“Feel-good programming that makes you think, too”
–Canwest News Service

ABOUT THE ISSUE

Sub-Saharan Africa is the world’s deadliest place to give birth. Each year over a quarter of a million women die in childbirth in the region. But Mozambique is combating high maternal death rates by implementing unconventional programs.

After the country declared its independence from 400 years of Portuguese rule in 1975, a civil war raged for 16 years, killing a million people and wrecking the country’s infrastructure. By the time the war ended in 1992, the health care system was devastated and one in ten women were dying in childbirth. There were only 18 obstetricians for a population of 19 million. Since then, Mozambique has cut the maternal death rate in half.

As the figures now stand, the country is one of the few countries on track to achieve the fifth United Nations Millennium Development goal to reduce the maternal death rate by 75 percent by 2015. In 2004, Mozambique introduced a new health care initiative to train midwives in emergency obstetric care in an attempt to guarantee access to quality medical care during pregnancy and childbirth.

ABOUT THE FILM

The film Birth of a Surgeon follows Emilia Cumbane, one of the first midwives-in-training. She performs Cesareans and hysterectomies in makeshift operating rooms in rural Mozambique. We follow Cumbane from her home in the Mozambican capital Maputo, into intensive medical classes, through night shifts in the delivery wards, and watch as she fights for recognition of her surgical competence.

With more than half a million women dying in pregnancy or childbirth worldwide, Mozambique’s surgical training programs are being hailed as a model solution in confronting the maternal health crisis facing developing countries. The film captures one woman’s story on the frontlines of improving maternal mortality but it also demonstrates how low-cost, community-based health initiatives are changing the face of public health in Africa.

“I like to be a midwife,” Cumbane says. “I think it’s a good profession – to produce people.”

The first class of almost 30 surgical midwives trained in delivery techniques and advanced surgery graduate in July 2008. For the 2009 update, WIDE ANGLE host Aaron Brown travels to a rural hospital in Mozambique to meet with Cumbane to see how both she and the program are faring. Cumbane, now the head of the maternal ward, has a two-week-old baby herself, and Brown explores the successes and obstacles she has faced over the last year, as she has tried to juggle her personal and professional commitments, all the while working to help save women’s lives.

CIA World Factbook: Mozambique
Information about Mozambique’s geography, population, government, military and economy.

BBC Country Profile: Mozambique
Information about Mozambique’s history, leadership, and media, with links to BBC stories on the country.

New York Times Topics: Mozambique
The New York Times page includes breaking news and archival articles about Mozambique.

MOZAMBIQUE AND UNITED NATIONS ORGANIZATIONS (GENERAL)

UNICEF: Mozambique
An overview of United Nations Children’s Fund information and statistics on Mozambique.

World Health Organization Country Profile: Mozambique
An overview of health concerns in Mozambique that includes a country profile, a page dedicated to the WHO’s actions in Mozambique, a page dedicated to the UN pilot initiative in Mozambique, and the WHO’s areas of work in Mozambique.

UN Mozambique: 2008 Mozambique Report on the Millennium Development Goals
Report evaluates Mozambique’s progress, during the last five years, towards achieving its Millennium Development Goals with a focus on the areas of economic growth, access to education, reductions in infant mortality rates, and improvements in environmental use regulation.

MDG Monitor: Mozambique (Progress in Reducing Poverty and Child Mortality)
An initiative of the United Nations that tracks the efforts of the second national poverty reduction strategy developed by the government of Mozambique, but with deadlines guided by the MDG targets. The site includes a breakdown of progress by goal for Mozambique.

CHILD AND MATERNAL MORTALITY

White Ribbon Alliance
The White Ribbon Alliance for Safe Motherhood is an international coalition of individuals and organizations formed to promote increased public awareness of the need to make pregnancy and childbirth safe for all women and newborns in the developing, as well as, developed countries. It has members active in 140 countries around the globe.

World Health Organization: Maternal Health
A compendium of information from the United Nations agency that directs and coordinates global public health policies including the issue of maternal health- site includes general information on maternal mortality, statistics and technical information, publications, multimedia, and information on WHO programs and activities.

World Health Organization: Making Pregnancy Safer in Mozambique
A situation analysis of the state of maternal health in Mozambique over the last ten years. The Demographic and Health Surveys highlight national improvements related to the use of reproductive health services in the country. In 2007, the WHO released a Report on Iniquities in Maternal and Child Health in Mozambique (PDF).

UNICEF: The State of the World’s Children 2009 (Maternal and Newborn Health)
A report that examines important issues in maternal and newborn health and outlines the latest paradigms in health programming and policies for mothers and newborns aimed at improving maternal and neonatal health with a focus on Africa.

Averting Maternal Death and Disability Program
Columbia University’s Mailman School of Public Health works with developing countries and international agencies to improve availability, quality and utilization of emergency obstetric care. The program’s midlevelproviders.org compiles research about mid-level providers, also known as non-physician clinicians, who deliver essential clinical services and emergency obstetric care.

Women Deliver
A global initiative to reduce the maternal and newborn death and disability rate in the developing world. Family Care International is the host organization for the Women Deliver program.

MIDWIFERY IN THE UNITED STATES

North American Registry of Midwives
The North American Registry of Midwives (NARM) is an international certification agency that establishes and administers certification for the credential of “Certified Professional Midwife” (CPM). A CPM is a credentialed, independent practitioner who has met entry-level NARM standards who has completed both a written examination and a skills assessment both inside and outside of hospital settings.

