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GETTING TO NGO OZ By Robin Friedlander
Published on March 2009 In the world of global health, every NGO, volunteer, private philanthropist, and local government office is like Dorothy searching for the Emerald City. In this case, however, The Wizard of Oz happens to be the UN and the WHO, the two powers in international health that decide which projects, donations, and development goals will ultimately find a home. If Bill Gates wants to donate one million dollars to Banepa, Nepal, for universal teeth whitening, he has to get their approval. So when you work for an INGO (international non-government organization), your elegant plan for anti-retroviral donations, or cataract surgery clinics, or in my case cervical cancer screenings with the INGO Jhpiego, amounts to little more than a good story. That is, until you are granted a meeting with Oz. To get to this Oz you must steal behind blast-proof gates and traverse a maze of white UN-emblazoned SUVs, and this is the easy part. The hard part is convincing someone there to give you, your organization, or what you think is an effective and important public health initiative, a moment’s notice in the first place. An audience with the UN is no small achievement. Jhpiego organizes women's and reproductive health projects all over the world. It is affiliated with Johns Hopkins University and has funding from important donors like the Gates Foundation and USAID. One of Jhpiego’s biggest projects is CECAP, a cervical cancer prevention program that has gone well so far in a number of countries, including Malawi, Ghana, Thailand, and the Philippines. Cervical cancer is the number one cancer-killer of women in the world (breast cancer is more common, but cervical is more deadly) and it mostly affects the developing world. In the US and the UK few women get cervical cancer because these countries have established screening programs. If you forget to show up for your pap smear in England the government literally calls you at home. Click on any of the images below to start the image gallery. You must have JavaScript enabled on your browser in order for the gallery to work properly. The gallery is best viewed with the Firefox browser.
In the developing world there tend to be more pressing problems. Resources are scarce, and getting women to live through childbirth is enough of a challenge, forget prevention and diseases like cancer. Cervical cancer, however, is unique. First, it is caused by a sexually transmitted disease called the human papillomavirus (HPV). Eighty percent of people in the US have HPV, which also causes warts, and more and more people in the developing world have the virus now too. In addition, because cervical cancer kills women in the prime of their lives, it takes an especially significant socioeconomic toll on communities and families. But unlike many other types of cancer, cervical is often preventable. If you screen for cervical cancer, either using a pap smear or by Visual Inspection with Acetic Acid (VIA), it is possible to catch the transformation of normal cells into cancer cells and scrape, freeze, or burn them off. Both screening and treatment are relatively easy, and in the developed world they are commonplace. But in countries like Nepal, women rarely see a gynecologist unless they are having an immediate and life threatening problem, and even then they might be reluctant go to a doctor. There is no "culture of prevention," to put it in NGO-speak. Still, Nepal’s health care system is further developed than that of a lot of countries in Africa with similar GDPs. Nepal has chemotherapy and radiation technologies, one major cancer hospital, and a government clinic in most of its 72 districts. Nepal also shares a border with India, which serves as a pipeline for advances in medical science. This makes Nepal a reasonable place to introduce cervical cancer prevention, which is where I, novice medical student and former radio lackey, came in. My job in Kathmandu was to write a situational analysis. I was assigned to determine which, if any, strategies addressing cervical cancer had been implemented so far, and to assess what the obstacles would be to starting a prevention program in the future. Analyzing this situation meant lots of tea, because to figure anything out in Nepal you have to make personal visits. People are not comfortable talking on the phone, even to answer simple questions, nevermind email. It is the polar opposite of the public relations world that I used to inhabit as a radio producer, where publicists, agents, and magazine editors never want to see your face if they can help it. In Nepal they want to see it, maybe even touch it, and definitely feed it tea. The many meetings I attended gave me the opportunity to interview Nepal’s experts in health and development, and to understand the work they were doing. I met with representatives from NGOs like Family Health International and the Safe Motherhood Network, as well as local cancer specialists and women’s health advocates. Sometimes my task was to present the details of Jhpiego’s cervical prevention plan. Other times I used diagrams, pictures, and powerpoint slides to explain what exactly cervical cancer