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Professor Asha George takes up Appointment at the UWC School of Public Health (SOPH) as SARCHI Chair in Health Systems, Complexity and Social Change

Author: Interview with Shun Govender

Coming to UWC from Johns Hopkins University Prof George praises UWC and the School of Public Health for its international recognition as institutions of excellence and the humility with which they go about their work.


We are thrilled that you have come to UWC and the SOPH! Congratulations and we wish you well. I think the School’s an exciting place and I am sure you will have the time to find that out. Could you tell us something about yourself?


Sure. I come from India where you just look outside your window to realise just how privileged you are and that not everyone has the same opportunities – and you can't ever walk away from that. So from a young age I always had questions about inequality and social justice. That led to me inadvertently towards public health. I say "inadvertently‟ because even when I enrolled at the School of Public Health at Harvard University to do my Masters, I don‟t think I quite understood what I got myself into!

Public Health does bring together many people concerned with social justice. At the same time there are pressures in public health that sometimes is at odds with the activism that‟s also part of it. As a young person I was concerned with how to change the world and it wasn't clear to me that getting training in big institutions was necessarily equipping me with the skills to do that. It's an irony that I've come back to academia. But after working with different organizations and contexts, I realised that I really enjoy teaching, working with young people in dialogue, encouraging them to explore new avenues and that there's a freedom unique to research and training.

A lot of my training has come from working. People have very different ways of learning – but public health is also a field of practice. All my higher graduate education took longer than anticipated because I sought opportunities to work with incredible people. Amongst many mentors, I spent ten years with Professor Gita Sen, who is an incredible intellect and respected advocate. The learning came not so much from degrees gained, but from the opportunities that enabled me to work with incredible people and contribute to larger projects.


You straddle the academic reflective dimension and the practical activist policy dimension. Is that a tension in public health?


In some parts of public health there's a lot of pressure to produce publications and bring in grant money. I think it‟s how you negotiate those organisational pressures and keep those tensions in balance. It's not an easy path, because to be effective in policy you also need to know what you‟re doing, as it needs to be based on evidence. But there are many different kinds of evidence and evidence that just stays in publications is not meaningful. There‟s a reason why you do research and write, and that‟s to record, reflect and effect change. It‟s a back and forth. You can‟t be engaged in policy processes or informing programmes if you don't have evidence and learning to bring to the table. At the same time there‟s a lot of learning by working with policymakers and practitioners. They have a lot of learning to share which needs to feedback so that research is grounded in the practical challenges and the solutions that people are trying.


Being in Public Health as an academic requires a multidisciplinary/interdisciplinary approach to your own basic research focus. What is your research focus and how do you manage this openness to other disciplines?


My first degree is in Social Sciences in International Relations and Development. I did a Masters in Public Health, and then I felt strongly that you couldn‟t work in public health in low and middle income settings without understanding the social context in which public health was embedded. Therefore my PhD is in Development Studies. I had Hilary Standing, a social anthropologist, as my Advisor. My focus was on maternal mortality and health workers in India. So my topic was still public health but I changed disciplines on purpose because I felt it needed that richness from other disciplines. I knew by then that public health was my topic but that I wasn't an epidemiologist or a biostatistician. To really bring in the other aspects I needed to not be in a School of Public Health. While there is space to bring in these other disciplines into public health, you do sometimes find yourself a little bit on the margins. But you learn a lot by being on the margins, because you look in and across and learn from the different view that you have.


Despite such a location, you are widely published. What are the areas you work in?


My work started with a focus on women‟s issues, particularly gender and public health. I started with very broad literature

reviews, but I wanted to see how things actually happened on the ground. I moved back to India and worked with a research team in a rural district for almost seven years. I feel all my all my training in public health comes from that time! I got to understand how a district health office functions, what kinds of challenges government health workers face in providing services. The market in India is totally unregulated. You have the private qualified doctors, some of whom are running for political office, you have the informal providers – it's a very dynamic and complex area, but it allowed me to understand how important a health systems perspective is.

So I started with a focus on gender and health, but when it came to actually seeing how things happen on the ground I came to see that you have to understand service delivery and the broader contextual factors that influence the health systems context that explain why women fall through the cracks. You need to understand the perspectives of the health workers, the health managers...I mean your first reaction is anger. You see so many people dying for no good reason and that fills you with a lot of anger. But you have to work with what is the working environment and the conditions of the people who are meant to respond. Some of the issues are at the level of the individual but that individual is within a broader context.