Midwives Alliance of North America
The Midwives Alliance of North America is a professional organization for all midwives that aims to unify and strengthen the midwifery profession in order to improve the quality of health care for mothers and babies.

American College of Nurse-Midwives
The American College of Nurse-Midwives is a professional organization that represents certified nurse-midwives and certified midwives. It administers and promotes continuing-education programs, establishes clinical practice standards, and provides research for nurse-midwives and midwives in the United States.

Midwifery Education Accreditation Council
The Midwifery Education Accreditation Council is a federally-recognized accrediting agency approved by the Department of Education that has developed education standards and criteria for midwives.

American Midwifery Certification Board
The American Midwifery Certification Board is a American organization that administers certification for Certified Nurse-Midwives and Certified Midwives.

“Part of the reason this is so important is that throughout Africa, the rate of infant mortality but also maternal mortality is still far too high,” Obama told the pool of reporters following him. Ghana’s maternal mortality ratio is about 40 times that of the United States.

Obama’s visit put the spotlight on a United Nation’s Millenium Development Goal (MDG) that, according to a new report (PDF), has seen the least progress so far out of the collection of goals aimed at halving extreme poverty by 2015. The sluggish gains made in reducing maternal mortality over the past eight years – MDG 5 – may even be reversed, especially in the poverty-stricken countries of sub-Saharan Africa and South Asia. In fact, the global economic crisis could hamper progress on all eight of the targets established by world leaders in this “blueprint for a better world.”

“Maybe this is an opportunity,” notes Francesca Perucci, chief of Statistical Planning and Development for the U.N. Statistical Division, which coordinated data gathering and preparation of the 2009 report. “Maybe donor countries will finally start giving attention to the message that is loud and clear: We don’t see progress on MDG 5.”

The halfway progress assessment shows that the developing world still accounts for 99 percent of women who die from complications during pregnancy and childbirth. The U.N. and its partner agencies measure progress on maternal mortality by tracking cause of death and monitoring access to emergency obstetric care and prenatal visits. Over the last decade, the U.N. figures have barely changed.

So far, donor countries have expressed their intention to maintain the funding targets they set for the Millenium Development Goals in 2000, but the targets are a percentage of their gross domestic product and the actual dollar amount will be reduced as the economy contracts.

“You have to consider this is a time when the poorest countries will see their own internal domestic resources decrease, so they’ll need additional money, not less,” said Perucci. “If aid decreases, this will jeopardize any positive trends.”

The limited resources have led agencies to focus on projects that deliver immediate results, such as purchasing and delivering bed nets to reduce malaria. This will likely mean less less funding for equipping hospitals with staff that can treat pregnancy complications.

“With maternal mortality, you have to rethink the overall health system. It’s a lot more complicated,” said Perucci. To reduce maternal mortality, the U.N. suggests building more hospitals, improving transportation systems so that women can reach them in time, and informing expectant mothers of what they need to do when complications arise.

Access to family planning services could also improve maternal health. Contraceptive access hovers around 22 percent in sub-Saharan Africa, and is especially limited in refugee camps. But even these programs may be hard to expand. The U.N. report points out that funding gaps for family planning programs have been conspicuous since the mid-1990s.

This week WIDE ANGLE travels to Mozambique, where a bold grassroots initiative to train midwives in advanced life-saving surgery has significantly reduced the country’s maternal mortality rate. The film Birth of a Surgeon follows Emilia Cumbane, one of the first midwives-in-training. She performs cesarean sections and hysterectomies in makeshift operating rooms in rural Mozambique.  Check your local PBS listings for air times.

The film Birth of a Surgeon follows Emilia Cumbane, one of the first midwives-in-training. She performs Cesareans and hysterectomies in makeshift operating rooms in rural Mozambique. We follow Cumbane from her home in the Mozambican capital Maputo, into intensive medical classes, through night shifts in the delivery wards, and watch as she fights for recognition of her surgical competence.

Click below to listen to a discussion about the causes of maternal death, the importance of maternal health and the progress that is being made in Mozambique and around the world now that this issue is on the international development agenda.
Lynn Freedman is a human rights attorney and the Director of AMDD, Averting Maternal Death and Disability.
Helen de Pinho is a physician from South Africa who works with AMDD. She recently traveled to Mozambique to meet with mid-level medical providers there. EXPERT INTERVIEW TRANSCRIPT:
LYNN FREEDMAN AND HELEN de PINHO

LYNN FREEDMAN: Women everywhere in the world who die in childbirth die from basically the same set of causes. Mostly direct obstetric causes—things like bleeding, or hemorrhaging, infection, obstructed labor. We know the medical interventions that will save a woman’s life if she has one of those complications. The big, big issue is getting those medical interventions to the women who need them, and so that’s where the big challenge comes in—ensuring that women in remote rural areas, women who perhaps don’t have the money to get to a facility much less get into the facility, pay for the services. To make sure women in that position get access to life-saving care.

There’s no question that the current number of surgeons and surgical technicians in Mozambique cannot meet the enormous need for emergency obstetric care.

HELEN DE PINHO: There are 26 obstetricians in Mozambique. Fourteen of them are in the central hospital in Maputo, and I think only about three or four or five are actually out in the rural area, so that gives you an idea of distribution and numbers. And a similar kind of distribution pattern for surgeons in Mozambique. The role of the non-physician clinician has always been there in many of these countries; that’s not new. The surgical midwife, yes, that is new. And that will change, but what that would do is strengthen what’s already happening. It doesn’t shift…it doesn’t displace doctors in any way, because they’re just simply not there.

