Lessons from Jim Grant’s Vision for Public Health
by Kul C. Gautam
Deputy Executive Director, UNICEF
at the James P. Grant School of Public Health
BRAC University, Dhaka
24 November 2005
Certain names evoke profound sentiments of awe, inspiration, respect and gratitude in our hearts and minds. Mahatma Gandhi, Mother Teresa, Nelson Mandela, Rabindra Nath Tagore inspire us with examples of courage, compassion, struggle, and literary beauty.
Louis Pasteur, Jonas Salk, Albert Schweitzer, Florence Nightingale remind us of extraordinary contribution in medical breakthroughs, public health and compassionate caring.
Somewhere in the constellation of such extraordinary human beings, there is James P. Grant.
For those of us lucky enough to have known and worked with Jim Grant – and I see several people in the audience who have had that privilege – he would have left an indelible mark.
For me personally, the greatest privilege of my life was the chance to work with and observe Jim Grant at close quarters. He was my boss and mentor. As I said in an article in this book – which I would recommend as required reading for all students and faculty of this school – Grant was a visionary with a missionary zeal.
I have never encountered another man, or woman, whose faith in human propensity for doing good was so profound, and whose capacity for seeing a silver lining in whatever dark cloud was so total.
Jim Grant was one of the true giants of public health in the 20th century.
It is, therefore, so very fitting that BRAC University decided to name its School of Public Health after James P. Grant.
Jim Grant was a great admirer of BRAC. He was inspired by its outstanding work and achievements. In 1992 UNICEF gave its highest award, the Maurice Pate Award, to BRAC. As he conferred the award to Fazle Hassan Abed, Jim Grant was effusive in his praise of BRAC and the remarkable progress being made for children and human development in Bangladesh against great odds.
At the end of my speech this evening, I propose to show you a short video clip of Abed’s tribute to Jim Grant at a memorial service following Grant’s death in 1995. As you will see, Abed and Grant, and BRAC and UNICEF, had great mutual admiration.
In some ways, Grant’s vision for UNICEF was to do at the global level what BRAC has managed to do in Bangladesh.
I know that many of the faculty members and all of the international advisory board members of the School personally knew Jim Grant. But I suspect that most of the students would not have met him or known him.
My talk this evening is dedicated to the students of this school. I would like each one of you, and future students of this school, to feel proud of your name, and your public health degree, being associated with the name of Jim Grant – who did more to bring public health to the doorsteps of more people than anybody else I can think of.
But linking your name with that of Jim Grant also carries a certain responsibility and expectation. We would expect you to try to emulate the example of Jim Grant in your life and work. You will see that it is a tall order, but as Grant would say, it is both a doable and a worthy mission.
In describing why the School was named after James P. Grant, this little brochure says that Grant, a distinguished Executive Director of UNICEF between 1980 and 1995, was credited with mobilizing resources to launch the child survival and development revolution that saved the lives of millions of children throughout the developing world. His legacy was in demonstrating the power of applying the art and science of public health on a massive scale.
And what a tremendous legacy it was!
Grant was a quintessential humanist and development professional. He came from a family of medical missionaries. His father John Grant was a pioneer of a public health approach that came to be known as “barefoot doctors” in China, which he subsequently tried to adapt to the very different circumstances of Bengal in his work with the All India Institute of Hygiene and Public Health in Calcutta.
During his 15 years as the head of UNICEF, Grant articulated and led a movement for child survival and development with relentless energy and unflagging commitment. He decried what he called the silent emergency, the daily tragedy of millions of children caught in the downward spiral of poverty, malnutrition, ill health and illiteracy.
The child survival and development revolution that UNICEF spearheaded under Grant’s leadership is credited to have saved the lives of an estimated 25 million children and protected the health of millions more.
Its success was predicated on the unique strategy that Grant helped devise emphasizing simple, low-cost, low-tech interventions like immunization, breastfeeding, growth promotion, and oral rehydration therapy – the latter discovered right here in Bangladesh at ICDDR-B and widely disseminated by BRAC and others.
Some critics have argued that Jim Grant over-simplified the world’s development challenges by boiling them down to just a few vertical, technical interventions aimed at reducing child mortality.
After all, development is much more than reducing the quantity of deaths. How about the quality of life, social justice, gender equality, economic development, human rights, protection of the environment, and building of systems and infrastructure to sustain development gains?
