics and reasoned persuasion. In both countries, we established self-financing drug supply systems, purchasing pharmaceuticals from international markets at considerable cost savings (Rohde, 1985; Rohde et al., 1993). Information on health status required large nationwide sample surveys to be designed and implemented as well as the development of routine health information systems, which were eventually computerized. Management of human resources required skills never learned in school. A full range of skills extending into anthropology, psychology, behavioral change, as well as data collection and use are needed to explain and motivate. Knowledge about research design, management of finances, personnel, drug logistics, and computer skills is useful as well, in addition to knowledge of public health and medicine. It takes a generalist to design and lead comprehensive health interventions.

In many countries, the health ministry is staffed largely by medical doctors. However, with the recognition of the importance of management skills, increasingly nonmedical personnel are taking charge. When I started work abroad more than 50 years ago, being a doctor was a vital credential, although clinical skills were rarely tested. Today, a broader range of skills and knowledge is essential to a career in global health. First-hand experience is more highly valued and sought in an advisor, whatever their degrees.

Simplify Technology—You Reach Far More People in Need

A sound knowledge of modern medical technology is important, but most standardized procedures are not readily extended to large numbers nor delegated to practitioners at a lower level of training. Major advances in public health can only follow careful simplification of more complex procedures. Management of cholera epidemics hinged first on standardizing the composition of intravenous fluids to a single solution rather than tailoring each infusion to the individual patient and their lab values. Then the cholera cot that collected fluids lost enabled volume replacement to equal ongoing losses without lab tests. Then a major discovery was made: The addition of a carefully calibrated quantity of glucose to the standard solution of replacement salts enabled rehydration orally (Nalin et al., 1968). This moved diarrhea treatment out of the hospital to clinics and eventually even into each household as mothers were taught how to make and administer oral rehydration fluid from home ingredients: common sugar and table salt (Figure 9). Quantities were determined by outputs: “For each liquid motion, replace with a glass full of oral rehydration fluid.”

Figure 9. Making home oral rehydration fluid from sugar and salt in Bangladesh.

Source: BRAC James P. Grant School of Public Health, BRAC University; used with permission.

Pneumonia, previously depending on a doctor listening over the chest with a stethoscope and requiring an X-ray for diagnosis, turned out to be reliably detected by counting a child’s respiratory rate (Cherian et al., 1997). Counting breaths, first using a watch or timer, was difficult in a rapidly breathing infant. Later, we found that a simple pendulum swings at a fixed rate depending only on the length of the string (36-cm swings at a rate of 50 times per minute). Observing whether a child breathes faster or slower than the pendulum swings eliminated the necessity to count every breath. Treatment consisting of 5 days of a common and cheap antibiotic cures most cases. Eventually, it was found that even 3 days of treatment would suffice [World Health Organization (WHO)/UNICEF, 2006].

Iodine deficiency causes goiter in adults and mental deficiency and deafness in newborns. This condition has long been known to respond to universal salt iodation at nearly no cost. However, in poor countries, salt comes from numerous small producers using evaporation of seawater or from local mines. Buyers had no way of knowing if the salt was fortified with iodine. Laboratory tests with several chemicals added sequentially were needed to measure the adequacy of iodation. We experimented with the essential reagents and found that if they were all mixed together in a small dropper bottle, a drop of this would immediately turn salt blue if iodine were present (Mannar & Dunn, 1995). This enabled testing at virtually no cost that could be carried out in the marketplace, in samples of household salt brought to school by children, or in homes (Figure 10). Even truckloads of salt were stopped and tested by authorities to ensure iodation laws were followed.

Figure 10. Schoolchildren in India who brought samples of salt from home to test for evidence of iodization.

Source: UNICEF; used with permission.

Vitamin A deficiency caused blindness in millions of children who had been consuming a diet without adequate yellow fruits and vegetables. Early signs were treated initially with painful injections or daily pills. But later it was shown that vitamin A given orally in an oily mixture could be stored in the liver. A capsule containing enough oily vitamin A to last 6 months is now given to young children in poor environments at 6-month intervals during immunization sessions, virtually eliminating blindness in previously high-incidence areas (Sommer, 2008).

In India and Bangladesh, provision of safe water was made possible by drilling tube wells fitted with hand pumps, replacing water from ponds and rivers. This substantially improved health and hygiene. Unfortunately, undersurface water in many areas leeched arsenic from the bedrock and, when brought to the surface and consumed, caused arsenicosis. Arsenicosis can cause cancer and death. To remove tens of thousands of tube wells was nearly impossible and would have re-exposed populations to groundwater that is invariably contaminated with bacteria, viruses, and parasites. Chemical treatment to remove the arsenic is cumbersome and costly. However, fortunately the arsenic was found in only some of the wells, and nearby wells were often safe. A simple field test kit was developed, and each well found to be contaminated with arsenic was painted bright red, whereas wells with safe levels of arsenic were painted green (Jakariya et al., 2007). Villagers, having seen the horrible effects of arsenic, were readily persuaded to drink only from green wells, whereas bathing, washing dishes, and the like were not harmful if the water from red wells was used (Figure 11).

Figure 11. Tube wells in Bangladesh painted red, warning of high levels of arsenic (but the water is safe for washing).

Source: BRAC James P. Grant School of Public Health, BRAC University; used with permission.

Psychological trauma in war zones, natural disasters, and in many deprived households afflicts tens of millions with post-traumatic stress disorder, often lasting a lifetime. In the late 20th century, psychologists discovered eye movement desensitization and reprocessing (EMDR), which uses well-researched techniques to effectively treat the effects of mental trauma of all kinds (Shapiro & Maxfield, 2002). Unfortunately, with approximately two psychiatrists per 1 million population, applying this technique, which requires weeks of sessions between a therapist and an individual patient, is simply not possible. Recently, a small group of EMDR-trained practitioners developed a simplified method called traumatic stress relief (TSR), based on key elements of EMDR, to enable a trained paraprofessional to treat groups of traumatized persons and obtain success after only a few group sessions (Pupat et al., 2022). With backup from psychiatrists for the most severe cases, the TSR approach may extend this relief to millions at relatively low cost.

