It was a picture perfect day in May of 2000, the dawn of the millennium, and the World Health Assembly was in progress in Geneva, Switzerland. Dr. Bill Foege, a leader of the smallpox eradication campaign—the greatest global health triumph in human history—was speaking to an audience that included the world's assembled Ministers of Health. You could hear a pin drop as he said, “There will be a moment when the phrase, ‘The world cannot be allowed to exist half healthy and half sick,’ goes from being a nice statement to an actual commitment. Where there is no turning back and the world, in the words of Toynbee, ‘dares to think of the health of the whole human race as a practical objective.’ That moment could come at any time in the future, but it might just as well come today...”1
Dr. Foege could see it, he believed it, and he was right. On September 25, 2015, global leaders convened at the United Nations headquarters in New York to declare their commitment to achieving health and well-being for all by 2030. It was goal number three of 17 Sustainable Development Goals and, with it, the world dared indeed to declare the health of the whole human race as a practical objective. That day has come and the leaders of 193 countries have committed to its success.
The power and the potential of this moment reminds us of another one that occurred in 2000, when global leaders declared their commitment to eight Millennium Development Goals. All eight were to be achieved by 2015, and goal number five was to reduce the risk of dying from pregnancy and childbirth worldwide by three fourths. We did not make it, but we did achieve a feat that many doubted possible—reducing maternal deaths by 45%. Goal number four was to decrease deaths of children younger than 5 years by two thirds. We fell short here as well, but, once again, made remarkable progress by reducing childhood deaths by over 50%. Those reductions translated into saving the lives of 48 million children since 2000 alone! The number one goal, to cut extreme poverty in half by 2015, was achieved 5 years ahead of schedule in 2010. These dramatic achievements taken together are living, breathing evidence that we can take this global commitment to the health and well-being of all and realize its potential for the women, children, and adolescents we serve around the world.
Thousands of obstetrician–gynecologists from around the world gathered in Vancouver to attend the 2015 International Federation of Obstetrics and Gynecology (FIGO) meeting and, as we entered the Vancouver Convention Center, there was a giant photograph of the Earth from space. That image and perspective was made possible by the Apollo mission to put a man on the moon. As grand as that mission was, we now have an even more important one: assuring the health and well-being of each and every person on this planet. On this, we simply must succeed, but we will do so if, and only if, we have both the will and the way to do it. Let us examine each in turn.
THE WILL TO SUCCEED
First, the will. When President Kennedy announced in 1962 that we would put a man on the moon by the end of the decade, he had a powerful vision that enabled those whose help was vital for assuring its success to not only see it, but also to believe in it and commit to it.
Dr. Mahmoud Fathalla also had a compelling vision, one captured in the title of the Hubert de Watteville lecture he gave at the FIGO meeting in Washington, DC, in 2000: “Imagine a World Where Motherhood Is Safe for All Women—We Can Help Make It Happen.” His masterful address, delivered within days of the launch of the Millennium Development Goals, became a powerful declaration as he said: “Maternity is not a disease. Maternity is the means for survival of our species. Women have a right, a basic human right, to be protected when they undertake the risky business of pregnancy and childbirth” (emphasis added).2
Dr. Fathalla could see it, he believed it, and he helped all of us to see it and believe it, and that vision was of immense importance in establishing the will of the global leaders who made the commitment in 2000 to dramatically reduce maternal deaths. That vision and will were reinforced when not only those leaders, but also the entire world had compelling evidence in 2015—a 45% reduction in maternal mortality—that given sufficient political will and priority, we could indeed make dramatic progress in assuring that women are protected when they undertake the risky business of pregnancy and childbirth.
FINDING OUR WAY
So will is essential. We simply will not get there without indomitable will. However, we will need more than will. We will also need the way if we are to achieve health and well-being for all. So, what will it take to “find the way”?
The Need to Be Mission-Driven
First, we will need to be mission-driven, purposeful, and goal-directed. There is ample precedent for believing that when the will is strong enough and the purpose grand enough, we can find the way to succeed.
At the beginning of the Apollo mission, it was apparent that computing capacity would be key to the success of the program, but existing computers were too large and too heavy for use in the spacecraft. The need to solve this challenge helped drive the development and use of the computer microchip. This mission-driven innovation was absolutely critical to finding the way to put that first man on the moon. The Apollo mission would have failed without it.
So, the first of three major points about “finding the way” is that our efforts must be goal-directed. Our pursuit of that goal—assuring the health and well-being of all—must, like the Apollo program, be mission-driven.
