Looking Forward, Looking Back
Even before Dr. Howard Koh became President Obama’s Assistant Secretary for Health at the U.S. Department of Health and Human Services, a job he held from 2009 to 2014, he was deeply passionate about how public health projects could help to stem the AIDS epidemic.
From 1997 to 2003, Koh held the post of Massachusetts Commissioner of Public Health. In that role, he helped usher together activists in Boston and health practitioners in South Africa. Those were some of the first steps of South Africa Partners. In 2003, Koh moved to the Harvard School of Public Health where he held three roles: the Harvey V. Fineberg Professor of the Practice of Public Health, the Associate Dean for Public Health Practice, and Director of the Harvard School of Public Health Center for Public Health Preparedness. In those capacities, he got Harvard involved in the work of South Africa Partners.
After five years in the Obama administration, Koh is back at Harvard as Harvey V. Fineberg Professor of the Practice of Public Health Leadership and as Director of the Leading Change Studio at the Harvard T. H. Chan School of Public Health and the Harvard Kennedy School. His focus at Harvard today is bringing public health leadership education to all of Harvard’s schools.
Here, Koh reflects on the early evolution of the Sister State-Province relationship between Massachusetts and the Eastern Cape of South Africa, the growth of those early programs, and South Africa Partners’ $17.5 million grant to further expand its HIV work.
You were integral to the first steps taken by South Africa Partners to develop relationships between the U.S. and South Africa. Tell us how it came together.
In 1997, then-Governor William Weld signed a so-called twinning agreement, a sister state and province agreement, between the Commonwealth of Massachusetts and the Eastern Cape Province of South Africa. This twinning agreement established a partnership to address areas of health, trade and education that would be mutually beneficial to both regions.
I was then the Commissioner of the Massachusetts Department of Public Health, and Mary (Tiseo, co-founder and Executive Director of South Africa Partners) came to see me. She asked if we wanted to use this twinning agreement to start collaborations in the area of public health, and particularly HIV. I was delighted to support that request, and as Commissioner I established a Massachusetts-South Africa Health Task Force, particularly looking at the HIV/AIDS epidemic.
So that’s how it all started. We began an exchange between government officials, academic leaders and community-based organizations in both countries. I have a lot of memories of hosting many meetings and gatherings where we heard from our colleagues from overseas — we had conferences in Massachusetts with leaders from South Africa and the Eastern Cape talking about the issues they were facing. We had panels of Eastern Cape and Massachusetts leaders speaking and brain storming together. There was so much enthusiasm from so many colleagues who wanted to contribute.
Pretty quickly, the relationship moved to partnerships between practitioners right in the field, correct?
Yes. Early on, there was a formal signing of an agreement between the Masimanyane Women’s Support Center of South Africa and the Codman Square Health Center in Boston. That agreement allowed both groups to deal in a unified fashion with a number of public health issues and human rights issues as well — including discrimination, immigration status, the rights of women and improving access to health care.
In public health, it’s relatively easy to start something, but sustaining progress over many years can be very difficult. So this partnership, which started almost 20 years ago, has blossomed into this wonderful global partnership that has now reached all the provinces in South Africa.
What do groups get out of working together like this, particularly when they’re geographically so far away?
Well, first of all, the world is getting smaller, and every society faces common challenges with respect to public health threats. Public health by definition is interdisciplinary, and it’s a field where interdependence is prized and valued. We can always learn from the experiences of other societies and other countries.
Over time, we learned a lot from our colleagues in the Eastern Cape. They taught us about how important it is to keep people retained in care. These are themes that are seen around the world with respect to HIV care — identifying HIV-positive patients, linking them to care, retaining them in care, making sure they have access to antiretroviral treatment.
As you know, I’ve just finished five years as the U.S. Assistant Secretary for Health, and in 2010 I had the privilege of being at the White House when President Obama personally unveiled the first U.S. domestic HIV strategy. And these same themes were absolutely prominent.
I must say that when I was helping to implement the U.S. strategy as Assistant Secretary, I often thought about our efforts with South Africa many years before.
Harvard University is one of the academic partners involved in many of South Africa Partners’ programs. Were you involved in helping bring Harvard in?
Actually, yes, I was happy to do so. After I left the Massachusetts Department of Public Health in 2003, I became a Harvard professor for the first time. I remember setting up a meeting with Mary and then-Ambassador Sheila Sisulu and our Dean at the time here, Barry Bloom, who is a global health expert. My Harvard colleague Professor Paul Campbell has also been a great partner and collaborator.
Why do you think it’s important that the U.S. Centers for Disease Control and Prevention helps fund health programs internationally?
Everybody in public health now recognizes that we have to be dedicated to viewing our work as being part of a global community and not simply a U.S. community. When the globe experiences what we endured through the Ebola threat, it reminds us that diseases do not respect borders and we have to be fully aware about what’s happening to nations around the world with respect to battling public health threats. The Centers for Disease Control has supported this type of work in a very important way, using a systems approach of prevention, care and treatment.
Can you talk about the importance of public-private health partnerships to co-leading a comprehensive approach of prevention, care and treatment?
It’s often said that in our country, until relatively recently, we’ve had more of a sick care system than a true health system. So we need to be very strategic and very comprehensive in how we get people into care and make sure that they’re receiving the treatment and prevention that they need and deserve.
I think the AIDS care effort by South Africa Partners with what used to be called I ACT and now is called LinkCARE is, in very many ways, a model. Because there has to be a comprehensive set of services that are not just medical but also embrace support services. We have to bring in professionals not only from the clinical setting but also partners from the community. Everybody has a role to play, and if we set up these systems and work together, public health can improve as a result.
Do you feel more hopeful now, about what’s being done to combat HIV?
In 1981, I was the chief resident in medicine at Boston City Hospital, and I distinctly remember the first several cases of HIV that came into the hospital. At the time, we did not know anything about this new illness. It was a devastating, acute condition. Survival was measured in months. There were no good treatments, and the discrimination and stigma were overwhelming. I’ll never forget that as a clinician and physician, and I’ll never forget the patients I cared for and the terror they must have felt. I had the incredible honor of sharing some of those thoughts when I delivered a plenary speech as Assistant Secretary at the 2012 International AIDS Conference in Washington DC.
I’ve lived through this whole chapter of public health history over the last three decades, and we’ve witnessed AIDS transforming into a chronic disease. It’s now very treatable, although it still has many, many challenges.
Each country has its own unique features with respect to facing this common enemy. We knew, in 1997, when we started to collaborate with South Africa Partners, that our partnership was going to be a step forward, but that it would be a long journey. Years later, there’s much good news to celebrate, and we’ve made a lot of progress both domestically and globally but there’s so much more to be done.
Is there anything you wanted to add?
It’s an honor to work on these issues, because for over several decades the eyes of the world have been on South Africa. There’s universal, global respect for South Africa’s aspirations for human rights and a stronger society. So if partnerships like this can help and advance progress, we’re thrilled and honored to be part of it. I also want to stress that what Mary Tiseo has accomplished for public health has been just stunning and awe-inspiring — I just think she’s a phenomenal example of a great, global leader, and I’m very proud to continue to work closely with her and South Africa Partners.