THE PIONEERS IN MEDICAL AND PUBLIC HEALTH PROFESSIONS IN ETHIOPIA:
NARRATIVES AND ATTRIBUTES OF LEADERSHIP
By Dr. Ahmed A. Moen, Howard University, Washington, D.C. USA
• “Some are born great; some achieve greatness, some greatness thrust upon them”. Anonymous.
• For large majority of Africa’s population sustainable balanced development is still a deferred dream only to be fulfilled with hope, resourcefulness and resilience. Leadership is one component of the equation but the other is grassroots organization for change, stability and peace for all.
This is an opportunity to reflect on the lifetime narratives and attributes of our mortal and the living health professionals as fallible humans with indomitable spirit to serve the needy, heal the sick, mourn the dead and nurture the offspring through education and guidance. All of the above attributes of leadership and greatness inspire hope for many to enjoy health as: “…a complete state of physical, mental and social well-being and merely the absence of disease of infirmity and is a fundamental human rights …” [WHO, 1946] The theme of this paper is not humdrum rhetoric of who the Ethiopians were or lament who they are now when we know we are diverse peoples with more in common than differences. It is an effort to personify leadership attributes of heroes and heroines, some of whom considered to be icons, exemplars or charismatic persons who lived in present or bygone history. These trail blazers will be remembered for a single or all of the above mentioned three attributes of greatness within a broader spectrum of their ideas and actions. Among the distinguished attributes usually included patience, resilience and vision intended to leave durable legacy for the entire health professions.
For sure, good leaders are fallible, accountable, responsible human beings. However, the balance sheet will show that their lifetime narratives were as challenging as ours. Their deeds will remain on books as instructive guidance for many succeeding generations. Of course, not every person who was or is “first” of this or that generation will be remembered as having a singular or plural attribute/s which signified the pioneer status. However, given the variety of contexts and timings, their contributions will b0e considered equally and they will deserve memorable mention in the history of medicine and public health.
Collecting and restoring institutional memory where there were no systematic journal keepers or chroniclers is a daunting job and subject to lapses. To recall the outstanding attributes of leaders behooves us to remember the relevance, context and styles of their involvements as change agents and how seriously they kept the promise for the entire health professions. Indeed, the urgency to recollect their significant works by ways of oral or written narratives before the living memory reservoir dries up or fades way is civic and scholarly obligations. Those of us who remember tidbit narratives told by their friends, parents, relatives, biographers or those who have scholarly interest in studying leadership styles and attributes owe the Ethiopian health professions some debts. The best way to pay back is to focus on their invaluable legacy which should be judged by a continuum scale of relative ideas and actions taken from the time their first deeds were enacted as beacons of hope on the hilltop.
A good number of the Ethiopian health professionals named or unnamed in this paper qualify to be heroes and heroines because they have paved the trails for the succeeding generations. By no stretch of imagination this is an exhaustive list of the numerous names and works of health professionals in Ethiopia. Those of us, who remember other unnamed personalities, are kindly invited to bring on their favorite lifetime heroes or heroines for recognition. It is important at this time to recognize selective pioneers as examples and their works as our legacy to keep. I
In the final analysis, the first generation will be remembered for their efforts to start self-reliance and national pride as a cornerstone when they set the first foot on health profession as role models. Of course, being a “pioneer” is a relative designation for someone who was the first, but the attributes are elaborate and can extend to include successive generations who keep adding to the list of creative deeds and innovations during their lifetime.
To compare merits or demerits of leaders whose lifetime works set examples for the best and the brightest is a healthy democratic exercise. The results will be on the two sides of the ledger for judgment by vested stakeholders and historians. The ledger will reveal the context, time, organization, vision and mission under which they performed in transparent or concealed manners. Ultimately, the succeeding generations have the rights to give verdicts on their strengths as good guidance or minimize their mistakes as lessons to be avoided. At any rate, in either scenario the succeeding generations need to add their contemporary contributions to enhance the legacy and special narratives of the history of leadership on their own and submit evidence of continuity. Critiquing the works of particular professions may involve positive or negative judgments and no one is immune from criticism. The criticism, however, should be considerate and respectful than an uninformed generalization on what went wrong. At any rate, the purpose of any analysis is to inform, learn, trust and remember the past or present history of the medical and public health professions.
History repeats itself in positive or negative terms. It has always been felt that unless we as people come individually or collectively to terms with our past history, business will always be as usual. Cynicism and incrimination will creep and needlessly jump to mind in order to devalue the “other”. This mind-set usually shuts off rational discourse and lead to hurtful sarcasm and inestimable mocking of the “other”. The result is dismal failure to reconcile and forgive one another. Blaming and praising have to be on the balance and justly be addressed as genuine efforts to make a difference in the quality of relationships and conversations on public affairs.