With the advent and widespread use of electronic devises capable of transmitting information, tracking individuals such as those with COVID exposure, and even conducting laboratory tests in the field, simplified health technologies will be not only cheaper but also available to far more people in need. Simplifying proven methods of diagnosis, treatment, and reporting is the critical step to reach millions with innovative health technologies. When assessing a new tool, look for ways it can be made simpler, cheaper, and easier to use.

Train and Develop Systems Incrementally—No “Big Bang”

Doctors train for 5 or 6 years and more, and nurses train for 3 or 4 years. Yet training of lower-level workers, especially CHWs (who are often volunteers), is generally restricted to a few weeks or months at best. The manual for barefoot doctors in China was a tome of nearly 1,000 pages. The CHW manual I studied in Indonesia filled three notebooks, each to be learned in a few weeks of instruction. I studied both of these manuals and found that they covered scores of conditions using vocabulary and explanations geared to a much more sophisticated learner. I wondered if it wouldn’t take a doctor to fully comprehend what was being conveyed. Graduates of these brief courses retained only the barest knowledge and demonstrated almost no skills in diagnosis and management of diseases; they could not sort out the common from the rare, nor could they prioritize their work. I termed this approach the “Big Bang” training. I noticed in Indonesian villages that many women were keen to learn skills that would help them in their family life and that they could share with neighbors. However, their educational level and limited time constrained the range of knowledge and skills we could reasonably impart. Also realizing that some form of service to the community was revered and expected from each family, we taught each small group of women specific skills in which they would become a Kader (the local term for “expert”). Nutrition Kaders ran the monthly weighing session, diarrhea Kaders taught hygiene and the making and use of oral rehydration, family planning Kaders motivated and resupplied contraceptives, and garden Kaders grew demonstration plots and provided seeds. We even had rabbit-raising Kaders, fish-pond Kaders, and chicken-raising Kaders, each with considerable proficiency in sharing in their own field of expertise (Rohde & Hendrata, 1982). No one was overburdened with skills or demands on their time and resources. All had something to offer.

In Indonesia, a World Bank–funded project invited our pediatric department to do the training of CHWs who would work full-time in their home villages. We established 10 priorities from our analysis of survey data in the villages. We then designed 10 free-standing modules, each to be taught in 3–5 days and culminating with field activities to reinforce the lessons. The first module was community fact-finding, conducting a survey, interviews, and focus groups. The module ended with a prioritizing exercise. The trainees were sent home to apply their new skills and return in a month to present their priorities based on objective findings and felt needs. Then, they could choose their next training from any one of the 9 remaining modules with a brochure describing knowledge, skills, and evaluation of each: diarrhea, immunization, nutrition, family planning, respiratory illness, pest control, water sanitation and hygiene, TB, and, later, HIV. Again, they had a month to practice the skills, educate the community, keep records of results, and return with questions to clarify and solidify their experience. At the end of the year, with a total of only 20–30 days of training and lots of experience with implementation of each module, they had confidence in their new abilities and were providing a comprehensive array of needed services. Later, in Haiti, we used a similar approach to train hundreds of Agents de Sante who became the backbone of the national primary health care approach (Rohde, 1985).

In Bangladesh, BRAC recruited volunteers from their many women’s solidarity groups organized around microloans for income-producing projects. With incremental training, these CHWs were allowed to charge a set fee for the commodities they supplied: contraceptives, vitamin tablets, oral rehydration packets, skin ointment, and, later, sanitary pads, reading glasses, and services such as blood pressure measurements and diabetes care (Rohde, 2005). For more chronic conditions, they were given an incentive pay. For example, a CHW would receive a small payment for each of her TB patients who successfully completed a full course of prescribed daily drug therapy. This resulted in cure rates greater than 90%. Women were treated in the privacy of their homes (important in a traditional Muslim society), and the CHWs received a modest income from providing the services (Figure 12).

Figure 12. Home visits by BRAC community health workers in Bangladesh brought confidentiality and confidence.

Source: BRAC James P. Grant School of Public Health, BRAC University; used with permission.

Information systems in health care have expanded the data items collected. Unfortunately, this has become a significant impediment to clinic-level health workers, who record the information in numerous registers and spend days each month consolidating and reporting the totals without making any use of the data themselves. Computers have only made the situation worse by asking for more detailed items on each program area. Demands have risen to as many as 2,000 data items requested in each monthly report, resulting in inaccurate, late returns never used by those who collected the information. In South Africa, I encountered more than 40 monthly forms requested by individual disease programs and authorities within the department of health. Submissions were sporadic, tardy, incomplete, and often fabricated. We started a new system by asking clinic nurses what information they needed to evaluate their own work and to measure progress. “Don’t worry about what Pretoria or the World Health Organization want—decide what you need to function better,” we urged. They came up with a list of 24 data items, from which 20 indicators (a numerator and denominator for each enabling the calculation of a percentage to measure achievements) were developed (Rohde et al., 2008). Each clinic was invited to choose 5 indicators that they wished to improve, and graphs were posted on the clinic wall demonstrating progress from month to month. Upon reaching their targets, new indicators were chosen to monitor, eventually covering most of the 20 indicators.

The old forms were discarded and concise monthly reports were submitted to district offices by the 5th day of the month, from districts to the province by the 10th day of the month, and to the national office by the 15th day of the month. National managers had at last key measures of program progress and, importantly, could identify which facilities had weak performance in immunization, family planning, antenatal care, TB treatment, HIV counseling and testing, as well as measures of key drug stockouts, non-working refrigerators, and the daily caseload for the nurses. There were now data on which to base management decisions (Rohde et al., 2008). Holding the data to a workable number of items has been a constant battle because often program managers ask for more details and international agencies request prodigious numbers of indicators that in aggregate would paralyze any frontline worker. Although additional data and indicators have been added slowly and others dropped, the incremental approach has allowed workers at all levels to learn, adapt, and integrate more information into their work patterns and decision-making. They now use the data to guide their own work, no longer burdened by useless data collection.

Health systems that are developed gradually and modified to fit local needs by local people are far more likely to be resilient and adaptable over time compared to a large-scale, system-wide design brought in from outside. Incremental training and local modification build resilience and ownership. Build on success, even at a small scale, and do not feel pressed to do “everything at once.” One component done well and with the community is far more enduring than comprehensive interventions devised by outsiders and implemented only partially. Promising “Health for All” is bound to lead to disappointment.

