Helene Gayle Gives Keynote Address to the American Public Health Association

The following address was delivered by CARE President and CEO Helene D. Gayle at the annual meeting of the American Public Health Association on November 5, 2006 at the Boston Convention and Exhibition Center.

Good afternoon. It is always wonderful to be back at APHA; for me, attending APHA is like coming home. It is also wonderful to be sharing the honor of speaking today with my friend and colleague Paul Farmer. I'm sure I speak for everyone here when I say that Paul's work through Partners in Health is a huge inspiration to all of us.

Just a couple of weeks ago, Paul and I were also together as part of very moving awards ceremony honoring the legacy of Eleanor Roosevelt. Besides being a remarkable first lady, Mrs. Roosevelt was the first chairperson of the U.N. Commission on Human Rights and responsible for drafting the U.N. Universal Declaration of Human Rights. Perhaps more than any other person, she helped gain acceptance for the very notion of human rights — that is, the idea that all women and men have inherent dignity, and all women and men deserve justice, for no other reason than that they are human beings.

Human rights lie at the heart of our commitment to public health. Every human being has the right to make the most of their lives and their abilities. And when it comes to doing that, one's health is a fundamental ingredient.

After about 25 years working in public health, I have joined CARE — an organization whose central mission is to fight and eventually end poverty. I have been asked many times why I went to CARE. My answer is simple. I see the work at CARE as a key element of the work we do in public health.

The fight against poverty is a crucial part of the fight for public health. Poverty and poor health are closely linked in a vicious cycle. Poor health is both a cause of poverty and a consequence of poverty.

The cycle is devastating. But it also provides an opportunity for us. Just as poverty and poor health are intertwined, so are their solutions.

Whenever we help people protect themselves from disease or recover from illness, we are also fighting poverty, by helping people maintain their ability to improve their lives and the lives of their families.

And whenever we fight poverty — whether through disaster relief or education or agricultural assistance — we are directly helping the cause of public health, because we are giving people the tools they need to flourish and thrive.

If we recognize the links between poverty and poor health, we can do a better job of fighting both.

As a public health physician I feel there are many tools and approaches in public health that we share with the fight against poverty. After all, poverty is really a disease — and it can be fatal. It kills through starvation — up to 20 million deaths every year. It kills with unclean water — more than 3 million deaths every year. It kills by lack of access to medicine. The world officially records these deaths as starvation deaths or diarrheal deaths or malarial deaths. But the truth is, millions of people die every year because they are poor. If they weren't poor, this is not how they would die.

Such a deadly epidemic, afflicting such a large percentage of the world's people, must be fought. And as with any epidemic, we cannot focus only on treatment. We must focus on prevention as well.

For too long, our work has dealt largely with the consequences of poverty. We deliver food supplies and medicines. We provide books. We send generators. This is worthwhile and generous work, and it ought to continue. But it cannot be our only strategy. This approach may keep poverty at bay for a time. But when the food runs out, or the medicine is gone, or the generator breaks - the old problems return.

Just as in our efforts to improve health, we need to focus on preventing poverty — by attacking its root causes, not only its consequences. To do that, we can be most effective by pursuing a three-part strategy: embracing a rights-based approach, forging partnerships, and empowering women. Let me talk about each of these in a bit more detail and share some of the related experience CARE has developed over its 60-year history.
First, we must embrace a rights-based approach to fighting poverty.

That may sound idealistic, but it's actually essential and realistic — it means elevating our battle from one against inequity, to one for justice.

That means not just building schools, but also fighting for the right of girls to be educated.

It means not only providing food aid, but also fighting for the right of farmers to sell their goods for fair prices in world markets.

It means not only digging wells, but also fighting for the right of all people everywhere to clean water.

We need to embrace this rights-based approach because the people who suffer from poverty are also suffering from the injustice of having their basic rights denied them.

We embrace a rights-based approach not only because it is the right thing to do, but also because it is a smart strategy for change. It's how we will create sustainable solutions, rather than short-term fixes. Putting rights at the heart of our work means giving people the tools to create positive change in their lives and to hold themselves and others accountable for making that change happen.

Let me give you an example of the rights-based approach at work.