is, and why a particular official or group should care. I also had the chance travel to remote medical schools, to witness squalid emergency rooms where medical records were written in pencil on damp log books, and to spend time observing deliveries at Kathmandu’s Maternity Hospital. For once I felt like I was doing something useful during my medical training, compared to studying for multiple-choice tests. The first thing I discovered was that there was no official data on how many women in Nepal actually have cervical cancer, or on how many women are at risk. Collecting enough data to estimate these figures, and therefore to demonstrate the urgency of prevention, became one of the primary goals of my work. In addition I had to understand everything from the local cost of screening supplies, to women’s cultural attitudes toward gynecological care and talking about sexual behavior, to the extent, successes, and failures, of the limited cervical cancer screening camps that one NGO and two local hospitals had conducted on their own initiative. It took about a month, but eventually I accumulated enough information to write my report. The purpose of the document was to convince the ultimate judges at the UN and the WHO of the importance, feasibility, and necessity, of backing the implementation of a national cervical cancer screening program in Nepal. Without their support, neither the government, nor the other organizations crucial to the success of such a program, would have the impetus or the funding to go forward. I initially presented my report to Nepal’s WHO Chairwoman for Reproductive Health a woman who “sits” both physically and metaphorically in the UN offices. Two days later I would present the report to her again, in a meeting that included the important government officials and other stakeholders who will play a part in any future cervical cancer prevention effort. Going forward the plan is for a coalition of NGOs, politicians, and government health officials to write national guidelines for a screening program. The hope is that someday, with money from the government and people like Bill Gates, Nepali women will be regularly screened for cervical cancer. But before I got to see my work come to fruition, I was on a plane home to New York and medical school. I am still waiting to hear of any progress on cervical cancer screening from my former colleagues in Kathmandu, and hoping that having been to Oz for tea was not just the end of a month-long dream. When I think back on my work; meetings with Nepal’s reproductive health elite, a 26-page report finished in the nick of time, numerous terrifying bus rides on mountain roads to obscure hospitals in rain forests, and becoming the country expert on a topic I knew nothing about when I landed in Kathmandu; I cannot help but think of all the hardworking people at local and international NGOs worldwide, and the unique industry of which they are a part. Usually, when companies compete for a contract, their driving interest is profit. But NGOs in the health sector are bidding for the chance to save lives, feed the hungry, and cure disease. They all have a common interest at heart, and their individual glory comes in being selected to do things their way. The UN and the WHO often act like ringside judges in the selection process, doling out funding to favorite organizations and causes. The system creates competition, which ultimately leads to better ways to help people, and yet also leads to staggering redundancy. Many reproductive health-related NGOs in Nepal have a plan for screening and treating cervical cancer, yet they lack the central coordination needed to efficiently get a nationwide plan off the ground. Meanwhile every one of them is clamoring to be heard by the UN for one cause or another. It is a medieval court system flourishing in the twenty-first century. My experience showed me that those working on the ground to improve health across the developing world need to be better integrated with the institutions that fund their work, and vice versa. I hope that my generation of future doctors and public health leaders will seize the opportunity afforded by improvements in both medical and communication technologies to bridge the gap among organizations all working towards the same goals. In the meantime, the NGOs, health workers and government officials working on behalf of health worldwide will continue to make progress in the land of Oz. Robin Friedlander is a second-year medical student at Columbia University. After graduating in 2003 from the University of Pennsylvania with a degree in International Relations, she worked in New York City, first at New York University Medical Center in psychiatry research, and later as a producer for Dr. Mehmet Oz’s radio show on Oprah Winfrey’s Hapro Radio station. In the summer of 2008 she traveled to Kathmandu to work with Jhpiego, an INGO based in Baltimore, Maryland, on implementing a cervical cancer screening program in Nepal. For questions or comments please contact Robin at ref2121@columbia.edu or read her blog, Live From Kathmandu. Article downloaded from http://www.globalpulsejournal.com/2009_friedlander_robin_ngo_oz.html | ||||||||
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