Local Lessons, Global Solutions on Urban Health

Tuesday, February 12, 2019
A child runs beside the waste-burning area of a dump in Dhaka, Bangladesh.
Dr. Alex Ezeh

Professor of Global Health, Dornsife School of Public Health, Drexel University

Dr. Nilesh Kalyanaraman

Chief Health Officer, Health Care for the Homeless


Director of the Global Health Program and Senior Fellow for Global Health, Economics, and Development, Council on Foreign Relations

The future of global health is urban. There are 4.2 billion city dwellers worldwide, accounting for 55 percent of the world’s population. The population of city dwellers globally is projected to grow by 2.5 billion by 2050, with nearly 90 percent in lower-income nations in Africa and Asia. The evidence suggests that urban residents have better health than their rural counterparts but that the advantages of urban life are unevenly distributed. Too little attention has been given to the essential role of health-care delivery, especially among poorer and more vulnerable populations. With shared challenges, there is an opportunity for health-care providers to low-income populations in different nations to learn from one another.

The featured speakers for this discussion were Alex Ezeh, professor of global health at the Dornsife School of Public Health at Drexel University in Philadelphia, and Nilesh Kalyanaraman, chief health officer at Health Care for the Homeless in Baltimore. 

BOLLYKY: All right. We are going to get started.

Welcome to the Council on Foreign Relations and tonight’s event entitled “Local Lessons, Global Solutions on Urban Health.” I’m Tom Bollyky, the director of the Global Health Program, senior fellow for global health, economics, and development.

It is an evening event. It’s cold, it’s wet, and it’s raining, and you came anyway. We’re so grateful. You will be rewarded. We have two tremendous speakers tonight and I know it’ll be a lively, insightful conversation.

Urban health is a topic of great interest to us here at the Council. For those of you that haven’t seen the interactive we released this week on the future of global health, it’s urban. And that case for the future of global health being urban is pretty self-evident.

The majority of the world’s population lives in cities. That’s been true since 2008. As of 2017, the majority of population in low- and middle-income countries now lives in cities as well. The population of city dwellers globally is projected to increase by 2.5 billion people by 2050 with nearly 90 percent of that increase occurring in lower-income nations in Africa and Asia.

Urbanization is a good thing. Urbanization is historically the way countries have become wealthy. And the rapid urbanization occurring in low- and middle-income countries offers the opportunity for billions of people to have better access to jobs and health-care services and a gateway to the global economy. But to reap those benefits, those populations will have to confront the great inequities and health challenges of modern urban life.

And tonight we’re going to have a conversation about just how to do that by extending health services to vulnerable populations in urban settings. As part of that discussion, we’re going to try to connect the international conversation about how to address health needs of vulnerable urban populations with the domestic conversation about how to address the same challenge. By doing that, we hope to pull out some shared themes and new ideas for the future. It is, admittedly, an experiment, but this connecting the domestic to the international conversations about persistent health challenges is something we hope to do more in the coming year. And we have two ideal speakers for this inaugural attempt. You have their bios, so I will only introduce them briefly.

Alex Ezeh is the professor for global health at the Dornsife School of Public Health at Drexel University. He comes to that post after having spent seventeen years as the founding executive director of the African Population and Health Research Center. You will not find someone more knowledgeable on international urban health than Alex. Whenever I have questions about international urban health, I call Alex. For his sake, I don’t know if I should recommend that you all do the same—(laughter)—but you should certainly read his work and follow what he’s doing in the future. Alex really is a great resource.

Nilesh Kalyanaraman is the chief health officer at Health Care for the Homeless in Baltimore, Maryland. He’s the research chair for the National Health for the Homeless Board. Nilesh has been working in community health in urban settings for over twelve years. He’s deeply knowledgeable, so he’s a great resource, too. And I’m grateful for him for being here, too.

This event will proceed as follows. Both speakers will speak for about ten minutes each. Alex will go first, I will ask them a few follow-up questions, and then turn it over to you all.

A few last housekeeping items before we get started. Tonight’s event will be on the record and for attribution, which means the event attendees are welcome to use the information heard, attribute it to the speaker, and share it with abandon on social media, so be forewarned. Please refrain from leaving early, and silence your electronic devices.

And with that, I turn it over to Alex to start us off.

EZEH: Thank you. Thanks, Tom.

And thank you all for being here this evening.

As Tom indicated, my name is Alex Ezeh. And for the ten minutes that I have, I will make my points, which is three by three, three points in three different areas. And one is what we really know about urban health. And Tom has already laid the foundation for that.

For many of you that are here, you’re probably already very familiar with all of those, and that’s the global demographic shift, that a lot of the population growth that will happen globally will happen in urban areas. And Tom has already read the numbers. 2.5 billion and 90 percent of them in low-income countries in Africa and Asia. Africa alone will add more than 1.2 billion people to contribute to this over that period, so it could be a massive shift in population.

And what we know globally is that actually the rural population in many places will begin to decline and much of the growth that you will see will actually outpace the global growth, meaning that the urban growth will be much faster in a number of places. So these shifts are very important because it means that that’s where the people will be. And if we really want to improve health, that’s where we need to do more.

