Joy Phumaphi: We were not immunized

At the end of October, the world's population will cross the 7 billion mark and continue to climb. Over five weeks, Global Pulse interviews several world leaders about how to slow this explosive growth.five weeks, Global Pulse interviews several world leaders about how to slow this explosive growth.

Joy Phumaphi began public service in Botswana as a local government auditor. From 1994 to 2003, she went on to serve in Parliament and then became Minister for Health in the midst of the country’s AIDS crisis. She later became the Assistant Director General for Family and Community Health Department at the World Health Organization and the Vice President of the Human Development Network at the World Bank. She currently is on Aspen Global Health and Development’s Global Leaders Council for Reproductive Health. Phumaphi spoke to writer John Donnelly about the key role of community health workers in introducing family planning and saving lives and the far-reaching impact of a letter from a seven-year-old boy named Kenneth.

How did you get started on issues of women’s reproductive health?

It started at the beginning. I was born in a rural village. Households in Botswana had three homes. There’s a home in the village, a home in a place where they plowed the land, and a third place where they look after their cattle. Botswana is the size of Texas and at the time when I was born it was a population of 1 million. Now we have 1.8 million. I was not born in a medical facility. I was born in the place where we did our farming. It was in October, and my grandmother was the midwife.

At that time, many women in the village were pregnant and gave born during the plowing season. Of those babies born that plowing season, only 40 percent of us survived. It was malaria season. People were far away from the village. Babies died. I always felt like I was fortunate. I was among the 40 percent who survived during that rainy season.

One early memory for me was when my younger sister Linda died. She was two years younger. She died from measles and we were not immunized. When someone dies in the family usually children are chased away. I hadn’t seen my mom for two days, and I decided to sneak in and see my mom. I was just about to turn four. I saw my sister in a coffin, a plain wooden coffin. My mother was on a mat, on the ground, weeping. That memory will never leave me.

When I started primary school, in the same village, we were not in a classroom. We were taught under a tree, writing on slates, with chalk stone. There was an outbreak of German measles, almost two years after my younger sister died. The impression we had was that in Germany there must be a lot more children dying of German measles. I remember writing a letter to these German children. We understood that measles kill, and so we wanted to send a letter to Germany for all these children who were dying.

What do these early lessons tell you?

For me, really the most powerful messages that come out of some of the experiences was the importance of skilled attendants, the importance of antenatal care services, the importance of protecting the health of newborns and children, whether through immunization or nutrition. Nutrition has always been very important for me. As I become older, I realized how important it is for the mother.

To the extent to which she is healthy, it is really important for the cognitive ability of the baby’s brain. 

How does family planning fit into this?

Once you see women becoming pregnant when they want to be able to space their children, when they want to have access to family planning, to me that is a waste. That woman has the potential she wants to realize, but can’t.

What’s the best way to help that woman?

One of the things we have done in Africa, and it’s very unfortunate, is that we’ve focused on the traditional health worker, and left out the community health worker. We once had community health workers and then we stopped those programs. What we need to develop is a cadre of trained community health workers who can work in a few critical areas of intervention. Ethiopia, for instance, has introduced a very good program. Their training program for community health workers is quite robust. Rwanda also has a good program. These are examples that other countries can follow.

Can you give an example of how community health workers can make a difference?

When I was Minister of Health, I received a letter written by a seven-year-old boy named Kenneth. He was about to turn eight. He had a huge problem. He was living with his grandmother, his mother was dead, his father was dead, and he has HIV/AIDS. He was told because he is HIV positive he didn’t have
many years to live, but there were medicines to help him. He wanted to have access to these medicines. He had traveled a long distance with his grandmother to the health facility, and they told him the medicines were not delivered. He asked me in the letter, ‘Can you help me?’

Now during the days when we had community health workers, the parents of that child never would have died. What the community health worker used to do was to be responsible that the right family planning commodities were available to those parents.

What the community health worker did was make sure those parents were at least using condoms, and if one of them was positive, she would have made sure they had protected themselves. If we had kept the community health workers, the number of people who were HIV positive and who wanted to have babies, would have been very, very small. Because we didn’t have community health workers, because we didn’t educate people in villages, you had cases like Kenneth, who was a brilliant little boy.

He received straight A’s on class. I visited him and grandmother. He told me he wanted to be a doctor. He knew he was very sick and he wanted to help others like him. Kenneth, and children like him, started on an AIDS treatment program with Harvard. He was one of the first to go on the program, but he went on ARVs (antiretroviral medicine) late. He struggled for several years. When he died at age 13, I was out of the country. When I returned, I went with his grandmother to his grave. To me, Kenneth was an important turning point in the fight against HIV/AIDS. He represented the plight of a new generation of people who had no parents.

How was he a turning point?

In Botswana, when I started at Health Minister, I didn’t have a budget allocation for AIDS drugs. I went outside the country to look for money. I went on TV here in the United States to mobilize interest for funding. This was a time when Africans didn’t take ARVs. They were widely available elsewhere. I had other Health Ministers in Southern Africa encouraging me not to introduce ARVs. They said it was too expensive. They said they couldn’t afford it, that it was unrealistic to start it, that we must wait until the price was low enough. I told them we can’t wait, we have children like Kenneth. I wanted every single Batswana who wants treatment to get treatment. We couldn’t wait. Botswana was the first country in Africa to introduce a comprehensive HIV/AIDS program.