In 2010 there was a terrible earthquake in Haiti that caused unprecedented destruction. Thousands of people died, homes were destroyed, and what infrastructure existed was decimated.
Shortly after the earthquake, the country experienced a devastating cholera outbreak. There had never been a case of cholera on the island before.
Cholera is a nasty disease that can kill a healthy adult in as little as three hours. It is easy to treat, but thousands of people in Haiti died before health workers were able to control the epidemic.
How can this be?
Yes, Haiti is poor and the infrastructure was in disarray. But surely the people who planned the response knew that cholera was a possibility?
It bears repeating that although infectious disease is spread from bacteria and viruses, there is always, always a social component to disease. As Charles and Clara Briggs wrote in their excellent ethnography about a cholera outbreak in Venezuela, Stories in the Time of Cholera: Racial Profiling During a Medical Nightmare:
Epidemics are ‘mirrors held up to society,’ revealing differences of ideology and power as well as the special terrors that haunt different populations[…]
Cholera created a charged, high-stakes debate about the lives of the people it infected, and competing stories bore quite different policy implications.
So what stories were being told about the cholera outbreak?
At first, the international aid community including the UN tried to blame poor infrastructure. Health workers stepped up education campaigns about clean water use (which is kind of a joke in a country that was completely ravaged by the earthquake). The response tended to emphasize existing problems with the water delivery system, poverty, poor hygiene, and living conditions that were ripe for this type of epidemic. The UN launched a major cholera aid package that some say was just repackaging an aid effort that already existed.
But in the end, they had to own up. It turns out that UN aid workers brought it with them. Not on purpose. But still. They were actually the vectors.
It’s fitting, I suppose, that this is the conclusion. After all, the history of Haiti is an endless story of outsiders bring poverty, violence, disease, devastation.
So how do you create an epidemic? Act first, think later. Don’t ask for advice. Don’t consult an anthropologist. Hope for the best. Rely on old worn-out narratives. Emphasize feeling and emotion. Charge in to save the day.
Cholera was the most vivid example of the latest tragedy visited on Haiti, but surely there were more. What about the American aid workers who went to save the day, like this guy, but came back feeling disappointed when people on the street just wouldn’t stop begging for money:
It’s very frustrating because, again, it’s this strange combination of being dependent, but also expecting it. And that can be very disheartening because the reality is no aid project is going to work if you don’t have people that you’re trying to help bought into it in wanting to help themselves.
Or the foreign aid that often benefits companies from the US while at the same time undermining local economies. Or that fact that medical aid organizations can sometime swoop in without trying to integrate themselves into the existing medical system, with the unintended consequence of leaving the local healthcare system in worse shape than they found it.
Haiti is trying to sue the UN for damages. Here’s hoping that they win.
The group gave tablet computers to poor children in Ethiopia with apparently stellar results. In this particular region of Ethiopia, the children were particularly impoverished, did not read, and were not going to school. “We went in, gave them the tablets and walked away,” said Matt Keller, the Vice President of the Global Advocacy.
These kids are learning faster than they would be learning in school. When you give a child that tablet and all the other children in the community have the tablets, the children learn form each other, they teach each other, the dynamic is so intense that I have to say yes, it’s better than a classroom.
The story jumped out at me because as a parent, I am repeatedly warned against exposing my child to too much “screen time.” I just got an email from my child’s preschool teacher that cautioned television watching before bedtime, and in my social circles, dropping off a bunch of iPads to kids and then just letting them sit there and play with them all day would be seen as tantamount to child abuse.
What happens when toddlers zone out with an iPad? asks Ben Worthen in the Wall Street Journal, and concludes that the things aren’t good for his child because he goes into a sort of trance and it becomes a daily battle to get the boy to put the thing down and go
the fuck to sleep to bed.
Apparently they can be a great tool for kids with autism, cerebral palsy and various other disabilities. But table comptuers can also make it more difficult to sleep, and there is persistent concern about their effect on children’s brain development, attention span and learning ability.