Personal ideas and actions are measured by certain norms and standards of responsibility. Yet, humility is an honorable intellectual challenge for leaders to be remembered as righteous as saints. Individually and collectively we own up our actions as participants, sideline observers or involved actors. Throughout history, the Bible and the Qur’an in many verses and chapters offer words of wisdom for nations in the same way as social psychology such as “Maslow’s hierarchy of needs” describes human needs and priority for survival. Some readers on P2P stretched unwittingly Maslow’s theory to explain the African state of mind and dissatisfaction with their leaders. However, my faith-based perspective on history of civilization rewards good deeds and admonishes the succeeding generations to stand up for what they do.
I hope the following remarks do not appear as a sermon from the pulpit down. I wanted it to be a public discussion on serious world problems and leadership attributes of this or that generation. However, history is a dynamic process and those who did it will be judged by it when we are accounted for personal ideas and actions as continuous intergenerational responsibilities. These words of wisdom are refreshing to the mind and heart. It says: “For the people that have passed away, they shall reap the fruits of what they did, and us of what we do. You shall not be asked about what they did. But surely you will be asked about what you do.” In a simple language: “Be proud tomorrow of what you did today.” I will be glad to send the footnote reference of these verse and chapter, if anyone asks me.
In reviewing the narratives of our role models and their leadership styles we are making a political statement about significant milestones that we have achieved or learned about the history of medical and public health professions and add it up on the autobiographies of great role models. Many of them are still out there without due recognition. On the contrary, we are not only looking for the charismatic or polarizing public figures with high credentials and expertise to bias what we did in the past and need to do in this day and age. We are looking for pragmatic “situational leaders” whose actions matter and how they learned to do the right thing on the job is instructive. Mostly we are looking for specific human characters to measure moderation and realism kept in the arsenal of the leaders in order to trigger change given the material and human resource constraints. These diverse inputs help to determine the personal attributes of success or failure, when appropriate. We hope we will live up the standards we established for good leaders in the medical and public health professions.
Frankly, we are not denying that borrowing from comparable Euro-American leadership styles can be adapted with reasonable cultural nuance. At the same time we do not condone mediocrity by any universal standards and we can do it if we try to harness our potential resources to meet higher expectations. For example, hospital-based or ambulatory clinical services require high tech preparation whereas we can do the same by modifying our health care delivery system to do more with little resources. As a former hospital administrator, I can vouch for the difference we have made because of the talented, motivated, creative work force which made a difference. It is in this context that we are able to define leadership attributes that distinguish our home-grown aspiration to move forward with self-reliance in short period of transition from total dependency to interdependency and from interdependency to full ownership of our limited capital and human resources.
We’re interested to learn how organizations modeled on Euro-American cultures can quickly adapt to change, thereby fitting the African organization man’s vision of the future after independence during and after colonial in the 20th century. This transformation period exemplified and personified the narratives of our pioneers and their legacy as change agents. This can also be illustrated by their ability to transform missionary owned health care delivery system to entirely self-sufficient public ownership of most of the facilities and their operations. Of course, there are some who are dissatisfied with the outcomes because of our scarce resources, but you’ve got do with what you have to do.
As an objective African health professional, the notion of self-reliance, by any means, does not deny appreciation for the expatriates who contributed to the modern health care and socio-economic growth. We also do not deprecate faith-based medicine and its ethics to promote humanitarian interdependency as public good. To some, the period of African liberation has generated negative dependency and triggered hidden passion to rebuild the image of Africa as rich in natural and human resource. Many P2P discussants may disagree with my assumption and ask the question are we better off now? This is an unfair question when we know there is qualitative difference in human development index. However, there are countries that are trying to do a fair share of the work with the little they have. I cannot help but to say that theis provocative question challenges us to do better than look backward and move forward. My modest experience tells me that Africa is a dynamic, growing, diverse continent with complex health and development needs that cannot be satisfied by the works of one generation. Its development is an on going process that requires patience, persuasion, persistence and polite conversation coupled with tolerance for different opinions. The least we can do is build a stable foundation and leave it to the succeeding generations to share the burden of change – “to whom much is given… much is required.”
THE STATE OF MEDICAL AND PUBLIC HEALTH PROFESSIONS IN ETHIOPIA: SELECTIVE NARRATIVES
Given all of the above historical circumstances in the 20th century, the leadership attributes of greatness of the medical and public health pioneers can justly be described as actions taken by situational leadership on whom “greatness was thrust” to achieve self-reliance and pride. They were persons driven by ideal values and willingness to take some risks to make a difference in the life of others;
Dr. Martin Workneh was teenager pupil when he traveled alone to England and ended up studying medicine as his career choice given the fact that he came from a humble social background and blessed by kind sponsors. The Battle of Adwa in 1896 and World War I in 1914-18 came back to back during his young adult life. The war and peace concerned him as the first Ethiopian physician when he was able to see his first Ethiopian patient in 1906 in Emperor Menelik II Hospital, a fully equipped modern hospital established by the Russian Red Cross. However, it was obvious for him that living in a state of violence and war during his prime medical practice time set backward human development agenda which was characterized by abject poverty, death, diseases, famine and ignorance right down to this day and age
Dr Melaku Bayen was a another medical student and a political activist when he was studying medicine at Howard University a renowned 141 year old topmost Black University in America. He was an African scholar who helped bridge the African American quest for freedom with Ethiopia in its struggle for liberation from Italian occupation. He interrupted his studies when his was a senior medical student but went back on track to graduate as the “first” American medical graduate to practice general medicine in Ethiopia but, unfortunately, he died of a preventable disease in 1940s at a prime age.
