A Discussion with Milton Amayun, Global Health Specialist, USAID-Benin
Background: This discussion between Milton Amayun and Katherine Marshall recounts Dr. Amayun's extraordinary career in international public health that is continuously and across many dimensions inspired by Christian faith. Dr. Amayun was trained in medicine in Manila, Philippines and later received his Master's degree in public health from Harvard University. He has just taken up a position directing USAID's public health programs in Benin, after a career largely spent working for World Vision and International Aid, in all corners of the world. He was an early leader on addressing HIV/AIDS challenges and has actively promoted innovative child survival programs and public health more generally.
Interview Conducted on February 16, 2010
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Your career has been spent from the very start on international public health. How did you begin?
My Christian faith was a major factor in my life from my earliest memory. I came from a very pious, religious family. Both my parents were pastors and faith was just part of life every day. They spoke often about Christian values, among them the importance of education and of service; there was a reason we are in the world. Our values equally covered private and public life. My mother was a Pentecostal, my father a Baptist. I was born in Luzon, northern Philippines. Ilocano was my first language, then English. I learned Tagalog when I went to school. We were three brothers and two sisters. All of us shared this sense of service, even to the point where it became competitive! And all are now involved in medicine and public health, my sisters both as nurses and my brothers also as doctors. Even before I started grade school, my father and mother planted the idea of medicine as an ideal career and it stuck. What guided us in our career choices was this sense that our purpose is to be an instrument of God’s love.
My mother’s influence, as I look back, had special importance. She was unusual in having finished high school (most girls did not in that place and time, especially from prominent families like hers) and she married late, at 34, also very unusual at that time and place. She had a strong sense of obligation and desire to care for others. She started a school for girls, with her own resources, and helped many people. To this day, people come to me telling me how she helped them long ago. She never missed a chance to emphasize how important studies and education were for all of us. She passed on the tradition.
I went to grade school in my hometown in Ilocos Norte (extreme northwest part of Luzon), then competed for a slot in what was then a new scholarship program for the Philippine Science High School in Metro Manila. I was selected, one of only 150 of several thousand applicants. So I left home at age 12, and lived in a dorm; I recently went back to celebrate our 45th reunion. It was a unique experience and a special program & for example, French and world literature were both taught, though it was a science-focused school. The philosophy was to encourage us to develop our gifts wherever they might lead. After high school, I went to university in Manila also, studying zoology, then went directly on to medical school and my residency in family medicine.
When did you encounter World Vision?
I first met World Vision through the Baptist Church that I attended while I was doing my medical training. A friend I met there worked for World Vision, so during my vacation times while in medical school, I did volunteer work for development projects supported by World Vision. I was sent to many parts of the Philippines, especially the mountain areas, initiating public health activities: vaccination campaigns, improving hygiene facilities and promoting better child nutrition. We advised villagers on clean water and how to avoid gastro-intestinal infections. And later, World Vision came to me when they needed help in Thailand, and wanted someone who they were familiar with and was not too expensive!
Had World Vision been active for long in the Philippines?
World Vision first began to work in the Philippines in the 1950s. It was one of their early country programs and soon became one of World Vision’s largest country offices (today India is the largest). When World Vision’s Vietnam program closed in 1969, World Vision turned its focus on child sponsorship to the Philippines. That quickly became a large and important program.
How did you get started on your international career?
I worked for the first, extended period on relief and emergencies, always with World Vision. When I finished medical school and was doing residency as an emergency room physician, World Vision sought me out. It was the time of the Indochina crisis in 1979, and there was an urgent need for doctors. World Vision required their physicians to have been trained in emergency medicine, speak French, and free to travel - right away, like within days. This was during the Marcos regime in the Philippines and it was not easy to travel internationally & background security checks for travel authorization were required for a passport, and this could take months. As it turned out, I was ready to travel when World Vision called me on a Monday morning asking me to lead their first medical team leaving for the Thai-Cambodia border that Friday night.