In Bangladesh, CARE collaborates with sex workers on HIV education. Our goal is to give these women — often the poorest of the poor, the most marginalized and the most vulnerable to HIV — the tools they need to protect themselves from infection, while treating them with the dignity and respect they deserve as human beings. We firmly believe that there is much to abhor about the sex industry, especially what it does to girls and young women. However, while we are committed to working to change the human rights abuses associated with this system and to expand women's economic options, we are not prepared to sacrifice the lives of sex workers today.

We began a program to train groups of sex workers to become AIDS educators for other sex workers. If any of our trainees didn't know how to read and they wanted to learn, we arranged classes for them.

Once the women were trained, they traveled throughout their communities, leading workshops on prevention and passing out condoms.

Eventually, the women reported back to us that — in the course of doing their new work — they were facing heightened hostility and violence as they tried to raise awareness about AIDS, from the police and thugs in the street who saw these women as less than human and were threatened by their newfound sense of purpose.

But these women were empowered by the training they had received, and they took very seriously the important job they were doing to protect other women from disease. So rather than give up, these women decided to find strength in numbers.

With our help, a group of sex workers registered with the government as an NGO called Durjoy Nari Sangha, which means "Invincible Women's Association."

Today, they have nearly 2,000 members. They run a daycare center for children of sex workers and raise money to send the children to school. They fight against stigma and discrimination.

As one member of the Invincible Women's Association said, "We protest wherever a sex worker is being repressed. Now no one gets away with injustice to a sex worker."

As importantly, the health of the women has also improved. With our support, the project established a protocol for drop-in centers, to provide treatment, care and useful information to sex workers. The results are heartening: between 1998 and 2004, syphilis rates dropped from nearly 35 percent to 6.5 percent, sales of condoms increased by 144 percent and consistent condom use increased by a factor of ten.

Is there a long way to go? Yes. But if we had focused on providing education and condoms and not giving them skills and tools to understand their rights as human beings we never could have achieved such positive results in the lives of these women.

These results were only possible because the women achieved them on their own — because they gained a sense of empowerment. That's what a rights-based approach can do.

Another reason our program in Bangladesh was so successful was because we formed genuine partnerships with the women we wanted to help. This is the second part of our strategy: building partnerships with the people on the ground.

Partnerships are crucial for boosting public support for change. They allow more people to participate in the decisions that affect their lives. They strengthen our ideas by submitting them to people whose knowledge is firsthand and valuable. And because we strive for true partnerships — that is, relationships between equals — they nurture a shared sense of mission and respect.

Here's an example of how one of our partnerships works in practice.

CARE and Columbia University have worked since 2000 to reduce maternal mortality in rural Peru. We knew that a major reason for high maternal mortality rates was that many women in remote parts of the country gave birth at home, rather than in a local health center. Part of the reason for this was that the women didn't feel comfortable in the health centers. Another reason was that, frankly, the health centers weren't in great shape. The health workers didn't have up-to-date training and they didn't have the equipment they needed.

So we sent a team of doctors, nurses and midwives from the regional hospital in a remote region of Peru to a maternal health institute in Lima. There, they took courses in clinical skills and the latest maternal health information, and they brought that knowledge home to pass along to the smaller health clinics throughout the countryside.

We also worked with local women to create a welcoming, friendly hospital environment to attract new and expectant mothers. We made sure that every center had staff members that spoke the local language, and we outfitted every center with the vertical birthing chairs that many of the women prefer.

In the first five years alone, we've seen the number of women having babies in local health centers increase substantially, by almost 100 percent in some centers. Overall, maternal mortality in the region has been cut in half. In one district, 37 women died in 2000 — and not one so far has died in 2006. These results have attracted the attention of the government, which is now considering scaling this model for maternal health throughout Peru.

By working with local health workers and local women, we've been able to create health centers that dramatically improve the chance that Peruvian women will live through childbirth to raise their children. Because these centers are run by well-trained personnel — who are empowered to train other workers as well — they are in excellent shape to continue to build on these results.

That's the power of partnership in action.

You may have noticed that the examples I've mentioned focus on women. This is not a coincidence. The third priority we bring to our work at CARE is putting women at the center of everything we do.

This is not because we are all a bunch of nutty feminists. Or, I should say, it's not only because of that.

It's also a strategic move. Women and girls suffer disproportionately from the dangers of poverty. They make up 70 percent of those living in extreme poverty, living on less than $1 a day. About two-thirds of illiterate adults in the world are women. Women produce 50 percent of the world's food, but own less than 1 percent of the world's farm land.