Dr. Widad Kidane Mariam was born to an Ethiopian émigré family in Palestine during the Italian occupation of her country of origin. She studied medicine at the American University of Beirut and became the “first female” medical practitioner and topmost physician administrator in charge of medical services division in the Ministry of Health in 1960s-1970s. She was also a grassroots organizer responsible for founding the first Ethiopian Family Planning Association and Maternal and Child services for the homeless in Addis Ababa Municipality when she received her call to be the first Ethiopian gynecologist to volunteers after hours the Swedish Save the Children Fund project in Addis Ababa. Like Dr. Melaku Bayen she, unfortunately, died at a prime age, however both of them will be remembered as pioneers in medical and public health services. .
Dr. Asrat Woldeyes was another example of a person who was born and raised in Ethiopia during the Italian occupation and forty years after Dr. Martin Workneh became the first British educated physician. He was trained as the surgeon at Edinburgh University in Scotland. He became the first Ethiopian Medical Director and general surgeon at the Princess Tsehai Memorial Hospital in 1950s-1960s; later on he was appointed to be the third Dean of the Addis Ababa University Medical briefly within 20 years of his matriculation from Edinburgh University. Thing back then were different for foreign trained Ethiopians in medicine. Being a hospitalist as opposed to primary care gatekeeper physician gave the individual higher status than a health officer and primary care physician engaged in health center clinics in underserved rural areas where the majority of the population live and work anywhere in Ethiopia or Africa. The divide between hospital medicine and public health clinic eventually melted down when the leadership and dedication of undetermined number of pioneers of public health officers and medical doctors were able to graduate from the Gondar College of Public Health and the Medical School of Addis Ababa with double tracks in 1970/71.
These exemplars were involved in civic and professional leadership while studying and practicing their healing arts several decades apart from one another in three continents at the time when Ethiopia was a resource poor country and the world was in state of war and economic depression thereafter for decades. The leaders’ views converged on the primacy of self-reliance and national pride for independence as change agents who answered call. It did not matter whether Dr. Widad was born in Jerusalem or Drs. Workneh, Melaku and Asrat were born in Ethiopia and educated abroad, what maters most their pioneering spirit for public health service.
At that point in time self-reliance and national interests were mutually inclusive and the dream has yet to be fulfilled by a modern state at the turn of the 20th century. The modern state has the responsibility for the health, social, educational and economic welfare of its citizens. Constructive engagement in the state affairs was bona fide citizenship duties to safeguard the common good. In so doing, ideas and actions, intended or unintended, were committed in the name of common good that benefitted all citizens. Right after the Ministry of Health was established in 1948; almost all medical and public health practitioners were employees of the Ministry of Health. They also served as technical consultants in their respective specialties. They truly believed and practiced” do no harm” and “people’s health comes first” .The founders of organized health professions in those formative and transitional period sought not only autonomy but also an advisory status on behalf of their associations (EMA and EPHA) through imperial charts given by relevant ministries and departments of the Ethiopian governments with the blessing of the Emperor as a patron.
One person described politics as “the art of the possible” and other described it as “the mother’s milk of the civil society.” However, Plato described it as citizenship rights. He said: “The political association and the totality that results from the association of citizens in cities [Athens and its environs] correspond to the association of the bodies that constitute the totality of the world.” Situational leaders emerge from people. They, in particular, learn how to win friends and negotiate the interests of their constituencies for selfish or altruistic reasons. Undoubtedly, no one person “is born great” with superior “gene”. What it may mean that the person can have a hereditary lineage descending from special social or political rights and privilege. On the contrary, all men and women are born equal but inequity after birth makes a difference.
Mostly “situational leaders” are also achievers that are “some achieve greatness. However, most of this leadership attribute can be “learned” via organized professional development plans. In this respect, community and professional peer recognition work hand in hand to motivate excellence. But in Ethiopia as in many developing countries, recognition comes with approval from modern and the traditional healers practicing medicine in two parallel tracks. Health needs and knowledge determines who will be suitable leaders with superior evidence-based skills. The Ethiopian health policymakers, for example, have recognized and legalized two tracks of medicine in order to insure access to health care as a necessity for a growing number of the population. Moreover, in the second traditional medical practice track, the latter ascribe to them and they believe they are descendents of hereditary line, thereby empowered by a host of religious and spiritual supernatural beings. They have the rights and privileges to diagnose and treat patients.