Delegate to “Lower Levels”—They Know What Is Going On

One clear lesson I learned during my pediatric residency was that if the neonatal nurse called to say a newborn looked bad, I asked no questions but ran to the unit. Nurses living with patients for hours each day have a far better sense of how the patients are doing compared to doctors who visit once or twice in 24 hours. They are sensitive to changes in behavior, movement, and feeding, in addition to the more objective vital signs. Nurses were often the best teachers I had.

The closer people are to the community, the more capable they are to initiate and sustain health and other development activities. Doctors and public health experts may have the technical know-how, but they will never reach into the homes of the poor on the scale necessary to effect community health. Only by training and delegating medical care to “lower-level” persons and backing them up with supportive supervision and more complex care can universal health coverage be reached.

On a trip to newly independent Bangladesh in the 1970s, I visited Dr. Zafarullah Choudhury, a friend I had met while both of us were providing health services to refugees during the liberation war. Zaf, initially trained in the United Kingdom as a surgeon, was convinced that doctors monopolized medical knowledge and procedures. He had trained some young women to perform tubal ligations, a sterilization procedure requiring abdominal surgery under local anesthesia (Figure 13). He asked me to witness the procedure and assess the skills of these women. In a tiny fiberglass hut, hot with no ventilation, I gowned and masked and then scrubbed in to assist this young surgeon who executed a very precise, well-performed surgical procedure. I complimented her, and she asked that I record the surgical notes in the patient’s chart. “Isn’t that something you should do, as the surgeon?” I asked. “I am sorry,” she replied, “I have not yet learned to read or write.” Flabbergasted, I did as she requested. Later, Zaf was attacked by the medical authorities for “malpractice,” which under the law was defined as “practice significantly of inferior quality to locally prevailing standards.” He challenged any obstetrician in the country to perform the procedure alongside his trainees and for them both to be judged by international experts (Z. Chowdhury & Bachman, 2009). No one took him up on it, and the case was dropped. He also provided nonsurgical training to numerous other illiterate women who became health workers in his district.

Figure 13. In the operating theater, where a young, trained community worker in Bangladesh performs a flawless tubal ligation procedure by mini-laparotomy.

Source: Jon Rohde.

Fifty years ago, malnutrition afflicted up to 50% of young children in Indonesia. Much effort was made in recommending diets, increasing food production, and providing food supplements, but these directives had no noticeable impact. Our pediatric department continued to treat severely malnourished children requiring great expense and considerable time. Outcomes were generally poor. In Java, women traditionally met once a month for an arisan, a joint social gathering during which each brought a handful of rice and drew lots to see who would take home the entire pot of rice. No one won a second time until each had won the pot once, but it provided a brief windfall to the family budget. The Home Affairs Ministry encouraged these groups to take on some activities for “family welfare” at their monthly gathering, and many groups asked our pediatric residents to give talks on child health to the assembled women. “How do we know if our child is growing healthy as she should and before she becomes malnourished?” was a frequent question. We began weighing each child monthly with the simple slogan, “As a healthy child grows in age, she must grow in weight.” When a child did not gain for a month or two, the entire group took up advising the mother on how to get the child to eat better, to pay attention to hygiene, to stimulate the child more, along with a host of other bits of village wisdom in child-rearing. When we realized that women could weigh their children accurately with local hanging bar scales used in the markets and could mark the results on a colorful chart, weighing became the central focus of the monthly gathering. Mothers paid special attention to any child who, despite looking and seeming well, did not gain weight. Rather than waiting for the child to appear malnourished, they intervened at the first sign of growth faltering, and they did so within local means. Undernutrition declined by nearly one-half in participating villages. The monthly arisan in Java, and eventually across all of Indonesia, became a health-gathering organized by more than 200,000 volunteer mothers in some 60,000 villages with additional interventions such as oral rehydration, iron supplements, vitamin A capsules, and even immunization (Oendari & Rohde, 2020; Rohde & Hendrata, 1982; Rohde & Northrup, 1978). By delegating responsibility to trained village women, the reach and impact of nutrition and simple health measures were brought to millions of children on a monthly basis in their own neighborhoods.

In Bangladesh, BRAC, realizing that diarrhea remained the major killer of children, undertook to train one woman in each household to make oral rehydration fluid from home ingredients (sugar or molasses, and salt) and administer it to a child at the first sign of diarrhea. Trainers visited each household and painstakingly taught one woman at a time how to make and use the solution. Trainers were paid on the basis of testing of mothers by an independent team several weeks later: If the mother hadn’t learned adequately, she was retrained and the original trainer was not paid for that household. Many experts were skeptical and insisted that doctors, who were in woefully short supply in rural villages, needed to oversee rehydration. It took 10 years, but these trainers reached 13 million homes to teach the mothers there—virtually all the homes in the country (Figure 14). By that time, the number of diarrhea deaths had declined by more than half. During the past 40 years, the case fatality rate from childhood diarrhea has decreased from 4.2% to 0.3%. The administration of oral rehydration at home has accounted for 40% of this decline (A. M. Chowdhury & Cash, 1996).

Figure 14. Over 10 years, 13 million mothers were taught one-on-one by BRAC fieldworkers in Bangladesh to make home oral rehydration fluid.

Source: BRAC James P. Grant School of Public Health, BRAC University; used with permission.

The medical world was astounded to learn about the impact of barefoot doctors, who were peasants in China trained to manage many common illnesses and to impart hygiene and health education to their workmates in the commune, where they performed agricultural work together. When I first visited there in 1979, I found an extraordinary improvement in public health from the earlier epidemics of bilharzia, TB, leprosy, sexually transmitted diseases, and dysentery. There was a wide integration of traditional treatments such as herbal remedies, acupuncture, and moxibustion with the use of modern drugs by trained peasants. They handled the vast portion of complaints, but even more important, they had an established referral system that ensured more severe cases arrived in a timely way at a higher-level facility for care. I even met a man who had been rushed to Shanghai, some thousand miles away, after his hand had been severed by an agriculture machine. His hand was successfully reattached and regained function. Delegation to staff closer to the community ensures far greater impact on illness care and prevention.