WIDE ANGLE: Lynn, you mentioned that there’s this new energy about addressing maternal mortality. Can you speak about this new energy, where it’s come from, and why now?

LYNN FREEDMAN: Well, I think maternal mortality has…has certainly risen to the top of the development agenda, helped enormously by the fact that it is one of the Millennium Development Goals.

The Millennium Development Goals are a set of eight goals that the U.N. general assembly passed at the turn of the millennium in the year 2000 to guide poverty reduction efforts in the world in the coming millennium, or at least the coming 15 years.

But they also include three health goals. One is HIV, TB and Malaria. Another is to reduce child mortality. And MDG 5 is to improve maternal health with two goals: one is to reduce maternal mortality by 75% and the second target under improved maternal health is to have universal access to reproductive health services.

So that has put maternal mortality itself on the health and development agenda.

HELEN DE PINHO: …if I can just talk to what’s happening in Mozambique at that. What we see is first of all very high-level commitment to reducing maternal mortality. And then also to—recognizing the sort of continuum of care, from when the woman first becomes pregnant or even before she comes pregnant, to make sure that –that young girls are adequately fed, that—that they are nutritionally well—well-nourished. That there is family planning accessible. The policies are good, they’re there. And now it’s a matter of actually getting them implemented in all the areas.

WIDE ANGLE: How will that later affect the health of the entire system?

LYNN FREEDMAN: Well, there’s no question that a huge proportion of newborn deaths are actually attributable to the things that happen during pregnancy and delivery. We certainly want to make sure we pay attention to and care about the woman herself and her survival. But, we also acknowledge that the survival and life of a newborn is very closely linked to what happens to the mother and indeed, the life, well-being and survival of the rest of her family, not just thethe baby she’s giving birth to right then. The ramifications of maternal death or maternal survival go well beyond just her children. It’s her family, it’s her community, it’s productive work for the country, and it’s her own right to be a participating member for society.

WIDE ANGLE: Thank you Lynn, and thank you, Helen.

LYNN FREEDMAN: Our pleasure.

HELEN DE PINHO: It is a pleasure, thank you.

Download the mp3 of this interview

Below is a list of the MDGs that relate to health concerns, and a look at Mozambique’s progress.

Sources: Report on the Millennium Development Goals: Mozambique 2005 (pdf), The State of the World’s Children 2008: Child Survival (UNICEF)

DR. MARGARET CHAN:
Thank you.

AARON BROWN:
What’d you think of the film?

DR. MARGARET CHAN:
I really like it. It’s a very compelling story. With this film, you are bringing to the American people issues that are happening far away, in far away countries. But these are issues that we need to pay attention to. So, you, basically, are opening up a world for the American people and this compelling story is important. And I thank you.

AARON BROWN:
What are the limits to this kind of medicine? When I first watched the film, the idea of making an incision to me was unimaginable. I don’t think I could do that. But, a cesarean, in and of itself, is not the most complicated medical procedure there is.

DR. MARGARET CHAN:
No, it is still not simple.

AARON BROWN:
None of them is simple. But, so what are the limits to this kind of medicine? Can we take kids or young people have gone through high school and teach them to do other medical things? And what point do we have to say, “No, we need a doctor?” Because, fundamentally, what we have here is a shortage of doctors.

DR. MARGARET CHAN:
Absolutely. I mean, you raise a good point. Let me just comment on the shortage of doctors. The World Health Organization did a world health report in 2006. In the whole world about 60 countries are in dire situation in terms of having enough doctors. And many of these countries are in Sub-Saharan Africa. You know, that part of the world alone needs one million doctors. Now, it takes a long time to train that number of doctors, doesn’t it?

AARON BROWN:
Yeah.

DR. MARGARET CHAN:
But, the ministers of health in these countries on a daily basis deal with the here and now. People are dying. They don’t have enough doctors. If I recall, what I saw on the film, the Vice Minister of Health was asking the question, “When your people are dying, when you don’t have doctors, what are you going to do?”

So, I think, the Mozambique story is a story of courage. It is a story of innovation. And this is what we are talking about. Can we come up with some ways– new ways of thinking? Think out of the box. How can we train enough people to provide care? And I put it to you, the world now has about one billion people who have little or no access to care. Now, that’s the health imperative, the moral imperative makes us do something.

You know, in the eyes of some of our professionals, this is a very controversial approach. You are training midwives to do surgery. Now, the international community is actually talking about relevant training or some call appropriate training for appropriate service.

They are not just training the midwife in a few months. The midwife has gone through a three-year training program to do a cesarean section. And the bottom line is that the initiative may start out as a controversial program. But, it has been, now ten years down the road. The country has managed to reduce maternal mortality by more than half. It is a result that counts.

AARON BROWN:
I read somewhere that they’ve compared the work that these women have been able to do when required to do it with the work that traditional doctors– OBs have done. And they find little or no difference in outcomes. Outcomes are what this ultimately is about.

DR. MARGARET CHAN:
Absolutely. Outcomes and results. But, you know, we are also seeing that depending on whose lens you’re looking at this program is controversial. But, if you talk to the political leaders, the Minister of Health in Mozambique, in Malawi, in Tanzania, they’re also using similar programs.