With the above attributes in mind, the perceived status and rewards for good or bad leadership is relative and different, but coexistence of medical profession with traditional healing arts is a must for the good of the society with limited alternative solution to solve all health, economic and social problems at hand. Ultimately, there may emerge multiple ways to fairly address some if not all social and political dilemma dialogue and peaceful coexistence.
THE UNIQUENESS OF THE ETHIOPIAN MEDICAL AND PUBLIC HEALTH PROFESSIONS
In Ethiopia, unless 1948 Proclamation is superseded by new laws and regulations, the privileges and rights of health practitioners are universal, fair and equal. The Medical Practitioners Registration Proclamation No. 100 of 1948 in the Negarit Gazeta said: “ Nothing in this Section (Proclamation) shall be construed to so as to prohibit or prevent the practice of a system of therapeutics according to indigenous methods by person recognized by the [local community] to which they belong to be [duly trained] in such practice.” Furthermore, “medicine” means and includes “a physician, surgeon, dentist, pharmacist, midwife and nurse and any other person who holds himself out to the Public as being able or prepared to examine, diagnose, treat, prescribe for or dispense for patients for gain.” [Underlines mine]
The above Proclamation explains the equal status of medical practitioners and two tracks of leadership in health professions in Ethiopia. This will dismiss the legal misconception of quality of care and safety of the public by harmonizing coexistence of scientific and alternative traditional healing arts. In way some of P2P discussants have already passed a judgment not only the inferiority but also the suffering of the people from injurious policies and apathy of the political leadership. This misconception emanates from the notion of quality medicine is technological dependent outcomes. Cameroon in West Africa, for example, has one of the legally registered associations of traditional medicine and practices. The first founding president was a physician trained in Cameroon and France and a full professor of internal medicine in the health Sciences Center of the University of Cameroon at Yaonde. On two scientific symposiums held at Howard University College of Medicine in 1986, he was invited to address the issue of alternative medicine in resource poor countries. The consensus was that the duality of modern and traditional health care will eventually be resolved by health education and promotion of quality health care. Time and time again, political radicalization of the health care professions during the socialist revolution in many parts of Africa in the 1960s-1970s seems to have lost the battle against entrenched health beliefs and practices when there were no better alternatives as a result of resource constrains. Partnership among equals is indispensable and none can live without the other. Regulating traditional medicine was meant to protect quality patient care by whosoever practicing the healing arts but enforcement of the laws is still a problem in Ethiopia as in the rest of Africa.
In essence, the pioneers who were culturally sensitive and politically competent leaders saw self-reliance as their challenge and for which they encouraged and regulated medical care as a national priority. On the contrary, there were others who gave little value for practicing in minimally technology-based care as opposed to the high technology-based care in Europe and America. By accepting to trade off places, the reward for being “pioneers” was gratifying and a good reason for lifetime achievement in public health service. Because of their sacrifice, we can understand why self-reliance was driven by national pride to remove external cultural dependency. On the other hand, one feels that from this experience emerged the attributes of rugged “situational leadership.” This is an arbitrary designation that describes the risk takers in frontline health care delivery systems. Those leaders acted as peers and consultants to the public health establishment in order change and resolve core health and development needs with the little resources at their disposal then.
Self-sufficiency and continuity of health services delivery system mean simple technology, health promotion, disease prevention and cost effective care accessible to the medically underserved and economically marginalized populations. An important aspect of hospital-based medicine is high tech and specialized medical care tied to sophisticated referral system from the ground up. However, the national health policy is slowly tilting to simple technology with heavy preventive education and public health education and clinical interventions, when appropriate. The leadership for change rests on shared responsibility between the medical and public health practitioners and the impermeable bureaucracy. The early signs of change in public education and practice started with the establishment of the Gondar Public Health College and Addis Ababa Medical School in 1954 and 1964 respectively. The country was gripped by fast transformation and change. However, it slowly became evident for the pioneers using their unique partnership status to attract the attention of policymakers. Both medical doctors and public health practitioners put “people health is first” in their minds and hearts and looked at the greater picture.
If history is a good guide, then there is a huge difference in an organization with medical service as its core value in Ethiopia and Europe or America. Because of the political and professional independence the Ethiopian Medical Association and the Ethiopian Public Health Association, their strategy was to win acceptance for their professional expertise. Moreover, when EMA and EPHA were established more than forty years ago, their autonomy was neither a critical nor a fundamental reason for survival as nongovernmental service organizations. The founding members have had cordial relationships with the power structure and policymakers by the virtue of their status as appointed advisors on the National Medical Advisory Board of the Ministry of Health, technical committees and special projects. There were more opportunities to collaborate and share technical expertise in exchange for credibility and integrity of the profession more than any other considerations. The advice and consent role played by the professional leadership carried greater weight to enhance mutual peer respect and trust. As a result it helped the politically appointed lay ministers and bureaucrats to depend largely on the scientific and technical assistance by consensus.
