By Maryska Valentine and Caroline Liou, Department of Global Health, UW
It’s fair to say that Dr. Agnès Binagwaho — MD, M(Ped), PhD, Vice Chancellor of the University of Global Health Equity (UGHE), former Minister of Health of Rwanda, and a member of the National Academy of Medicine (NAM) — is among the world’s foremost global health champions of our time.
Dr. Agnès, as she likes to be called, was recently in Seattle where she gave a talk for UW students on “Transforming Global Health Through Education”. We had the chance to talk global health with her and get her take on effective approaches to global health and why health is key to development.
You led Rwanda's National AIDS Control Commission from 2002 to 2008 during which time HIV care dramatically improved. According to the U.N., the number of people dying from HIV each year fell from 15,000 to 7,700 — 44 percent in six years — and the number of new infections was cut in half. In 2011, you developed a HPV vaccination program and nearly 93% of eligible girls were vaccinated. What was the key to these incredible successes?
The key behind this functional national program is implementation science, which is what we teach at The University of Global Health Equity. We use a scientific, evidence-based approach – this together with focusing on making sure your program serves the most vulnerable, to get everyone in. It was not me in my office designing a program for the people, we designed it with the people who are going to implement and facilitate it, with the people who are the beneficiaries, and with those who are near or related to the beneficiaries. These are the principles behind our successful programs, not only on HIV and HPV, but malaria, and more.
In Rwanda, 93% of girls are now vaccinated for HPV, as well as 11 other vaccines. This is because of the way health is delivered through a participatory approach. We create trust. To create trust we cannot lie to the people – when it’s hard, we need to tell the people we will suffer but we have to pass through this, as we don’t have a better solution. Because there is trust, when you have a new vaccine and you explain what the new vaccine will do, they trust you. For the HPV vaccine, we had to talk about prevention of cancer. Cancer wasn’t really known at the time because it is a non-communicable disease in a population with low life expectancy. Women were dying giving birth, from malaria or HIV. Now that people live longer, we have started to talk about cancer. In 2011 when we started the HPV vaccine, people in villages didn’t really know what cancer is. Women knew what the uterus is, but they didn’t know they had a cervix. We had to talk about a disease in a place of your body you didn’t know you had. It was an education process that went smoothly because there was trust. When we talk about something totally new we raise questions, and where do women go when they have questions? They go to the people they know and trust – the pastors, teachers, local leaders, and community health workers. So we start by educating those people. Then we educate the media, and parliamentarians. Then after these people understand, we start the national campaign. So when parents ask anyone about the HPV vaccine, they find out it’s true. If the pastor says one thing, and I say something else, they will trust the pastor. So we used this approach to cultivate trust. It’s about respect. The right to information and participation are human rights. It’s a duty to give room for people to participate in their own health, and to do that they need to be informed.
You led the development of The University of Global Health Equity and you serve as the university's Vice Chancellor – how is the approach to global health at your university different from other health universities or global health programs?
We are unique because we have equity in the heart of everything we do. We have named the university like this because to sustain the program we need to be inclusive, we need to work so everyone can benefit. And we need to consider those who are being missed – why are some people not benefitting? Do they have something better, or are they out of track? If they’re out of track, it’s the business of everybody. We are different because we focus on the most vulnerable. And we focus on implementation science – behind every program that works is the science of implementation. We are also unique because we are based in a rural area, as the majority of people who are poor live in rural areas. We want to educate people to attain high-level skills, a sense of equity and are happy to live and serve in rural areas where the majority of people live.
You received the Roux Prize from the Institute for Health Metrics and Evaluation (IHME) at the University of Washington. Given your connections with UW, how can an institution like UW Department of Global Health do important global health work?
We should partner because you are great and we are great! The University of Global Health Equity cannot be global on a hill in Rwanda – but it can be global if we have global connections. Same for DGH UW. There are so many players in GH –and I strongly believe we can achieve far more if we work together. We both have young people, and less-young-people, to educate – but all of us work for a better world so we have to work together.
At the recent Women in Global Health Leadership meeting at Stanford University that you participated in, participants discussed how women continue to represent most of the health workforce worldwide yet remain the minority in global health leadership. What advice would you give to young women and men in health to help us achieve gender equity in health leadership?
Gender equity in health leadership is about opportunities for advancing and promoting women, as you would promote and give advancement and advantage to men. One difference between women and men is that for biological and social reasons, women can be out of their working track during the period where they may have kids and may be breastfeeding, which can also be a competitive time for their professional advancement. Secondly, the majority of institutions don’t offer advantages to women because of this. This is a social and structural element that disadvantages women to reach higher positions. This needs to be changed. I think pregnancy and lactation periods should be considered as a service to the nation and people, and every woman should be awarded as if she is expecting to give birth to or nurturing the next Nobel prize winner. It should be considered a mentorship.
You’ve said that "health is key in development.” Can you explain why this is?
First of all you need to be healthy to work or study. Without a healthy working force, there is no advancement for a country. But also, if you are sick, the money you have is spent on recovering and maintaining health, not for developing your family or community. Developing your family or community is key to developing a country. Otherwise, you may have a sector or only some people who will remain healthy and develop, and the rest who will remain vulnerable and poor, and will pull down the overall development of the country. There will be development in two speeds that is not sustainable – and this can create social unrest. People who have nothing to lose will destroy what the others try to build, so the best way to develop is inclusive development. For this we need to be healthy.