And the second is the belief we’ve had over the years about the urban advantage, that urban areas are centers of excellence, and better health, better education, better development indicators happen in urban areas. And for many years we believed that, and that’s been true.

But what we’ve not always understood that points here, which is the intraurban and intracity inequities in key indicators of well-being, that sometimes they are so massive and they blow up the urban advantage or question the urban advantage that we tend to believe.

So in many instances, there are differences between cities—and it doesn’t matter whether we are looking at low-income countries or high-income countries—there are huge inequities within urban areas and within cities. And the magnitude of those inequities sometimes transcends the differences between countries or between high-income and low-income countries because there are pockets within our big cities where health outcomes will be as bad or as poor as it is in the low-income countries. And these are realities of what we know today.

But there are things we really do not know as much about. And one of them is really understanding the disease profile within urban poor settings. Many times we will assume that the disease profile in these settings is the same as the city as a whole or the country as a whole. And so that affects how we enter and what we do and the priorities we set for these cities.

Some of the work we’ve done in Nairobi over the last fifteen, seventeen years to nineteen years suggests that if you look at the growth of the disease profile of small communities, you will be shocked at some of the indicators of this. Let me give you an example, that a third of the cause of death for children under five comes from something like acute respiratory infections due to indoor pollution. But if you look at where is indoor pollution in our health programming and our child health programs, you cannot find it anywhere else. 40 percent of the adult deaths, and particularly for men fifteen years and older, is coming from injuries. And where are injuries in our understanding of the health burden and the health programming and the health interventions that we do in urban settings? You really don’t see it coming there. So the lenses we have in thinking about what are the patterns of morbidities that exist within these settings is poorly skewed and we don’t understand as well what they are.

The other thing we do not understand will be the service delivery models that work within these settings. We assume that because this has worked in country X, it could work here. Because it has worked in rural areas, it can work in urban areas. And we do this transfer of knowledge and experiences in other settings to the urban environment and to these slum and urban poor settings, and many times they fail. They fail because they do not take into account the different social-organizational context and realities of these communities.

And so we need to understand better. How do we structure service delivery within these settings? I can give you an example. If you work in a slum setting where most of the residents will leave at five in the morning to go do a job outside and come back at eight o’clock in the night, and you have a facility that provides care eight to five, most of those population would not be served. And so understanding how we believe our services within this setting is a gap that still needs to be clarified. And many times they are context-specific, and we need to understand the realities within different contexts to be able to do that.

The third thing we’ve not fully understood is really the fact that people who live in these settings, even though they may be less educated than we are, make less money than we do, have less whatever in many—in many indicators we can look at, they actually may be more knowledgeable about what interventions can work within their settings and what delivery model, modes, and delivery mechanisms can be most effective in delivering health services to them.

I learned this the hard way. We did some work for many years in the slums of Nairobi where we demonstrated that women who live in slum communities have much higher levels of maternal mortality than Kenya, almost 40 percent higher. And KfW, the German development bank, decided to work with the Kenyan government to improve maternal health outcomes in the slums. And their strategy was to intervene and provide what they called vouchers for women in the slums to go and deliver in any health service and they don’t pay anything other than the cost of the voucher, which was about two dollars to three dollars.

Three years of implementing this program, there was no shift at all in the number of women who were delivering at home. About 50 percent of the women still delivery at home and 30 percent of them will have a voucher in their hands that they have paid for and still deliver at home. So sitting there with one of those women and asking, why would you buy the vouchers and still give birth at home? And she looks at you with your Ph.D. as if you are stupid and dumb and said, where do you want me to go at 3:00 or 2:00 in the morning? Of course, you know, babies do not need to tell you when they are coming out. And maybe 50 percent of the births do—(inaudible)—I don’t know what drives that.

But at that point in time, even if you can bribe the security to come out and put the health facility, where is the transportation? Where is the health facility? Maybe the closest you can go to is outside the community. And we then worked with them to think about systems and processes and interventions that could bring health-care services closer to the community. And, of course, there’s no public health sector, so you have to work with the private health sector—you have to work with young people, young men in the community to provide escort services for the women’s homes to the health facility. You have to work with community health workers.

Do I have two minutes?

BOLLYKY: You’re doing great.

EZEH: I’m fine? OK.

You have to work with community health workers to connect them to the health facilities. And in 58 percent cases where there could be emergencies, we work with an ambulatory service that could get them to the referral center. And—(inaudible)—you can reduce double digits the number of women who deliver at home out of about three thousand births that we register every year in the slums—in those slum communities.

The ideas that drove those interventions, that is changing the way that services are delivered, they are coming from the women themselves in those communities. So they do have knowledge, they do have ideas, and we need to be able to recognize that better and know better ways of engaging with them.

And my last point is really what we need to do. If we’re going to deliver health services or educational services or financial services, whatever services they are that we need to deliver to rich people who live in these settings, we need to—there are certain things that we need to be able to do to get that to be done effectively.

One is a better characterization of these vulnerable populations in urban settings. The data systems that we have completely miss maybe a chunk of this population. We don’t know as much as we should. Think about the—you know, you can do a household census; they are not in households many times. And even if you do—even if they are in households, they are not there when you go there.

You can think about all the places you really do not consider as living places. And if you think about it, the data systems that we use to look into health—inequities in health outcomes, we are looking at maybe national surveys. And we know they underrepresent these populations.

