In Defense of Unsustainability

Editor’s note: This piece is part of our “Failure Series,” where we examine the messy and difficult work of creating equitable systems. The ‘F’ word has a bad rep in global health, but the truth is we all fail. We encouraged Global Health Corps’ community members to share their own stories of failure to help inspire a culture where setbacks aren’t end points, but merely milestones on the way to progress. Enjoy!

If you’d like to join a community of changemakers who embrace failure as part of the process of changing the world, apply to be a Global Health Corps fellow today at

During the winter of the year I spent as a Global Health Corps fellow in Malawi, I traveled to a health center in the central part of the country. I worked in monitoring and evaluation with the amazing Elizabeth Glaser Pediatric AIDS Foundation, and my year as a fellow took me all over the country. The health center had the characteristic architecture of many hospitals in the area: white concrete on a cleared plot of land, low to the ground, windows open to let in cool air. Yet this center had one thing about it that makes me remember it over five years later — a huge blue water tank sat empty near the entrance. It was about ten feet tall and, like most things in the dry season, covered in a fine coating of dust.

When one of the health center staff members saw me snapping a picture of it, he scoffed. A gift from the NGOs, he laughed, kicking at the waterless tank. Useless.

Anyone who has worked in global health has a million stories like this one, stories of good intentions left unfulfilled, promises unkept. Stories of foreign NGOs with brilliant ideas left unfinished when funding dries up or enthusiasm wanes. The water tank, the health center employee had told me, was part of a project from a Florida-based company to help increase access to clean water, but it had been abandoned months before without a word from the team that put it there.

Outside the Chiwamba Health Center, Malawi, 2010

The ubiquity of these abandoned projects has created a backlash. Now, the self-proclaimed global health elite are obsessed with “sustainability” — every project must pass a litmus test that it would survive were the sponsoring organization to flee the country and drop its funding. Creating sustainable change was a core value of the organization where I worked during my fellowship in Malawi and at many of the NGOs where my co-fellows were placed.

But sustainability is an ideology as rigid as any other. “Is that sustainable?” is a pinprick that can deflate the most creative public health ideas; it’s a phrase that generates a thousand uninspired plans and wastes millions of well-meaning dollars. It’s a catch-all accusation that paralyzes public health projects and, often, prevents them from making real change. And it wasn’t until I returned to the United States to work in the most unsustainable health system in the world that I realized how stifling the cult of sustainability can be.

One example of how “sustainability” can impede effective global health projects comes from my work in pediatric HIV during my fellowship year. The NGO I worked for was part of a broad consortium of international organizations that, rightly, partnered with the Malawian Ministry of Health to ensure our work wasn’t being duplicated. As part of their emphasis on “sustainability,” many of these organizations focused on continuing education for doctors and nurses employed by the Ministry of Health. Ongoing professional development, it seemed, was a way to support “sustainable” improvements in the Malawian healthcare system.

Much of our work focused on training nurses to consistently test pregnant women for HIV and how to appropriately follow-up on babies born to HIV positive moms. But during a good chunk of my fellowship year, many of the health centers we worked with had no HIV test kits. The kits were paid for by the Global Fund, and gaps in the supply chain were rampant.

To the group of NGOs in the Ministry of Health consortium, paying for the kits with emergency funds seemed like a stopgap measure — it was “unsustainable,” since it couldn’t go on forever. So it rarely happened. The NGOs kept on training the nurses, showing them Powerpoints on HIV testing and malaria prevention and tuberculosis. But even though they knew how to prick a patient’s finger to test for HIV, more often than not, they simply didn’t have the tests in stock. Because of the cult of sustainability, these nurses didn’t have the tools they needed to put their education to use.

Fast forward five years, and I’m now a primary care doctor in West Philadelphia, back in my native United States. We have no short supply of HIV test kits here, but many of my patients who live in poverty are excluded from the insanely expensive healthcare system in which I now work.

My practice is lucky to have a partnership with the Penn Center for Community Health Workers, a project with a decidedly unsustainable ethos that targets some of our most vulnerable patients. I recently got to spend a few weeks with a community health worker named Cheryl Garfield, who helped me see why sometimes short-term interventions can be effective.

Together, we were dispatched to help out high-risk patients who had recently been discharged from the hospital. Cheryl and I went to the home of a blind, wheelchair-bound man who had come to the emergency room with complications from high blood sugar levels. His basement had a foot of raw sewage in it and the entrance to his home had five or six stairs, so he couldn’t get out to get to his follow-up appointments. Together with his son, we helped him out to his ride, went to see his diabetes doctor, and then ate lunch together in the hospital cafeteria. The patient told us his leaky roof was one of his foremost concerns — certainly higher on his list than titrating his diabetes medications — so we set up a visit from an agency that helps poor homeowners pay for repairs.

Can “unsustainability” help in a place like Southwest Philadelphia?

Could we do all this every time he had a doctor’s appointment, forever? No. Yet I think it still had value. We helped him access primary care in a uniquely vulnerable time, right after a hospital discharge. We helped him tackle the issues he saw as his biggest problems, thus freeing up energy to address his health and keep him out of the hospital.

By design, Cheryl’s support only lasted four to six weeks. But for those four to six weeks, everything was our responsibility. In Malawi, I sometimes felt that the cult of sustainability allowed us to wash our hands of certain projects or approaches; not so with Cheryl.

The model that the Penn Center for Community Health Workers is a part of is called hotspotting, a primary care intervention that became famous when Atul Gawande profiled a hotspotting project in Camden, New Jersey for the New Yorker. The theory of hotspotting is that an intensive, short-term intervention can kick-start healthy behavior and help high-risk patients get some of the inertia they need to start navigating our complex healthcare system. It’s all-in care for our sickest patients; nothing is outside of our scope or not our responsibility. It’s the opposite of sustainable.

And yet there’s evidence that it works. A growing body of literature shows that this aggressive approach helps keep sick patients with multiple medical issues out of the hospital, and it saves hospitals money, too.

Part of the problem with the sustainability myth in global health is that we — we the global health community, supporters and practitioners of health equity around the world — define what is possible. At those Ministry of Health meetings I sat in on during my fellowship year, the NGOs saw it as unsustainable to pay for the HIV tests themselves yet sustainable to allow the Global Fund to do so — except that 15 years before, the Global Fund didn’t exist.

But because the international community started to see HIV tests and HIV medicines and tuberculosis treatments and all the other important things the Global Fund pays for as its responsibility, what once was a dream has become the norm. Now, an HIV positive woman in Malawi can expect that her baby will be born HIV-free. It’s on us to make that sustainable.

Southwest Philadelphia.
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