by Osefame Ewaleifoh, PhD/MPH candidate
A few weeks ago we visited Douentza, a picturesque community south of the Mopti region of Mali as part of the Northwestern Access to Health Project (AHP). I was struck by the beauty and joy of the local children playing and running down the dusty streets. You could hardly tell from the expressions on their faces that this country had gone through conflict just a few months ago. As we drove away leaving the playing children behind a question lingered in my heart, what is the future of these beautiful children and what is the most meaningful investment we can make in that future?
Mali, like much of Sub Saharan Africa, lacks adequate medical and public health resources – children die every day from entirely preventable conditions like malaria and malnutrition. Still, despite such obvious needs and our best intentions, we are faced with the stark reality of extremely limited resources. Consequently, any meaningful and sustainable long term solutions to public health in the region must find a way to reconcile the reality of limited resources with the reality of dire need.
There is really nothing new about the reality of limited resources. A central premise of modern economics and Adam Smith’s 1776 Wealth of Nations[i] treatise was the realization that humans individually cannot fulfill all their needs and wants because the means we have are limited, thus division of labor and the assignment of preferences become imperative. To address this reality of limited resources in our personal lives we adopt a scale of preference (do I buy this car or do I save for a vacation?) and opportunity cost (what can I sacrifice to get what I want the most?). The realization that our needs are limited and the capacity to intelligently allocate our resources to meet those needs, in the order of importance, is the core of every sound personal and corporate strategic plan. Perhaps it is time we embrace and adopt the concepts of scale of preference and opportunity cost as we think about the future of public health in developing regions of the world.
The central challenge in resource allocation in public health is the fact that everything seems “urgent” and “important”. It seems both important and urgent that we address infectious diseases, maternal mortality, clean water access, malnutrition etc., but is this really true or is this urgency fabricated? If we really care about sustainable and impactful long-term change we must ask ourselves the hard question – not what matters, but in the long term what will make the most significant impact? This position does not suggest that each of these causes are not important, they all are – it raises the question, where is the epicenter?
In the Seven Habits of Highly Effective People Steven Covey speaks of the quadrants of choice[ii]. In summary he argues that every decision we make falls into 4 distinct quadrants: i) Urgent and important, ii) Not urgent but important, iii) Urgent but not important, and finally iv) Not urgent and not important. The wisdom of the Covey quadrant is how much it empowers us to triage. Until now the four quadrants have been used primarily as a corporate and personal tool to improve resource and time management. I submit that contemporary public health could gain from modeling grounded in the quadrant of choices.
The Covey quadrants becomes particularly powerful as we consider complicated resource allocation questions like how to better allocate limited resources to address the overwhelming public health needs in Africa and the developing world. From malaria to malnutrition and maternal mortality – there are simply not enough resources internally or externally to meet the economic and public health needs in Mali or Sub-Saharan Africa in general. To embrace this reality is to re-evaluate our criteria for choosing and supporting projects that we believe will truly improve live outcomes. As we encounter public health needs we must continuously ask ourselves the question – where does this fall on the quadrant of choice?
Currently the biggest driver of public health resource allocation is often perceived need – an external interpretation and projection of what we think is needed by others. The limitation of perceived need as a basis of resource allocation is the fact that it is fundamentally an assumption. Perhaps it is time to replace perceived need with long-term strategic planning – grounded by community consultation. The focus on the long term impact might help provide clarity in the choice between what’s important and what’s urgent. The reality is that most of the public health work we do in the region now – even if we succeed – in the long term they wont really matter. Thus we must ask the question, fifty years from now what investment would have made the most impact? What investment would have empowered the community to help themselves stand – water access, hunger, infectious diseases or education? I submit that while each of these causes is a worthy contribution, comprehensive world-class education is the single most significant investment that can be made to address the public health need in Africa.
Education as a public health tool falls under quadrant two of the Covey quadrants – it is not urgent but it is important. In the short term, education seems like it does not matter very much; however in the long term education might be one of the only factors that actually matters. In a world of limited resources, we could build an Africa with fat, healthy but illiterate children who remain perpetually dependent on the goodwill of others or we could invest in the future of a lean Africa with a goal of 100% literacy, empowerment and intellectual independence.
There are no magic bullets to solving the complex public health problems in the world, but education comes very close. Based on empirical studies and personal anecdotes, it is increasingly clear that illiteracy is the epicenter of a lot of public health challenges in developing countries. Illiteracy affects everything from economic outcome to malnutrition to personal agency. According to Dr. Yacouba Guindo, a community physician in Mali, “If the problem with malnutrition was just poverty, the wealthy in the community will be well-nourished. However, this is not the case. There are malnourished kids from wealthy families and well-nourished kids in poor families. Contrary to widespread opinions, the real problem driver of malnutrition was not poverty; it was illiteracy and poor education.”
For most in the West it is difficult to appreciate the full implication of illiteracy on a community. Recent data show that in sub-Saharan Africa only about 40% of the population spent at least four years in school and learned the basics. This means close to 60% of the population is functionally illiterate. All of this in 2014, when humans now routinely talk about space exploration and Mars as the next frontier. More importantly, imagine the future of a community where only 40% of the children ever spent any time in school.
According to studies and modeling simulations by UNESCO (fig below), focusing on education as a public health strategy will lead to a decrease in child marriages, early birth and fertility rates. This point is striking because some of these issues are complex multi-factorial sometimes cultural challenges that little else can change. We can keep running around trying to tackle each of these issues individually or we can focus on the epicenter – providing a world-class comprehensive education for every child.
Just one generation ago, my family lived in the middle of nowhere in a small village called Obedu in West Africa. There was no doctor, no electricity, no running water and one school, with a few very good teachers. I am here today because my father had the rare opportunity to go to school – that opportunity changed everything. There are lots of really great ideas on how to contribute to public health in Africa. However, I am convinced that in the long term, the single greatest true investment to public health will be to commit our limited resources to a world class education for every child.
Take action for change:
– Call on world leaders to ensure education’s central place in all new development goals after 2015 by visiting and pledging at http://www.education-transforms.org/en/?page_id=159
– Learn more about the impact of global education in improving quality of life at http://www.education-transforms.org/en/ and http://www.unesco.org/new/en/education/themes/leading-the-international-agenda/efareport/statistics/
– Share and support “Girl Rising,” a global campaign for girls’ education. http://girlrising.com/
[i] An Inquiry Into the Nature and Causes of the Wealth of Nations by Adam Smith.1776 http://www2.hn.psu.edu/faculty/jmanis/adam-smith/wealth-nations.pdf
[ii] The Seven Habits of Highly Effective people, Steven Covey. Put first things first. pg.151