In public health, we talk about providing appropriate technologies for the situation. Is dropping off a bunch of tablet computers to poor children an appropriate technology? Does it make sense in the context that they live?
Do we have different standards for the health of our own children and the health of other people’s children, poor children? Would we want this for our own children.
Paul Farmer talks about creating a preferential option for the poor, arguing that it is the role of the non-profit and charity world to charge themselves with offering the poor people of the world the same –if not better — medical care as wealthy patients in developed countries.
Idealistic? Yes. But it’s something that I always think about when new programs are rolled out or when a researchers is talking about their groundbreaking work in a poor country.
What do you think?
Have you heard about One Laptop per Child ?Do you worry about whether too much “screen time” affects the health of your own child(ren)? Are there other programs that you know about that employ new technologies innovative ways? Tell me, I want to know!
Today I’m excited to launch a new feature called Profiles in Health. Every week I’ll interview a woman (and maybe even a couple of men!) working in women’s health. I’ll talk to clinicians, activists, policymakers, public health professionals, midwives, writers and more.
For my first interview, I’m profiling my former colleague and friend, Sarah Harlan. She’s currently a Program Officer for Knowledge for Health at the Johns Hopkins Center for Communication Programs.
Sarah has a BA from Grinnell College in Iowa, and an MPH from UNC Chapel Hill. She’s worked for Planned Parenthood, Ipas and Family Health International, and has traveled to six countries – including Nicaragua, India and South Africa – doing reproductive rights work. She’s a calm, focused presence with a knack for making order out of chaos, a much needed skill in a field that is often filled with frantic deadlines and hectic schedules!
I talked to her last week about reproductive rights, HIV and what it means to be a woman working in international public health.
You have an MPH in Maternal Child Health, and you’ve been working in the reproductive health field for about ten years. What do you do in your current job?
I work on the research, monitoring and evaluation of the Knowledge for Health Project (K4Health) at the Johns Hopkins University Center for Communication Programs. It’s a USAID-funded 5 year project that’s working to improve the dissemination and uptake of current knowledge on reproductive health, family planning and HIV in low and mid-income countries.
I analyze the needs of various countries in order to inform the materials that are produced, like eLearning courses and online toolkits. Once we produce the materials, I help evaluate them, asking questions like: How do people like them? Can they be improved? What can we do better in the future?
It’s important to know whether what you are doing is actually working, and figuring that out is part of my job.
What do you do on a daily basis? What does an average day look like for you?
Even though I work for Johns Hopkins in Baltimore, I’m a remote employee: I live in North Carolina! That means there are a lot of phone calls; I’m often on the phone for two or three hours a day with different colleagues. I do a lot of writing reports, online publication, a journal manuscript and blog posts. I also look at data about the tools that we are using and analyze it, drawing conclusions about the success of the project and reporting that to our funder.
One great part of my job is that I get to travel to see what our offices are doing in the field. Most recently, I went to Addis Ababa, Ethiopia for a week and a half. We had done a series of needs assessments in 5 countries, looking at the information needs of family planning and reproductive health providers. I went Ethiopia to facilitate a dissemination workshop on the study we did there. We invited about 50 health professionals and had a daylong meeting to talk about the results of the needs assessment. We got to hear their ideas about what to do, based on that information.
The project I’m working on now is based in Indonesia, so I’ll be traveling there some time in the new year.
You were a Religious Studies and Latin American Studies major in college: what made you decide to pursue public health?
I first became interested in women’s health while I was studying the Catholic Church’s effect on women’s reproductive rights in Latin America. I thought about going to graduate school in Latin American Studies, but that didn’t seem right. Then, at one point I thought of becoming a nurse or nurse practitioner, but I wasn’t sure that the focus on science was going to be the right fit for me.
