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.
For almost two decades, breast cancer has been a very visible public health issue. Women over the age of 40 (or sometimes 50) are pressured by doctors, health advocacy organizations, friends, family and pop culture to submit to a yearly mammogram. It could save your life, we’ve been told.
We’re told not to worry about the discomfort or pain, the strangeness of having your boob squished like a pancake in a giant X-ray machine, the possibility of false positives. We’ve been reassured that the level of radiation to which we are exposed is minimal.
This insistence on yearly screening has seemed problematic to me for many years, in part because of my own observations working in the healthcare industry.
For a year, I had a job at the Family Medicine clinic at the University of Washington. My job was to check in patients, call in referrals, file their paperwork and be the friendly face they saw at the front desk.
One of the things I noticed was the number of scans that women were being asked to undertake. Full body bone density scans. Mammograms. Abdominal x-rays. Pap tests. The doctors offered (and sometimes directed) women toward an onslaught of screening tests. On the other hand, male patients were rarely sent for routine screening exams.
It doesn’t take a genius to guess that this might be an issue. After all, we have no reason to think that researchers or clinicians take women’s health more seriously than men’s health. Yet there is a history of putting women’s bodies under the microscope, of seeing them as breeding grounds for disease, of poking and prodding and monitoring.
This annoyance and irritation at the way female patients were treated by the medical field t propelled me into graduate school. Why was there such an interest in promoting mammography? What were women really getting out of it? What did the pink ribbon really mean?Do mammograms really save lives?
Turns out, the answer is no.
A new observational study published in the New England Journal of Medicine oncluded that mammograms don’t work. In his beautifully argued op-ed in the NYT yesterday, David Newman points out that although observational studies are not the gold standard, in this case the approach was strategic. The study confirms the conclusions drawn from a series of clinical trials: Mammograms might increase diagnoses and may increase treatment, but they don’t save lives. You’re just as likely to die from a breast cancer detected from a mammogram as you are from breast cancer you detect yourself.
So why do doctors and health advocates persist in pushing women to get the test?
Newman puts in this way:
[T]he trial results threatened a mammogram economy, a marketplace sustained by invasive therapies to vanquish microscopic clumps of questionable threat, and by an endless parade of procedures and pictures to investigate the falsely positive results that more than half of women endure. And inexplicably, since the publication of these trial results challenging the value of screening mammograms, hundreds of millions of public dollars have been dedicated to ensuring mammogram access, and the test has become a war cry for cancer advocacy. Why? Because experience deludes: radiologists diagnose, surgeons cut, pathologists examine, oncologists treat, and women survive.
While Newman doesn’t bring in a feminist or gendered analysis of this issue, it’s sitting right there, the pink elephant in the room. Just like the continued marketing of hormone replacement therapy, or the lack of non-invasive methods to detect cervical cancer, mammography has been accepted practice for so long because culturally, it’s perfectly fine to expect women to submit themselves to poking and prodding and examination.
What do you think? Have you had a mammogram? Will you get one (or stop getting one) after hearing about this study?
Back when I was young and idealistic, there was nothing I loved more than a good protest.
I vividly remember the first time I attended a demonstration — it was on Parliament Hill in Ottawa, Canada and were were protesting the incarceration of Nelson Mandela. After that, I was hooked.
I’ve marched against police violence in Seattle, white supremacy in Montreal, and sexual assault in Iowa City. I’ve taken back the night more times than I can count, and I’ve faced off against loggers (one of whom was wearing this T-shirt) in British Columbia’s Clayquot Sound as part of a protest against clearcutting.
I once demonstrated against impending restrictive abortion regulations in Seattle, and carried this sign:
On my way home, a young boy stopped me and asked me to explain what the sign meant. Awkward.
I used to get goosebumps and a thrill at the first sound of a good chant. I loved rousing speeches promising social justice, peace and equality. During the Bush
reign of terror administration, I took a bus from Iowa to Washington,DC to protest the invasion of Iraq. The experience was thoroughly exhilarating at the same time that it was extremely depressing. Enormous demonstrations were held all over the world, but we all know what happened in the end.
