"If you tell them, ‘Don't cut trees,' then what next?" asked Emmanuel Mtiti at "Population, Health, and Environment: Lessons From East Africa," an event hosted by the Environmental Change and Security Program (ECSP) on Thursday, May 8, 2008. "It's like telling Americans, ‘Don't drive.'" Mtiti was joined by Gladys Kalema-Zikusoka and Kuntai Karmushu, who described their integrated population-health-environment (PHE) programs in Tanzania, Uganda, and Kenya, respectively. Echoing comments at past events in ECSP's PHE meeting series, the speakers emphasized that environmental conservation is more effective when implemented in concert with livelihood improvement projects. They also agreed that integrated approaches are more effective and efficient than single-sector approaches.

Community Health Care Benefits Gorillas, Too

Kalema-Zikusoka founded Conservation Through Public Health (CTPH) to serve the health needs of people living near Bwindi Impenetrable Forest, a protected area in Uganda that is home to half of the world's remaining mountain gorillas. The communities around Bwindi—like other remote, politically marginalized communities—are often underserved by government health services. "They're the last people the government thinks about," said Kalema-Zikusoka. Making matters worse, the close proximity of humans and gorillas results in the transfer of a number of diseases—such as scabies and tuberculosis (TB)—between the two populations. "There are so many areas where gorillas can pick up diseases from people," she said. Recognizing that improving the health of the gorillas and their human neighbors requires simultaneously improving peoples' livelihoods and quality of life, Kalema-Zikusoka founded CTPH in 2002.

The main component of CTPH, the Human Public Health program, is a grassroots campaign to educate citizens about hygiene and to strengthen community-based health care—a common strategy in PHE programs, which often serve inaccessible communities far from doctors or medical care. Empowering communities to treat some common illnesses reduces their dependence on the services of a government that may not be meeting their needs.

CTPH takes advantage of effective, pre-existing local institutions and methods to communicate its messages and gain the trust of the people it serves. The program has partnered with local drama groups to put on educational plays for more than 7,000 people. CTPH includes local healers in its programs, which not only enables earlier diagnoses—because a healer is usually the first health provider a sick person seeks out—but also allows the program to persuade the healers that they cannot treat TB and HIV/AIDS with traditional remedies. Because it seeks partnerships with local healers rather than circumventing or diminishing their role in the communities, CTPH has established a unique rapport—and one that is good for people's health.

CTPH's early success in providing health services, educating people about family planning methods, reducing human interaction with wildlife, improving livelihoods, and strengthening the local ecotourism industry is promising. The program has found that targeted home visits can reach even the poorest, most remote households. CTPH faces challenges in persuading health centers to devote resources to family planning, which is "not considered a priority," said Kalema-Zikusoka. However, by continuing to respect local traditions and adapting existing tools rather than designing wholly new methods, she is optimistic that CTPH will continue to be successful.

Protected Land Protects Livelihoods

"We really use our land to improve the livelihood of our society," said Karmushu, health and conservation programs coordinator at the Il Ngwesi Group Ranch in central Kenya. Like CTPH, the Il Ngwesi ranch has successfully used a multisectoral approach to promote rural development. Eighty percent of the ranch's 16,000 hectares are devoted to conservation efforts, including a very successful ecotourism endeavor that Karmushu calls "the Il Ngwesi backbone." Il Ngwesi's ecotourism enterprise—which employs community members, is run sustainably by the community, and directs revenue back into the community—has enjoyed steadily increasing revenue since 1999.

The ranch's profits are used for education programs, HIV/AIDS awareness efforts, conservation and security improvements, and infrastructure development. The community participates in spending decisions, which Karmushu says is "one of the key things" driving the ranch's success.

Karmushu listed several important factors in the success of the group ranch: community ownership, participatory decision-making, equitable revenue distribution, respect for Maasai culture, and support from partners like the U.S. Agency for International Development. In 2002, the ranch won the UN Environment Programme's Equator Initiative Prize, which recognizes outstanding local efforts for poverty reduction and biodiversity conservation in the tropics.

The ranch's remarkable environmental success—including the reintroduction of both the black and the white rhino on its land—has complemented its economic achievements. Challenges to the continued success of the ranch include preserving the delicate balance between the needs of the people and animals using the land; mediating tensions between older and younger generations; national political instability; and under-representation of the poor in high-level decision-making on the ranch. But, Karmushu emphasized, "using conservation to reduce the poverty of our people" has led to impressive and sustainable successes.

Trust Created by Integrated Approach Is Key to Success

Mtiti presented the case of the Lake Tanganyika Catchment Reforestastion and Education (TACARE) project, run by the Jane Goodall Institute (JGI) in the area surrounding Tanzania's Gombe National Park, which borders Lake Tanganyika. Launched in 1994 to address rapid land degradation, TACARE was expanded in 2005 to include the Greater Gombe Ecosystem.

Villagers around Lake Tanganyika often cite land as their only resource, but deforestation and the resulting soil erosion and diminished crop productivity threatened land in the entire Greater Gombe region. A 2.9 percent population growth rate and large numbers of refugees in the area augmented the challenges, necessitating urgent action. Though TACARE initially focused on the environment, it quickly became clear to the program staff that to achieve success, they would have to "put people at the center of implementation," said Mtiti. According to a survey of the villagers, land degradation was not a top priority; they ranked it behind livelihoods, health care, education, and access to safe water.

In response to the villagers' concerns, TACARE transitioned to what Mtiti called a "holistic model," which focuses both on environmental sustainability and other community needs. However, he noted that it took nearly four years for program officers to fully comprehend that "we cannot work with the communities unless we include their priority problems." Because this focus developed organically in response to the needs of local people, it helped establish TACARE's legitimacy in the community. "They know that we care about them," said Mtiti, "so when we come up with a new idea, they know that we still care." Paraphrasing Jane Goodall, he said, "Only if people living around the wilderness become our friends can we conserve."

Like CTPH, TACARE works hard to gain traction in the youth community. Both programs engage young people using drama workshops and other educational tools. TACARE also participates in JGI's Roots & Shoots program, an environmental and humanitarian initiative for youth. They hope that by educating young people about the benefits of conservation, sustainability, and family planning, the projects will become self-sustaining.

Benefits of PHE Approach Outweigh Challenges

The challenges described by Kalema-Zikusoka, Karmushu, and Mtiti are not new to those who have been following ECSP's PHE meeting series. Chief among them is the challenge of funding, which continues to be laden with antiquated, inflexible requirements that are not geared toward funding innovative, multisectoral programs. Mtiti remarked that perhaps a "donor education" program would help bring the donor community up to speed on the changing nature of development programs.

An obstacle that sometimes slips through the cracks of high-level discussions of the PHE approach is that villagers can have unreasonably high expectations of multisectoral programs. The effectiveness of these programs, Mtiti said, gives them the appearance of an almost limitless capacity to improve living standards in the communities they serve, leading people to "think they can do everything." Although this speaks to the success and community buy-in PHE programs regularly achieve, it leads to disappointment when it becomes clear that these programs cannot solve every problem in a community.

These obstacles, though, are outweighed by the benefits offered by the multisectoral PHE approach, which, as Kalema-Zikusoka, Karmushu, and Mtiti demonstrate, can improve livelihoods, conserve natural resources, and promote family planning. What Karmushu said of the Il Ngwesi Group Ranch might as accurately describe the entire PHE field: "We are just starting."

Drafted by Sonia Schmanski and edited by Rachel Weisshaar and Meaghan Parker.