They train non-doctors to do surgical processes. But, I think there is no disagreement amongst professionals that, number one, they should be properly trained. Number two, they should be properly supervised. Or there is another level of referral if, indeed, she’s not able to manage complications relevant to her level of training. She needs to have backup or what we call a proper referral system. But, the situations we’re talking about in some of these countries are so difficult. Distance is also our big challenge.

AARON BROWN:
I want to talk about the broader moral imperative that you mentioned. Let me come back to the doctor question for a second. We’re sitting here in Seattle. If you go to any of the hospitals in Seattle, to Group Health or Swedish or Harbor View or any of them, you will run into doctors from Thailand, doctors from Africa, doctors from India.

Many of them were trained in India or Thailand or Africa. But, they leave. They’re making $250 in Africa a month. Does the developed world have a responsibility in a sense to leave those doctors alone? To practice medicine in the country itself of their birth?

DR. MARGARET CHAN:
I know exactly what you’re saying. This is the kind of issues the World Health Assembly discusses on a regular basis. Shortage of doctors is actually a worldwide problem. And that’s why you see migration of healthcare workers from developing countries to develop countries. This global shortage of doctors– as I said, it is all relative. But, it is acute in developing countries.

Now, in the discussion at our assembly, there are talks about ethical recruitment. And, in fact, some countries for example, United Kingdom has actually started discussions with other countries. Okay, can we come up with a conduct of ethical recruitment? What are some of the obligations? Some of the things that the developed countries can do to assist developing countries? So that, you’re not robbing them from healthcare workers. They don’t have enough. And you’re taking healthcare workers from them. But, then, we need to go back to the question why do these healthcare workers leave the country? Is it all right for us to stop them from seeking a better life?

AARON BROWN:
Right. They are leaving for the same reason that people have immigrated to this country, to the United Kingdom, throughout history, because there is a better life for them.

DR. MARGARET CHAN:
Right.

AARON BROWN:
So, in one sense, do you really want to penalize them? On the other hand, they have been educated there. A country’s turning out 250, 300 doctors a year and four actually stay in the country. Is it reasonable to say, “Look, you have an obligation a four-year obligation to public health? Or a six-year obligation?” Now people can argue about what the number is. That’s not the point. But, that you at least have an obligation to begin your medical practice at home. Then, go– then go. If that’s what you need to do.

DR. MARGARET CHAN:
And, in fact, you bring up a very important point. And this is the kind of issue we discuss among my member states. First and foremost, let me put it very clearly. Many people migrate– it’s not just for the money. For a professional– you know, you really need to have a supportive environment. And an enabling environment where you can really do your job. If, a country does not even have the medicines, they don’t even have the equipment.

I mean, it is not difficult to see that they are disillusioned. It is as important that they are not moving just for money, but the sense of professional achievement, a good environment for them to do their job. But, having said that, you know, the point you raise is also being discussed.

If the country has invested in the training of doctors or nurses or midwives for that matter, people are beginning to say, “Should we not ask them to serve a number of years in the country who invested in their training?” I think this is now coming to be an interesting discussion. And, in fact, some countries are already doing that.
If they do not serve that duration, they are required to pay back the country’s investment in their medical education.

AARON BROWN:
You said– I think it was on the day of your appointment– that you and the organization ought to be judged, basically, on two pillars. The health of women and healthcare in Africa.

DR. MARGARET CHAN:
Right.

AARON BROWN:
Why those two?

DR. MARGARET CHAN:
I did say that, using those two indicators to measure the success or otherwise of the work of WHO. I’m doing this is because I’m committing myself to science, to evidence. If you look at the evidence, Africa as a continent, particularly the countries in Sub-Saharan Africa, they have about 25 percent of the world’s disease burden.

And, yet, they only have about three percent of the world’s health manpower. And it’s no wonder why we are seeing, the big gap of health outcomes. So, that’s why Africa is important for the World Health Organization. But, Africa is also very important for many development partners including USA, Japan and the countries in Europe, China and so on and so forth. And the second point is, again, if you look at the health of women, they have a long time to play catch up. Why am I saying this?

Again, if you look at the maternal mortality rate, for about 20 years, the world failed to make improvements. Every minute, we have one woman dying from the complications of pregnancy and childbirth. In 21st century, why do we allow that to happen? Especially when we know the solutions. And that’s why I’m compelled by the evidence, by the statistics, and really to make sure that the health of women in this world and the health of the people of Africa would be given high priority in the organization.

AARON BROWN:
But you actually go a little bit further than that. Number one, you don’t limit your discussion of the health of women to women who are giving birth.

DR. MARGARET CHAN:
No.

AARON BROWN:
That’s number one. You talk generally about the health of women. And in that same talk and one of the things that jumped out at me is that you talked about the importance to the social economic order of women in these cultures that, quite honestly, are not always women friendly. But, that women have an enormous role in how the society functions.

DR. MARGARET CHAN:
That’s true. I mean, the way I look at– speaking as a woman– I understand what it means to be a daughter, and to be a wife, and to be a mother, and also to be a career woman. The multiple roles that women can play in a society if given the opportunity is really a tremendous asset.

But, as you quite rightly put it, in many societies even as we’re talking, women’s status is so low. Woman cannot have a decision making power. I heard one story. A woman was in labor in a country. She couldn’t even make the decision to go to a hospital or to a clinic. She had to wait for her husband to come back to give that permission. I think we really need to do something to change that.

AARON BROWN:
It’s hard to have healthy children if you have unhealthy mothers.

DR. MARGARET CHAN:
Absolutely.