This closed circuit policymaking process was acceptable and workable cultural and political model with the least threats to the autonomy of EMA and lately the Ethiopian Public Health Association (EPHA). These are not value judgments and mutual admiration of two heath professional organizations that I am associated with for four decades at home and Diaspora. My understanding of the structure and functions of EMA started when it had open membership for medical and allied health professionals as full or associate members. The founding fathers and mothers were partners for change than outsiders. EMA and EPHA have survived volatile political, social, economic and ideological assault on its leadership and membership. But they preferred not to compromise “people’s health is first” and “do no harm” as the guiding principle for the common good at anytime and under any condition of service.
The uniqueness of organized medicine and public health is its understanding of the felt need for survival and the necessity for cooperation under moderate leadership in a volatile political transition period. Protection of mutual interests and survival played key role in serving the mutual interests of the association and the policymakers whose structure and functions are legally authoritarian and functionally bureaucratic. Getting along was not a matter of choice but a necessity to move forward when the opportunity knocks at your door and public service calls you to fulfill an altruistic mission. The reward will be continuation of the advisory expected of high credential professionals.
There was a time when physicians were hired to perform patient care only and their voice cannot be heard inside the power corridor of the Ministry of Health. No Ethiopian with medical and public health degree served in a political ministerial portfolio. Because of the unequal dependence on the advice and consent no Ethiopian with MD, PhD or DrPH degree before 1974 Socialist Revolution ever served as Minister of Health. Dr. Jemal Abdul Kadir, an eminent academician and medical specialist was appointed as the “first” Minister of Health. His tenure was short but he was followed by two full-time ministers of health and several ministers of state with MD; two PhDs and one Doctor of Public Health (DrPH) as of 2008. One of the appointed pioneers with DrPH degree was the first female Minister of Health after Dr. Widad Kidane Mariam who was the first female Ethiopian Chief of Medical Services. A hybrid of leadership with medical and public health leadership ushered irreversible change for good. The presence of the professional association as independent entity outside the Ministry of Health has significantly contributed to public health policies and the relationship with Ministry of Health could be relatively tenuous but minimally disruptive when the rest of the country underwent radical transformation and regime change. Apathy, ambivalence and frustration were also observed because of the uncertainty of the policy and ambiguity of the vision and mission of public health service.
The relationship between the founders and the public health establishment may have been tenuous but not totally disruptive as that of the Ethiopian Teachers’ Union and General Labor Union whose rank and file membership was relatively politicized and vocal political players for social change. The huge shortage of health professionals and poor private sector that cannot absorb the surplus of human resources outside the public service also suffered from premature structural adjustment which laid off undermined health professionals for various reasons. At any rate, no one can deny the constructive political and professional engagement of the pioneers to help lay the foundation of public health for many decades of the 20th century. .
The Ethiopian Medical Association (EMA) was founded in 1961 with a Royal charter granted by the Imperial Government and Emperor Haile Sillassie I agreed to be its patron. Although there were few Ethiopian physicians in the country, expatriate doctors played a prominent role in the early history and accounted for the majority of its membership.
The objectives of the association are to promote the professional excellence of members in preventive and curative medicine; the medical research and improvement of public health through annual and special conferences and publications; maintain intellectual education of its membership: maintain “professional freedom”; and provide professional and technical advice to the Ministry of Health and other
concerned organizations. The exchange of clinical knowledge and research information at the local and international levels, as well as putting “universal code of ethics” as their guiding principles. These values allowed EMA to maintain a standard of behavior that is always humane and rational, for dealing with lives of people. Members were expected to pay their regular dues and its membership included associate status such as fellows, allied health professions, as pharmacists and health officers. Dr.Fride Hylander, a Swede physician, was the first president of the Ethiopian Medical Association when the Government officially recognized the association.
While the core professional values were mostly adapted by organized medicine in Ethiopia or Africa, the ethics, scientific education, as well as peer reviewed standards are similar. Quality care, membership growth and development and scientific information sharing were institutionalized. However, there are cultural, functional and structural underpinnings unique to the organizational behaviors and practices in Africa and Ethiopia. The roles played by organized medicine in the Euro-American evolved from common body of established political and cultural operative procedures. For example, the effectiveness and efficiency of the Euro-American organizations are enhanced without whatsoever contradiction for its ability to “negotiate” its membership interests and influence health policies and legislations, among others.
To conclude this segment of organizational behaviors and cultures unique to the Ethiopian health professions, one wishes to have fair and equal space to compare and contrast the systemic challenges facing the Ethiopian Public Health Association (EPHA) which represents well-educated public health educators and practitioners comparable to its counterpart in Europe and America. EPHA is a national, independent, voluntary professional association established in 1989. It succeeded the Health Officers Association which dates back to 1960s which was made of Ethiopians well before the Ethiopian Medical Association. Later on, the first attempt to organize was in the Gondar Public Health College campus in 1966 suffered temporary setback. The former Health Officers Association which could be considered as the precursor of EPHA was founded in 1975. EPHA was legally registered as the successor of the previous attempts in 1989. It is a multi-disciplinary, not-for-profit professional association with a large number of memberships in Ethiopia.