Now, what if we can actually change just one single indicator in our national survey, in our—in our censuses by looking at precincts or clusters or enumeration areas and identifying when we do our listing as slum or non-slum? All of a sudden, when we create our initial sampling frame, we can actually have three domains—rural, urban slums, and urban non-slums—and we can be able to actually understand what is going on within slums.

The point here is this: Even when you use the demographic and health surveys, great as it is, in urban areas the households are displaced by about two kilometers, so you cannot even use the—(inaudible)—to recreate the slums. So we need a different way of understanding this and really being able to understand the data systems that comprise these populations. We can understand their profiles, their health profiles and other profiles, which can then help us to make the case for the types of investments that are needed within those populations.

The second thing we need to do is that other interventions and designs to deliver health services within the urban environment need to understand the multisectoral influences on health outcomes in urban areas. It’s not just the absence of health-care services. It is the security situation and how you manage police relationships with the communities; it is environmental. I mean, the ideas that drive health in the urban environment are actually the shared neighborhood effects, the social environment, the physical environment, you know, that they share in common. That is the thing that drives health outcomes in those settings. And so when we integrate households at that level, it’s not about poverty, per se. It’s about the shared environment within which these factors interact.

And we need to recognize that the drivers of health and health outcomes in these settings are multifaceted. And simply putting a health facility in there without any attention to the other domains that affect health would not be as effective in driving this.

And the last thing we need to do is engage those vulnerable populations in thinking about solutions and designing those solutions that can respond to your health needs. They have ideas that can work within their settings, but many times we design this in Washington and we take it to them. And many times, they miss the boat in terms of what is really needed within a particular context to drive a fundamental shift and change in the health outcomes.

I can stop there and pick up questions.

BOLLYKY: Nilesh.

KALYANARAMAN: All right, thank you. I just want to note one thing—sorry. I just want to thank Diana for coming here. (Laughter.) So I’ve been a primary care doctor for over twelve years and Diana was actually my first boss when I started here in D.C. back then and has been an amazing mentor.

So I’m just really excited that you’re here.

So I wanted to share a—share a story of a patient of mine that kind of illustrates some of these points. I feel like Alex and I coordinated our talk, but we haven’t spoken until this evening.

About five years ago, I was—I was in our walk-in clinic and I was—I was seeing a patient who had come in. She had a backpack on, she had a cane, she was walking with a limp. She looked like she was apparently [in her] fifties. She sat down and she told me that she had an infection on her leg. And I said, how do you know it’s an infection? And she gave me that look that said that I was the dummy, right? (Laughter.) And all right, just show me your leg, right? And it’s an infection sure enough.

And so as I’m taking a look, the electronic chart is booting up, I take a look, and it says that she has diabetes, she’s in her early forties, not in her late fifties as I thought, and that her diabetes was really just out of control. So normal blood sugars are in the low one hundreds; hers were in the high three hundreds. And diabetes like that, it makes you more prone to infections amongst a whole host of other things.

And so the antibiotics were the easy part. Then we talked about her diabetes and what’s happening and is she taking her insulin three times a day. And she said no, I’m taking it twice a day. OK, how come? Well, I only [eat] two meals—I only eat breakfast and I only eat dinner. I can’t get lunch. And that’s because she is going to soup kitchens, and that’s where she gets her meals. So I said OK, fair enough, that makes a lot of sense. Take your insulin twice a day and come back and see me in about six weeks. So she did.

And when she comes in, her blood sugar is still in the high three hundreds. So I was, like, are you taking your—are you taking your insulin? Yes. All right, let’s ask a different question. How many times did you miss your insulin this week? About five or six times. So if you’re doing the math, that’s about five or six times out of fourteen times. OK, so what’s going on there? And then she proceeded to tell me that she is—she pretty much stays wherever she can stay, so if she’s in a shelter a few nights and somebody is kind enough to let her crash on their couch—on their couch for the next few days, she’ll go do that. And if she gets thrown out and can’t make it to the shelter in time, she’ll sleep on the street.

But what happens is that she’ll have her insulin with her, right—she might be in the shelter and then she’s out for the day, the insulin’s at the shelter—and then she meets somebody, runs into somebody who lets her stay on their couch, and she goes and her insulin stays behind. And so this happens a few times every week, and so she misses a bunch of doses.

And so I was trying to talk to her about, OK, is there a way to keep it on you? She’s like, I’ve been through all that, I’ve tried to do all of that, there’s really no good way to keep it on me. And her words were “If I could have my own place I can control my sugars.” I was, like, OK, but that’s not happening yet, so what do we do? She said the same exact thing.

And so over the next couple of years, she came in. Sometimes she’d come in at her appointment, sometimes she would just walk in and I would say sure, I’ll see her, whenever she comes in I’ll see her. Often times it’s a transportation issue, she just couldn’t, either didn’t have the money or the bus trip was too long, it was just a pain to come.

So we do this a number of times, and I kept hounding her around the diabetes, but also about, OK, I got you, so what are we doing about the housing? And after a couple of years, she got engaged with our case management services, and she said, “I’m working on housing, don’t bother me about my diabetes.” So I made a deal with her. I was like I won’t—I won’t bother you about your diabetes as long as you’re working on housing, despite the fact that it hurts me inside to not mention it at all, that’s what I’m supposed to do.

