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From Polio to PEPFAR and Beyond: Can the GHI Reform the Way We Do Global Health?

For many in the blogopshere [1], [2] and the Twitter world Secretary of State Hillary Clinton’s speech on Monday reenergized our commitment to the Global Health Initiative (GHI) and the promise of transforming the way we practice global health work. Like many, I was left with questions of how exactly this initiative will work, but Clinton’s passing reference to the polio outbreak in northern Nigeria also reminded me of the imperative that GHI succeed.

In 1999, Nigeria saw a spike of 981 polio cases but by 2001, only two years later, the country had made steady progress towards eradicating this preventable disease, reporting only 56 cases. Soon after, however, rumors that the polio vaccine could sterilize children began to circulate and were interpreted in the predominantly Muslim northern Nigeria as a ploy to curb population growth in Muslim communities. The United States President’s Emergency Plan for AIDS Relief (PEPFAR), the Centers for Disease Control and Prevention (CDC), and the United States Agency for International Development (USAID) were all working in the country at the time. Yet, as Clinton noted in her speech, “We had our aid program and our development experts on the ground doing extraordinary work, but we didn’t anticipate and quickly respond to what became a series of rumors about how the polio vaccine was a design to sterilize Muslim children.” Soon the rumors became so widespread that community leaders in the north began to heed them and refused to allow the polio vaccination campaign to proceed. Clinton went on to say that, “no matter how hard our development experts or our doctors or our nurses or anybody from one of our agencies worked, that problem undid much of the efforts that we were engaged in.”

I was also working in Northern Nigeria in early 2004 as part of a team evaluating adolescent reproductive health programs. Wherever I went, whomever I met with—state health authorities, imams, and even the community health extension workers—people wanted to talk about the polio immunization problem. They wanted to know where was the funding, where was the support for dealing with this? How did polio fit into the objectives I was discussing on promoting family planning and HIV prevention and treatment? If I wasn’t working on the outbreak who was?

They were questions I wasn’t equipped to answer, and conversations I didn’t follow up on because they didn’t fit in my purview of family planning and adolescent reproductive health. But the discussions stayed with me. Today, they haunt me especially when I look at the data: in 2004, Nigeria reported 782 polio cases. By 2006 the number had climbed to 1143, reversing much of the polio eradication work in Nigeria of the last decade. It is legacy that lingers. Last year, more than 500 Nigerians contracted polio. Yet, any funding the US government has put into polio eradication in Nigeria is by far dwarfed by the more than $1.5 billion we’ve spent there through PEPFAR.

Reflecting on concrete examples like the polio outbreak makes it clear to me, if we are to make real progress in global health we have to change the way we do business. In my own work, I have seen too many examples of US agencies failing to collaborate effectively while, at the same time, advising national ministries and programs to better coordinate their work. I am hopeful that GHI will change these scenarios, but it requires that the US government develop and act on concrete, detailed plans that prioritize country ownership and leadership and allow for a more flexible use of resources in emergency situations.  

This means taking “a look at every program and policy that we have across the government, and more effectively design[ing] and execut[ing] those to deliver on that promise of integrated networked power,” as Clinton said. It is challenge we can all commit to meeting, and we are eager to hear more details from Clinton and other parts of the Administration on how GHI will be funded and governed. How will funding flow from GHI? Will there be ongoing consultation with development partners, including international nongovernmental organizations as GHI gets off the ground?

A great, informative read on the subject is the Center for Strategic and International Studies’ commission report on Smart Global Health Policy, which, among other things, proposes an Interagency Council for Global Health, led by a senior global health coordinator, to facilitate coordination by setting benchmarks, reviewing progress, improving data, and building accountability.

Like everyone else, I would like more information on what will really be new and different about GHI. I also think we should all get informed and actively find ways to share our thoughts on what the US government can do better as it develops a more detailed GHI implementation plan.