It was this lifelong interest in social justice that propelled me to seek employment in the non-profit women’s health field. When I finally got a full-time job writing for a major reproductive health and HIV organization, I was beyond excited.
But instead of rousing speeches and radical movement toward social justice, I found career climbers and male dominated board rooms. Public health initiatives seemed top-heavy and destined to fail, success was measured in tiny percentage points. People talked about “stakeholders” and “gender champions” and said things like “scale-up” and “roll-out” and “capacity building.”
The employees at this non-profit didn’t protest, in fact, they found protestors to be quite threatening. I was enlisted to help write a paper about the travesties committed by ACT-UP. And yes, dear readers, I did it.
This morning, there was an article in the L.A. Times about a group of young people disrobing in front of John Baynor’s office in protest of cuts to domestic AIDS funding. I found myself thinking about the importance of this type of dramatic, confrontational action. There’s no worry about funders disapproval or concern that you might be burning bridges with potential allies. This kind of action reminded me that there are still plenty of people who are able to concoct creative ways to engage with the political process, to express rage at inequality, and yes, even to demand social justice.
I’m not much of a sign-holder anymore, perhaps those kinds of actions are best left to the young and idealistic. But while I might not be one of the people who strips naked on Capitol Hill, I’ll always be sitting on the sidelines, silently cheering them on.
What do you think? Do you go to demonstrations? Do you think that protests like these are good tools for political change, particularly when it comes to health policy?
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!
I didn’t post here yesterday because I was hard at work writing up a piece about Call the Midwife for Bitch Magazine’s blog. If you’re interested, you can read it here.
Today is World Food Day.
There’s always something when it comes to children and food.
They can be unbearably picky. They can be greedy. They can miraculously survive on different combinations of white flour, sugar and food coloring for months and months on end.
I’m thinking about this today because my son hasn’t been feeling well. On Wednesday he threw up in the morning, and then again in the afternoon. He went to sleep early, and seemed okay when he woke up, but then he was upchucking all over again the next day. He’s stopped throwing up now, but he still says he feels sick. He refuses dinner yesterday night, choosing instead to languish on the couch while we all watched Lars von Trier’s
not really that child appropriate Melacholia.
When it comes to throwing up, I always worry. He was born 12 weeks premature, which is notoriously hard on the digestive system. He was so small, just two little pounds. He had terrible acid reflux as a baby, making digestion and burping very painful. It’s been years since then, but whenever he catches a stomach bug, it brings back those memories.
It makes me obsess about food.
He’s small, and I worry that he’s losing weight. After he stopped throwing up and eased back into regular food, I bought peanut butter ice cream, and protein shakes. I scrambled some eggs with half-and-half, and took him out for French fries and a grilled ham and cheese sandwich soaked in butter. And then I worried that I shouldn’t be letting him eat meat because what if he gets E.coli? Or mad cow disease? Or salmonella?
But then I have a reality check.
In 2011, almost 7 million children under the age of five died, most from conditions that were preventable or treatable with access to simple and affordable interventions. A full third of childhood deaths are related to malnutrition.
Malnutrition is a cycle. Women who don’t get enough to eat give birth to malnourished children, and the cycle continues. Furthermore, men tend to have more access to food than women, and women are the ones who are look after the children in most settings.
Not having enough food is mostly prevalent in Sub Saharan African and Southeast Asia. In the US, we don’t worry really about malnutrition.
The number one killer of children in this country is accidents. That’s a whole other level of worry. You can put a helmet on your child, or make sure you keep an eye on him when he’s on the monkey bars. You can buy a great car seat, and put a fence up around the pool. There are lots of things you can do to keep your child safe, and they probably won’t die from an accident.
But malnutrition? That’s a whole other ballgame.