I spent the next two and a half years along the Thai border, first the Cambodian border, then the Laotian border. We were working in refugee camps, providing basic health services.
Where did you go next? Were you still working on humanitarian medicine?
World Vision then assigned me to northern Somalia, to work in the refugee camps where Somaliland is located. That was a very difficult assignment, perhaps the most difficult in my career. The camps were huge and there was nothing there but rocks and sand and brush. We were far in the desert, near the Red Sea. The refugees we served were ethnic Somalis, streaming across the Ethiopian border. Somalia then was an American ally. (Siad Barre (1919-1995), though he was a Marxist, was leading Somalia and was a surrogate for the US). The Russians and the Cubans were allied with Ethiopia. The camps were in the middle of nowhere and I knew absolutely nothing about the culture or region. We had none of the things I was used to in terms of supplies and facilities & we had nothing but the supplies we flew in from Nairobi or trucked in from Djibouti. I did not speak the language. My team and I were responsible for 78,000 newly arrived refugees, who were on the verge of starvation. There was no water except what could be dug from a dry river bed. The gulley next to our camp was an open defecation site. Simultaneous epidemics were raging & gastroenteritis, TB, scabies and other diseases. This assignment has been one of the most challenging in my professional life. It made me realize that when disasters occur, they occur in clusters. Insecurity made the health problems worse, as did the lack of food and water.
And there were things to get used to, including harmful cultural practices. I remember most vividly a horrible case of a young girl who had been excised & not only were her genitals lopped off, but the practice of full infibulation there was extreme & the raw edges of the cut were held together with thorns. It was a shock I had never expected to see & a young girl in a pool of blood and no one would say anything about what had happened. I had to bring her from her hut to the clinic. That was my first face-to-face encounter with what many call female genital mutilation.
I spent six months in Somalia, and that was long enough. I think we were able - even with the little we had - to make a difference. We stabilized mortality, built latrines, and motivated the community leaders to clean up the camps. We even had a competition for cleanest camp and I remember winning the national competition. We laid whitewashed stones all around the camp to separate the areas and sections divided by alleys and paths. Long afterwards, someone told me that they remembered the neatness of that camp, amidst the chaos.
But Somalia left scars with me, and even caused me to question my faith: how could such horrors happen? How was such unfairness possible? I had nightmares for a long time afterwards. But I did get over it, and my natural idealism eventually overcame my doubts.
From Somalia I worked briefly at headquarters in California, got married and eventually went back to the field with my new bride: to Costa Rica, Cambodia, Ethiopia, Senegal, headquarters in California, Eastern Europe and Washington, DC. Between Cambodia and Ethiopia, we took time out for me to earn my Master of Public Health from Harvard.
Your wife is from Finland and has shared much of your mission and career. Where did you meet?
Raija and I met at a Christian medical students and doctors conference in Switzerland in 1978. We were both new graduates from medical school at that time and we represented two countries from opposite ends of the globe. At that time, she was preparing to be a missionary to Nepal.
Indirectly, I was actually responsible for her eventual recruitment to World Vision: after the conference, we corresponded while she was in High Wycombe, the UK, at the Summer Institute of Linguistics, and then in Liverpool, doing a program in hygiene and tropical medicine. In one of my letters, I suggested that she stop by the World Vision UK office in London. She did and they hired her on the spot! They offered her a job in Thailand, just as I was moving to Somalia. We stayed in touch; I also visited her home in Finland. We were married in August 1982 in Thailand, and our families both came from opposite directions to help us celebrate.
Our first assignment as a couple was in Costa Rica in 1982. I was still working on relief, with refugees and emergencies like floods and earthquakes. We both had to learn Spanish from scratch, which I enjoyed. We first lived with a Spanish-speaking families who spoke not a full sentence of English; then we rented a tiny apartment within the farm of President Pepe Figueres.