Before I went to graduate school I worked at a Planned Parenthood clinic as a health care assistant. At the time the health care assistants were doing everything from answering the phones, to providing intake counseling, to doing injections. I speak Spanish, and we had a lot of Latino patients, so it was a great opportunity. One thing I liked about Planned Parenthood was that it was a woman-driven organization. That’s not that it didn’t have men employees, but the priorities were set by women, and that was really nice.
I knew I was interested in reproductive health and family planning. After working at Planned Parenthood, I realized I was more interested research and policy than in being a clinician, and I thought public health would be a good balance of the topic area and the methods that I was familiar with as an undergraduate. Public health is so interdisciplinary. You have to know about history, anthropology, and you have to be a good writer.
When people think of the health fields, they mostly envision doctors and nurses, the actual health providers, they don’t usually think about public health. What is the difference do you think? Why is public health important?
There are a lot of things that go into health and medicine. That larger view of health on the population level is such a compliment to science and clinical work.
I’ve been reading Tinderbox, the book about the AIDS epidemic in Africa by Craig Timberg and Daniel Halperin. In it, they talk about the things the West has done to combat AIDS that actually made it worse, and much of it has to do with neglecting the bigger picture.
During the Bush administration when PEPFAR was created, the administration appointed clinicians who were focused on treatment but weren’t trained in population level care and programmatic and policy issues. They didn’t really consult anthropologists or public health professionals – if they did, it was minimal. That was a real weakness of PEPFAR at the beginning – that public health people weren’t helping steering the priorities.
If clinicians and public health folks were working together more, there would have been a more comprehensive plan that focused on the bigger picture, not just on treatment. The book is a great illustration of why it’s so important to have a social science approach and a clinical or “hard science” approach to addressing health issues.
I’ve written about the gender gap in both clinical medicine and in medical research, but haven’t addressed gender issues for women working in the public health sector. What is it like being a woman working in this field? From your perspective, does it seem like international public health is a field where women can succeed professionally?
From what I can see, public health seems to be dominated by women, and the trend is that women are having more positions of power. Or maybe this is just the case in reproductive health, but I think it’s happening in HIV too, because of a renewed focus on women’s prevention options like microbicides and pre-exposure prophylaxis. Whatever the reason, it seems like more and more primary investigators and spokespeople are women.
At the same time, in every organization I’ve ever worked, there are more women than men, but the men tend to be in charge. It can be frustrating, but I think it’s starting to change.
A lot of this work is grant funded, which means that organizations tend to focus on what Bill Gates thinks is important, or what presidents of various nations are important. That’s one reason why family planning issues fell of the radar for a while in the 1990s: funders decided there were other health priorities that didn’t focus on women. HIV has traditionally been given a male face – even though women and children make up such a huge population of new infections – and a lot of that is because decisions are made and funding is men.
What do you like the most about the work that you are doing now?
Too often, organizations jump into planning an intervention without knowing if there’s a need.
K4Health is research-based advocacy: you’re going and collecting the evidence, finding out where the needs are, planning an intervention around that. I like that I know we’re evaluating whether things are effective. To me, it just makes more sense: it leads to a better use of resources, and ultimately can do a lot more good.
What advice would you have for women who are thinking of pursuing a degree in public health?
Before you do the degree, look around and see what public health organizations are actually doing. When I went into the Maternal Child Health program, I was very idealistic. I don’t want to tell people to curb that, but you have to realize the limitations of working within institutions and structures.
Remember: unless you get to be at the very top of the field, you’re not setting the priorities or determining the focus of a project. You can put your own personality and creativity into it, but you need to be realistic about where the jobs are.
That said, there are a lot of unique and interesting opportunities in the field. I’ve learned how to use a video camera and do video editing and given professional presentations. I’ve published in journals, taken photographs, and gained some public health programmatic and research skills at the same time. These are things I didn’t predict I would be doing. There is so much new energy in family planning and reproductive health, with the London Summit and (hopefully) renewed funding, and it continues to be an exciting field.