For those who knew Jim Grant, this was a false and superficial critique. Far from being simplistic and narrowly focused, Grant had a broad and holistic vision of development. He was very aware of the multi-faceted nature and complexities of development. He spoke forcefully on issues ranging from the need to end the “apartheid of gender”, to reducing military expenditures, providing debt relief and fair terms of trade for developing countries.
He argued for restructuring foreign aid and national development budgets in favour of basic social services. He challenged the prevailing orthodoxy of powerful international financial institutions and called for “adjustment with a human face”.
Let us recall that in the 1980s, the structural adjustment policies imposed by the World Bank and IMF forced many governments to balance their budget by cutting expenditures on health, education and social services.
The consequences were immediate and devastating – rates of malnutrition increased, governments were unable to replenish essential drugs or even pay the salaries of health workers and teachers. It was the poor people, and especially children, who suffered most from such cut-backs.
Grant protested loudly, and got UNICEF to make a well-reasoned and passionate case for protecting the poor and vulnerable in designing structural adjustment programmes. UNICEF’s call for “adjustment with a human face” gathered strong support from development activists, and eventually forced the World Bank and IMF to change their policies.
Grant championed for the adoption of the Convention on the Rights of the Child (CRC) and spearheaded for its universal ratification. Today, the CRC is the world’s most widely accepted human rights treaty. I hope that students at this school will familiarize themselves with this Convention. It can be a powerful tool to support your work and advocacy.
You can invoke the Convention to argue that health is not just a good thing to have if you can afford it or if somebody offers it to you as charity. It is a fundamental right of people, especially children, and governments of developing countries and donors alike have a legal obligation to allocate the maximum amount of their available resources to ensure that no child is deprived of his or her right to health care services – to reduce infant and child mortality; to combat disease and malnutrition; to have access to clean drinking water and sanitation; to ensure maternal health care; for family planning education and services – in short, for primary health care.
Grant advocated for the child survival revolution with a small number of highly “doable” interventions, not as a simplistic formula for just reducing mortality, but as a “Trojan Horse” for combating poverty, promoting democracy, slowing down population growth and accelerating economic development.
You might ask, but how could just a few focused interventions in child health contribute to such a broad development agenda? Well, for those who feel that reducing mortality is just a small or insignificant contribution to broader issues of economic development, I would commend you to a brilliant lecture by Amartya Sen entitled “Mortality as an Indicator of Economic Success and Failure”.
In it Sen argues how mortality can serve as a proxy for progress on many fronts of development, and the manner in which mortality reduction is pursued can empower peoples and communities to fight poverty, inequality and injustice.
Nothing is more disempowering to parents than to see their children die. Inability to save their children makes parents feel powerless and fatalistic. On the other hand, when parents feel that they can take action to save their children’s lives, they feel a sense of empowerment rather than helplessness.
When parents know that simple, low-cost actions can save their children, they begin to demand such services. When parents feel confident that their first children will survive, they tend to have fewer children. When they have fewer children, they care more about giving them the best possible education and upbringing. Thus, starts a virtuous cycle of empowerment and upward mobility.
Jim Grant’s vision for child survival did not just rely on a few technological fixes to reducing mortality. It called for unleashing the power of social mobilization and moral persuasion which has an extraordinary transformative power.
Grant personally persuaded hundreds of leaders – democrats and dictators alike – as to why it was in their political interest to promote child survival interventions. He did not want them interested in small scale pilot projects and marginal, incremental progress. He wanted to see action that was commensurate with the scale of the problems.
Going to scale, shifting gears, making quantum leaps in child survival and development were his sacred mantras.
Grant found it unconscionable that 15 million children were dying every year – 40,000 everyday – in a world which had the knowledge and means to prevent most of those deaths. This led him to advocate for a massive increase in coverage of such life saving interventions as immunization and oral rehydration therapy.
Immunization coverage in developing countries was less than 20 percent in the early 1980s. Grant argued that the world needed to increase it to 80 percent by 1990. Many thought that such an increase was unrealistic. Indeed, if we followed the normal incremental approach such acceleration would have been impossible.
Most ministries of health did not have the manpower, financial resources and organizational outreach to make a quantum jump in immunization services. Recognizing this, Grant developed a two-pronged strategy to overcome this constraint.
On the one hand he would approach, not just ministers of health but also the presidents, prime ministers, governors and mayors to adopt immunization (and other child survival interventions) as their own programmes and not those of the ministry of health.