From there, we were transferred to Cambodia in late summer 1983; this time I was World Vision’s national director in Phnom Penh. We had a French speaking medical team, so I had to brush up on my French (I had forgotten most of my high school French). Raija went through a week’s crash course in French; this was an entirely new language for her.
Raija was Team Leader for the National Pediatric Hospital. She and her team worked side by side with local young physicians and with medical teams from Vietnam. We cared for many orphans whose parents had been killed during the preceding decade. We were there in 1983-84, a tough period, not long after the fall of the Pol Pot regime. Everyone we met had a story of horror, of mourning. There was a pall of gloom in the country. It was hard to find anyone who had anything positive to look forward to. It was not only bearing the pain of losing those who had died, but also handling the guilt of being alive: Why us? Why not me instead of my parents, my brothers, my children?
We spent long hours listening, and had many chances to reach out with the Christian message of God’s love. We told them that those who mourn will be comforted. We found people eager to grasp for some concept and faith that was higher than them. All their previous bearings had been shattered. And it was not only the past that they had to suffer under. Their political present then was also very difficult, and mistrust was everywhere. Relationships with the Vietnamese confused peoples’ thinking; there was a psychological game of hide and seek, around what it meant to be a Cambodian. The Vietnamese were very present in those early years, and there was much talk of socialist principles. At the same time that Cambodians felt a debt of gratitude to the Vietnamese, they were confused because they also wanted to feel national pride and wanted to be truly independent.
We made some of our very best friends during those years, Cambodians and expatriate alike, friends who still treasure our shared experiences during those dark years. I got great pleasure recently from helping Dr. Chhour Y. Meng, my friend who heads the National Pediatric Hospital. We raised funds for a new HIV/AIDS wing three years ago. I went back to Phnom Penh speak at the building’s inauguration a year later. The King (King Sihamoni) presided over the dedication.
After Cambodia, I went to Harvard (1984-85), for a Masters in Public Health, majoring in health policy and management. Our first son was born while we were in Boston. Harvard was a great melting pot, with people from all over the world. After graduation, I met many of them during my travels as Director of International Health Programs at World Vision.
What did you do after the Harvard program?
After Harvard, we went back to Ethiopia, where I was based in Asmara in the north. This was part of Ethiopia then, and the country was literally under siege from rebels.
Once again we were in the midst of the horrors of war, and navigating all the political maneuverings around it. The Eritrean rebels were trying to establish an independent state, while Tigrayan rebels from the northwest were then trying to force the Marxist dictator, Mengistu Haile Mariam, out or power. We were forced to live in the Nyala Hotel because the Cubans (Ethiopia’s allies) had taken up all the housing in Asmara. We had to make do with a small room, on the 5th floor of the hotel with our six-month old son Joshua. Water and electricity were always uncertain. One night, we were surprised by the sound of gunfire. From our window, we could see the exchange of firepower between the rebels and government troops from our window. The rebels had mounted a surprise attack on the town. There was nothing we could do except get on our knees and pray for safety.
Based in Asmara, I was in charge of a feeding program in a very remote district, Shire, of Tigray province. I remember the chief of the commune especially well, Comrade Adamua. He was supposed to be the communist government leader; he was tall and his shoulders were broad. With a military bearing, his word was law. We knew he could literally send you to the gallows. We organized Bible study sessions in our compound every week, with some reading, singing and testimonies. On several occasions, the comrade came and sat quietly on a chair at the corner. He said nothing, just sat there, listening, then joined us for the Sunday meal. And we let him & we had no choice. But we wondered if we would be clapped into jail at any moment!
That assignment did not last long, until 1986, when the rebels encroached and forced Mengistu out of Ethiopia into exile in Zimbabwe. I heard that Adamu was one of the first beheaded by the rebels who were giddy with their new power. We were glad that at least he had heard the Gospel message during those times he came to our Bible studies. And I hope that he knew what he needed to do. I have come across many like him across my life. But, looking back on that dangerous time, I had no doubt that what we were doing was right. My faith gave me enough to be able to encourage me and affirm me in our work, no matter how dangerous or risky.