The Need to Be Science-Driven
The second point is that our pursuit must be science-driven. We have to be certain that our interventions are on target and that they are our very best shot at solving the problems we are trying to solve. We saw this clearly with the launch of the Safe Motherhood Initiative in 1987. At that point, Dr. Allan Rosenfield, a visionary leader and American College of Obstetricians and Gynecologists Fellow, had recently written the landmark Lancet paper entitled “Maternal Mortality—A Neglected Tragedy: Where Is the M in MCH?” Again, we see the key roles of vision, political will, and priority. However, 10 years into the Safe Motherhood Initiative, we had made limited progress in preventing maternal deaths. There were multiple possible reasons for our failure to make much progress, including, as we noted, a lack of political will.
However, a knowledge gap played a pivotal role as well. One of the major strategies of the Safe Motherhood Initiative was improving the skills of community health workers and traditional birth attendants coupled with antenatal screening and referral. However, by 2005, findings from two blockbuster research programs—one led by Allan Rosenfield and the other by Dr. Wendy Graham—had shown us that a high proportion of maternal deaths in low- and middle-income countries followed obstetric emergencies. We would simply not be able to help mothers and newborns survive these complications until we could put emergency obstetric and newborn care services in place. In sum, we were off the mark in prioritizing some of our key interventions.
So, we have to get our interventions right, but being science-driven will require that we also succeed in putting these interventions into practice. Without success on this front, our innovations will not reach those we intend to serve. Doing so, however, will be far from straightforward because the emergency obstetric and newborn care services needed to prevent maternal and newborn deaths require well-trained surgeons, appropriately equipped operating rooms, safe blood, and essential medications and supplies. Ninety-nine percent of all maternal and newborn deaths now occur in low- and middle-income countries, where the health systems must be strengthened for these interventions to be implementable.
Many women in these settings will deliver in a room that has no running water, no electricity, and limited equipment and supplies. How do we put these life-saving and life-enhancing interventions into place successfully and sustainably and at scale, even in the low-resource settings where the vast majority of maternal and newborn deaths now occur? We have three choices as described by Greenhalgh and colleagues: “letting it happen,” “helping it happen,” and “making it happen.”3 There is no doubt that to succeed we are going to need to “make it happen.” That leads us to a new and enhanced focus on implementation.
Historically, much of our efforts to put interventions into practice in global health have been largely unidirectional, from research to practice using diffusion and dissemination, corresponding to “letting it happen” and “helping it happen.” It is increasingly clear that solving the challenges faced by those in the field who are attempting to implement these interventions—“making it happen”—requires that we learn more from what is working and what is not working in practice.
As Professor Larry Green has said, “If we want more evidence-based practice, we need more practice-based evidence.”4 Fortunately, there is a rapidly evolving field that is focused on this practice-based evidence and on “making it happen,” and it is called implementation science. It is a new interdisciplinary field, but it has been around long enough to give us a better understanding of implementation challenges and to provide new frameworks, strategies, measurements, and tools to help us address them.
As we begin to explore the important role of implementation, I want to be clear that emergency obstetric and newborn care services are just examples of the numerous evidence-based interventions we must successfully implement to assure the health and well-being of those we serve around the world. Women, children, and adolescents continue to suffer from conditions that we have interventions to treat, and they will continue to suffer from them until we find a way to implement these interventions successfully where they live. Soft drink companies have found ways to bottle and sell their products successfully in precisely these same settings. How can their success become our success?
A synthesis of the implementation research evidence by Professor Dean Fixsen et al in 2005 led to an important “formula for success.”5,6 It includes three interrelated factors, with all three required for successful outcomes. First, we need to begin with effective innovations such as a new technical innovation, a new policy, a program, or a practice. Second, we need effective implementation of these interventions, because even if an intervention is 100% effective in a randomized trial, if it cannot be implemented, no one benefits from it. Studies show that effective implementation requires competence, leadership, and organizational support.5,6 Third, we need enabling contexts to support implementation. In considering contexts, we often think about infrastructure. However, systems in global health are, to a large extent, human systems, people working together toward a common goal, and we need for these systems to support effective implementation of effective innovations.
These three components—effective innovations, effective implementation, and enabling contexts—are inextricably linked and all are required for successful and sustainable outcomes at scale. Implementation science is about making these three components interact with each other synergistically so that innovations will be more suitable for the contexts into which they are being implemented and contexts will be more ready and more supportive for successful implementation.
The Need to Be Team-Driven
The third major factor to highlight in “finding the way” is that it is going to take highly effective teams to get this done. We need all hands on deck working closely together in strong partnerships and real collaborations. We are a vital part of the way—all of us!