So a lot of my work shifted to understand that context, for example, understanding the accountability of health workers being linked to their working conditions, the pressures they face and also how communities interface with service delivery. I worked on community accountability, how women's groups and community monitoring have improved the quality of services by working with health workers and how to re-strengthen village health committees as a health mechanism in India.


Anger, yes, at the system and the problems. Is that leading to a sense of despair or hope when you look at the southern world in terms of health systems and resources available?


I think it's an issue of politics! I have never agreed that there is a lack of resources. Coming from India, certainly being here in Cape Town, you see wealth all around. So it's really about how does a nation set its priorities. In India it‟s been a real challenge to get the government to allocate spending to health. Donors don't set the agenda in India, it‟s the Indian government, and I think South Africa is also setting its priorities. I think that is very important, but then it's also about how people have a voice and an influence over those priorities.

Gandhi fought against the British, but his concern wasn't just kicking the British out, but also how were we going to govern ourselves. I think we have a lot of questions to ask in this regard about Brazil, India, South Africa. We‟re very proud countries with a lot of history and contributions, but we need to really introspect.

So I don't agree that there's a lack of resources – at a broader level. When you go to disadvantaged areas and you see health facilities and the people coming to seek services, it can be very shocking. The working conditions can be terrible. People can be very ill and in really bad shape...but at the same time you see an incredible resilience and you see people working in those contexts who rise to the occasion. One has to be careful to not write it off. People know, they have ideas themselves on what is appropriate. They have a lot of ingenuity on how to fix things. They're just not often given the opportunity or a voice.


You work in Africa. What are your impressions of African countries in this regard?


One of the things that I really struggle with is: What does "Africa" mean? Apart from the colonial history that is very diverse, you have very complex countries that have their own histories before colonialism. We have to be careful not to over-generalise

What's really shocking to me is how rapidly change can happen, both for good and for bad. You've seen some countries make rapid gains and unfortunately we've some countries make rapid declines. That should keep us conscious that change is possible, to not fall into gross over-generalisations. It also means that you can't sit on the sidelines.

I find in my experience in working in the two countries I worked in recently, namely Tanzania and Mozambique – I've really been inspired by my colleagues based at fellow universities who are really embedded in their policy contexts. They're often classmates with people in the Ministry, or in many instances trained those in the Ministry. There is a relationship and I think that is something that is not often considered. It's these relationships that are really important.

What I'm worried about is the resilience and robustness of teaching and research institutions in Sub-Saharan Africa and in India. I think it's a strategic investment that for a whole range of reasons is faltering. South Africa is moving forward and has a huge opportunity to strengthen. Think tanks are very useful, but they don't teach! You have to think of the next generation.


Your experience teaching public health to students?


That has been a huge motivating factor in my life. After being part of some very large organisations, such as the UN, it was refreshing to be back in a teaching see people so enthusiastic about the field of public health and enthusiasm for what they can contribute. I think it's important to give back to people who are starting their careers, and hope that they keep that flame burning even as they move up in the world and not get swallowed by these large organisations.


Why SOPH and UWC as your new base?


UWC has a tremendous reputation for contributing to change. I feel myself very privileged to part of that team. David Sanders ha][inspired and trained so many people on primary healthcare, made so many contributions to People Health Movement; his books are like bibles to many people. The quality of the work and the seriousness of the scholarship of people like Helen Schneider and Uta Lehmann are very inspiring. So I feel very privileged to be part of a faculty that is still striving and contributing to social change at the very heart of its mission.


Your hopes for this institution and your place in it?


Some very innovative things happening in health systems research and policy are happening here. The work that Uta and Helen are doing with UCT on the learning sites working with local managers, seeing how we embed health systems research with practice, the long-distance training that UWC does with people who work within the health system is really important. So I'd like to contribute more to the things that UWC is already doing.

Then also to build further linkages. Health Systems is an emerging field – so from UWC to strengthen that field nationally, regionally and globally. I think there are people doing really important work in Sociology, in Gender Studies who can be brought closer to public health. So I'm looking forward to working across and beyond the School of Public Health at UWC and reaching to the other institutions based in the Western Cape.


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