But my next assignment took me in a different direction.
How so? You left the emergency work?
We were assigned next to Senegal for two and a half years (from 1987-8), and there I began to work on child survival. Child survival was just then becoming the vogue worldwide in global health. We wanted to save many of the children of the savannah who routinely died of measles and diarrhea. So we were vaccinating day and night. We had ambitious targets because the objective was to make Senegal a showcase for child survival. I was in charge of a district and we achieved 86% vaccination during our first year. I went back recently and found children there who were named after us!
The district I was responsible for, in the north, was huge and during our time there, we went through a series of problems: famine, locusts (vast swarms of them that looked like clouds), refugees from Mauritania, disease, economic troubles. Peanuts were the main crop. I developed a real expertise in child survival during this period.
And because of my success, World Vision picked me to come to Headquarters, in California. And I spent the next four and a half years (1990-94) there. My tacit goal was to learn how to get money from USAID, and thus how to write proposals.
You are very well known for your skill in fund-raising. What were the challenges at that time?
With increasing interest in child survival, the atmosphere was highly competitive and we had to learn to write good proposals. And we were very successful, and in a short time had more projects than Save the Children or CARE.
And during this period we diversified into HIV/AIDS. I wrote the first HIV/AIDS proposal with World Vision’s name, in Tanzania. It was one of the first to be funded by WHO for a project of its kind. This was after the Uganda civil war that drove Milton Obote into exile. The Tanzanian soldiers who had fought in Uganda came back with the disease they called Slim (HIV/AIDS). The Evangelical Lutheran Church of Tanzania proposed the project and we helped them to find funding.
Other early HIV/AIDS Prevention projects were in Zimbabwe and Kenya. Because these were funded by USAID, I was asked to testify at Congressional hearings about the impact of HIV/AIDS on children. Very few people were talking about the issue at that time. We also began to be involved in health policy reform and urban health during this period.
Another important area of change was the former USSR. I was invited to look at opportunities there for World Vision. I went to many of the new countries & Belarus, Russia, Ukraine, and was involved in a project in Chernobyl. We slept in what seemed a freezer in Armenia, helped earthquake victims, worked in Georgia. We were active all over the former USSR. I was a very prolific proposal writer!
One project and conversation truly stands out. Some colleagues and I were in Moscow looking at nursing training. The nursing profession in Russia at that time was horrendous. Nurses were trained as part of regular medical training, just the earliest parts. And nurses were treated like dirt and they treated patients like dirt also. Dr. Natalia Malt’seva, the lady in charge of nursing education, took me aside, and she said, “Dr. Amayun, please help us. Our nurses are not kind to patients, they do not understand compassion. Patients are seen as a collection of organ systems, not as people.” She said she was a Christian believer, and that she understood that World Vision was a Christian organization that believed human beings had a body and soul. She was a Lutheran from Latvia. She asked me to find a partner from a Christian nursing school. So I developed a proposal with Azusa Pacific University’s nursing school2, which was successful. And the program was a stunning success, and the entire nursing curriculum for Russia was rewritten. Textbooks were rewritten and a first association of nurses for all of Russia was formed. The project was funded by USAID. The key was a holistic approach and a focus on compassionate care.
