So welcome back, everybody. I thought it'd be good to share some of what Carl Taylor
was involved with in the last two decades of his life, 25 years or so, and how that
related to the broader changes in primary health care on a global basis. When Carl
retired as the Chair of the Department of International Health in the mid-1980s, he
went to China as the country representative for UNICEF there, and he
went there with a clear understanding from Jim Grant, who was still executive
director of UNICEF, that he would be free to try an alternative model to GOBI, to
the very highly selective approach that UNICEF had been promoting around the
world. And with that backing of Jim Grant, Carl among other things, he, he set out to
work with the Chinese on a more comprehensive approach to primary health
care that became known as the model counties project in China, which was a way
of working with communities and local health care providers on health care
priorities, particularly those of mothers and children in the very poorest parts of
China, which by that time, even though China had been progressing, there were
still major parts of the country that had very poor health conditions, particularly
for mothers and children. And so, he started that effort and the model counties
project, I don't have time to go into details of it, but it varied from place to
place, but it involved the central level government working with the more local
district-level activities to strengthen maternal and child health, with
participation of the community. And it grew over a period of ten years after Carl
came back from China, to reach 400 million people. And because of the nature of
Chinese society, and their lack of openness this isn't widely known in the
broader world, because there haven't been publications about it, but we have many
stories about that and, we do teach about this in our course on Case Studies In
Primary Health Care. This gives me the opportunity to put in a plug for the
course we teach at Johns Hopkins called Case Studies In Pr imary Health Care,
which goes into much more depth of many of these issues. And fortunately, for you,
this course is on OpenCourseWare, and is availaable to anyone with internet access,
and so on this slide here, you see that we have the link for you, where you can go
directly to this course and take it, and it has a series of recordings related to
specific cases and throughout our Coursera course, we are alluding to some of the
cases in a very superficial way that we discuss in more depth in our Case Studies
in Primary Health Care course. But, you are welcome to pursue this, if you want
to, and have time to get into more in-depth work on, primary healthcare from
the key studies approach. Also on this same slide, you'll see, in the lower part,
a web link to a symposium that we held at Johns Hopkins several months after Carl
Taylor died, and this is an interesting series of presentations by people who were
closely associated with Carl throughout his career, and I was very honored to be
one of the presenters in this. And this symposium reviews, with great fondness and
admiration, the many contributions that Carl made to global health and to the
Department of International Health, as well as his important contributions to
primary health care. But in the early 90s Carl Taylor was recognized by President
Bill Clinton, here with a very distinguished award for his contribution
to global health, and you see that, in spite of their philosophical differences
Jim Grant and Carl Taylor continued to be close friends throughout the remainder of
their lives. And after Carl came back from China, he became engaged in a whole new
approach to Community Health and International Health, that he was
fascinated with, and he thought had tremendous potential, that became known as
the Seed Scale Concept, and it's described in some detail in their book Just and
Lasting Change. But Carl worked with his son Daniel, who you see on the left here,
who was the founder of Future Generations, for almost two decades in the
establishment of program s that utilized the Seed Scale principles, which are
focused broadly on development going beyond health, and concern with the
environment, and grassroots participation for broader development issues, and I
don't have time to talk about that here. But the Future Generations program started
with a lot of work in Nepal and on the Tibet side of Mount Everest. These are
community health workers in the Mt. Everest region of Tibet that they helped
establish, and also through their work in Future Generations, they developed Seed
Scale programs in Peru and Arunachal Pradesh, which is an isolated corner of
northeast India and Afghanistan. And in fact, Carl spent two years, right before
he died, from age 88 to 90, as the Country Director for Future Generations in
Afghanistan, and here you see him sitting with some local community people, talking
about health issues, which is what he loved to do. He was a person of the
villages, and he saw this as an opportunity to end up his life, going back
to his roots. But you see here their book Just and Lasting Change, When Communities
Own Their Futures, and so you can tell simply by the title the, the nature of
this very different from the biomedical model. And these are just a few of the
concepts of the SEED-SCALE Paradigm that he and his son, Daniel, developed, but a
whole approach towards working with communities to try to engage them, empower
them to be able to improve their health, but at the same time, scale it up in a
large scale, and many of these ideas came from Jamkhed as well. Not only has Jamkhed
been influential in development of Alma-Ata it's also been influential in
Carl Taylor's thinking, and so, embedded in here is some. variety things that
developed at Jamkhed, but through other experience that Carl has as well, and this
idea of three-way partnership, linking the top-down with the bottom-up through and
outside agent. The community being the bottom-up, of course, the top-down can be
defined in different ways. But, they saw many examples in which an outside agent
can help to do that, and we need more of that because it's so hard to bring about.
