Emory University Woodruff Health Sciences Public Health

Contaminated water in tsunami-ravaged Indonesia, HIV in Africa, family planning in India: MPH students learn vital lessons about public health in the field.

Stephanie Maurissen was on the way to Bolivia to help clean up a river contaminated by metal from a silver mining operation when a coup overturned the government and politicized the decontamination project. She had to make new plans—fast.
“Flexibility, flexibility, flexibility,” says Deborah McFarland in listing the most essential quality in doing international field study. “Nothing ever works the way you think it will. You have to adapt.”
McFarland, associate professor in the Hubert Department of Global Health, directs the Global Field Experience (GFE) program, in which Maurissen participated this past summer. “The field experiences are a testing ground for students,” says McFarland. “Some get verification that they have found their niche. Others come back and say this isn’t what they want. These experiences also put students in the trajectory of their role models. They help shape the next generation of public health advocates, policy-makers, and researchers. That’s a legacy.”

INSPIRATION IN BURKINA FASO: SALLY HONEYCUTT

The Scenarios from Africa project takes the best ideas from African teens about how to prevent AIDS and puts them on film, directed by internationally acclaimed artists. Originating in Senegal, Mali, and Burkina Faso, the HIV/AIDS education project for young people has now spread to 35 countries in Africa. Sally Honeycutt headed to Burkina Faso this summer to evaluate the impact of the films.
In Titao she found inspiration. It came in the person of Konfé Fatao, a local teacher and AIDS activist. Titao is a remote village with no electricity, and Fatao is able to show some of the 28 Scenarios films only when he has gas for a generator. However, when there is no gas, he is still using the content of the films to spark discussions about AIDS with his students. He acts out scenes. He quotes dialogue. He asks questions.
Through Fatao, Honeycutt visited villages even more remote than Titao to hold focus groups with Africans between the ages of 15 and 24 who had viewed the films. She wanted to find out what the young people thought of what they’d seen. Which scenarios seemed the most real to them? What situations existed in their own communities that led them to confront AIDS? The most common theme that emerged from this focus group and others Honeycutt conducted was a prevalence of transactional sex, ranging from sex between a girl and boyfriend who brought her gifts to sex between a girl and an older man in exchange for a commodity such as a cell phone.

Honeycutt also observed eight screenings of Scenarios to see how partners were using the films. She found a great variation in use, with a frequent discrepancy between an ideal and actual use of the films. Whereas Fatao was an inspiring presenter, other facilitators lacked training and support to lead effective discussions.
Previously, Honeycutt had served in the Peace Corps as a maternal child health educator in Gabon in central Africa. The reason she returned to Africa—in fact, the reason she enrolled in the MPH program at the RSPH—was to get missing skills. While she was well versed in program management, she wanted to add project evaluation and research skills to her experience and hone her ability to apply theory. This field experience, funded by an O.C. Hubert Fellowship in International Health, allowed her to do just that.

LESSONS FROM THE TSUNAMI: ASTRID SUANTIO

By the end of the day in Aceh, Indonesia, Astrid Suantio would have a sore throat. She was there to evaluate and monitor a point-of-use water intervention in relief camps for displaced people in an area hardest hit by the December 2004 tsunami, but her fluency in the local language made her a frequently sought translator.
After the tsunami, these camps opened with temporary housing consisting of 12-room barracks, with five to 12 people per room. The high population density contributes to an increased risk of outbreaks of infectious diseases. A lack of clean drinking water makes diarrheal disease a particular concern in the camps.

Suantio, supported by the Eugene J. Gangarosa Scholarship Fund, was evaluating an intervention developed by CDC scientists and provided by CARE International Indonesia called the Safe Water System (SWS). The SWS consists of water disinfection with chlorine, safe storage in narrow-mouthed containers to avoid recontamination, and behavior change communication. During three months in Aceh, Suantio took surveys throughout the Aceh province to see how people were implementing the SWS in emergency conditions. Working with colleagues, she went into homes to process water samples, test for E. coli, and interview people about use of the SWS. She gave workshops on the SWS for local nongovernmental organizations and community leaders, and she helped CARE with a hand-washing project for people living in the camps.
“The most valuable life lesson I got in Aceh is that human beings are incredible,” says Suantio. “They have the greatest capability to cope with pain and move on with life. Even though I heard many stories about the tsunami from the affected people themselves, not one person that I met still dwelt on the sadness caused by the tsunami. Yes, they talked about it and still mourned their loved ones, but they were also optimistic, trying to rebuild Aceh and their communities as fast as they could, believing the new Aceh would be better than before.”