AARON BROWN:
And if you have unhealthy children, you’re gonna have unhealthy adults.

DR. MARGARET CHAN:
It’s very logical. I mean, I always look at the mother/child as a unit. As you quite rightly put it. If the mother’s– condition– now, this is another important issue we need to look at. We are seeing quite a lot of teenage pregnancies. If the mother, herself, is not fully developed– psycho, social, physiologically and physical health, and, yet, she’s carrying another life– you see the point.

AARON BROWN:
Yeah.

AARON BROWN:
One of the things in the film I think that’s discouraging, honestly, is that how women– how many of the patients in the film see themselves– as simply bearers of children. That’s all they are. That’s all they are to the society. That’s all they are to their men. And after they’ve beared this guy’s children, if he dies, they’ll go bear someone else’s but, they can’t see beyond that. And the culture doesn’t see beyond that. And how do you and the people that you work with chip away at that?

DR. MARGARET CHAN:
I recall the midwife surgeon in the film mentioned, “Women in some countries value their ability to bear babies.” Okay? But, if you look at the experience from these countries, this attitude of women. Actually, the women are paying a price. And in some instances, they are paying their lives for that. And I can’t agree with you more. I mean, more needs to be done to improve, to change that. But, changing the culture of a society—

AARON BROWN:
Right, how do you do that?

DR. MARGARET CHAN:
Changing a practice? It’s not easy.

AARON BROWN:
Of course not. First we recognize it. This is a problem. But, these are cultural issues ingrained in populations that go back centuries.

DR. MARGARET CHAN:
That’s right. And that’s why I say it requires social, cultural, legal changes. Led by political leaders. I hope– we hope to see more enlightened political leaders. We need to empower woman. Give women, a voice in the decision-making process. Give women a political voice where they can champion, for their own welfare. And, of course, for us. United Nations– organizations, agencies– we need to do our part. We need to do our work. And we need to bring this to the attention of the leaders in the country. First and foremost, the Minister of Health. We need to present the evidence. And show the best practice in different countries.

The one clear example is the health outcome. The persuasive power of evidence is very strong. Let me put it to you. The maternal mortality rate, which is the number of woman dying per 100,000 life births. In a developed country, you’re talking about seven per 100,000.

In a developing country, we are talking about 450 per 100,000. In Sub-Saharan Africa, we are talking about 900 per 100,000. But, of course, the low status of woman is only one of the factors. And there are a range of other factors that we need to consider and work collectively to bring improvement to the health of woman.

AARON BROWN:
Are you confident that people like yourself– public health experts– people who are acutely aware of what’s going on in Africa or in Asia or wherever– that the views you hold strongly, passionately are felt by people on the ground in the ministries of the countries of Sub-Saharan Africa or– the Asian Subcontinent. I mean, wherever there are people who are not getting the medical attention they need?

DR. MARGARET CHAN:
Clearly, in my interactions with ministers from health from developing countries, they know the problem. And they understand what can be done. But, we must also look at the conditions on the ground. When you are in countries of conflict, when you’re in countries where you just simply don’t have the resources to invest in building– a strong health system to provide care to people. And those are the challenges we are looking at. We talked earlier about the lack of health manpower.

The health workforce is a huge problem. When some of your healthcare workers die of HIV AIDS, tuberculosis and malaria. When some of them migrate. When the government, because of conflict, did not invest enough in training people. So, it is a whole host of factors leading to this very– wide, disparity in health outcome.

The ministers of health understand the issues. We need to escalate this problem to heads of governments and the heads of states. Why? Well it’s no secret. In most countries, Minister of Health is not the most powerful and– well resourced ministry. As part of my job, whenever I have a chance to talk to a head of states and head of government, I bring this to attention to the top level.

AARON BROWN:
And what do they say? I mean, don’t you wanna grab them by the lapels and shake them? And say, “Your– your women are dyin’? Your babies are dying.” Out of every 100,000, 900 women are dying in childbirth needlessly. They don’t have to die.

DR. MARGARET CHAN:
Well, of course, I’ll do my part. But, my part is not good enough. Heads of governments, I have to say, committed to achieving the millennium development goals. And which is an extremely– how should I say? Aggressive, ambitious.

AARON BROWN:
Ambitious. Absolutely—

DR. MARGARET CHAN:
Ambitious.

DR. MARGARET CHAN:
Sometimes you do need to set audacious goals. And then, that would motivate the governments to increase their domestic investment in health as well as mobilizing development partners, donor countries, foundations, philanthropies. To invest in countries in priority health areas.

UN Secretary General, Mr. Ban Ki-moon appointed a special advisor to look at innovative financing for development. Now, we need to be creative and imaginative. We need several things. The donor countries need to honor their commitment in ODA [Official Development Assistance]– point seven percent of the government’s national income to help developing countries.

The countries need to up their domestic investment. And then, the others come around. At the end of the day, we’re doing this for global solidarity. Now, in a highly connected and highly inter-connected and interdependent world– when health is so much out of balance, it’s not a safe world.

AARON BROWN:
One of the things you said is you can take all the donated drugs in the world. If there’s not a public health structure in place to administer those drugs, to monitor the progress of patients on those drugs, it’s really just a warehouse full of drugs. So, in some ways comes back to where our conversation began. If there aren’t healthcare professionals on the ground, they clearly, don’t have to be doctors in the traditional sense that we think of them because we’ve just watched how non-doctors, paraprofessionals, whatever you wanna call them, can do extraordinary things.

But, there has to be a structure to deliver healthcare.

