Women leaders helped Charles Holmes—recently named dean of the University of Michigan School of Public Health—see how community trust and locally driven solutions can make maternal and HIV care safer, more accessible and built to last.

In the Zambian districts where it operated, the five-year Saving Mothers, Giving Life initiative helped reduce the maternal mortality ratio by 41 percent (from 480 to 284 deaths per 100,000 live births) and in Uganda, by 44 percent. This multipartner initiative was supported by the Centre for Infectious Disease Research in Zambia and relied on building trust in communities by ensuring that the interventions were responsive to the needs and outcomes of the community in question.

Charles B. Holmes, a physician-scientist and global health leader, has spent his career working and learning alongside women to improve access to healthcare—sexual, reproductive and maternal—and create lasting resources for communities in need. 

In late 2012, the physician-scientist and global health leader moved to Zambia, where he spent four years as CEO of the Centre for Infectious Disease Research in Zambia (CIDRZ), which works to implement on-the-ground healthcare, conduct research and train public health leaders. Under Holmes’ leadership, working hand-in-hand with community leaders, CIDRZ was able to gain the trust of local communities and provide critical healthcare, including community education, maternal care, infant care and primary healthcare, among others.

For decades, Holmes has brought healthcare to communities in need in Africa, especially Malawi and Zambia, as well as ensure the permanence of the resources.

He says his work would be impossible without the influence and support of women mentors, collaborators and successors.

Part of this is understanding how healthcare services are being received by locals. In one case, a new clinic was built in an informal settlement to address a healthcare desert. The clinic was very busy for several days after opening.

“There were babies being weighed, mothers having their blood drawn, and all this great healthcare going on, and then all of a sudden one day nobody showed up,” Holmes said.

A member of staff went into the community to try and understand why people had stopped showing up, the reputation of the clinic and how they might better address their healthcare needs. Holmes says he and his staff learned the healthcare services, including measuring babies, taking blood and other laboratory tests, were rumored to be witchcraft. These rumors discouraged locals from seeking out the clinic.

In response, an outreach team provided community education and rebuilt trust in the clinic in a “matter of days.”

During his tenure, Holmes was surrounded by women who informed and shaped his experience. One such woman is Beatrice Grillo, who served on the board of directors for CIDRZ.

“I considered her to be a real mentor of mine. … She had an economics background, and had led a number of NGOs, and was on the NGO council in Zambia … She taught me about governance, financial stewardship, transparency, institution building,” he said. “Both the woman that would succeed me, and I, benefited from her mentorship.”

Grillo pushed the organization to be better, he says.

Holmes also talks about the critical role of Roselyne Raelly, then the CIDRZ human resource director, who has since died. She “was an incredibly committed leader with a really, really strong kind of character and integrity.”

When Holmes first came on as CEO, he was made aware that someone had sexually harassed an employee, who reported the event to the organization. The report uncovered a lack of appropriate response procedures and prevention within the organization that Holmes and Raelly worked together to address.

“Roselyne had this incredible wealth of people in her life, [a] network of people in corporate environments, and workplace safety and HR, and so she actually called and got tremendous amount of advice on … how to handle this acute issue … and we handled it well,” Holmes said. Raelly “really helped guide the process of putting into place the preventive measures, educating incoming staff and existing staff on these issues, putting into place systems like hotlines that would build trust and accountability throughout the organization.”

In planning his transition out of his role as CEO, Holmes championed Izukanji Sikazwe, his deputy CEO at the time and renowned Zambian physician-scientist, to take over the position and ensure CIDRZ would become a permanent resource for public health in Zambia.

Sikazwe “was clearly an excellent leader, and someone who cared a lot about the quality of services that we were providing, and had a great deal of pride in them, and when they weren’t going well, was very quick to address those issues.” Holmes said. “She went on to lead the organization extraordinarily well for the next seven years, she grew it, she maintained great relationships with the board and with the government, as well as our funders at CDC and USAID and elsewhere.”

Today, Sikazwe is head of HIV at the Global Fund to Fight AIDS, Tuberculosis and Malaria.