We are also more likely to endure significant health crises, because one essential human right in particular is withheld from us: the right to have control over our own bodies and to make decisions about our own health.

We see this injustice played out every year for millions of women — in the 87 million unintended pregnancies that occur ever year, the half a million women who die every year because of complications related to pregnancy and childbirth, and the18 million unsafe abortions that are performed on women every year.

We also see this in the growing numbers of women who are infected with HIV because they engaged in one single risky behavior: not using intravenous drugs, not having sex with multiple partners — but simply having sex with their husbands.

So when we focus on women — and on women's rights and empowerment — we're also focusing on fighting the most cruel, most painful aspects of poverty.

But let's not suggest that women are victims. They are powerful. They are a huge resource which the world has left nearly untapped, because of false notions of what women are worth and what they are capable of achieving.

When you empower women — when you give women tools and opportunities for improving their lives — they don't just help themselves. They help all the people around them.

Allowing women and girls to go to school has an effect on the health and wellbeing of an entire community. For every year that a girl goes to school, infant mortality goes down by 5 to 10 percent. In Africa, children of mothers who receive five years of primary education are 40 percent more likely to live beyond the age of 5. And when women are educated, farming becomes more productive, and malnutrition rates go down.

Giving women economic freedom is another powerful way of fighting poverty. CARE is seeing that in Afghanistan, with a program that organizes savings groups for women in Kabul. The women meet every week — 7,000 of them, in 300 different groups throughout the city. They all make regular contributions to a group savings fund, from which they can borrow to finance micro-enterprises. The women are each other's venture capitalists and loan officers. While difficult to convince at first, their husbands are now supportive of this, since their wives are now able to make financial contributions to their households. For many of the women, these savings groups represent the first economic freedom they've ever experienced.

I didn't fully appreciate how brave these women are until I traveled to Afghanistan this April. The same week that I visited, a school that CARE helps run was burned to the ground — because it was a school for girls.

We're not just fighting inertia or indifference in some of the places where we work. We're fighting against people who purposefully and violently stand in the way of advancement for women.

So just by joining a savings group, an Afghan woman is taking a real risk. That kind of strength in pursuit of freedom is a powerful engine for change.

Women everywhere are filled with ideas, energy and courage — and the world has ignored them for far too long. If we want to end poverty, the women of the world must be our full partners in the fight. They are, quite simply, the key to our success.

I think we can end the epidemic of poverty — and with it, the many public health crises that plague the world's poor.

If we embrace a rights-based approach to poverty — if we form partnerships with people on the ground — and if we empower women to become agents of change and workers for justice — we will go a long way towards pulling up poverty by the roots.

The public health community has always been a powerful ally in the fight against poverty. We have unsurpassed experience working to reduce health disparities driven by social inequity and working for change in low-income communities. We know how to build partnerships.

We know how to reach people through education. And most of all, we have a proven commitment to human rights — like the right to drink clean water, the right to breathe clean air, the right to live in an environment free of toxins, the right to receive life-saving medicines and vaccines and the right of a woman to control her own body.

Together — with this community's ideas, knowledge, creativity, dedication and commitment to social justice — we can rid the world of grinding, debilitating poverty. We can fight the injustice and hopelessness that feeds it. We can stop this epidemic. And we can make powerful strides toward fulfilling the promise of universal human rights.

I started this speech by mentioning Eleanor Roosevelt. Nearly 50 years ago, at another speech — the 10th anniversary celebrations of the Universal Declaration of Human Rights — she gave the world a map to follow in the fight for justice and peace. Whether or not we knew it, we've been using it ever since. She said:

Where, after all, do universal human rights begin? In small places, close to home — so close and so small that they cannot be seen on any map of the world. Yet they are the world of the individual person: the neighborhood he lives in; the school or college he attends; the factory, farm or office where he works. Such are the places where every man, woman and child seeks equal justice, equal opportunity, equal dignity without discrimination.

These are the places we operate, as public health workers — neighborhoods, schools, factories and farms. We work where people live. We go where people need us. And we fight for justice and dignity — as part of our fight for public health — so that all people everywhere can have the healthy, productive lives they deserve.

Thank you for the work you do every day, and thank you for listening.