And so over the next year—and it took about a year for her to go through the process of applying for housing, being vetted, getting an apartment, and moving in—I did not mention her diabetes. I dealt with her pain issues. I eventually was actually able to do cervical cancer screening for her, but that was only after I found out that she had been raped when she was young and so did not like to have that exam. And so we—I actually had another doctor do that exam for her, a female doctor, which made her more comfortable.

But after that year, she said, “In a few weeks I’m moving in, I’ll see you afterwards.” And so I saw her about two months after she moved in. And I’m, of course, checking my chart to see what her sugars are, and they’re about a hundred and fifty. And she comes and I ask her how’s her housing. She said it’s the first time she’s felt safe in years. And I didn’t talk about her diabetes at that visit either.

And I tell you this story not because it’s exceptional, but because it’s common. These are the stories of the people that we see in an urban environment. And I’ve worked in New York, in Atlanta, in D.C., in Baltimore, and the stories are the same. The challenges in their neighborhoods are the same.

And so when we talk about health-care delivery to vulnerable populations in an urban setting, there are a couple of facets we need to tease apart. There is a health-care infrastructure in our—in our inner cities. It exists. The question isn’t where it is, but who can access it? And so, generally, people can get acute care services when they need it. Some states have expanded Medicaid, which has been a godsend for people—they can actually access care. We know the phenomenon of people going to the emergency room to get their care, but people can get acute care.

But what we want to see them do is then manage their chronic diseases and then move on to prevention. And it’s not linear, but that’s a framework to think about it. But those are the things that we want them to do because those are the right health care things to do.

But there’s a factor in there that has been missing in our conversations that Alex was talking about. We now call it the social determinants of health, but they’re truly community effects and they’re basic human needs. And it’s the—it’s the fabric on which our health-care delivery system is trying to fight against, right?

When I—when we’re seeing somebody for any of these conditions, and they’re struggling to get meals or they are—they have housing instability, they can’t get to your office, those are lot more proximate needs that people have that need to be met. And frankly, they’re more important, and they should be more important, right? It’s a lot more important to know where you’re getting your next meal than if your blood pressure we controlled. One of them affects you today, the other one might affect you in ten years.

And so when we’re thinking about our systems—and this is what I do every day. I mentioned this patient that I saw, but I also oversee the integration of our health services. So how are we stitching together our medical, our behavioral health, our dental, our case management services and creating a network of care to provide services to this population? What we’re seeing time and again is that we’re missing that piece, that piece of how we’re addressing the basic human needs.

So I touched on some of them in the patient that I was talking about—housing, income, just not even having the money to get food, food insecurity, needing to go to specific places at specific times to get the food—and we know that those programs do the best they can with limited funding, and so that food tends not to be as nutritious as it needs to be—transportation, but, of course, safety, safety is really critical. And so many of the people that we see in these vulnerable settings have experienced trauma. And that’s the fabric. Trauma is the fabric that we see in our urban settings.

And so how are we as a health-care system or concept trying to address that? And we see it in fits and starts. There’s new—there’s new efforts around moving housing into hospital settings, but those are really focused on return on investment, monetary investment. We see that in food programs, but those are typically targeted to people with particular conditions, transportation for particular conditions. So we see all these conditional attempts to address these basic needs. And what our challenge is, where should it be dealt with?

When we think about what’s the—what’s the driver of health, these social determinants of health have a greater impact than direct health-care delivery. And so that’s why we see more and more that the infrastructure of health is trying to address this, right, because it is—after everybody gets up to speed on the standards of care and has it available generally—I’m assuming those Medicaid non-expansion states are going to come around in a couple—but once we have the infrastructure in place and we’re all kind of equal on that footing, what is the determinant, what is the differentiator? And the differentiator is being attuned to these basic human needs. That’s really the purpose of our health-care delivery system, and that’s where it’s going, is to be able to deliver those needs that aren’t being met through other sectors.

And we see that—we see that funding for housing has gone down over the past four decades. We see that food programs are constantly under threat. The idea that you have to work really hard to meet your basic needs leaves no time to do anything else. We see the effects of trauma, and that’s the idea of adverse childhood experiences and how they impact health across a broad range of measures well into adulthood.

So when we look at the data in Baltimore, chronic disease is still the number-one killer, heart disease, but the things that go into creating that heart disease happened when those people were five and ten and now we’re trying to catch up when they’re fifty, and it’s not going to work. It’s just not going to work. And so that’s what I see as our challenge.

That’s why I said, when I was listening to Alex, I was like this is—I’m glad to see that we’re seeing the challenges. It’s what are the communities we’re living in, how are we setting them up to be healthy?

BOLLYKY: Great. Well, those were two remarkable presentations. I’m so glad to have you both here. So thank you for that.

So many common themes in your remarks. We generally think urban health will be better because of the increased availability of health-care services compared to rural settings. And it’s interesting to hear the common themes in your talks. First that because we don’t have the data understanding of these populations, we don’t understand their health needs. Second, what we do know suggests we target the wrong health needs often, whether that be the diabetes in Nilesh’s particular case or some other more immediate problems mentioned. And third, because we don’t have a good understanding of these populations, we target them with the wrong or poorly designed services. And then there is the backdrop of the social environment that [is] shaping the health needs of these populations from an early age.