I had the privilege, after Carl died in early 2010, to work with his son, Henry
Taylor, who's on the faculty here, and colleague at USAID towards editing some of
Carl's last writing before he died that became published in the Lancet, and
interestingly enough, for the purpose of our lecture it, the title of this, and
Carl was thinking about this right until his last days what would Jim Grant say if
he were alive today, what would his stance be on these issues about the selective
versus more horizontal approaches? And, these last words, I think, are very
powerful and, and they touch on so many things that we have been talking about in
this lecture, so I thought I would just share them with you. Our greatest mistake
has been to oversimplify the Alma-Ata vision of primary health care. Real social
change occurs when officials and people, that is, the top-down and the bottom-up,
when officials and people, with relevant knowledge and resources come together,
with communities, in joint action around mutual priorities. And that's the
outside-in agent that, needs to be there, to pull these two very different groups
together. The interplay between comprehensive or horizontal, and selective
or vertical approaches requires careful blending. It is my conviction that, if Jim
were here now, he would champion this blending, adapted to the local context
with a focus on communities, to ignite the next child survival and development
revolution. One of the articles in the Alma-Ata series in The Lancet in 2008 was
on community participation, and I think it's a reflection of the growing
recognition of what's been missing in so much of global health work which is a real
partnership with the community and a real engagement of the community, and the
enormous benefits that can come from community empowerment and womens'
empowerment for the sake of health in a technical and real medical kind of way,
and the randomized control trial that I mentioned reported in t he Lancet from
community participatory women's groups is one of many examples now, of the power of
this approach. The figure on equity empowerment, and, the one on the Women's
Group Community, Mobilization Action Cycle, come from this article. But, the
process of transformation of women that was built into this study that I mentioned
earlier from De Paul is one of the emerging themes in global health. It's
going to increasingly gain more power, I think, as we better understand how to
implement this and measure its impact for health. So let us summarize the vast
material that we have reviewed here. And say that, from my standpoint, primary
health care is a simple concept on the surface, but when you get into it, you
very quickly come to realize that is a, a very complex and very fascinating area to
be thinking about in the field of international health and global health. I
think, increasingly, people are recognizing it as a very important
fundamental strategy for improving the health of populations in a long term and
sustainable way, and we desperately need to find locally appropriate ways to link
vertical and horizontal approaches in a way that's equitable, engages communities
as partners, promotes community empowerment through the Seed Scale process
that I mentioned, which Carl and his son were so capable at identifying and
conceptualizing. This author from the Lancet, spoke to this very important
issue, as we move forward here in development of programs and global health.
Walley wrote that the emphasis has to shift from showing immediate results from
single interventions, to creating integrated long-term sustainable, and I
have added here, effective health systems, which can be built from a more selective
primary health-care start. So, this whole notion of using, very selective
approaches, as an interim way, in which we can build these more integrated programs,
I think, is a very powerful idea. And I love this statement from Carl Taylor,
which again reflects the need for responding to the local context and whe re
the people are, and what's practical and appropriate within the local resources
that are available. There is no universal solution, but there is a universal process
to find appropriate local solutions. And I think that is the challenge for primary
health care, and for much of global health as we move forward. So thank you for
paying attention. I hope you've learned some new things, and I hope your interest
in this important area is growing as a result of this.