I took on more responsibility within World Vision, as director for international health, and we saw a rapid expansion of World Vision’s international health programs. I had many glimpses of inspiration that confirmed that this was my calling. Among these milestones was writing the first USAID funded project for Vietnam. While my team and I were putting together the proposal, we were assigned minders (read: spies) at every turn. In Danang, our minder spoke excellent English, and he was with us every minute we were outside of our hotel. A couple of times, he commented that World Vision had the cross as its logo, and I worried that we might find ourselves in trouble. But I answered that yes, we did not hide that we were Christian, but that spreading the faith was not our role. Compassion and love were what we were there for. On our last day, he took me aside and spoke to me privately. He was, he said, a Christian himself, secretly. He was crying, saying that he had been the youth leader of the Baptist Church, and had had no one to talk to for ten years about his faith. He could tell no one. And he asked me to leave him my bible, which I did. And later he became one of the first people who received a community development fellowship at Eastern College in the USA. But we were walking on eggshells in Vietnam at the time. And that glimpse of faith left me inspired.
During this time, I became a US citizen; it certainly made the visa challenges far easier to navigate! We were involved all over the world, in Palestine, Africa, Asia, Latin America, and Haiti. We were very much in demand for child survival and other projects. And we became very much involved in the Balkans during the violent period there. A particularly vivid memory was working in Croatia, on hospitals. World Vision was able to get money from Japan for rehabilitation, involving Bosnians and Croats. We were able to bring together Bosnians and Croatians in trying to rehabilitate the hospital, on the front lines of the conflict. In going from village to village and working with the community, we were able to bring about at least some degree of reconciliation.
At this point, Andrew Natsios, who was Vice-President for Programs at World Vision then, asked me to return to the US, this time to the Washington office, to be team leader for health and also director for Asia and the Pacific, the Middle East, and Eastern Europe. We worked with USAID and with the UN, over most of the world.
This started my period of absolutely non stop travel, hop skipping to every region of the world. We were everywhere: Palestine, North Korea, Indonesia, Papua New Guinea, Lebanon, India, everywhere. I had a huge portfolio. I began to find that I was tired.
And so when World Vision went through a protracted reorganization, I got an offer from International Aid, in Michigan, to become their vice-president for programs. I made the change. That was in 1999.
What did you do at International Aid? You spent three years there?
The work was on many of the same topics but we had only four field offices so it was more manageable. They were Albania, Philippines, Honduras, and Ghana. I was freed of the constraints of a large organization and we did important work, especially on health-related skills training.
But after three years I was called back to World Vision, though they agreed that I would work from my base in Spring Lake, Michigan, and from an office that International Aid provided me for free! So I spent the years 2001-2007 back at World Vision without moving from the International Aid building.
During this last period, I spent a great deal of time developing World Vision’s HIV/AIDS portfolio, but I have always seen myself as a mentor, selecting staff and helping them to grow and emerge on their own. That is something that I take great joy in. World Vision was remarkably successful in building its projects & I specialized in the Global Fund, and we are principal recipients in several countries, and sub-grantees in many others. I was very much involved in the global AIDS scene, the World Health Assembly, and International AIDS congresses. But again, the travel was just too much, and being so successful was a problem since resources always seemed to go to the parts of the organization that were in trouble, not to those that seemed to be flying. So I went back to International Aid for a time, to my old position.
Can you talk about the significance of your work with CCIH (Christian Connections for International Health)?
I got involved in CCIH and have done it always on the side, in my “spare time”, but building that network has been very important. It has grown from almost nothing to an organization with over 150 members, and its annual meetings are a major focal point for learning and generating new ideas. We also have sponsored the wonderful student conferences at Calvin College that bring students from many Christian colleges. The aim is to develop a pool of future leaders interested in global public health, and motivated by their faith. I was board chair of CCHI for six years.
And what now? What led you to the change to USAID and to Benin?
It all started with my son, who announced to my wife and me in late 2008 that he had committed to work in Bangalore for three years. He is a graduate of Wheaton College (Illinois), and had worked, using his own funds, in Mexico. He raised the money for his intended work in India.
When we heard this, my wife and I, separately and without knowing the other was doing so, began to pray. And I told her, after a time, that God was telling me that it was time to go back overseas. And she said that God was telling her the same thing. To make a long story short, I explored many options, but the assignment in Benin was the one that God had previously prepared for us.