Needless to say, the structures and functions of the Ethiopian Public Health Association (EPHA) as a professional membership organization came into existence few years ahead from the Ethiopian Medical Association. EPHA constitution articulates the values, cultures, structure, functions and the rights and privileges of its membership. It is important to note that there were a growing number of Gondar Public Health College graduates who were among the “first” to obtain medical degrees in Ethiopia and Europe who served in the ministry of health, police and army and who also belong to EPHA and EMA membership. While the focus of EPHA is population-based public health care services, its mission, goals and objectives are supportive of the Ethiopian Medical Organization in that “people’s health is first” as long as one practices medicine and public health. Essentially, the two organizations have structural similarities inherent to grassroots membership organizations. While the narratives of the pioneers and leaders of both organizations have striking agreement and unqualified commitment to self-reliance and national interest come first, EPHA’s history and modus operandi relatively varies because of the diverse professional credentials and career paths of its membership as precursors of the public health service. In other words, necessity has created cross-over memberships of the Ethiopian Medical Association, as well as their advice and consent role in Ministry of Health. However, most of the public health officers formed the backbone of the national and regional top health administration positions.
The Ethiopian pioneers during the first half of the 20th century were the forerunners for change and self-reliance as national policy goals and their legacy should have not been lost as lessons to be learned by the present generation of highly qualified professionals, some of whom seem to be ambivalent about their role in a dynamic and fast changing economic hardship that opened the gateway for “brain drain” and leadership depletion. Brain retention and attraction can be shared responsibility between the health professions and the public health sector to negotiate incentives and benefits usually given to expatriates as substitute for losing indigenous trained human resources to neighboring Africa, the West and the Middle East as new market with lucrative benefits. The public health service as a major employer cannot survive without partnership with the pri0vate professional organizations to help it redraw human resource redistribution and retention as an integral component of capacity building and professional leadership development agenda to move forward as guided by sustainable and balanced human development index that favors resource poor countries.
In retrospect, the critics of the closed circuit- advice and consent- culture felt that this dual role of the founding members of the medical and health profession that begun with cozy relationships may have compromised the autonomy and independence of the health professional associations. Henceforth, they cannot negotiate and differ on policymaking matters from strong power position so long as they have lost the leverage of their independent edge. However, for the sake of argument, it is important to note that the advice and consent culture is an effective two-edged sword one of which protects the interest and co-existence of the majority of health practitioners who are the backbone of the bureaucracy headed by lay ministers for many decades in the past. The other edge is appointment on the National Advisory Board puts the profession on higher moral ground because it puts “ people’s health is first” as shared power. Accepting dual positions in the decision making circle seemed to the right professional way to answer the altruistic call to serve people.
Studies of professional organization’s sustainability and viability in transitional societies with limited experience in membership organization, democratic culture and financing mechanism usually have serious flaws which stem from multiple negative factors: Lack of regular dues, ambivalent loyalty; and the apathy of the membership to exercise their democratic, competitive participation which results in extended or indefinite tenure of leadership. Limited earning capacity and free time to serve at will without compensation inhibits growth and development. Moreover, growth and development of leadership track in the health professions differs qualitatively from other service organizations. But these inhibitors can be overcome by recruitment and retention of younger generation as change agents. To resolve the corrosive apathy and ambivalence which look backward to move forward visionary situational leadership are need.
TEAM BUILDING AND LEADERSHIP DEVELOPMENT
The other dimension of leadership track that emerged from the transformation of the Ethiopian medical and public health education and services is the concept of “Team Leadership.” It is one of the unique attributes in countries with dire human resource shortage. In Ethiopia, “Team Management” started with an undetermined number of frontline heroes and heroine of the public health service made of multidisciplinary middle level managers of care – health officers, nurses and allied health practitioners. They were educationally and professionally competent, their performance was not only adaptable, but also provided comprehensive frontline community health care for a widely dispersed population depending on public health centers and rural hospitals in Ethiopia. Together the multidisciplinary team formed the backbone and lifeline of primary care; their grassroots constituency and decentralized decision making process empowered them to act as “situational leaders” and “gatekeepers” of the health care system. They were proficient not only clinically but in sanitation and environmental health aspects impacting sustainable health and socio-economic development.
Dr. Halden Mahler, former WHO Director described environmental health and water resource use as a national public health priority underpinning the quality of life and human development index in resource poor countries. The Gondar public health team which includes a trained sanitarian working together with the rest of the Gondar Public Health graduates – health officers, community nurses and laboratory technicians – provided comprehensive community based health and development services. This multiple interventions were embodied in the 1978 Declaration of Primary Care and Health for All by WHO.