	On-the-job, in-the-field training

	The Global Field Experience (GFE) awards partially support field research around the globe for 45 to 55 students each year. While many students arrive on campus with previous international experience, the GFE awards allow them to apply newly acquired public health knowledge and skills to real-life health settings and challenges worldwide. Working on a public health project in the field gives students value-added, practical skills that will enhance their future careers, says Deborah McFarland, who directs the program. These awards represent one of the distinguishing hallmarks of the global health program in the Rollins School of Public Health. “Clearly one of the things that differentiates Emory is the global field experience,” says McFarland.

	Supported by three endowments—the Eugene J. Gangarosa Scholarship Fund, the Anne E. and William A. Foege Global Health Fund, and the O.C. Hubert Fellowships in International Health—the GFE awards usually cover airfare, Medevac insurance, and a portion of living expenses to enable students to gain international field experience. Often students procure additional support from sponsoring organizations. And as a group, they raise funds through the annual sale of a calendar featuring photos taken during the previous field experiences. Last year this RSPH Student Initiative Fund contributed $9,000 to the GFE program, sending eight students abroad for research. A recent commitment by the Hubert Foundation will double its endowment for GFE awards, allowing more students to participate. Maya Ravani applauds that move. She evaluated a clean water campaign in Kenyan schools this summer and is continuing to help the CARE-affiliated project develop a water curriculum for teachers. “Without this support, I wouldn’t have been able to go,” says Ravani. Not only does the global field experience come with financial support, it also jump-starts completion of the master’s thesis. The application process is thorough, requiring potential participants to choose a project and make the networking connections they will need. Students are helped in that networking by a faculty with connections worldwide. Finally, the field experience is the first step in establishing a global health career, where experience abroad is a prerequisite. For more information on supporting a global field experience, please contact Kathryn Graves, assistant dean of development and external relations, 404-727-3352, kgraves@emory.edu.

PLANNING FAMILIES IN INDIA: JENNIFER SCHARFF

When Jennifer Scharff was working as a Peace Corps volunteer in Togo, she saw four girls die of self-induced abortions. By contrast, this past summer, she worked on reproductive health in India, where abortion is legal.
     For her global field experience, Scharff, a Woodruff Scholar at the RSPH, chose to study women’s decision-
making power and perceptions of contraceptive methods in rural India. Through surveys, focus groups, and interviews, she assembled a reproductive health portrait of families in Pune in the Maharasta region, gathering information about contraceptive knowledge and attitudes.
     Working out of the Vadu Rural Health Program, she found a fertility rate of 2.8 children per family. Currently 80% to 90% of all contraceptive use in India is female sterilization, reflecting Indira Ghandi’s push for it in the 1970s. The government also offers birth control pills, condoms, and IUDs free of charge and supports a media campaign encouraging families to limit children to two. A woman typically lives with her husband’s family, although, as Scharff found, that trend is starting to change in Pune as the economy is improving (particularly when wives don’t get along with their mothers-in-law).
     “I saw things changing right before my eyes,” Scharff says. “The middle class is small, but it is growing quickly.”

During her study, which was supported by a Hubert Fellowship, Scharff discovered a lack of contraceptive education by physicians. Some women lacked a knowledge of the side effects of contraceptives. They blamed contraceptives for backache, heart attacks, and loss of fertility. Some of the women were afraid an IUD would go into their hearts. “The approach of doctors to counseling about contraceptives is, ‘Don’t ask, don’t tell,’” says Scharff. She also found that contraceptives were not used for family planning to space children—something that she would recommend.
Scharff plans to return to work in both India and Africa, and she remains committed to reproductive health in the developing world. That’s a big step for a Memphis native whose parents never had passports until their daughter began working overseas.

WATER EFFORTS IN KENYA: MAYA RAVANI AND RACQUEL STEPHENSON

The Safe Water System was working so well on a small scale in Kenya that CARE decided to dramatically ramp up the effort in schools in the Nyanza province this year. With connections arranged through the Emory Center for Global Safe Water, Maya Ravani headed over this past summer to assist the organization in evaluating the effort. She wanted to see if schoolchildren were effective promoters of safe water handling and proper hand washing to their classmates and families. But what she found was a project big on enthusiasm by its partners but short on staff and resources—only one field officer to implement the program at all 45 schools, only one truck to transport the oversized storage containers for holding disinfected water, schools located so far apart and on such rough roads that only one or two could be visited in a day, and intermittent outages of electricity.