In South Africa, as HIV spread like an epidemic through the population in the late 1990s, clinics run by trained nurses were unable to meet the demand for HIV testing with the concomitant need for one-on-one counseling before and after the test. HIV-positive volunteers, who had been “through it all” and were on treatment, took over the testing services and became the prime motivators of drug adherence by newly diagnosed HIV-positive pregnant women in the mothers2mothers program (McColl, 2012).

The United Nations estimates there are currently approximately 1 million CHWs throughout Africa (UNAIDS, 2017). Most are not salaried but receive periodic incentives and reimbursement of expenses. They are often trained and supervised by local NGOs and generally supplied with drugs and equipment from governments. Many started as “fever workers” responding to widespread malaria, which accounts for up to half of all health complaints, with presumptive drug treatment. Most have now been taught to use a rapid test with a drop of blood to more accurately diagnose malaria and treat with an up-to-date improved combination medicine. They provide bed nets for families and demonstrate their proper use. Most countries have added tasks, such as to provide oral rehydration solution for child diarrhea; treatment of rapid respirations with antibiotics; provision of contraceptives; and, in some, identification of possible TB cases and overseeing their daily treatment for 6 months, after which they can be considered to be cured. The few doctors in Africa are almost exclusively in urban settings, so the CHWs are often the only care available in rural areas (Figure 15). They have brought the most relevant and effective health technologies to families far beyond the reach of the formal health systems (Perry et al., 2014).

Figure 15. Community health workers in many countries deliver a wide variety of health services where there is no doctor.

Source: Cover of David Werner’s (2020) book Where There Is No Doctor.

In Dhaka, with a population nearing 10 million (6 million of whom live in slums), mortality in pregnancy was in the range of 300 deaths per 100,000 births, in contrast to 30 among the well-to-do and 10 in developed countries. After navigating a slum through narrow mud-filled paths no more than 1 meter wide, it is not difficult to understand why most deaths occur at home. How could a poor woman in labor get out to seek help, and if she could, where would she go? We found that because many women had no transport and did not know where to go, they were reluctant to leave home until complications had advanced. If they got to a hospital, they were often neglected until it was too late. In 2004, BRAC decided to take on this challenge despite its lack of previous experience in urban areas. In each slum of 10,000, BRAC rented a room on the periphery with water, electricity, and a latrine—facilities not available in most hovels (Figure 16). BRAC hired two traditional midwives found in the local slum to conduct free deliveries in this convenient and clean location. CHWs identified pregnant women, did simple antenatal exams, and convinced most mothers to visit the birthing room several times for education on safe delivery. The midwives were given brief training to recognize anything abnormal, trained on use of a cell phone, and given a number to call to refer a woman having difficult labor. At first, ambulances were called, but traffic is so congested that rickshaws replaced them to take women to the University Hospital. A BRAC worker stationed there, informed in advance by mobile phone, would alert the doctor on duty and had cash to purchase needed supplies such as gloves, IVs, and medicine, all in short supply in the hospital. Arriving women were ushered directly to the doctor by the BRAC worker who purchased the needed medicines at an outside drug store, and appropriate life-saving procedures were rapidly initiated. Within 3 years, maternal mortality declined by half and neonatal mortality declined even more. Home deliveries without a trained provider present, which previously had accounted for more than 80% of births, decreased to less than 20%. Most of the remaining home births were among women who had a precipitate delivery. In recent years, as BRAC has trained professional midwives to man local maternity centers, hospital referrals have declined because the professional midwives are able to perform many of the tasks previously available only in hospital. More than 125,000 deliveries have occurred in these slum birthing rooms and centers, with mortality less than half the previous rate (Marcil et al., 2016).

Figure 16. A mother delivering in a clean “birthing room” in the slums of Dhaka, Bangladesh, assisted by a traditional birth attendant.

Source: BRAC James P. Grant School of Public Health, BRAC University; used with permission.

Guinea worm, or Dracunculiasis, is an ancient parasitic scourge caused by a worm, the larvae of which are ingested in unclean water and grow to 1 meter or more in the flesh, usually of the leg. The mature worm releases larvae under the skin, which causes a blister and severe pain and itching, leading the victim to seek open water for relief, into which the worm injects its larvae and the cycle repeats. Because the tissues around the emerging worm are inflamed and usually become infected, the worm cannot be pulled out or it may break, releasing more larvae into the body and causing a severe allergic reaction (Figure 17). Traditionally, the worm is wound slowly on a match stick and extracted in a week or two, with pain, infection, and scaring. This disease was widespread in desert areas of India, where water was obtained by digging large deep holes with steps leading down to fetch water, called step wells. Guinea worm patients sought relief in the water, thereby spreading the disease. UNICEF and the Government of India had extensive programs to close these wells and replace them with hand pumps, but there were thousands of step wells and their use was an ancient tradition. Exploring one of these areas, I encountered a traditional doctor who assured me he could extract the worm provided a patient came to him prior to the formation of the blister and pain. Naturally skeptical, I asked Dr. Sharma (an Ayurvedic doctor) to teach me. In the dry season when the worms emerge, I joined him on his desert rounds as people came from far and wide to avail his skills. Indeed, for those with worms under the skin that could readily be seen and palpated, he made a small incision under local anesthesia and gently pulled the worm, massaging along its length until it was fully extracted. The traditional “medical knowledge” was described as “clearly wrong” because modern doctors only encountered these patients after the worm had started to emerge and inflammation bound the worm to the tissues, making extraction impossible. Even when I showed these skeptics fully extracted worms, they refused to believe! So, I brought a film team to the field and made a series of instructional videos showing how Dr. Sharma identified and extracted the worms. We provided vehicles and gave every village self-addressed postal cards that would alert us to an early case. Dr. Sharma or one of his trainees would go to a village, extract the worm, treat any other cases, and convince the village leaders to keep any cases out of the water. This early and painless extraction resulted in many cases presenting increasingly earlier in the season and, along with improved water supplies, led to a decline in transmission (Rohde et al., 1993). There were approximately 40,000 cases in 1985 when our program began; the last guinea worm case in India was in 1996. We sent Dr. Sharma to Nigeria to teach doctors there how to readily extract the worm. Guinea worm eradication efforts in Africa, largely through improved safe water sources and simple filters, have reduced cases to only 54 in 2019. In 2020, 27 human cases of Guinea worm disease were reported worldwide. Total eradication of this ancient disease is now near (The Carter Center, 2021).