DR. MARGARET CHAN:
Absolutely.

AARON BROWN:
And in too many places, there’s not.

DR. MARGARET CHAN:
That’s– that’s right. And that’s why your story on Mozambique is a story of a country dealing with one heath problem. When we look at the world as a whole, we’re talking about many countries with many health issues. And I don’t think, WHO or any organization can give them a solution. We believe the country should find their own solution based on their needs.

And also, they must have the ownership. And building a stronger health system, a functioning health system. We’re talking about infrastructure. We are talking about health or workforce. We are also talking about logistics, as you put it. I mean, what is the good of having commodities sitting in the warehouse and not delivered to the clinic? In a country I visited– Kenya– they restructured their procurement system and their delivery system. They work with the private sector, and through contracting out.

And they could, with existing resources– the same resources do more and faster. And there is no such thing as in the past trucks stop. Of course, you know, this is an initial improvement that they are putting in place. More needs to be done.

Of all the countries I have visited, something positive is happening. Government is trying their best. Development partners are also coming on board. Especially the G8 countries.

And the UN agencies–, we need to get our acts together. We need to be more coherent and we are moving towards that under the United Nations reform—-which we are a strong partner. So, all in all– I think global health has many positive actors.

And I should never forget the importance of civil society– their contribution. I mean, they are a very important force. Not only do they champion for special groups of people. They can– actually hold government accountable. And many things positive are happening.

AARON BROWN:
I appreciate that– good things are happening. And sometimes, the good things get lost in this.
And one of the things that people need to understand including the impatient people like me is that this is a huge problem.

You talked earlier about creating a– measurement of your own success. The health of women and health care in Africa. How do you measure it? How do you know?

DR. MARGARET CHAN:
You ask an excellent question, because we need to have objective indicators. Let me give you an example. I mentioned earlier about maternal mortality rate. More than half a million of women are still dying from pregnancy or childbirth related complications. And this figure has not gone down in the last 20 years. So, if we are putting in place a range of measures to strengthen the health system, to make sure women have access to the full range of sexual and reproductive health.

So, that when they are pregnant, they can get antenatal care. After giving birth to a baby, if it’s the family’s decision to space children, we call it either family planning or child spacing, depending the culture and the religion–these are services are available to women. So, during her entire life course, at critical stages of her development, we need to make sure that she has access to service.

Now, access to service can be decided by economic ability, by whether or not she can make that decision. Does she have to ask her husband for permission to see a doctor? So there, requires cultural, social, legal changes. That will take longer time. But improving the health system to make health services accessible to women is more an intermediate. But immediately we can take the preventive power of some of the measures that we know.

For example, family planning. It is hugely under-utilized. And of course, when I talk about family planning, I’m not suggesting the mechanism, I’m just talking about the concept. And I was educated when I was visiting some countries in Middle East.

AARON BROWN:
I’ll bet you were.

DR. MARGARET CHAN:
(LAUGHTER) And, they don’t use the term “family planning,” they use the term “birth spacing.” I think, we need to be culturally sensitive. And also sensitive to the various religions. But at the end of the day women should be given the chance to have access to care. Now, why didn’t I bring out the notion of family planning? If it is used properly, according to experts, some 15 to 35 percent of the deaths we are seeing can be reduced. And that’s why the interventions, the methods to improve women’s health are known. They’re not rocket science. But they are not being scaled up to the scale we need.

And also, in some countries, the systems are not there. Meaning, they don’t have people, they have work force and they don’t have clinics. And when women get to a clinic, they don’t have medicines. They don’t have for example, blood transfusion. And that’s why women die– they literally bleed to death. So, some of these are situations we see on the ground.

It’s not that countries don’t want to help their women. It needs to be a process. They need the resources, they need the human capacity, and they need the know-how.

AARON BROWN:
But I think what I wanna know, Dr. Chan, is I believe you want to be held accountable.

DR. MARGARET CHAN:
Yes, indeed.

AARON BROWN:
Okay. And– what I’m wanting you to tell me in a sense is at what point can I look at the objective data and say, “You are succeeding or you’re not.” Is that three years? Five years? 20 years? When do we get to your report card?

DR. MARGARET CHAN:
That’s an excellent question. I was given a five and a half year term by my member state. My 193 member states. And I’m now, leading the organization to concentrate on key issues and key programs. I have mentioned earlier the millennium development goals. If we look at all these items, with a microscope, you will see, I mention maternal mortality. We need to look at also whether the nutrition of woman, young girls in particular, are taken care of.

We also need to look at some of the neglected tropical diseases which are affecting women in a big way. And what about the relationship between HIV and female infection. Now, the feminization of HIV in sub-Saharan countries is a big concern.

AARON BROWN:
Yeah.

DR. MARGARET CHAN:
What about the relationship between transmission of HIV from mother to child? Now, if we do not provide antenatal care to women, if we do not provide HIV testing to woman, to help them to understand the HIV status, we can’t even begin the treatment. The treatment is available. And it works.

AARON BROWN:
Is it reasonable to expect that at the end of your five and a half year term, we would look at the numbers in– some of the most difficult circumstances any of us could imagine, and say, “They’re better.” Or, do we have to wait 20 years to see that they’re better?

DR. MARGARET CHAN:
I think we should be able to begin to see some good results. Aaron, I have to be honest with you, I’m fully accountable for my legitimate manageable interests. But in order to make improvements, we need solidarity. We should never forget the government should be held accountable for providing services. WHO cannot replace the government. Not at all.