     Racquel Stephenson went to the same locale as Ravani, but she worked with hospitals rather than schools to evaluate implementation of the SWS. The program was launched there in 2004, and she wanted to see whether the nurses’ teaching practices and utilization rates had changed. She faced her own challenge when a nursing suspension by the government in Siaya put the project on hold, giving her no ongoing effort to evaluate.
     Both students—supported by the Gangarosa Fund—decided to change gears. Ravani worked with baseline data previously collected and pitched in to help the field officer implement the program. Stephenson decided to supplement her one-year follow-up with a population survey to see how many people had received information about the SWS and to determine the sources of that information.
     “I had a totally different idea of what I’d do,” says Ravani, “but you can’t really know what’s going on 7,000 miles away until you get there.” She is continuing to help CARE Kenya in developing an age-appropriate curriculum for the SWS that can be replicated in other regions.
     Stephenson returned from her first overseas research experience confident that she has evaluation skills that can be applied to future assignments. “The organizers allowed this to be my project. They were stakeholders, but this project became my baby,” she says.

FIELD NOTES

MAPPING CHAGAS DISEASE IN LATIN AMERICA: AMY KRUEGER

Amy Krueger found her global field calling in Guatemala, working to help eradicate a devastating parasitic disease.
This past summer with the support of the Anne E. and William A. Foege Global Health Fund, Krueger worked with the International Development Research Centre (IDRC) and the Laboratory of Applied and Medical Entomology (LENAP) on a project to prevent Chagas disease. Chagas is transmitted through the triatomine parasite, which is found only in Latin America. The disease produces flulike symptoms, and in its chronic form, it can lead to lesions in the heart, esophagus, colon, and peripheral nervous system. More than 100 million people, or 25% of the inhabitants of Latin America, are at risk of being infected with the parasite, and in Guatemala, 730,000 people are affected, with 30,000 new cases each year.

LENAP and the IDRC are taking an ecological approach to decrease infestation by the triatomine parasite. Researchers at these organizations believe that changes to the ecosystem can lessen the impact of the disease. The project on which Krueger worked encourages the replanting of natural habitat for the wild animals on which these parasites normally feed.
Krueger’s specific research role was to record the latitude and longitude points on each house in the two study villages of La Brea and El Tule. She took GPS coordinates on approximately 300 homes, mapping each house and collecting information on the types of vegetation. She also collected plant samples in the Guatemala countryside to document dominant species. With this information along with earlier collected data on socioeconomic status and variables such as the presence of chicken coops, she is now completing maps and a spatial analysis of the high risk factors for contracting Chagas.

PORTABLE WATER FOR ECUADOR: STEPHANIE MAURISSEN

As an intern at CARE headquarters in Atlanta in the water sector, Stephanie Maurissen read a lot of reports from the field that she didn’t understand. They seemed too idealistic to be true. But after a summer of studying the implementation of an actual water system in Ecuador, she changed her mind.
     Maurissen’s summer field experience, supported by the Gangarosa Fund, gave her the context she needed. She learned that two obstacles to implementing water systems in Latin America are sustainability and ownership. In the past, agencies have installed new potable water systems, only to find them broken after a year or two with no back-up plan for maintenance and no money for repairs. By failing to involve the local community in the installation and maintenance of the system, agencies miss an opportunity to give ownership to the people who will use the system.
     CARE was trying to avoid those pitfalls. The organization was building deep wells and installing pipelines to bring water into homes as well as offering hygiene education. It required the community members themselves to provide the manual labor for the project—no small requirement considering the work entailed in chiseling miles of beds for pipes into granite. In turn, CARE not only provided the initial expertise for installing the system but also trained a local operator who could fix it when it broke down. CARE also instituted a tariff system from $0.80 to $2.00 per month for water usage, the money being banked for future repairs.
     Maurissen evaluated the social services component of the CARE study, finding that the implementation in Ecuador was working well. She synthesized previous evaluation documents into one comprehensive guide, developed a community questionnaire to evaluate the project, and tested the evaluation tool in six communities: three with potable water systems and three that are currently on the waiting list for these systems. She found the time community members saved in not having to carry water into their homes was being funneled into a microenterprise set up by the community.
     In the course of her research, Maurissen also discovered a career calling to improve water systems. She’s already begun by setting up a water alliance in Latin America.