There are 20 million young children around the world don’t have enough to eat or don’t have access to clean water; and for every child who is sick, there is a mother experiencing a personal crisis. Before I had a child, I couldn’t really understand this. But I’ve seen my baby with no fat on his little body, eyes sunken, bum like two deflated balloons. I’m haunted by it, but I know that the chances of us revisiting those days is slim.
My kind of maternal anxiety is a luxury.
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.
Oh, occasionally a women’s health blog/fair/publication/clinic will include information about heart disease, or nutrition, or even chronic illness. For the novelty factor, it might include something about HIV. But most of the time the term “women’s health” is about getting knocked up, not getting knocked up, and boobies.
I’m as guilty as the next person when it comes to limiting my scope: I wrote a dissertation on breast cancer, a master’s thesis on breast feeding, and worked for an organization that focused on reproductive health.
Unlike womb health and boob health, mental health isn’t typically classified as a women’s health issue. That’s unfortunate, because mental health could possibly be the most important topic when it comes to women’s health. After all, if you don’t have your (mental) health, nothing else matters.
Whether it’s post-traumatic stress disorder, postpartum depression, bi-polar disorder, depression and anxiety, or even loneliness, mental health is something that is shaped by gender.
According to the World Federation on Mental Health, depression is not only a worldwide crisis that affects 350 million people a year, it is also a highly gendered affliction:
While depression is the leading cause of disability for both males and females, the burden of depression is 50% higher for females than males (WHO,2008). In fact, depression is the leading cause of disease burden for women in both high-income and low- and middle-income countries (WHO, 2008). Research in developing countries suggests that maternal depression may be a risk factor for poor growth in young children (Rahman et al, 2008).
This risk factor could mean that maternal mental health in low-income countries may have a substantial influence on growth during childhood, with the effects of depression affecting not only this generation but also the next.
Treatment is different for women too. We’re more likely to be diagnosed with depression than men, even if we both give the same list of symptoms. And women are more likely to be prescribed mood altering psychotropic drugs.
Furthermore, there are significant health disparities when it comes to women’s mental health, and not just having to do with unipolar depression:
- Women experience twice as much serious mental illness as men
- Women have a life-time prevalence of alcohol dependance that is more than twice as high as that for men
- Postpartum depression and anxiety are common, but poorly diagnosed and treated. That means many (if not most) women suffer through this alone.
- Women and girls are at least twice as likely to have an eating disorder than are men or boys.
What’s the reason for these disparities?
It’s complicated, but the inequalities inherent in patriarchal societies bear some of the responsibility.
Eating disorders emerge because of an unrealistic image of the female body that is presented in the media. Postpartum depression goes untreated, and can lead to further mental health problems. Women experience more poverty, more workplace harrassment, and do more caregiving for family members than do men.
Furthermore, according to the World Health Organization, the high prevalence of sexual violence to which women are exposed and the correspondingly high rate of Post Traumatic Stress Disorder (PTSD) following such violence, means that women are the largest group of people affected by this disorder.
We don’t like to talk about mental illness in this country, and we don’t do a great job of treating it. We throw drugs at it (there’s been a gigantic increase in the number of Americans on anti-depressants, but are we mentally healthy?) We pay lip service to it. But more often than not, we ignore it.
In the US, even if you are lucky enough to have insurance, chances are that it doesn’t offer mental health parity.
For once, the US is not the only country doing a shabby job of providing healthcare. According to the WHO:
Mental, neurological, and substance use disorders are common in all regions of the world, affecting every community and age group across all income countries. While 14% of the global burden of disease is attributed to these disorders, most of the people affected – 75% in many low-income countries – do not have access to the treatment they need.
Reading this onslaught of bad news may not make you feel very mentally healthy, whether or not you’re a woman. But it’s important to share this information as a reminder that mental health is a major health issue for women and that it should be addressed under the umbrella of women’s health.
It’s easy to focus on babies and boobies, but looking at other health issues through a gendered lens may help decrease women’s morbidity and increase quality of life.
What do you think? Do you know any women’s health organizations that are working on this issue? What does the research show about mental health disparities? Are there things that clinicians can do to better protect the mental health of their female patients?