Figure 17. A traditional doctor removing a Guinea worm by sterile surgical extraction in India.

Source: Jon Rohde.

Delegation to lower-level workers with proper training and support extends appropriate health measures far beyond the reach of formal health systems. Mobilizing the skills and cultural acceptance of traditional healers is a further strategy to provide wider care. Mothers are the major providers of health in their families: Trust them, empower them, respect them, and you will see resilience and success in your program.

Seek a Mentor; Be a Mentor!

Even before I was in high school, I admired and spoke often with older folks who encouraged thinking about my future. Buck Greenough, 10 years my senior, married the girl across the street who was, even then, my vision of a perfect wife. I followed him to Amherst College, then to Harvard Med, and as I watched him go off to East Pakistan to treat and do research on cholera, my view of my potential expanded. No longer was I wed to the idea of an academic practice and a home on the shore near Boston. I spent 3 formative years in Dacca following the work Buck had done before me. I admired him as a model for my education, my research, my career, and as a social activist. To this day, now 60 years later, I consult with him on important decisions and still find his advice useful and compelling.

Working at Children’s’ Hospital in Boston was exciting and rewarding, but I was determined to spend my life in poor countries where pediatric problems and interventions were very different. Fortunately, Professor Charles Janeway, the head of the hospital, recognized my resolve and kindly arranged for me to spend my final year of pediatric training at the Albert Schweitzer Hospital in rural Haiti. There, I encountered illnesses never seen in Boston: exotic infections such as blackwater fever (malaria), neonatal tetanus, and tuberculous meningitis; parasites causing elephantiasis or brain abscess; malnutrition of all sorts (swollen bodies of kwashiorkor and skeletal marasmus, pellagra, vitamin A deficiency blindness, and beriberi); and eventually HIV/AIDS. Dr. Larry Mellon, heir to the Mellon fortune, had been inspired by Schweitzer’s work and established this hospital in “the most deprived community he could find.” A man of deep humility and compassion, Mellon soon realized that the extensive sickness of his population was conditioned by extreme poverty, and he reached out with mobile clinics for mass immunizations and agriculture extension to introduce new crops and ways to conserve the soil. He drilled wells for safe water and provided employment in local handicrafts and work for the disabled. We became close friends as I spent days with him visiting the surrounding villages. We even spent evenings playing chamber music together along with our wives. Here was a man who could afford to do whatever he desired, yet his life and joy were one of dedication to others less fortunate. I cherish the model he offered me.

While I was posted at the Schweitzer Hospital to care for children, the huge community outreach previously established by Drs. Warren and Gretchen Berggren taught me the importance of community-based preventive services and the value of collected data to detect areas of need and health trends at the village level, long before clinical manifestations such as rising malnutrition appeared at the hospital. I carried appreciation for these lessons throughout my career.

When working for the Rockefeller Foundation in Yogyakarta in 1979, I was invited, along with my wife, to accompany James Grant and his wife Ethel on a visit to China, where he had been born nearly 60 years earlier. He had just been named the new Executive Director of UNICEF, and our 3-week trip provided ample time to talk pediatrics and child welfare (Figure 18). We became fast friends, working together for children for the next 16 years until he was snatched away by untimely cancer. While I provided ideas on what could be done at scale in health and nutrition, he carried these to a global level through his Child Survival Revolution. I accompanied him on world travels and saw how he unabashedly would not take “no” for an answer from heads of state, agency heads, and bureaucrats in nation after nation as he promoted the elements of nutrition and child health I had taught him. It was a beautiful and inspiring relationship that encouraged me to reach into international fora and led to my favorite job as head of UNICEF in India from 1993 to 1997.

Figure 18. James P. Grant, Executive Director of UNICEF, with child. Grant was a great mentor.

Source: Jon Rohde.

Through Grant, I attended a meeting of the International Physicians for Prevention of Nuclear War, co-founded and led by Dr. Bernard Lown, who had won the Nobel Peace Prize in 1985 stating, “We are not indifferent to other human rights and hard-won civil liberties. But first we must be able to bequeath to our children the most fundamental of all rights which preconditions all others: the right to survival.” I had met Lown in my medical school days seeking his guidance on a research project I was conducting. This reconnection after 25 years led to a long-lasting friendship that has guided me in new directions. Despite his international reputation as an innovator in cardiology, Lown believed that every physician must actively take up a mission to protect against the annihilation of human beings throughout the world by prevention of nuclear war. His constant preoccupation with this threat was one of the greatest public health contributions of any physician in the past century. I have endeavored to contribute in a small way following his lead. In this, his 100th year, we continue to write and strategize how to reduce the nuclear threat. Like Grant, he is still not intimidated by the powers arrayed against his mission.

As you gain experience, younger folks will begin to look to you as a mentor. Your greatest success may be in motivating and guiding willing colleagues to see and realize their own potential. In Yogyakarta, I worked every day with young doctors, residents in pediatrics and public health. Dr. Yati Soenarto was particularly attentive, taking notes on ward rounds and often seeking guidance on cases. I pushed for handwashing after each patient I examined, while nurses and doctors alike reminded me that I had just washed my hands moments ago. I made a point to ask the social environment from which each child came, and always found at least one patient a day about whom I said, “I don’t know, but let’s go to the library and find the answer,” even though I was sure of a diagnosis. Years later when visiting Dr. Soenarto, who had become the Professor of Pediatrics in the new University Hospital, she wanted to show me that wash basins and soap were next to each bed according to her design. Each chart had a social analysis, and the library that I had initiated in the Pediatrics Department was greatly expanded and used. Dr. Tonni Sadjimin, a motorcycle-riding tennis friend and co-founder of the field activities in community medicine, carried on the course for medical students and expanded it to the nursing school and promoted village exposure for medical students nationally. The continuity of my work was ensured by those I had mentored.

When Jean “Bill” Pape returned to Haiti from medical school at Cornell in New York in 1981, I helped him set up and fund a special diarrhea ward for treating the leading cause of death in children. Under his guidance with the use of oral rehydration, mortality of children arriving at the hospital with diarrhea plummeted from approximately 35% to less than 2% in less than a year. When the first AIDS patients presented at the hospital, most often with intractable diarrhea, he began caring for these unfortunates. His careful observations and research established the nature of this previously unknown disease. He has gone on to publish hundreds of papers and to found a special hospital and research institution dedicated to infectious diseases in Haiti that has achieved international funding and wide renown (Groupe Haïtien d’Étude du Sarcome de Kaposi et des Infections Opportunistes or better known as GHESKIO). He says it all started with the diarrhea unit in the pediatrics ward.