Dr Halden Mahler, a physician by training and a medical missionary by vocation and a politician gave medicine and public health added value and a shot in the arm when he said: “The number of water taps per 1000 is a better indicator of nation’s health than the number of hospital beds.” This inspirational message was heard clear and loud in many parts of the health policy decision making centers. Advocates of environmental health and anti-global warming such as Al Gore seized the opportunity as a world class leaders to put the health and the environment crisis on the agenda of human growth as a priority Both Dr. Halden Mahler and Al Gore were good examples of “situational leaders” where political will and prestige are translated to constructive engagement of the political power structure such as the National Government, UNPD, WHO, UNICEF, EPA and so on and so forth when they proclaimed that “people health is first.”
The resilience and equanimity under duress are among the indispensible attributes of leadership in medicine and public health. Measured responses and consensus on what is to be done help us get forward and decide the future course to achieve balanced health and development growth. Dr. Carl Taylor, my mentor and professor of international health at the Johns Hopkins University and one of the harbingers of the 1978 Alma Ata Declaration of Primary Care – Health for All by Year 2000- began his medical career in missionary medicine in India. Nothing can be more frustrating than to serve in resource poor country characterized by multiple diseases, hunger, and ignorance threatening human survival. His concern was to change real life conditions in India which used to be a classical example of demographic explosion and abject poverty then as it is now in Africa. He told me, in no uncertain terms, for him to succeed in his mission is to believe in himself and answer the call. He said: “Frustration is a state of mind inhibiting personal actions in a dynamic or static environment. However, “management by frustration” is not all that bad. It is a quick way to figure out the best solutions to move from point A to B rather than standing still on the crossroads watching the world goes by and wondering what we have done to change our frustrated mind set.” In other words, to him as to many of us considered leadership is a challenge fraught with risks. Risk taking leaders are self-made architects of change (some achieve greatness) driven by personal ambition or altruism whichever the leading cause of success with least human cost. They have the skills and knack for problem solving as their end-game strategy than a process fraught with doubts and frustration. Come to think of the new generation of leaders equipped with higher multidisciplinary qualifications such as those I read on P2P, progress can occur as easy as keeping the momentum and window of opportunity wide open thereby avoiding the incorrigible trap of apathy and ambivalence.
TRUST-BUILDING AND DIALOGUE: THE EMERGING E- GENRATION CULTURE
I submit that I take trust building is the butter and bread of any relationship in the family, office and other walks of life. The root of the leadership problem in an organization can be resolved by more dialogue with peers. It is as simple as to say that the role of the leader is to gain peer confidence and the role of the followers is to trust its leadership. This democratic leadership culture can be nurtured and learned at home, in schools, in the community and on the job as civic education. Leaders cannot lead uncommitted members because the rights and privileges to demand service are contingent on reciprocity of the membership to meet its obligations. Trust-building in modern as well as traditional “wiyiyit shengos” or “public talk-shops” begin with transparent, constructive dialogue. It is very hard to run an organization by uncertain rules of engagement. The worst that can happen is when the intentions and deeds of the membership and leaders start with doubts and disrespect. Respect is earned and trust is its lubricant. Peer respect gains confidence because confidence is the body and soul of any professions. There is no place for doubts in an organization whose code of oath is “do no harm.” Trust is built by the rights of privacy and dialogue between the patient and provider which occurs at every encounter. In such a democratic culture of patient-provider dialogue, the same culture can be extended to the professional peers and the membership to effectively make health professionals as role models for dialogue. Those who can listen, diagnose, treat and rehabilitate numerous and diverse clients in their daily business, they can also lead civil society to practice shared responsibility for peace and stability.
In political and social organizations in Ethiopia, as well as many other developing countries that I have consulted on conflict resolution, trust-building appears to be a key issue for many organizations no matter where on this globe they are. Trust is an open ended two-way street on which civil society builds its democratic culture. Pragmatically speaking, successful organizations are characterized by members who are serious stakeholders; pay their regular membership dues on time; give gifts and donation; volunteer their free time and talent as needed to sustain and own the organization. The membership rights and privileges are reciprocated by performing reasonable service to the best satisfaction of the profession. (Italics is mine)
If we examine the reasons for the rise and fall of professional, social or political organizations which we have observed around in our political culture, it is the misconceived rights and privileges which say do-what you want to do without reciprocity in kind and where the intension does not match the action. Sorry to say, it is not the organization’s fault, it is people’s culture and the concept of freedom of association and belonging without price to pay. In other words, leaders and followers share blame or praise, as a matter of fact. The lessons learned from the Euro-American civic membership organizations is the degree of freedom to disagree without being disagreeable and the desire to engage dialogue and trust-building inherent to the fabrics of the political cultures of the organizations.