No organization, no development partner can replace the government. The government must be made aware of their situation. They must be supported with technical know-how. With technical capacity building, and with the resources to improve the health of women. Why I keep coming back to women? I don’t want to give the sense that I’m forgetting about men. In fact, maternal mortality health is a very sensitive indicator. All you need to look at is a country’s maternal mortality rate. That is a surrogate for whether the country’s health system is functioning. If it works for women, I’m sure it will work for men.

AARON BROWN:
Do you get impatient?

DR. MARGARET CHAN:
No, I don’t.

AARON BROWN:
Why?

DR. MARGARET CHAN:
Impatient with what?

AARON BROWN:
That the problem is enormous. Sometimes, it seems intractable. 20 years ago, there was someone sitting in a similar conversation saying, “I’m gonna make this better somehow.” And you look at maternal mortality rates, and they’re not better. And so there’s a sense of intractability to some of this. And don’t you ever want it better now?

DR. MARGARET CHAN:
Well, you’re right. But I have to say that I don’t want to sound pessimistic. It’s true that there’s still a long way to improve the health of women. But, we are making very good progress in-improving the health of children. For the first time, we see, mortality for children fall below the ten million mark, because of successful immunization. Because of, back to nutrition programs. And we are seeing for the first time in 2007, three million people, in this world, getting access to antiretroviral medicine for HIV/AIDS.

We are seeing, countries making the marks for– tuberculosis. But of course, with tuberculosis we have new challenges. A drug resistance in the form of tuberculosis. So, in a world where this is actually a competition, between human and also the microbes. This is– an ongoing sort of– evolution and also detente. And so that is what is so exciting about global health. And that’s why I never get impatient.

AARON BROWN:
There are G8 summits on– climate change and global warming. There are G8 summits on economic development, there are G8 summits on terrorism and how to combat it. Do we need to gather the richest countries in the world, the most powerful countries in the world, and have a G8 summit on– on public health initiatives, on global health, on maternal health and mortality and do we need that kind of focused commitment where for a week, that’s what all of us in the world are thinking and talking about?

DR. MARGARET CHAN:
Actually, the G8s are already paying a lot of attention to global health. And the G8, not only walked their talk, they talk about the importance of global health. They also stepped up to the plate with resources. Let me give you an example. Polio eradication. The G8 countries contributed more than 55 percent of the close to five billion dollar investment in this global eradication initiative.

And of course, you know, the– G8 countries are also supporting the scaling of millennium development goals. They are paying particular attention to the importance of HIV/AIDS, TB, malaria, maternal and child health. So, of course, we would like them to do more. But I don’t want to give people the sense that they are not paying attention to global health.

AARON BROWN:
I agree that a lot of money is being spent by developed countries, rich countries, in a lot of important ways. I’m not always sure that the populations of those countries know that. And the idea of this sort of focused attention on the problem is to get not just the head of state to care, because the head of state’s probably been briefed on it and understands the problem, it’s to get every citizen who pays attention to the newspaper or the television that day to care. To understand. That’s one of those things those summits do, is they focus us, all of us, on a problem.

AARON BROWN:
And in fact, these summits do talk about climate change, food crisis, and global health. And that brings me to a very important point, which is the power of the media. If the media does not talk about these issues, the general public will not be able to appreciate the size of the problem.

DR. MARGARET CHAN:
It is true, the lens of television, stories like what you are doing on Mozambique. Through, you know, printed media, radio, will bring up the awareness and also highlight the importance. And then people will begin to contribute.

AARON BROWN:
Well, I hope that’s true.

DR. MARGARET CHAN:
It is true.

DR. MARGARET CHAN:
It is happening.

DR. MARGARET CHAN:
Look at malaria. Americans are contributing.

AARON BROWN:
Yes, they are.

DR. MARGARET CHAN:
I mean to Malaria no More to– to different initiatives.

AARON BROWN:
Yeah.

DR. MARGARET CHAN:
Look at what your president is doing. President’s malaria initiative. The PEPFAR–a commitment to improve HIV/AIDS. I’m just talking about the US context. Of course, other G8 leaders are doing that. But we should not forget another group of countries–The emerging economies. In the old days, perhaps they were receiving support from the developed countries. Now, we should ask the question: are these countries in a position to contribute?

AARON BROWN:
So, this is the so-called second world countries. India, China—

DR. MARGARET CHAN:
That’s right, Brazil.

AARON BROWN:
Brazil.

DR. MARGARET CHAN:
Thailand.

AARON BROWN:
Yeah.

DR. MARGARET CHAN:
I mean these countries, their economic improvement is such that, they are becoming donors even in the World Health Organization. They are donating resources so that we can support countries in Africa and in Asia.

AARON BROWN:
The point you made earlier about– we live in an interconnected world in all respects. Not just in the ones that are beneficial to us. You know, it’s not just about trading partners.

DR. MARGARET CHAN:
That’s right.

AARON BROWN:
We are connected in all sorts of ways and what we need to do, media needs to do, the film does this really nicely, is we need to tell stories that are compelling. That aren’t– I describe this as, that aren’t “eat your vegetables” news. You know, it’s not “here’s some Brussels sprouts, it’s good for you, eat it.” They’re just good stories.

DR. MARGARET CHAN:
That’s right.

AARON BROWN:
And you come away from a good story with the sense that, “Wow, I didn’t know that.”

DR. MARGARET CHAN:
That’s right, that’s right. I mean, she’s a brave woman.