It is helpful here to consider what Dr. Jeff Koplan and colleagues described in a landmark article published in the Lancet in 2009.7 Before that article was published, it was common to hear the term “international health.” However, Dr. Koplan and colleagues helped us to see that what we are striving to achieve is global health. It is not international—“this nation” and “that nation,” “our nation” and “their nation,” “we” and “they.” It is global—it is each and every one of us on this planet. We have health disparities throughout the United States, we have underserved populations in every one of our states, and we have some of the highest rates of both maternal and newborn mortality among high-income countries. So, let us make no mistake about it, our Fellows who are serving women, children, and adolescents in the United States are, along with our Fellows who are doing likewise in other countries, a vital part of our global health mission and team. Health and well-being for all is global health. All people the world over; everywhere.
In being team-driven, we will need folks on board from our youngest Junior Fellows to our most senior Life Fellows, and there is good news on this front. In a survey of the residents taking the 2015 Council on Resident Education in Obstetrics and Gynecology examination, 96% of respondents said that having a global health experience in residency was either somewhat important or very important to them—96%!8 We are going to have all hands on deck indeed! We will need all of us working together to develop and sustain the capacity needed to assure the success of our mission.
In the wee hours of an October night in 1960, presidential candidate John F. Kennedy arrived on the University of Michigan campus in Ann Arbor intending to get several hours of sleep before a busy morning schedule. Instead, he spoke extemporaneously to the students who had gathered where he was staying at the Michigan Union and asked: “How many of you who are going to be doctors, are willing to spend your days in Ghana?”9 Two weeks later, he formally proposed a “peace corps of talented young men and women, willing and able to serve their country…” What a powerful vision! Dr. Tim Johnson and his colleagues at the University of Michigan saw it and, 26 years later, launched a program in Ghana that has led to unprecedented success in training Ghanaian obstetrician–gynecologists. A total of 246 obstetrician–gynecologists have been trained and 238 of them are still practicing in Ghana. That is the power of vision, and that is getting all hands on deck sustainably.
We had a strong start in building teams as a college when Dr. Ralph Hale worked with FIGO in 2000 to launch a program with our colleagues in Latin America, one that became a highly successful collaboration still thriving today as CAFA (the Accreditation Committee of the Federation of Central American Associations and Societies of Obstetrics and Gynecology—American College of Obstetricians and Gynecologists), a partnership created to provide accreditation for residency programs and to develop and administer certification examinations in Central America.
The work in Latin America was our primary global focus until Dr. Jim Martin, American College of Obstetricians and Gynecologists president from 2011 to 2012, made global women's health a major theme for his presidency. He led the creation of the Global Operations Advisory Group and the Office of Global Women's Health. At one of our early Global Operations Advisory Group meetings, Jim said we have three groups we serve in our global health mission: our members, our colleagues, and women around the world. The American College of Obstetricians and Gynecologists is doing just that.
We have come a long way from those early days when the American College of Obstetricians and Gynecologists had a Committee on International Affairs that met for 1 day once a year, and we are where we are today in contributing to the improvement of global women's health care because of strong American College of Obstetricians and Gynecologists leadership, tireless support from the American College of Obstetricians and Gynecologists staff, and the outstanding work done on American College of Obstetricians and Gynecologists projects by our Fellows. So many more of our members are making vital contributions to global health through their clinical practices, universities, and volunteer activities. This work has its own rewards—rewards deep within that come from serving the underserved, whether they live in sub-Saharan Africa, South Asia, or our own backyards. Our field is filled with people who have big hearts and, for those who have been looking for opportunities and are interested in joining in the American College of Obstetricians and Gynecologists’ current global women's health projects, signing up for volunteer activities the American College of Obstetricians and Gynecologists is helping to facilitate, or want to contribute in any other way, you can contact the Office of Global Women's Health at firstname.lastname@example.org.
DELIVERING ON THE PROMISE OF HEALTH AND WELL-BEING FOR ALL
When then United Nations Secretary-General Ban Ki Moon announced the new Sustainable Development Goals, he said “the new agenda is a promise by leaders to all people everywhere.”10 For the sake of the women, children, adolescents, and families we serve in each of our communities and in the communities of our colleagues around the world, this is a promise on which we must deliver. It is a promise whose pursuit is at the heart of that wonderful song “Climb Every Mountain,” whose chorus exhorts us to “Climb every mountain. Ford every stream. Follow every rainbow. Till you find your dream.”
It is fitting to close as we began, in Dr. Foege's address to the World Health Assembly. Just before saying that “that moment could come at any time,” he said: “There is a point in every movement, where a line is crossed. There is a drop of water that finally causes a glass to overflow, a moment when a friendship becomes permanent, a minute when a vaccine actually provides protection.”
We are at that point. The line has been crossed. We have dared to make the health of the whole human race a practical objective. It is a dream whose time has come, and we will climb this magnificent mountain and we will realize this dream. We can see it, we can believe it, and we will—together—find the way to do it. For the sake of all we serve, we will reach the summit together, and we will deliver on the promise. Succeed we can. Succeed we must. Succeed we will!