In his continued work in Malawi, Holmes works with Beatrice Matanje, CEO of the National AIDS Commission. Together, Holmes says, he and Matanje have “strengthened HIV prevention programs at the district level in Malawi” and “introduced … new long-acting HIV prevention agents.”

This work includes bringing long-acting injectable cabotegravir, an injectable form of PrEP, into Malawi. The drug was introduced in Malawi using a health systems approach and in a community conscious way, ensuring that the utility of the drug was accessible and available long-term. The rollout was handled by district health offices and policy decisions were informed by patient and provider preferences.

Long-term, sustainable interventions like these matter for people in need of this care.

For example, while taking a daily pill for HIV prevention seems like a reasonable prevention response, it does not take into account the experience of a woman who might have to explain the existence of the pills to loved ones or partners. Beyond privacy concerns, a daily pill can also raise concerns of harm if the person is experiencing intimate partner violence or domestic violence.

A long-acting, injectable form of PrEP every six months at a clinic or community center would be a safer and more realistic alternative for them.

“Malawi has benefited a lot from partnering with Charles in the field of HIV prevention,” says Matanje. “Together with the Ministry of Health and National AIDS Commission, he co-designed a data-driven, locally led HIV prevention model, known as the Blantyre Prevention Strategy, to tackle a complex HIV epidemic in Blantyre City and District.”

Holmes and Matanje work closely in their efforts to rethink prevention and build systems for HIV prevention rather than focusing on silver bullets. Both were among the authors of a six-paper joint series from The Lancet HIV and The Lancet Global Health on sustainable HIV prevention in Africa.

Holmes describes:

“About two years ago, we talked about what kind of initiative we could undertake that would build on some of what we had learned in Malawi. So she and I launched this sustainable-prevention initiative last year, just as the funding environment was beginning to change.

“We held a major convening in Malawi with representatives of 12 country governments and civil society. What was supposed to be a more technical gathering quickly became: ‘Oh, wow—the funding environment is changing fast. What can countries do now to protect the progress in their HIV responses?’

“I got to see Beatrice bring an incredible energy that drew people into really tough conversations and pushed them to come up with something useful. She is one of the most persuasive people I’ve ever met.

“Over the past year, 84 other people from that group and we met in Kigali in July and launched a Lancet series we had written last year. We had a powerful coming together of technical expertise and convening power that helped advance useful ideas at a very difficult time for global health generally. It would not have happened without her.”

The initiative unfolded as the Trump administration moved to freeze, then sharply curtail, U.S. foreign aid, including much of the prevention work supported by the President’s Emergency Plan for AIDS Relief (PEPFAR). Although a limited waiver allowed some HIV treatment and prevention of mother-to-child transmission to resume, it did not broadly restore prevention services such as PrEP for most people at heightened risk of infection.

In Malawi, where donors finance much of the HIV response, the disruptions exposed how dependent prevention programs remained on outside funding.

But Holmes’ work highlights the importance of local leadership and expertise, and especially the role of women in these spaces doing much of the translation work. In thinking about global health, we need to think local and be responsive to local needs.

Florence Riako Anam, co-executive director at the Global Network of People Living with HIV (GNP+), has “become a tremendous voice for making sure that as countries are making changes, they don’t trample what’s been great about global health and the HIV response,” said Holmes. “A lot of what has made the HIV response so powerfully able to meet people’s needs is that the response has listened to people and understood where there’s stigma.

“One of the really critical things that I’ve learned from her is that if you don’t have people at the table who are affected, you’re going to make decisions and you’re going to make assumptions that are wrong and that do a disservice ultimately to the translation of science to public health policy and practice.”

Looking at global health with a local lens brings critical pieces of long-term health into stark relief. Listening to women and communities on the ground makes policy and healthcare more accessible and safe.

Holmes, now dean of the University of Michigan School of Public Health, will take these lessons with him into his new role, where he says he hopes to “develop the next great public health practitioners, researchers, outreach workers—you name it.”

“This is a great time for us to introduce a whole new set of learners to public health in some different ways … The need to be able build deep trust with communities, not just in Michigan, but across the country and around the world, if we’re going to be successful in reaching them. I think there are real opportunities for students, for trainees to be part of that new wave of really effective public health.”

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