AARON BROWN:
Oh my God, yes.

DR. MARGARET CHAN:
She’s a brave woman in the sense she’s put in a dilemma, which we are often in. That’s not a good situation to be in. You know why? She has to make the decision whether to sterilize the woman or not.

AARON BROWN:
Yeah.

DR. MARGARET CHAN:
Straightly speaking, she will be blamed for doing it and she will be blamed for not doing it.

AARON BROWN:
For not doing it, right.

DR. MARGARET CHAN:
I mean she is courageous and she’s cool. Why? She’s doing what I call risk assessment. She just says, “Okay, I’m not going to make the decision now. I will do the caesarian section first.” It makes logic, because if that baby did not survive the surgery, that means a woman has only one shot. That’s a tough call. After successful delivery of the second baby, she– meaning the midwife surgeon, is in a better position to weigh the risks. The risk for the woman, she will die the next time, because of ruptured uterus or other complications.

And what about if she died? What happen to the two children? They become orphans. So, she was weighing — she doesn’t want to sacrifice the woman, she doesn’t want to sacrifice the well being of the two children. And she would say, “Okay, let’s do it.”

AARON BROWN:
Yeah, I find that one of the most powerful parts of the film. Because there’s a lot of stuff going on. There are cultural issues going on there. And it was the point in the film, where I wondered when I saw it, have the people trained her given her all the information she needs to make a very difficult call. That’s really– this is hard now.

DR. MARGARET CHAN:
This is hard. But the woman did ask her, “I want sterilization.”

AARON BROWN:
Right.

DR. MARGARET CHAN:
But the woman did not come with the husband’s consent.

AARON BROWN:
Right.
DR. MARGARET CHAN:
You know. If I was in her situation, I would look at it–maybe the husband did not agree, right? That’s one logical assessment. The other thing is maybe she didn’t even dare to ask.

AARON BROWN:
Right.

DR. MARGARET CHAN:
And if she asks, maybe the husband says yes. Who knows? There is uncertainty there. But there is certainty in terms of the woman asking her, “Please, I want to get a sterilization.” So, sometimes, that’s why it’s not easy to be in this profession as a doctor. It is actually a contract between the patient and the doctor. But when you involve the husband in that kind of setting– I’m sure your viewers would find this very different. I don’t think a woman in North America, in Canada or in US would need to go and get permission from the husband to get a sterilization.

AARON BROWN:
No, but if you think about it honestly, that’s a relatively recent even Western phenomenon. I mean in the debates in this country over– termination of pregnancies, sterilization, there’s always been a question of well, I’m not so sure on sterilization, but on the other, shouldn’t the father– shouldn’t the husband have a voice in this.

All I’m saying is that it is a relatively recent western phenomenon that women are allowed, it’s a crazy thing to say, “that women are allowed,” to make these decisions on their own. As if somehow they weren’t capable of it. But it is still relatively recent.

DR. MARGARET CHAN:
It’s true. But that is, as I say, progress.

AARON BROWN:
That is progress. That is absolutely progress, yeah. And that is why that moment in the film is so incredibly powerful to me, because you realize there’s a medical issue here but there’s a very complicated cultural issue going on here, too.

DR. MARGARET CHAN:
That’s right.

AARON BROWN:
And this young woman has to sort it all out on the spot.

DR. MARGARET CHAN:
Absolutely. It’s a very difficult.

AARON BROWN:
Oh, and by the way, there’s a TV camera.

DR. MARGARET CHAN:

It’s a difficult call. I mean that’s why she’s in the dilemma. But that’s reality.

AARON BROWN:
Yeah, but the wonderful thing about her as I watched her, is I trust her to make her best judgment. Maybe I’d decide something else, I don’t know.

AARON BROWN:
But she’s there, she has to do it, she comes across as smart, alive, I would wanna believe that somebody taking care of somebody I loved had as much going for her as she does.

DR. MARGARET CHAN:
That’s right. She’s very serious. I can associate with her very much, because she’s the type of person that I see on a regular basis. People who are very committed to public health. People who are committed even at the expense of making personal sacrifice. She was doing.

AARON BROWN:
Yeah.

DR. MARGARET CHAN:
And she had to leave her boy. But you know, her earlier childhood experience is really interesting. She talks about her mother– being an orphan. And she talks about how it’s important that children have a mother. And maybe, she is also influenced when she finally decided, “Okay, I’m going to meet the woman’s request to do the sterilization for her.”

AARON BROWN:
She’s an incredibly strong personality. I mean she just exudes this kind of– not arrogance at all, just strength. To challenge conventions, whether they’re cultural conventions or medical conventions. You do believe she believes she can do this.

AARON BROWN:
If you could just get people to understand one thing, what is it you want them to understand?

DR. MARGARET CHAN:
As I said, in a highly interconnected world, interdependent world, you are still, as a country, as a nation, the American people are doing a lot of good in other countries. Through your government, and through you know, foundations and philanthropies. And this is what I call global solidarity. We do it. We do it because of our instinct of care. And we do it because of our compassion. And we do it because of our common humanity.

AARON BROWN:
It’s so nice to meet you and have time with you. Thank you for that and thank you for your good work.

DR. MARGARET CHAN:
I really appreciate this opportunity to talk to you. And thank you once again for bringing– to the American people, the important– sufferings– in other parts of the world. And I would like to thank them for all the great good they are doing and would encourage them to do more.

AARON BROWN:
Thank you.