In Bangladesh, Sabina Rashid was an enthusiastic anthropologist who believed in experiential learning. She paid close attention to the framing of instructional objectives, active learning, and open dialogue used in my classes in preference to the didactic pedagogy traditionally employed in higher education. When she became Dean of the School 10 years after its founding, she led the entire faculty in revising teaching methods and objective evaluations, bringing accolades from WHO as a model school. Our graduates have had many notable successes. Miatta Zenabu Gabanya, a nurse from Liberia, became a national coordinator of the Ebola response in 2014–2015 and was invited to address the World Health Assembly in Geneva the following year. Noah Levinson established a community-based program in a Calcutta slum (Calcutta Kids) that has succeeded in reducing the incidence of low birth weight by two-thirds and malnutrition to single digits from nearly 30%. I have visited his project annually to spend a few days with his nurses and see first-hand the challenges he faces in the impoverished overcrowded slum. He carries on unfazed by the fiscal and bureaucratic difficulties and has brought improvements in the lives of the population not previously thought possible. Indeed, in order to ensure sustainability and ownership of the program, he turned its management over to the community and to the workers he had recruited, trained, and motivated.

Learning from those we admire and follow leads to motivating and nurturing those who follow us. This is the greatest impact one can have in a career in global health. Your goal should be to seek and follow mentors, absorbing their lessons, and to eventually become a mentor yourself.

Build and Strengthen Institutions

In 50 years living in the Global South, I have learned that the only way to ensure continuity beyond my presence is to build institutions. At first, in Dhaka, I benefited from the CRL with its hospital and field research area which had been created nearly a decade before my arrival, in part by Buck Greenough, my first mentor (Figure 19). At best, I added some capacity introducing radioisotope studies and trained technicians to maintain new equipment and conduct the laboratory work in this new field. Years later, I was appointed to the Board, tasked with overseeing the research, approving budgets, and raising funds. Today, the CRL has evolved into the International Center for Diarrheal Diseases Research (now formally called icddr,b), and its mandate has extended to all diseases found in Bangladesh, including AIDS, malnutrition, chronic diseases, and even COVID. It is funded by many countries at a level more than 10-fold from my time.

Figure 19. The “old” Cholera Research Laboratory—an unused police barge with patients below and doctors quarters (top); and the “new” International Center for Diarrheal Disease Research, Bangladesh (bottom).

Source: International Centre for Diarrheoal Disease Research, Bangladesh; used with permission.

Our response to the Great Bhola Cyclone of 1970 required a new organization to carry on the work of reconstruction beyond our tenure. We registered HELP as an NGO and recruited core staff to handle the purchasing of the large number of needed supplies, ranging from bamboos by the thousands to cattle, farming tools, and the accounting necessary to our several generous donor agencies. The fieldwork on the island continued to be by motivated volunteers, but unfortunately, management and clerical staff seeing large funds expended skimmed off what they could and brought the project funding to an end in a few years. However, the volunteer field staff had by then achieved most of the development goals on the island, having established farming cooperatives and fisheries with new craft and having built cluster villages with cyclone shelters. The new Bangladesh government took over much of the ongoing organizational and oversight work. My visit to the island in 2013 found it extensively developed with housing on stilts to avoid floods, farming and fishing cooperatives, electricity, a tarred 20-mile road, many schools, and a population of more than 70,000—seven times the number of survivors when I landed there in 1970.

The Rockefeller Foundation expected me to participate as a clinical faculty member in pediatrics at Gaja Mada University Medical School in Jogjakarta, Indonesia, where clinical training was totally oriented to modern hospital care. I soon realized that the major challenge was preparing young doctors for their newly mandated compulsory rural service in remote clinics. Over 8 years, with young enthusiastic residents, I established community exposure throughout the 6-year curriculum (described previously). The university took over the costs and my colleagues carried on the program, modifying and expanding it until it became a full-fledged school of public health within the medical school, now attracting international students with an English curriculum.

Meanwhile, in social pediatrics, I moved most activities into the villages, where we developed the monthly weighing child program called Posyandus. These expanded first from our pilot villages, then throughout our small province, and then became a national program as the government witnessed its success in reducing malnutrition as well as improving maternal and child health. The expansion became possible as we teamed with BKKBN (the national family planning program), which had a presence in each village and wished to offer more than just contraceptives. Thirty-five years after I left, the Posyandus continue to provide child services and family planning in approximately 65,000 villages throughout the country (Oendari & Rohde, 2020).

In Haiti, we established a network of community-run drug stores in the villages, supplied from a central store that purchased generic medicines internationally and sold them at a fixed price. These tiny shops provided the only medicines for miles. We also trained CHWs (who there were called Agents de Sante) using the modular incremental approach (described previously), bringing needed care into nearly unreachable villages (Rohde, 1985). Unfortunately, it was not long after the project ended that corruption permeated both of these programs and they collapsed. The only health institutions in Haiti that remain viable are in the private NGO sector, which has developed some remarkable programs, in contrast to the chronically corrupt, underresourced government services.

In South Africa, my work was inside government health departments. Although the newly apartheid-free nation was keen to redress the imbalances of the past, reticence to change and bureaucracy were significant impediments to progress. We had the independence and funds to work on improved health information systems and invited staff from the University of Western Cape School of Public Health in collaboration with University of Oslo to develop and train the 25 districts in our province (750 clinics serving a population of 7.5 million) in data collection, reporting, analysis, and use of information for management. Many of the group left the university to establish the South African Health Information System Program (HISP; Rohde et al., 2008), which I supported with contracts to expand nationwide and then to other African and Asian countries. Today, 20 years later, 15 HISP branches in Latin America, Africa, and Asia maintain and extend health information systems based on the HISP DHIS2 program, open source and free to all, in more than 70 countries.

