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 Primary
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 programs 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 the 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 where 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.