I was also struck by the two very different suggestions of approaches to addressing the challenge. Whereas Alex was talking a lot about data collection on the population level to start to shape how we think about services, the programs that Nilesh was talking about were very much around direct services and connecting patients to broader social services that might address their needs.

I’d be interested to hear the two of you to reverse roles. For Nilesh to talk about the data collection, what we do know in these populations, and how that data is shaping our programs.

And for Alex to talk a little bit about how programs are working, let’s say, in Nairobi, which Alex knows extremely well, to connect populations to broader social services—addressing social needs around housing and other factors that shape their environments.

Either of you can go first.

KALYANARAMAN: I’ll start then. That’s fine.

So at the population level when we look at—when we—when we look across the United States, we have a pretty rich collection of data that looks at health disparities and that can look at health disparities. Typically, we’ll look at them within cities, but can look at it across any census tract, frankly. And you can see health disparities at the rural—urban-rural level within cities, as Alex mentioned. You have—you have communities within cities that have disparities in life expectancy—I’ll speak for Baltimore—of twenty years. You can cross a street in Baltimore and go from a census tract that has about a seventy-six-year lifespan to about fifty-seven. I know that’s true; I drive down it every day. But that’s not atypical—that’s common. We have data that shows us where on health conditions, what life expectancy is, and also the social conditions that are there.

I think that what we’re—what our challenge is is tying those together as drivers and saying this is causing that. These are not just correlated factors; there’s a causality here. And the—and the challenge in that kind of research is saying that if we do this and invest in something that is outside of the health system generally, if we invest in housing, that we will see—we will see rewards thirty, forty, fifty years, sixty years down the line. Right? And also, because it’s a population effect, you see—you will see that if you invest in housing for a thousand people, right, some percentage of them will do better. You don’t know which percentage that is and that’s always the challenge of our population health. Of any population health intervention, it’s always the challenge in adopting it is that there isn’t—there isn’t that one-to-one: I know that if I do this, I will get this. It’s I know if we do this, we will get this.

And so we have the data. I would suggest that we have a lot of data that shows what we need to do and that it pivots more on a political issue.

BOLLYKY: That’s a grim lesson for international health, right? (Laughter.) Because at the end of the day, in the U.S., it’s we have the data, but we don’t believe it or we’re not using it. And given what a lot of international health efforts are focused on getting data, that’s a grim message.


EZEH: Thanks, Tom.

One of the areas, I think, is really understanding how to design services in such a way that they respond to the realities we may face. And let me give you a specific example. Kenya has a national policy of maternity leave, so if a woman gives birth, they will have three months of maternity leave. But you get those three months if you have formal employment that can give you that. Most of the women in the slums work in the informal sector in day jobs and [as] laborers and others. And so if you’re a woman and you’ve given birth and you depend on this, going into the neighborhood to wash clothes and get your daily meal and all that, how long can you actually survive without going to work? And you have a baby you cannot take to that worksite, so how do you manage child care? You might have to—maybe there is—they need to eat. And so [there is] the need to cater for just basic food needs for some women who would not have the money for daycare, and you can just lock up the child inside the room. And so when you see indoor air pollution and the acute respiratory infection being the major killer of children, it’s because they are spending a lot of time inside those homes as their mothers go out to look for a job.

So you start a program to say, what if you can get women in these communities who might be old and they don’t have—they cannot go to wash clothes in other places, but you can actually get them into a more decent place, let them stay there, and provide care for these children. Women can extract their breast milk, they can feed them with that, and they can go out and look for the job and use what they’ve got. They’re getting a small part of it to also support these other women who are providing care for their children. All of a sudden, you’re creating a market economy that works for them using resources that are very local and could be sustained in the longer term.

And so there are different ways to—but, you know, that is not a hundred-million-dollar program that years ago we would put money into. And my thing is that they say, oh, what we can do with small resources that are well-targeted to meeting specific needs that exist? And so I think the mindset we have of—and that’s why, for me, the real innovation comes is in thinking through, these are real challenges that are faced by real people. And what can you do at that micro level to make a difference and capitalizing on the resources that already exist within the communities?

When we did this youth thing, all we did was invest a thousand dollars in a youth—there might be, like, seven youth groups in a community. You put in a thousand dollars in each of them to support whatever their basic needs, and, in return, any woman that is unable will call them, and they will mobilize three to four people to come and walk that woman from their house to the health facility. And they did that. When this program ended, the village elders decided this is their wives and their daughters, they will do it. And so they organized amongst themselves to provide that security. And it is continuing, even though the program has ended.

So there are—and the other thing is that when we demonstrated that if you brought health services closer to the community and they can open beyond the eight to five of public sector facilities and all that, it will increase service uptake, whether you are looking at immunization, whether you’re looking at family planning, whether you’re looking at facility deliveries and all of those things.

The government of Kenya actually voted a lot of money to have a mobile outreach of—many of you may have heard this story—where they got, like, a hundred containers to deliver—to put clinics within the slum settings, but then got other containers, conditioned them with a hundred—I think maybe a hundred million dollars or so investment in that, but it never moved anywhere. The containers remained in Mombasa.