Leaders were persuaded that provision of such life-saving services would give them great political dividends at minimal financial cost.
On the other hand, Grant would approach religious leaders, the mass media, film stars and sports personalities, and non-governmental organizations like BRAC, to promote immunization, ORT and other child survival actions. Such outreach and social mobilization greatly reinforced and energized the usually weak and lethargic health ministries.
Finally, the actions or inaction of health services came under national spotlight. This helped to revitalize health services by giving them unprecedented political visibility and subjecting their performance to public accountability.
Grant was masterful in generating a healthy competition among countries, provinces and municipalities to outperform their neighbours. If an economically poor country like Sri Lanka could reduce infant mortality to a low level why was not a much richer country like Turkey or Colombia or Indonesia doing better?
Bangladesh in fact became a prime example for Grant’s advocacy as it increased immunization rates from 5 percent in the early 1980s to 50 percent in the mid-80s and 70 percent by 1990. Surely, if Bangladesh could make such progress there was no credible excuse for most other countries not to match it.
Grant was skillful in using such comparisons not to humiliate countries but to motivate them.
In the name of child survival, Grant was even able to help stop wars and create “corridors of peace” and “days of tranquility” to immunize children and provide other basic services.
In the mid-1980s Grant persuaded the President of El Salvador and got the Archbishop of San Salvador to broker an agreement with the leftist rebels to stop the war for a few days so health workers could travel throughout the country, without any restrictions or fear, and vaccinate children.
Such “days of tranquility” became a model and have been used in many countries at war, including Afghanistan, Angola, Burundi, Congo, Lebanon, Sri Lanka, Sudan, and elsewhere, including in the polio eradication campaigns of recent years.
In the name of child survival, Grant was able to convene the largest gathering of leaders in history, the 1990 World Summit for Children. That Summit adopted ambitious and measurable development goals. And it paved the way for the major world conferences and Summits of the 1990s, culminating in the historic Millennium Summit in 2000.
Indeed, the origins of today’s Millennium Development Goals can be traced back to the goals originally set by the World Summit for Children. The advocacy, implementation modalities and monitoring system for the MDGs are also greatly inspired by the experience of the Summit for Children.
For someone who achieved so much, who cultivated access to the world’s most powerful political leaders, and who acquired such great visibility, Grant was uncharacteristically unpretentious. He was always dignified, but he did not care much for protocol. He was readily approachable to staff and cultivated a wide network of contacts in governments, academia, the media and civil society.
A special characteristic of Jim Grant was his thoughtfulness and generosity in giving credit to others.
In UNICEF’s State of the World’s Children report, and in his public speeches, he unfailingly gave credit to WHO and it’s Director-General for the achievements being made in health, even when some UNICEF staff occasionally protested that such recognition was not warranted or reciprocated.
Grant often reminded us to “never underestimate the amount of good a person can do, if they do not mind who gets the credit”. He was a living embodiment of that principle. He was not only generous in giving credit to others, he also took an enlightened and far-sighted approach in sharing resources with others.
Grant was masterful in mobilizing resources. But he wanted those resources to benefit not just UNICEF but whoever else could help promote the cause of children, and expand the constituency for the cause.
Let me recall 2 special cases.
As a result of Grant’s persuasive testimony at the US Congress in the mid-1980s, the Congress was prepared to make a special allocation of $25 million to UNICEF to accelerate child survival. To the consternation of his staff, and even the Congress, Grant suggested that instead of giving the money to UNICEF, it should be allocated to establish a child survival fund to be administered by USAID.
His logic was that if a budget line was established for child survival in USAID, it would have a vested interest to maintain that account and would seek increased allocation in future. Indeed, Grant’s insight was prophetic. Since the child survival fund was established, USAID lobbied the Congress and got regular increases in its allocation from the initial $25 million to $40 million to $80 million, and eventually to over $300 million per year at present.
Had Grant not been so far-sighted and simply accepted the money for UNICEF, it would most likely have been a one-time allocation of $25 million to UNICEF. Instead he turned it into an opportunity to leverage a multi-year, billion dollar plus investment for children through USAID.
In yet another example of Grant’s enlightened insight and strategic vision, at the time of the World Summit for Children, the German government was interested to announce a major contribution of some DM50 million to UNICEF to work in the area of child labour.