As discussed previously, F. H. Abed, founding director of BRAC, wanted to institutionalize the optimistic global view of development long espoused by James Grant, Executive Director of UNICEF from 1980 to 1995. After Grant died in 1995, Abed asked me to design a School of Public Health within the newly formed BRAC University in Dhaka. Some years in the planning, the James P. Grant School of Public Health admitted its first class in 2005 with students largely from Asia and Africa (Figure 20). Like at Gaja Mada, the course was designed to expose students to the reality of public health in the rural areas, with each of 15 core courses having field exposure and relevant experience to solidify classroom learning. During the first semester of the full-year master’s in public health course, students lived in a rural setting, with exercises conducted in surrounding villages nurturing skills in community interaction and diagnosis. During the second semester, students lived in urban slums, learning specific skills in nutrition, reproductive health, environment, infectious disease, aging, and operational research. The school became recognized by WHO not only for the unique field experience but also for the performance of its graduates, who have shown innovation and maturity in managing public health programs in their own countries (Braine, 2007). Although I remained involved in some teaching and curriculum revision through its first 15 years, my major contribution was in support of the Bangladeshi staff who have led the school in both teaching and internationally recognized scholarly research of high relevance to health of the poor.

Figure 20. James P. Grant School of Public Health, BRAC University, Dhaka, Bangladesh, where students from throughout the world come for experiential learning of public health in the field; the 15th class is pictured here.

Source: BRAC James P. Grant School of Public Health, BRAC University; used with permission.

My greatest opportunity for institution building came when I was invited by James Grant to guide the health priorities of UNICEF’s global programs of health and nutrition for children. Building on an analysis I had done of global child mortality, I proposed honing down on three major killers: diarrhea, infections, and malnutrition. Growth monitoring and promotion, breastfeeding, oral rehydration, and immunization (or GOBI) formed the basis of Grant’s Child Survival Revolution, his effort to reach every child in the world with these critical interventions (Lawn, 2014). Later we would add diagnosis and treatment of pneumonia, estimating that these interventions alone would halve global child mortality. While WHO was skeptical and clung to its slogan of Health for All by 2000, Grant relentlessly pursued governments and agencies to implement this small package of activities universally throughout their countries. Mortality has declined from 15 million child deaths per year in 1980 to just under 5 million by 2019 (UNICEF, 2019). Diarrhea is no longer the top killer of children, and immunization rates are greater than 90% in many countries.

By far the most rewarding outcomes in global health are seeing institutions that carry on the work you have initiated or catalyzed. People you train, policies that are formulated and implemented, and programs that expand and evolve beyond your inputs are the tangible fruits of your efforts. Institutions long outlive their founders and have a life of their own: Think of Oxford, Harvard, Red Cross, Oxfam, and so on.

Transfer Skills, Knowledge, Ownership, and Credit to Colleagues

Go to the people. Live with them. Learn from them. Love them. Start with what they know. Build with what they have. But with the best leaders, when the work is done, the task accomplished, the people will say “We have done this ourselves.”

—Ancient Chinese proverb attributed to Lao Tzu

Global health is a process, not a discipline. This Taoist saying well summarizes the lessons I wish to impart. Humility is central to your role, although transfer of skills and attitudes is your contribution. Although your knowledge is valuable, it must be put in local context to be of use. Joint discovery and shared experience provide the most powerful and lasting learning. Trust comes only with time and perseverance and is rarely accomplished in brief visits or even stays of a few months to a year only.

At Gaja Mada, where I taught for 8 years, I left a medical curriculum substantially transformed to emphasize practical work in the community. Returning to visit roughly once a decade after leaving, I found physicians with whom I had worked now heading the Pediatric Department and elected Dean of the Medical School. The curriculum evolved but remained committed to community service and exposure, led by my friends and colleagues. Thirty years after I left, I visited to find the National Minister of Health and three of four Directors General of Health had been students of mine. I met hospital directors and provincial department heads who recalled our field visits together. The Posyandu system we jointly started in a few villages had spread nationwide and had become a source of pride as a national priority. Although I cannot claim credit for the many progressive changes, I am proud to see the leadership role played by students and young doctors with whom I worked for 8 years.

Haiti has chronically suffered from bad governance, as well as natural disasters: hurricanes, earthquakes, and even cholera. Valuable service to the poor of Haiti continues to be provided in the form of the work of the Albert Schweitzer Hospital where I trained in tropical pediatrics; the establishment of an internationally renowned research institution (GHESKIO) by Dr. Jean “Bill” Pape; the mentoring of Paul Auxilla, who continues to work within the Ministry of Health; and a number of NGOs supported by the rural health project I led.

The James P. Grant School of Public Health (JPG SPH) of BRAC University is today run entirely by a staff of Bangladeshis who have extended the MPH program with more courses, innovative teaching methodologies, and numerous research projects (Figure 21). Yet the school retains the principle of field experience unique to the institution. More than 500 MPH graduates have assumed responsible posts in their 40 or more home countries, many having received performance accolades (BRAC University, 2021). The school has added a midwifery training program providing formally trained birth attendants to the country for the first time. Due to the energy of the school leadership, the school is fiscally self-sufficient through both tuition and research grants. In a recent evaluation of BRAC University conducted by outside international experts, the JPG SPH was repeatedly cited as having exemplary policies and procedures ensuring academic excellence.

Figure 21. BRAC’s James P. Grant School of Public Health—now offering a comprehensive global health program in Bangladesh.

Source: BRAC James P. Grant School of Public Health, BRAC University; used with permission.

My 12 years living in India with a focus on the well-being of children left a number of important accomplishments, largely achieved by the government with encouragement and assistance from UNICEF. In the early 1980s, immunization levels were at approximately 10%. The systems to purchase vaccines, store and distribute them, and motivate families to have children fully immunized by their first birthday were very weak. The UNICEF director went out on a limb to promise the millions of dollars required to purchase and maintain refrigerated cold chains and distribution capacity. We trained thousands of health workers to sterilize needles and syringes, organize mass immunization days, and mobilize communities. I addressed special sessions of Parliament; appeared on television talk shows and news; and facilitated public vaccination conducted by well-known politicians, sports stars, and entertainers. By 1990, India had fully vaccinated 80% of its children before their first birthday and I had convinced the Health Minister of Delhi State to initiate a drive to eliminate polio. Remarkably, India succeeded in seeing its last case of polio in 2011 after a huge logistical and public effort involving literally millions of workers over more than 20 years. Twenty-five years after the first drive in Delhi, the Minister of Health for India, the same man with whom I had worked in the 1990s, convened a national meeting to celebrate the success of the country in eliminating polio and sustaining vaccination levels. Invited to speak, I could only thank and recognize the many Indian colleagues who achieved this remarkable feat.