And for me, it’s so painful because this could make a huge difference in changing service delivery and health outcomes within those cities. So there are things that could be done that are not billions of dollars or hundreds of millions of dollars that could make a real difference in terms of increasing access to health services for people in those situations.

BOLLYKY: Great. We have a little over twenty minutes left. I want to turn it over to the audience to give you a chance to ask questions. I will call on you in the order I see your placards. And if you have a question, if you’ll just say your name and your affiliation and I will call on you. When you ask your question, please make it sound like a question. (Laughter.)


Q: Hi. I’m Julia Fromholz. I work for Arizona State University Law School, but here in D.C. I’m not in the public health field, I’m just a fan of Tom and his book, which I recommend to everyone.

I have a—but I work in international development and the rule-of-law field. And I have a question for you based on what you—mostly on what you both just said. What is stopping the donors or the governments or whoever the funders are from funding what needs to be funded, what you said is not a hundred-million-dollar project? Why aren’t they funding that? Why did the containers get stuck in Mombasa? Why is the funding not going to housing? Is it that there’s not enough funding? Is it that donors are looking for something else? I’m curious about more of that.

KALYANARAMAN: Please, you can start on this one.

EZEH: So yesterday, I had a meeting that started at nine at the Center for Global Development where we brought together, like, eleven different funders, foundations generally, and about eleven CEOs of African institutions. And the whole conversation is, how do we support institutional capacity development in Africa to generate the type of knowledge that Africa needs to move forward and the type of systems that could support effective implementation of development assistance?

And what we know is that the current subcontracting model has failed development—(inaudible)—and has failed Africa. Because you can have a hundred-million-dollar program, by the time it gets to the ground it’s twenty million, and you are working to deliver a hundred-million goal. And so you keep running from one thing to the other and you don’t have the space to think and do anything. And it’s an—it’s an efficiency issue.

But more importantly, you have institutions that may have the ideas, but they don’t have the resources because their countries are not investing in research. And the research that comes from outside are already predefined on what they can fund and support based on the priorities of the funders, you know. And so there are a lot of challenges in terms of this. And we spent that whole day talking about, what should be the mechanisms to really create credible, effective organizations with the capacity and scope to operate at those—at the levels that we would want in—(inaudible)?

The other reason, for funders, it is also an efficiency issue. If this program takes two million dollars and you have four hundred million dollars to program, think about how many organizations you’d need to work with and what size of staff you need to manage that whole thing. So you go to organizations that have the capacity to receive the hundred million or two hundred million and then they can work in much more places with one-million-dollar organizations. And by the end, because they pass through these many layers of organizations, you know, it just creates those inefficiencies.

So there are real things. And unless we build local institutional capacity to drive the knowledge and the implementation of these programs, we can do what we’ve done for the last forty years, trying to build, you know—there is no development program in Africa today that doesn’t have capacity building as a major component of its intervention. And how is it that we’ve done this for fifty years, and still the reason why we are not investing at that level is lack of capacity? We can do it if we like for the next thirty years, but nothing is going to change.

So, for me, that is fundamental to really getting to the heart of what you are asking. We need to build those institutions. And we don’t build them with projects, we build them the same way we’ve supported institutions here for decades: to develop the capabilities they need, the systems they need, the processes they need, the human resources they need so they can return them to do the good work you want to see happen. Because what they’re doing is that you bring them on, you train them, and the moment they get the skill they move to the highest bidder. And so you get on this constant process of trying to rebuild your capacity, and you can never compete at the level that you need to do. So there are a lot of structural challenges with the way we’ve designed development aid and assistance in many ways that needs to be discussed.

KALYANARAMAN: In the—in the domestic area, I think it’s—there’s a growing understanding of the need to collaborate with communities and not deliver services to, but in concert with, the communities.

The challenge—the challenge is and will remain that it’s labor intensive, it takes a lot of time to do that, and it takes a lot of ceding control. And the tension that exists is the funder and/or the experts have an idea of how to do it. But I think your example is perfectly correct: If it doesn’t work, it doesn’t work, right? You can pour as much money into it, [but] if I don’t want to do it that way, I’m not going to do it. And if our goal is to improve outcomes, then we have to listen to the people who are asking for the changes to make those changes. But that is a—that is a low and, like I said, labor-intensive process.

Q: Thanks.

BOLLYKY: I have Sally, Lucy, Jimmy and Elisa.


Q: Thanks. I’m Sally Cowal. I’m with the American Cancer Society.

And maybe this question is pretty much like Julia’s, but it’s about the political will. I mean, I guess we have one pretty good example, both in the United States and internationally in the last thirty years, and that would be HIV/AIDS. I don’t know that it served everybody incredibly well, but I think we can all point to measurable things—the number of people in treatment, the prevention of new infections, so on and so forth. Why has it proved so difficult to build the political will coming from—how can we work—I guess the question would be, how can we work with these communities, domestically or internationally, so that—so that they can really exercise? How can we give them the agency to make their political leaders work for them? Because I think in future challenges, unlike maybe in HIV/AIDS in other parts of the world, there’s not going to be a global fund, so it’s going to have to be the people of Kenya saying cancer is an important issue or kids dying from respiratory infections caused by being locked in houses, this is our major issue. How do—how do you mobilize those populations at the grassroots level and have there be some effect at the top?

