September 2009

Meet Our Featured Guest Columnist:
Dr. Jeremy Kark

is the son of Sidney and Emily Kark, pioneering physicians who developed a model approach to community health in South Africa in the 1940s.

Q:  What does "health and human rights" mean to you?

A: I have opted to respond in the name of my South African-born parents whose own parents and grandparents emigrated from Lithuania from 1878 onwards to escape the repression, persecution and pogroms experienced by Lithuanian Jewry. They were drawn by the possibility of a better life for their families to countries such as the USA, South Africa and Palestine. Sidney (born in Johannesburg in 1911) and Emily Kark (1913) were acutely aware, as were many of their cohort, of the systematic injustice and exploitation imposed by the white-dominated system on indigenous Africans. These young people acted in many ways--some through political activism, assuming leadership roles in the liberal movements of South Africa. Sidney and Emily, both medical students at 'Wits' (the University of Witwatersrand in Johannesburg) in the 1930s, channeled their energies into ways to rectify massive inequalities in health, which they believed had underlying political and consequently social determinants.

Q: How and why did Sidney and Emily get involved in global health issues?

A: Sidney was a socialist leader while at medical school and Emily was one of five intensely political sibs (who variously identified with socialist, communist, and Zionist causes). Their broad view of the social, cultural, economic, and political determinants of health was influenced by their exposure to outstanding liberal university teachers in the humanities and the medical faculty as well as the brilliant liberal politician Jan Hofmeyr. They began modestly at medical school by setting up the "Society for the Study of Medical Conditions among the Bantu." Sidney, editor of the Leech, a superb medical student journal, published papers on topics such as "The economic factor in the health of the Bantu in South Africa" and "Problems of national health." For them, this was an issue close to home in addition to its global context. Subsequently, after medical qualification, Sidney undertook a nationwide nutritional status survey of South African children, followed by establishment in 1940 of the demonstration Pholela Health Center in a desolate region in the foothills of the Drakensberg Mountains in Natal (Kwa-Zulu). Following 18 years of complete immersion in practical and academic activities directed to the improvement of the state of health of disadvantaged communities, and of increasingly destructive government interference following the regime change of 1948, Emily and Sidney left South Africa in 1958 to spread their message of Social Medicine and Community Oriented Primary Health Care (COPC). On the way to Jerusalem where they developed a Department of Social Medicine and a demonstration community health center and established an MPH program, Sidney spent a one year period as founding head of the Department of Epidemiology at UNC-Chapel Hill.

As a Pholela-born son of Emily and Sidney, exposed since early childhood to their worldview, family discussions on politics, social inequality and the effects on health, I found myself during my final year of high school in Chapel Hill, North Carolina in 1959/60, naturally participating in civil rights activities (sit-down strikes and restaurant picketing) in then-segregated Chapel Hill.

Twelve years later, after completion of a medical degree and military service as  a physician in Israel, I participated in the second international MPH class (a program for training health professionals from developing countries established largely by a team of dedicated South African expatriates at the Hebrew University of Jerusalem). And 20 years after first leaving Chapel Hill, and several years after a sojourn in Chapel Hill in the mid-1970s to complete a PhD in epidemiology (so closing a circle), I began teaching epidemiology and tutoring students in the international MPH program at the School of Public Health and Community Medicine in Jerusalem, which I have continued for the past 30 years.

Q: Describe some of the success you have seen in your work

A: I believe that Sidney and Emily Kark would have counted the following among their successes:
-Demonstrating in their rural (Pholela) community health center practice that malnutrition should not be tackled only by individual care but through increasing agricultural productivity by the teaching of agricultural techniques such as contour plowing, the making of compost, and introduction of higher yield livestock, marketing, bulk-buying of seeds, a farmers' association and home vegetable growing, as well as school feeding programs and the promotion of cooperative bulk purchase of foodstuffs. The latter two activities were also successful in the Durban clinics. This lesson is as valid today as it was then.
-Demonstrating in Pholela, Durban and Jerusalem that health can be substantially improved through COPC (Community Oriented Primary Health Care);
-Development of the Kiryat Hayovel Community Health Center in Jerusalem which tested and propagated COPC programs, served as a teaching center of COPC and cared for new immigrants who had come to Israel following the establishment of the state.
-Global dissemination of the concept, through a broad network of contacts, that COPC can serve as a viable and sustainable vehicle to improve health of varied populations. The first Alma Ata declaration drew much from this experience;
-Satisfaction in the success of their colleagues and students from Pholela and Durban: for example John Cassel, who succeeded Sidney as head of the Department of Epidemiology in UNC Chapel Hill, and became a renowned social epidemiologist; Guy Steuart, who subsequently became Head of the Department of Health Education in UNC Chapel Hill and made important contributions to health promotion; Joe Abramson, a leading epidemiologist, author of acclaimed textbooks in epidemiology, research methods and statistical programs for epidemiologic analysis (productive even in his eighties) who succeeded Sidney as Head of the Department of Social Medicine in Jerusalem and still teaches in the international MPH program; Mervyn Susser and Zena Stein, famed epidemiologists who continue to make important contributions to global health, including extensive work on HIV/AIDS in South Africa; and a key public health figure, Jack Geiger, who developed community health centers in the US following his stay in Pholela and Durban in the 1950s.    
-Establishment of a long-term international MPH training program in Jerusalem that has affected the practice of public health in over 85 countries, in addition to training the leading public health personnel of Israel in a separate program.

I have gained satisfaction from teaching in this program that has to date graduated ~700 health professionals from predominantly developing and transitional countries. Numerous graduates have assumed key leadership positions in their home countries in the practice and teaching of public health in government, NGO and academic roles.

Q: How can young people make a difference?

A: Year after year I present the example of the community health practice in Pholela to our generally young international MPH students in their epidemiology course, an example which is still so distressingly pertinent to many parts of the world. The intent is to empower these young students, usually in early stages of their careers, who return to highly challenging circumstances. In Pholela, two ideologically motivated and competent young people still in their twenties, ventured out in 1940 into an entirely undeveloped region with a concept that they had formulated, trained personnel, developed contacts with key members of the community, assessed needs using epidemiological methods, and established an evidence-based and prioritized practice of community health, a practice that also provided quality personal health care and emphasized respect for the individual and understanding of her/his culture. They were fortunate to have had the backing of a far-seeing Ministry of Health in this undertaking. In spite of the difficult conditions, formal evaluations of the effectiveness of the practice were undertaken and published in the scientific literature. This was done in the absence of fancy technology and networked computers. So our graduates who return to situations where access to technology may fall below that of a research university can observe that with determination, commitment and the exercising of skills gained it is possible to achieve much. Many of our graduates have subsequently made substantial contributions in both public health practice and academic leadership, and are making a difference.