I joined the Indian Medical Association, viewed by many as a lobby for private doctors. Throughout the years, I convinced them to provide pro bono immunization in their practices. The Indian Academy of Pediatrics both promoted oral rehydration for all cases of diarrhea and encouraged breastfeeding in the face of commercial infant formula, which was making heavy inroads into poor communities. These two professional organizations provided volunteer inspectors to train and certify more than 1,000 hospitals as “baby friendly” by ensuring that the necessary conditions were present there to endorse and promote exclusive breastfeeding for newborns. The decline in breastfeeding was reversed, contributing to falling infant mortality. Working inside existing organizations provided a huge workforce, mobilized their members as endorsed by their own leadership, and ensured continuity of the program. In all these and other actions in support of child health in India, I worked with and through institutions that extended the reach and long outlasted my presence. They could truly say, “We have done this ourselves.”

When I moved to South Africa almost 25 years ago enthusiastic to participate in “building the new rainbow nation,” many of the newly “liberated” professionals with whom I worked in the Ministry of Health were extremely wary of outsiders who had “come to tell them how to do things.” I soon found that as a result of their prolonged isolation from the rest of the world due to apartheid, they were hungry to learn “how other countries had dealt with similar health challenges.” But, they did not want to be told what to do. I became a storyteller relating tales and experiences of the many countries in which I had worked or just visited, and I carefully avoided recommending anything specific for South Africa. They were pleased to have been able to say, “We have done this ourselves,” often building on new insights gained from the lessons of other countries. Today, South Africa has become a leader in dealing with HIV/AIDS, TB, and most recently in its response to the COVID pandemic. Its health system has become increasingly efficient in dealing with the “double burden of disease” (both diseases of the poor and diseases of the affluent), experienced by many middle-income countries. South Africa’s health system welcomes colleagues from throughout Africa to study in its medical and public health schools, and it is viewed as a beacon of health equity.

Conclusion

Global health offers a varied and rewarding career, not only for medical personnel but also for a wide range of other disciplines: management, logistics, human resources, training and education, finance, communications, anthropology, sociology, diet, nutrition and agriculture, information systems, climatology, and many types of architecture and engineering. Health is a net result of a comprehensive set of conditions in communities that lead to absence of illness and enjoyment of well-being. Whatever education you choose, it can be applied while working in a multidiscipline team to improve health; it depends more on your outlook and attitude for the relevance of your work to benefit others than on the particular expertise you bring.

Global health has evolved from its historical focus on specific tropical diseases to clinical care for the underserved to traditional public health with its emphasis on environmental factors and preventive measures to the current recognition that health is the summation of an entire range of factors that impinge on families and communities to either enhance or threaten well-being. In the past, the practice of global public health was often considered one for highly motivated individuals to leave their homes and travel to live and work in poor environments. Fortunately, today we see far more young people seeking training either at home or abroad, intending to return to their own communities and apply their skills to solving problems where they were raised. This provides far greater sustainability as well as cultural relevance. “Health by the People,” as promulgated initially by WHO in the 1970s (Newell, 1975), is a far more affordable and viable approach to health development than do-good outsiders, however well motivated. Your contribution to this movement, whether as a member of the community or a concerned and sensitive outsider, offers a lifetime of rewarding work. Your own learned lessons in global health will contribute to the laudable goal of truly reaching “Health for All.”

Further Reading

  • Chowdhury, A., & Perry, H. (2020). NGO contributions to community health and primary health care: Case studies on BRAC (Bangladesh) and the Comprehensive Rural Health Project, Jamkhed (India). In Oxford research encyclopedia: Global public health. Oxford University Press.
  • Lawn, J. E. (2014). The child survival revolution: What next? Lancet, 384, 931–933.
  • Newell, K. W. (Ed.). (1975). Health by the people. World Health Organization.
  • Oendari, A., & Rohde, J. (2020). Indonesia’s community health workers (Kaders). In H. Perry (Ed.), Health for the people: National community health worker programs from Afghanistan to Zimbabwe (pp. 149–164). USAID/Jhpiego.
  • Perry, H. B., Zulliger, R., & Rogers, M. M. (2014). Community health workers in low-, middle-, and high-income countries: An overview of their history, recent evolution, and current effectiveness. Annual Review of Public Health, 35, 399–421.
  • Rohde, J. (1985). The Rural Health Delivery System Project: Initiative and inertia in the Ministry of Health. In D. Brinkerhoff & J. Garcia-Zamor (Eds.), Politics, projects and people: Institutional development in Haiti. Praeger.
  • Rohde, J. (2005). Learning to reach health for all: Thirty years of instructive experience at BRAC. University Press.
  • Rohde, J., Chatterjee, M., & Morley, D. (1993). Reaching health for all. Oxford University Press.
  • Rohde, J., & Hendrata, L. (1982). Development from below. In N. Scrimshaw & M. Wallerstein (Eds.), Nutrition policy implementation (pp. 209–230). Springer.
  • Rohde, J., & Northrup, R. (1978). Mother as basic health worker: Training her and her trainers. In R. W. McNeur (Ed.), The changing roles and education of health care personnel worldwide in view of the increase of basic health services (pp. 139–166). Society for Health and Human Values.
  • Rohde, J., & Viswanathan, H. (1995). The rural private practitioner. Oxford University Press.
  • Sommer, A. (2013). Ten lessons in public health: Inspiration for tomorrow’s leaders. Johns Hopkins University Press.

References

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  • Perry, H. B., Zulliger, R., & Rogers, M. M. (2014). Community health workers in low-, middle-, and high-income countries: An overview of their history, recent evolution, and current effectiveness. Annual Review of Public Health, 35, 399–421.
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  • Shapiro, F., & Maxfield, L. (2002). Eye movement desensitization and reprocessing (EMDR): Information processing in the treatment of trauma. Journal of Clinical Psychology, 58, 933–946.
  • Sommer, A. (2008). Vitamin A deficiency and clinical disease: An historical overview. Journal of Nutrition, 138, 1835–1839.
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