KALYANARAMAN: I think the biggest challenge there is that in other—and you mentioned HIV. One of the—one of the things that helped to get funding was when it stopped being seen just as an issue for gay men. And is that—you have the disconnect between that, when those who have political power can see themselves in that condition, it becomes much more likely to be able to address it. But there is almost mutually exclusive categories of people who are poor and people with political power.

And working with—working with a population of people who are—who are poor, there’s no time for that. There’s no—there’s no time and there’s no capacity for that at a broad level. Of course there are people who are engaged, but that’s—when you get back to I need to—I need to make sure I can put food on the table, that’s the first priority.

EZEH: Also, I mean, in addition, I think the conversation around HIV/AIDS, the success we achieved largely was because we moved it away from a health conversation to security conversations and economic conversations, a broader development conversation. And so—and somehow that resonated with some people.

But even there, there are still challenges because within countries—I mean, the amount of money we’ve invested—I just recently the director of PEPFAR saying that they would spend 70 percent of their resources on local institutions. I cheered. But then I come back and said, who are those institutions that can absorb this investment in these countries, you know? And these are real things.

And so, for me, I think—I mentioned the data point before because a lot of the challenges of the urban poor remain hidden in urban averages. I mean, one of the work we did in Nairobi that demonstrated, that children born in the slums are sicker, have less—have less access to care, and have almost 40 percent higher mortality than those born even in rural areas. That was a starting point of a conversation to say we cannot let this continue. And different players then got on board to dealing with the health issues in urban slums in Africa.

But before, you look at the DHS, you look at urban, you look at rural, so there’s not an in between there. And now we’re asking, we can do better than that. And how many other—I would like to repeat the surveys we did in the slums of Nairobi in ten other cities in Africa to demonstrate that Nairobi is not unique. This pattern is the same across major cities in Africa. And if we’re going to address the issues of health in urban areas, we have to understand what is driving the poor health outcomes in slums.

The most recent DHS for Kenya showed that Nairobi has one of the worst child health outcomes. How is that possible? It is possible because of what is going on within the slums. If 60 percent of the population of Nairobi live in slums, their indicators would automatically drive the indicators for the county or for the city. So those are some of the areas that I feel that are quite important in moving this conversation forward.



Q: Hi. I’m Yonette Thomas with the International Society for Urban Health.

And hi, Alex.

My question is, Africa is pushing strongly towards UHC, universal health coverage. We sit in these conversations, and it’s about bringing state-of-the-art pharmacies and all these wonderful things. But at the city level, this issue of understanding patterns of morbidity is something we all just—we cringe because we really don’t understand the health dynamic at a municipality level. How do we push and engage this dialogue that’s going on on UHC to think about what is actually happening at the community level?

EZEH: So I think, you know, UHC is coming out because of the SDGs.

Q: Right.

EZEH: And people see it as a solution to our health challenges. And maybe it’s good if we—and the biggest challenge is really thinking about, what do you cover and how do you implement it in such a way that it is sustainable in the long term? So there’s quite—and countries are at different levels at this point.

For me, the starting point is actually the data systems that could highlight this and make it visible. And the more visible they are, the easier it is to incorporate those elements in the discussions and then thinking about what can be done. But at this point, you are looking at a national strategy. And there are a few countries that will have an urban health strategy that specifically looks at these intracity and intraurban inequities and how do you respond in different parts of the city.

But across the continent, I’m really not very sure that there—the conversation is about developing a national plan for investing in health coverage.

But beyond that, I think, in my experience, what works at the national level, you may need to, you know—you may need certain adjustments for it to work in certain parts of the urban areas and urban cities. And that conversation at this point, I don’t know, in many countries is not happening.


Q: I’m Lucy Mize with the Asia Bureau at USAID. And I know more about Alex’s world, so I’m going to ask Nilesh a question.

It sounded like it had been an epiphany for you that complex social systems are the foundation to deliver, ultimately, care. And that was after years of working. So how do you get student service providers to understand that it isn’t that antibiotic, that screening test that is going to be the key element to delivering care that meets those needs and in the international setting, it’s how do you get the hierarchical status symbol of providers to understand the community voice should be equal when they’re trying to find a health-care solution?

KALYANARAMAN: So there’s a number of—I think there’s a number of efforts underway to expose students, not just in the medical profession, but across a range of health professions, to what is essentially community health. I know that there are training programs, there are medical training programs that are centered in community health centers, community health care does one of those, exposing students to and doing what are considered outside rotations in underserved populations. They’re called AHEC programs, area health—I’m terrible with acronyms. Anyway—(laughter)—but essentially—I always remember the first one or two letters and then it peters out.

But essentially, they are—they’re opportunities to get them outside of the academic setting into typically underserved [areas], whether that’s rural or even urban underserved, because most of our medical schools are in urban settings. So we are seeing that slowly in terms of dental care as well. I would suggest that our—that our mental health system has been generally more attuned to these issues but grossly underfunded in terms of service delivery.

