So welcome back, everybody. I thought it'd be good to share some of what Carl Taylor was involved with in the last two decades of his life, 25 years or so, and how that related to the broader changes in primary health care on a global basis. When Carl retired as the Chair of the Department of International Health in the mid-1980s, he went to China as the country representative for UNICEF there, and he went there with a clear understanding from Jim Grant, who was still executive director of UNICEF, that he would be free to try an alternative model to GOBI, to the very highly selective approach that UNICEF had been promoting around the world. And with that backing of Jim Grant, Carl among other things, he, he set out to work with the Chinese on a more comprehensive approach to primary health care that became known as the model counties project in China, which was a way of working with communities and local health care providers on health care priorities, particularly those of mothers and children in the very poorest parts of China, which by that time, even though China had been progressing, there were still major parts of the country that had very poor health conditions, particularly for mothers and children. And so, he started that effort and the model counties project, I don't have time to go into details of it, but it varied from place to place, but it involved the central level government working with the more local district-level activities to strengthen maternal and child health, with participation of the community. And it grew over a period of ten years after Carl came back from China, to reach 400 million people. And because of the nature of Chinese society, and their lack of openness this isn't widely known in the broader world, because there haven't been publications about it, but we have many stories about that and, we do teach about this in our course on Case Studies In Primary Health Care. This gives me the opportunity to put in a plug for the course we teach at Johns Hopkins called Case Studies In Primary Health Care, which goes into much more depth of many of these issues. And fortunately, for you, this course is on OpenCourseWare, and is availaable to anyone with internet access, and so on this slide here, you see that we have the link for you, where you can go directly to this course and take it, and it has a series of recordings related to specific cases and throughout our Coursera course, we are alluding to some of the cases in a very superficial way that we discuss in more depth in our Case Studies in Primary Health Care course. But, you are welcome to pursue this, if you want to, and have time to get into more in-depth work on, primary healthcare from the key studies approach. Also on this same slide, you'll see, in the lower part, a web link to a symposium that we held at Johns Hopkins several months after Carl Taylor died, and this is an interesting series of presentations by people who were closely associated with Carl throughout his career, and I was very honored to be one of the presenters in this. And this symposium reviews, with great fondness and admiration, the many contributions that Carl made to global health and to the Department of International Health, as well as his important contributions to primary health care. But in the early 90s Carl Taylor was recognized by President Bill Clinton, here with a very distinguished award for his contribution to global health, and you see that, in spite of their philosophical differences Jim Grant and Carl Taylor continued to be close friends throughout the remainder of their lives. And after Carl came back from China, he became engaged in a whole new approach to Community Health and International Health, that he was fascinated with, and he thought had tremendous potential, that became known as the Seed Scale Concept, and it's described in some detail in their book Just and Lasting Change. But Carl worked with his son Daniel, who you see on the left here, who was the founder of Future Generations, for almost two decades in the establishment of programs that utilized the Seed Scale principles, which are focused broadly on development going beyond health, and concern with the environment, and grassroots participation for broader development issues, and I don't have time to talk about that here. But the Future Generations program started with a lot of work in Nepal and on the Tibet side of Mount Everest. These are community health workers in the Mt. Everest region of Tibet that they helped establish, and also through their work in Future Generations, they developed Seed Scale programs in Peru and Arunachal Pradesh, which is an isolated corner of northeast India and Afghanistan. And in fact, Carl spent two years, right before he died, from age 88 to 90, as the Country Director for Future Generations in Afghanistan, and here you see him sitting with some local community people, talking about health issues, which is what he loved to do. He was a person of the villages, and he saw this as an opportunity to end up his life, going back to his roots. But you see here their book Just and Lasting Change, When Communities Own Their Futures, and so you can tell simply by the title the, the nature of this very different from the biomedical model. And these are just a few of the concepts of the SEED-SCALE Paradigm that he and his son, Daniel, developed, but a whole approach towards working with communities to try to engage them, empower them to be able to improve their health, but at the same time, scale it up in a large scale, and many of these ideas came from Jamkhed as well. Not only has Jamkhed been influential in development of Alma-Ata it's also been influential in Carl Taylor's thinking, and so, embedded in here is some. variety things that developed at Jamkhed, but through other experience that Carl has as well, and this idea of three-way partnership, linking the top-down with the bottom-up through and outside agent. The community being the bottom-up, of course, the top-down can be defined in different ways. But, they saw many examples in which an outside agent can help to do that, and we need more of that because it's so hard to bring about. I had the privilege, after Carl died in early 2010, to work with his son, Henry Taylor, who's on the faculty here, and colleague at USAID towards editing some of Carl's last writing before he died that became published in the Lancet, and interestingly enough, for the purpose of our lecture · it, the title of this, and Carl was thinking about this right until his last days what would Jim Grant say if he were alive today, what would his stance be on these issues about the selective versus more horizontal approaches? And, these last words, I think, are very powerful and and they touch on so many things that we have been talking about in this lecture, so I thought I would just share them with you. Our greatest mistake has been to oversimplify the Alma-Ata vision of primary health care. Real social change occurs when officials and people, that is, the top-down and the bottom-up, when officials and people, with relevant knowledge and resources come together, with communities, in joint action around mutual priorities. And that's the outside-in agent that, needs to be there, to pull these two very different groups together. The interplay between comprehensive or horizontal, and selective or vertical approaches requires careful blending. It is my conviction that, if Jim were here now, he would champion this blending, adapted to the local context with a focus on communities, to ignite the next child survival and development revolution. One of the articles in the Alma-Ata series in The Lancet in 2008 was on community participation, and I think it's a reflection of the growing recognition of what's been missing in so much of global health work which is a real partnership with the community and a real engagement of the community, and the enormous benefits that can come from community empowerment and womens' empowerment for the sake of health in a technical and real medical kind of way, and the randomized control trial that I mentioned reported in the Lancet from community participatory women's groups is one of many examples now, of the power of this approach. The figure on equity empowerment, and, the one on the Women's Group Community, Mobilization Action Cycle, come from this article. But, the process of transformation of women that was built into this study that I mentioned earlier from De Paul is one of the emerging themes in global health. It's going to increasingly gain more power, I think, as we better understand how to implement this and measure its impact for health. So let us summarize the vast material that we have reviewed here. And say that, from my standpoint, primary health care is a simple concept on the surface, but when you get into it, you very quickly come to realize that is a, a very complex and very fascinating area to be thinking about in the field of international health and global health. I think, increasingly, people are recognizing it as a very important fundamental strategy for improving the health of populations in a long term and sustainable way, and we desperately need to find locally appropriate ways to link vertical and horizontal approaches in a way that's equitable, engages communities as partners, promotes community empowerment through the Seed Scale process that I mentioned, which Carl and his son were so capable at identifying and conceptualizing. This author from the Lancet, spoke to this very important issue, as we move forward here in development of programs and global health. Walley wrote that the emphasis has to shift from showing immediate results from single interventions, to creating integrated long-term sustainable, and I have added here, effective health systems, which can be built from a more selective primary health-care start. So, this whole notion of using, very selective approaches, as an interim way, in which we can build these more integrated programs, I think, is a very powerful idea. And I love this statement from Carl Taylor, which again reflects the need for responding to the local context and where the people are, and what's practical and appropriate within the local resources that are available. There is no universal solution, but there is a universal process to find appropriate local solutions. And I think that is the challenge for primary health care, and for much of global health as we move forward. So thank you for paying attention. I hope you've learned some new things, and I hope your interest in this important area is growing as a result of this.