To our surprise Grant suggested that the Germans channel that contribution to ILO. He reasoned that such financial support would energize ILO to give much higher priority to elimination of child labour and it would feel obliged and empowered to do so. Indeed, with that seed money ILO established the international programme for the elimination of child labour (IPEC) which has now become one of its highly successful flagship programmes.
Had UNICEF grabbed those funds, yes, we could have done a little bit more in child labour. But it was Grant’s judgment, with which all of us agreed in retrospect, that the establishment of IPEC at ILO did more to revitalize ILO’s action and advocacy in child labour than what UNICEF would have done to contribute to ending child labour.
Jim Grant was a frequent visitor and speaker at medical schools and schools of public health. He would have been thrilled to see an international school of public health in Bangladesh. It would have warmed his heart to see that this school has affiliation with and gets faculty members from some of the best universities and institutions in Europe, North America and Bangladesh. I recall he visited and spoke at most of those schools and institutions.
Knowing his great admiration for BRAC’s pioneering work, he would have said, Abed did it again!
This school’s close links with ICDDR-B, another world class international institution in a developing country offers you an extraordinary resource to ground your research and practicum in the world’s largest community-based health research laboratory.
The school’s own community-based experiential learning facility, BRAC’s rural training centre in Savar and the urban slum settlements of Dhaka expose the students to the daily realities of public health challenges.
With such assets, this school can aspire to do certain things that few other schools of public health can do. Right now you aspire to be a world-class school of public health, and you have the necessary assets and potential to become one. But what can you do to translate that potential into reality? How can this school make a mark as not only one of the world’s best schools of public health, but as a school of unique attributes and accomplishments?
I would hope that the school would be able to do that by simply following BRAC’s philosophy and practical experience in other areas of its work.
One of BRAC’s great strengths has been its belief that if provided with basic skills, organization and minimal resources, the poor, the landless, the illiterate are all capable of making remarkable strides in self-sufficiency and dignity.
Combining elements of formal and non-formal education, and reaching out to the children of the poorest families, especially girls, BRAC’s primary schools and its micro-credit programmes have proven to be powerful promoters of human and economic development, and of human rights and democratic participation.
If this same philosophy guides the work of the School of Public Health, I can imagine BRAC and the school pioneering another public health revolution in Bangladesh and beyond.
Let us recall that most of the world’s major health problems and premature deaths are preventable through changes in human behaviour and at relatively low-cost.
Jim Grant used to often quote a close friend of his, and another giant of public health, Dr. Bill Foege, a former director of the US Centers for Disease Control, who made the interesting point that it would cost more than $10 billion annually to add a single year to the life expectancy of an average American male through medical interventions.
But one could add 11 years to their life expectancy through 4 virtually cost-free actions: a) stop smoking, b) moderate alcohol consumption, c) change certain dietary habits, and d) do moderate amount of exercise regularly.
To these one could add a few more behavioural changes, especially relevant in developing countries today, such as: practice exclusive breastfeeding, hand-washing, safe sex, prevent drowning and readily avoidable accidents and injuries, etc. None of these require sophisticated medical technology, highly trained manpower or huge investments.
Under Jim Grant’s auspices, UNICEF came out with a practical little handbook called Facts for Life which shows how ordinary parents themselves and minimally trained community health workers, teachers, religious leaders etc. could help in behaviour change in families that would have huge health benefits.
With today’s information and communication technologies, now penetrating even the poor, remote communities, we can do so much more to revolutionize public health.
There are many examples of public health programmes that produce good results through behaviour change. Unfortunately, most of them are small scale pilot projects.
Bangladesh is one developing country where many such programmes are actually going to scale through the efforts of organizations like BRAC. That is why, Bangladesh is one of the few least developed countries, that is on track to achieving most of the Millennium Development Goals.
Certainly in terms of many of the health MDGs, such as reducing maternal and child mortality, fertility rates, girls’ education, etc. Bangladesh is even ahead of the MDG timeline. I would hope that our school of public health here would take advantage of the good examples in Bangladesh and elsewhere and teach its students how to be agents of dramatic acceleration in achieving and even exceeding the health-related MDGs.
It would be a fitting tribute to Jim Grant if the students and faculty of a school named after him adopted the classic Jim Grant approach of setting ambitious goals, creating awareness and demand from the communities, mobilizing all segments of society around such shared goals, creating healthy competition for achieving and exceeding the goals, and using the achievement as a spring-board for further progress on a broader development agenda.
May the spirit and vision of Jim Grant inspire us all to build this school into a world-class institution in the service of the world’s children.