Lessons can be learned from the transformation of professional organizations to negotiate membership interest and mistakes, if any. Mistakes are human and can be rectified by dialogue and compromise. Compromise is not a bad word. It means win-win situation where the price of win or lose is lost relationship down the road. One can only be inspired by hope, optimism, persistence, persuasion and resilience embodied in diversity of the Ethiopian cultures, ethos religions and practices. That is the test of leadership attributes that can be expected of organized grassroots traditions and the narratives of pioneers who seeded self-reliance and autonomy as we noted in the history of the Ethiopian Medical Association and the Ethiopian Public Health Association. History can be made at different time, different levels and by different generations. While the Ethiopian Public Health Association was entirely initiated by the Gondar Health Officers, the Ethiopian Medical Association was uniquely initiated by well-meaning expatriates who love Ethiopia. Now it is gratifying to see that the leadership is entirely Ethiopian. Self–reliance worked and will work.
FOOD FOR THOUGHT FOR CHANGE AGENTS
Dr. Asrat offered astute perspectives in an article that appeared in a special edition of the Ethiopian Medical Journal dedicated to Medical Education and Public Health Service in Ethiopia among many other topics presented by internationally known participants in 1972. . In that edition Dr. Widad KidaneMarian and I challenged the medical profession under the title of “The New Roles of Addis Ababa University Ethiopian Medical Graduates in Public Health Service.” [See Ethiopian Medical Journal Special Edition on Medical Education, October 1972]. In those days we have agreed that no organization can succeed without the will and commitment of its younger generation to continue the legacy of giving a fair share of the little they have. Self-reliance is a virtue which is a capital to be invested in the future. The role of the young graduates of the Addis Ababa Medical School is to be good gatekeepers of primary care by being frontline pioneers as the health officers begun their career path in 1954. I was intrigued by a conversation I had recently with an American and a Vietnamese colleagues when I read on the walls of the National Museum of North Vietnam about patriotic sacrifice. I visited it as a Board Member of Plan USA-Childreach which is an offshoot of the Multinational Plan International. When I saw our American delegation talking to Vietnamese about transforming allied health professions education in similar ways that the American assistance helped Ethiopia to establish the Gondar Public Health College in 1954, I realized you can win more friends by sharing positive ideas and dialogue than on the battle field. I asked why did you fight each other in the first place. In a way I thought of the first principle of politics. “Fiends come and friends go, but enemies accumulate.” The second thought was the narratives of pioneers and patriotic feeling at present world order. “To fight for freedom is a virtue; but to keep it is a challenge.” This reminds me of the narratives of our pioneers in this special and long article. We are as strong as we can be, if only we keep the flame of “people health is first” with peace and stability” eternally burning on the hilltop of the Ras Dashan Mountain.
To conclude that leaders and organizations are the product of their cultures and as said; ‘people deserve their rulers.’ An old poem by Dorothy Law Nolte, I read for the first time in graduate school of public health to prepare a paper on simulated social organizations course was “Children Learn What They Live”. It shaped my mind and soul about how important is good parenthood, love, peace and stability for many of those who live in countries characterized by high child, and maternal mortality, orphans and displaced HIV kids, hungry children in feeding refugee camps with no where to go. There are the background where we often raise children and let them grown in man-made social and political crises, It partly reads as follows: “if a child lives with criticism, he learns to condemn; if a child lives with hostility, he learns to fight; if a child lives with tolerance he learns to be patient; if a child lives with praise; he learns to appreciate; if a child lives with encouragement; he learns confidence; if a child lives with praise; he learns to appreciate; if a child lives with approval; he learns to like himself” and so on and so forth. Check out the tile and read it fully on Google.
On the balance sheet, as discussed here above we need to look to both sides of ledger in order to move forward with building human resource capital as educated people some of which are lost to brain migration to high resource countries. When one of the P2P managers whom I love and respect as a professional colleague discussed with me what can say about our leadership styles in Ethiopia and the growing interest coming from students and professionals in Diaspora, it was a food of thought and a good reason for me to select tidbits on the attributes and narratives of medical health professions with the combined objective to illustrate that medicine and public health are twin professions for which we are trained to put “people’s health first” at the heart of our personal goals. The lesson we learn from this unique Ethiopian leadership narratives is more relevant to sustainable, integrated, balanced health and development.
I was tickled by the audacity to write on the lifetime achievements of known and unknown leaders in Ethiopia at this moment. My sense of humor bailed me out and I decided why not put it on the table and be under the crossfire on P2P than in a classroom. I was reminded of the Ethiopian adage: “Bedg Yalle Work Inde Medab Newo.” That is to say” you don’t appreciate what you have until you’ve lost it.” Legacy we have and no one would like to lose it, as long as we have confidence and trust in the intergenerational leadership to continue the march forward we can be what we want to be provided we have peace, stability not only in Ethiopia but in Africa and the World. It was also said: “What man has done, another man can do, what never may be.” If Obama’s word is the prophecy that galvanized the e-generation, then let it be “Change We Need, Yes We Can”.
(Ahmed A. Moen, Professor of Epidemiology, International Health/ Health Management Sciences, College of Medicine& College of Pharmacy, Nursing and Allied Health Sciences, Howard University, Washington, DC; Senior Associate at the Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD)