Part Two of the interview with Dr. Oladele Akogun (bio) discusses the philosophical rationale behind CDI illustrated by examples from nomadic communities, and the challenges of bridging the gaps between universities and communities as well as researchers and implementers.
Global Health Council: What is so new and revolutionary about CDI?
Dr. Akogun: For the first time we have research that builds on community knowledge to resolve a community problem. Dr. Hans Remme, the manager of that research, broke the barrier between science and local knowledge. Before the community accepts any research outcome, it must be checked for its consistency with local knowledge. Any outcome that fails the test is thrown out as alien.
For example, several research products that we take for granted, such as insecticide treated nets, fail to meet their intended objective in Africa. Why? Because they fail the local knowledge conformity and community absorption test. The reverse is the case with CDI research.
Global Health Council: If this is true, why doesn’t more research emerge from communities?
Dr. Akogun: First, any research outcome requires medical community acceptance. Implementation of CDI was delayed until the Western-trained medical community was convinced of its consistency with current scientific knowledge and practice. At the outset there was great resistance to local people handling drugs. But the shoe is on the other foot as resistance from Western educated health practitioners is no different than community resistance to research products that do not conform to local knowledge. That is food for thought for laboratory research scientists.
Why do we so often arrogantly assume that scientific thoroughness and adherence to ethical guidelines will automatically result in communities taking our products without question, while we are unable to accept one from their stable of knowledge? We all have that egocentric belief that our view of the world is the correct one.
We go to them to instruct, train and inform, not to listen, learn or understand their knowledge. This arrogance reduces our ability to advance our commonwealth of knowledge. I am so delighted that WHO/TDR understands this and is doing a lot to direct the attention of young African health scientists to implementation-knowledge production.
Local knowledge is as valid and verifiable as science and must be respected so that we can harvest its collective benefits.
Global Health Council: For example?
Dr. Akogun: In one nomadic Fulani camp where I stayed for one week, the children perch on trees soon after evening meals and remain there till midnight. They observed that man-biting mosquitoes would not bite at the treetop above the level of human height.
At another camp without trees, the kids slept among the cattle. They observed that man-biting mosquitoes are unable to smell human beings among cattle since the odor of cattle dilutes that of humans. Many similar large deposits of local knowledge exist on which public health research can build.
Global Health Council: What can CDI do to empower nomadic and displaced/refugee communities?
Dr. Akogun: A great deal, especially for nomads, who are worse off than refugees in terms of health-care delivery. Unlike refugees, the nomadic community is constantly shifting, dispersing, aggregating and perambulating off the radar of any health service provider. A nomadic community that stops at any clinic for routine immunizations will likely be told that they were not included in the supply count. Despite these drawbacks, studies in Nigeria suggest that it may be even easier to use CDI among nomads than among settled peoples.
Global Health Council: Why is this?
Dr. Akogun: Nomads have a highly organized hierarchical structure that the camp members respect and obey. They have a superior and highly effective communication system that enables a single herder to move up to 1000 heads of cattle away from a danger spot within 20 minutes of notification. Nomads are very patient, intelligent and above all very curious people. Once they see the benefits of an activity and are convinced of the outcome, they cooperate.
Global Health Council: Is it really that easy?
Dr. Akogun: The main challenge at the moment is how to address the mutual distrust between them and the health care providers, given that health facility utilization is as low as 8% among nomads.
Global Health Council: Are you working on any projects to improve care for nomads?
Dr. Akogun: Yes, I have just received a grant from the Bill and Melinda Gates Foundation through the Grand Challenges Exploration Initiative to produce a robotic health assistant – called ROBODOC. I intend to exploit developments in communication, diagnosis and treatment of malaria to improve nomads’ access to health care.
The device will remove the alienation of marginalized peoples such as the nomads from the health system and increase access to health by 100%. We should have some preliminary results in November 2009. It is morning yet on participatology.
Global Health Council: Are the universities in Nigeria collaborating with communities in designing research?
Dr. Akogun: A university is a community sitting on the Ivory tower looking down at the community and beckoning it to come up without a ladder. They are elitist institutions within a poverty-stricken community, an oasis in the desert that provides little water.
My team made a hand-washing enhancement apparatus, the type used in Tanzania in the fight against intestinal worms. We were criticized for doing kindergarten science, producing something so ordinary. We should have developed a new computer that grows yams and cassava in the sitting room! Yet, it is acknowledged that our simple product could reduce the current prevalence of worms by as much as 45% among all children. I look forward to the truly African university where the community feeds the curriculum and knowledge production begins with and is informed by the local experience. We are yet to see the dawn of that era.
Global Health Council: That sounds discouraging, is it happening anywhere?
Dr. Akogun: At the Federal University of Technology, Yola, the Research and Development Centre focuses mainly on this. To us, research is meaningless if it does not first identify a problem it wants to solve. We cannot afford the luxury of doing research first and then finding some problem in society to solve with this new product.
Wole Soyinka, one of the leading thinkers of our time, suggested that we close the universities down and debate their needs before reopening them. While I do not endorse their closure, I would definitely attend the debate and advocate for communities to participate.
Global Health Council: Is there anything else related to research that needs to change to facilitate improved health and development strategies?
Dr. Akogun: Yes, the researcher-implementer communication gap needs to improve. In fact, it caused supply shortages of health commodities in the CDI study.
This research-implementer communication gap was a huge problem at the beginning of my career about 20 years ago. Implementers believed researchers had no business in the field and should stay in the labs instead of prying into records at health facilities or messing up ministry of health work plans. We overcame that by ensuring that implementers were part of the research team and that policymakers actively took part in research. We still need to do more work on developing the relationship.
Global Health Council: Did CDI enhance relationships between researchers and policymakers or implementers?
Dr. Akogun: Yes. CDI built upon the successes of the African Program for Onchocerciasis Control to bond all project stakeholders. With the shared interest in disease control, collaboration is the only way to proceed.
Global Health Council: Are there any projects promoting collaboration?
Dr. Akogun: Yes. The Common Heritage Foundation, a Nigerian NGO in partnership with state governments and the Parasitology and Public Health Society of Nigeria, submitted a proposal to develop a strategy to build the capacity for evidence-based policy. Such partnerships result in research that leads to implementation more often than when a researcher pushes a product on the ministry and expects them to use it. From the onset, mutual respect is necessary. Too often, research institutions are far removed from the reality of an environment and their means of communication are ineffective.
Global Health Council: Any ideas how to solve this research-policymaker communication gap?
Dr. Akogun: Health scientists need to be trained in how to communicate with implementers of research outcomes, just as a factory trains product marketers to reach consumers. Research communication has traditionally been through journals, but journals are brain-stressing documents that few non-researchers like to read – and certainly not policy makers. We should create other forms of communication to capture them – such as a blog that will be read by someone waiting to board a plane or attend a meeting.
Global Health Council: Are you doing anything about this research/policy gap at your University in Yola?
Dr. Akogun: Yes. I initiated a 12-month course for peripheral health personnel to update their skills in a formal setting. The university resisted my use of policymakers and implementers to teach the modules and wanted researchers with PhDs. We overcame that and now the course, in its 13th year running, has adjunct instructors from the private and public sectors. At the federal ministry of health in Nigeria, almost all the technical committees in public health are chaired by university personnel. Although still early in terms of policy/research collaboration, I believe we are slowly moving in that direction.
World Health Organization. 2008. Community-directed interventions for major health problems in Africa. Available from: http://www.who.int/tdr/publications/publications/cdi_report_08.htm
Akogun OB, Akogun M, Audu Z. 2000. Community-perceived benefits of ivermectin treatment in northeastern Nigeria. Social Science & Medicine 50:1451-56.
Akogun O, Audu Z, Weiss M, Adelakun A, Akoh J, Akogun M, et al. 2001. Community-directed treatment of onchocerciasis with ivermectin in Takum, Nigeria. Tropical Medicine and International Health 6 (3):232-43.
Kelly MG, Akogun OB. 1997. Rapid assessment of onchocerciasis prevalence and a model for selecting communities for ivermectin distribution in West Africa. Zbl Bakt 286:146-54.