Thanks Sarah! Best of luck in your work, and we’ll be sure to check in with you again sometime. If you’d like to be profiled or know someone you think I should talk to, send me an email at jcmoffett at gmail dot com.
Welcome to October. As you probably know, it’s National Breast Cancer Awareness Month.
That means you’ll be inundated by things like this
Breast cancer has become so hyper-visible that it’s hard to believe we really need any more awareness. So many of the activities related to breast cancer are just an opportunity for corporations to pay lip service to women’s health. National Breast Cancer Awareness Month has become just a tired ritual, when women’s magazines trot out their “Five Things You Need to Know about Breast Cancer,” articles and publish yet another “profile in courage” of a woman stricken with the disease who finds that it makes her a better, kinder, more spiritual person.
Every year, about 35,000 American women die from breast cancer. That’s over 100 women a day. Treatment is still limited to “slash, burn and poison,” and we don’t know what causes it.
As I’ve written elsewhere, men tend to set research priorities and be the main clinical researchers. But one of the best known breast cancer researchers is Dr. Susan Love.
This month, Dr. Love has launched a new research initiative dubbed the Health of Women Study (HOW), and she’s asked women’s health bloggers to help her publicize it. According to the study website:
The majority of women who get breast cancer have none of the known clinical risk factors. This means we don’t know what causes breast cancer or how to prevent it. The HOW Study is a first-of-its-kind international online study for women and men with and without a history of breast cancer. We will collect information about your health, your job, your diet, and your family history, among other topics that can help us get a better understanding of breast cancer and its potential causes. Periodically, we will send you questionnaires about anything and everything. All you have to do is fill them out online. It’s that simple. This is a partnership and we need you for the long haul. The more questionnaires you fill out, the more information we will have that can help us have a better understanding of why women get breast cancer.
Anyone over the age of 18 — male or female, with breast cancer or without — can join. There’s no poking, no prodding, no blood samples, no humiliating tests; just some online data collection.
This October, think before you pink .How about joining the study instead? I’ve done it. Will you?
His argument is important for people working in the health nonprofits.
He makes five key points:
- The for-profit sector pays people for producing value, but the not-for-profit sector does not
- Charities are discouraged from spending money on advertising even though it is an effective means of increasing donations
- Expectations for success are unrealistically high
- The expected time frame for success is unrealistically short
- The nonprofit sector is forbidden from paying investors a financial return to attract their capital.
Something is wrong when Coca-Cola and Burger King have a potential for growth that we deny, on principle, to the Boys & Girls Clubs and the National Breast Cancer Coalition
It’s certainly true that program managers often struggle to achieve deliverables that are set out by the funding agency rather than the experts in the field. It’s impossible, for example, to eradicate HIV in sex workers in Tanzania within one funding cycle, but NGOs must make it look like they achieved something tangible even if the reality is far more complex.
It’s also true that most fundraising for charities is done through low-yield initiatives such as social media, direct mail and the occasional benefit dinner. And although professionals can make a living working in the non-profit sector, the gynecologist who works for Planned Parenthood will never make the kind of money her colleague earns at a private health facility.
Pallotta’s fundamental argument is that nonprofit organizations aren’t being allowed to benefit from capitalist structures, and that if the nonprofit sector were deregulated and the association with high salaries and spending on self-promotion were to be destigmatized they would be far more effective tools in the fight against global poverty and health disparities.
As he says,
Business can’t solve all the world’s problems. Capitalism can — but only if it is permitted in the nonprofit sector. If we free the nonprofit sector to hire the best talent in the world, take fundraising risks, use marketing to build demand and invest capital for new revenue-generating efforts, we could bring private ingenuity to bear on those problems and would not need to look to government to fill the gaps.
It’s an interesting proposal.
But is quality of staff really determined by money? Would more pay really attract better people or just people who wanted more money? Would deregulating the nonprofit sector really make it more effective, or would it open it to more corruption? If NGOs were motivated by financial stressors, would they only take on issues where they knew they could succeed?
What do you think?