It’s a far cry from what I remember when I was training. Things are changing, things are changing in terms of orientation. I would—I would suggest that it was a lot sexier to do international work twenty years ago. And that is, if not flipping, at least evening out, that there’s a recognition that there is frankly just as much disparity to address here in the United States and oftentimes in the neighborhoods that those academic medical centers are in. And so it’s heartening to see. So I would suggest that it’s occurring already. And providing more training opportunities in these settings is going to be the key to doing that.

BOLLYKY: Great. Well, we have five minutes left and three questions, so I’m going to take all three of those questions. Try to keep them short so that everybody can ask. And then ask the speakers to pick and choose among the questions which to answer.


Q: Great. Thank you both for very insightful comments. Elisa Basnight, StrategyServ.

My question follows a little bit on Sally’s comment. But we all know, six hundred days away, yet, election 2020 is on the forefront of a number of people’s minds and activities. And we often hear “health care for all.” My question really is, is to what you both have discussed, is it health care for all, or should it be some modification of that just given the other wraparound and the other issues that we’ve identified in today’s discussion that if someone just—if someone has health care, that might not necessarily be the solution. So the question is, what could we recommend to policymakers if we are in discussions that, you know, could be recommended for a position, that it might be health care plus something? I would just love to hear your thoughts on recommendations for policymakers.

BOLLYKY: Great. Hold off on answering that for a second.

Jimmy and then Jacob?

Q: OK. It’ll be easy because Yonette and Elisa just asked the question I was going for, which is about universal health coverage and universal health care. And it’s clear that both of you talked about the clinics not being enough and a lot of social determinants and basic human needs. And I guess the advantage of universal health coverage for the health sector—I’m Jimmy Kolker, I was assistant secretary for global affairs in the Department of Health and Human Services in my last job—and the WHO can have that as a bumper sticker. The Norwegians, the Japanese, the Germans have that as their focus for global health aid. And it’s something where health advocates can be in the lead. What’s the next big thing? What’s the unifying principle that your experience means we should be advocating beyond universal health coverage?

BOLLYKY: Great. And, Jacob, you get the next question.

Q: Jacob Adetunji. I’m from Bureau for Global Health at USAID. I have two quick questions.

BOLLYKY: One quick question, we only have two minutes left. (Laughter.) OK.

Q: So let me pose this to Alex then, because you have cited DHS a couple of times and I have worked with DHS for several years. So in terms of definition of slum areas, how prepared are national statistical offices in providing clear demarcation of where the slums are? Nairobi may be different, but if you go to several countries, they cannot actually define for you what a slum is and where a slum is supposed to be. Because people oftentimes live according to where maybe their parents live, or you have rich people who live in urban slum areas and live in depressed houses. And you have—so you cannot look at a particular area and say—(inaudible)—here. For people who intervene, as development people, we want to look at where people are. It’s easier for us to carry interventions to where people are. But then there’s a mixture of poor and rich in several low- or depressed-housing quality areas in cities of developing countries. How do you think we should find a way of solving this? Because that’s a major issue.

BOLLYKY: Great. So the first two questions, pretty similar about what should we pushing for either as health or as, more broadly, after a focus on health care; second on the data question.

Do you want to take what we should be pushing for?

And then you take the data since it was directed specifically to you?

We only have two minutes left, so each of you just a minute.

KALYANARAMAN: Health care for all, good, a universal health care program. And I—and I want to emphasize that it’s the platform on which we can actually care for everybody. But I—and I—and I—if there’s one thing to take away, we are trying to address social determinants in the health-care space because it’s not being addressed elsewhere.

And so I don’t think it’s the best vehicle, but it happens to be the vehicle that we are using, at least within the health-care space, because it’s being frankly neglected in other—in the sectors where it needs to be addressed.

So I would say it’s health care for all plus investment in our—investment in our cities, investment in housing, investment in education, addressing trauma. It’s all of the above. And when we think about them as investments in our population, we in this room do that for our families. We in this room look for safe neighborhoods where all these opportunities exist.

So I’m always at a loss as to how folks are supposed to transcend an environment that we would not want to live in ourselves.



EZEH: OK. On the data, you can’t answer that in one minute. But I would say is that we have a paper that’s coming out in BMJ which is looking at, conceptually, distinguishing slums from non-slum urban areas. And it is both a methodological question and it is also a conceptual question. We think we know what slums are, but we really do not have a good definition.

In Brazil, they did a census that identified slums as a collection of households—more than seventy households in a contiguous area. In India, it was a hundred. And in Bangladesh, it was five households. Each of these will give you different data. And all we are suggesting is that if countries begin to identify that in their censuses, then we start at a point where we can at least at a national level know what they are, know what the deficiencies are, and then be able to see what we can do going forward and how we can improve those. But if we don’t have that, then it’s difficult to improve.

And I would say one thing to all the other questions, really, when you think about health in the urban areas, services are not enough because the drivers of poor health go beyond the health sector. It’s about transportation, it’s about air pollution, it’s about food systems, it’s about, you know, security and violence and all of those things that are critical, and bringing that multisectoral conversation becomes very important in looking at health in this—in this setting.

BOLLYKY: Great. Well, I truly enjoyed this event. I hope you did, too. Please join me in thanking these speakers. (Applause.)


This is a corrected transcript.

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