This past week, I have been working with a volunteer nurse from Canada on
the health coordination for One!’s school in Nallasopara as well as helping
with health check-ups for all the kids in the Khar and Nallasopara schools.
Another volunteer and I created all of the health folders for Nallasopara over
the last couple of weeks since they do not have a medical program there yet.
The children all get quarterly check-ups, but in this case we were triaging
those children that needed the most attention and could be given the care
immediately. For example, although getting a follow-up TB test is important,
the nurse did not have a test kit with her. Therefore, we looked at kids who
had dermatology problems such as fungal infections because that was an ailment
the nurse could immediately take care of with ointment or a prescription. In
rural medicine, you find that what we would think of as the most pressing
issues are not always the first ones attended to by health professionals. A lot
of that has to do with availability of resources, practicality of care, and in
some ways picking and choosing what to “heal.”

In addition, the nurse, Juniper, and I are training a community member with
no prior healthcare experience to be the new medical coordinator for the
families that live in this village (which includes writing down patient names,
deciding who needs to go see a doctor, doing follow-ups, and going with
patients to the doctor and asking questions on their behalf). I have mainly
been creating assessment sheets and questionnaires while the nurse does the
actual check-ups.

It’s been a challenge communication-wise because the nurse speaks English
and the medical coordinator speaks Hindi/Marathi and barely any English.
Because I speak all three and the coordinator feels comfortable speaking with
me, I have been serving as a translator between them.

Having gone on medical brigades and trips before, I am well versed in how to
conduct a check-up. However, I have never served as a translator before so this
task has been challenging for me. On Wednesday, I walked into the make-shift check-up area in the Khar school and immediately had one of the mothers start talking to me about her illness. Part of my research is to speak with families and gather “illness narratives” —-because I have found that the members of
this community start any story or complain about an illness with what they ate
or didn’t eat. Therefore, food has become the crux of any health story I have
ever heard in this community. It’s fascinating for me from a general health
perspective as well as thought-provoking data for my research study. For about
four hours, I sat next to the patients translating between them and the nurse.
These patients speak over three different languages and all of them have
various village dialects that are very hard to understand.

Essentially it was the nurse asking them a question in English, me
translating that into Hindi or Marathi, the patient replying, and then again
translating what they said into English. One of our last patients was a young
mother, about 18 years old with a one year old baby. She spoke Gujarati, which
I do not speak or understand. So this time the translation was from me to her
brother who spoke to her and then translated for me and I told the nurse. If it
sounds confusing—-it was like trying to put together a story from the
viewpoints of three different people. I often had to stop for a minute to make
sure I was making the correct translation and clarifying idiomatic phrases.

This young mother was not eating enough and therefore not producing enough breast milk for her baby. She told me she was eating only once a day so she could save the money her husband made. Her brother, the nurse, and I all tried to explain to her how important it was to eat 2-3 meals a day, if not for her—then for
her baby’s well-being. It was frustrating to see her just smile back blankly. I
felt as if everything was going in one ear and out the other.

And if that was not stressful enough, we had one mother who had sores on her leg from rat bites. She said they hadn’t healed for months and oozed pus every once in a while. When I asked her to show the nurse so we could clean them, she
shied away saying she didn’t “feel good” to let the nurse see her legs.
After some coaxing from me in the sweetest Marathi I could muster, she showed
us and then proceeded to tell me that she took a small butter knife and Dettol
(a brand of antiseptic) and scrubbed her legs raw every week. Upon here the
word knife, I didn’t even translate for the nurse before scolding this woman. I
got flustered and forgot that I was just supposed to be observing. However, imagining someone taking a knife to a wound just made me viscerally react.

And if that wasn’t enough excitement for one day, her son, Saif came in with
white jelly-like material covering both of his eyes. The nurse initially thought it was some bacterial infection, so we gave him a follow-up appointment but we both kept thinking about it after work. That night in our apartment we were going through common eye disorders on the internet and read symptoms on something called xerosis.

Xerosis is an abnormal dryness of the eye in which there is less secretion
from the membrane. Often, the cornea’s luster is reduced. If you looked at
Saif’s eyes, they looked like craters because his cornea was sunken in slightly. In addition, you could see small triangular spots near his pupils. You may be wondering what causes xerosis—-severe vitamin A deficiency. And Saif not only had a deficiency, but he had keratomalacia. Keratomalacia is an advanced case in which a kertain layer (white jelly-like layer) covers the eyes. Saif, like all the other children, gets one meal a day at the school. It consists of a lot of calories, but not many nutrients. A typical meal is rice, a little bit of vegetable like onion and potato, and sometimes an egg. However, the meal at the school is probably his only full meal of the day. The nurse consulted with a doctor back in Canada via email. The doctor’s response was that she had learned about xerosis and how severe it could be in the eye—but in all of her training, education, and practice—she had never seen a real case. It was a disease, she said, that medical students only saw in books. In developed countries, we often forget that what we call illnesses or problems of the past still do occur in other parts of the world in great frequency.

To me though, what was more interesting from an anthropological perspective
was what I heard another female teacher tell Saif’s mother as he was heading
out of the check-up area the next day. The nurse had already given Saif some
multi-vitamins and said she would follow-up with supplements to see if it
helped with his eyes in the next week. However, I heard this teacher speaking
in Marathi and chose to eavesdrop on the conversation. She was saying that Saif
should wash his eyes with rose water daily and use triphala lotion. Triphala is
an herb consisting of three different fruits and in Ayurveda is considered to
be a complete body cleanser and detoxifying agent. This teacher also went on to
say that walking on green grass and green hills would be good for Saif’s eyes.
To me, this last bit was the most interesting because vitamin A is known to be
found in green, leafy vegetables. However, this idea of walking on green, leafy
areas is definitely a traditional folklore type remedy.

Nonetheless, I am beginning to find a focus in my research hypothesis
focusing in on illness narratives and their connection with the food and
nutrition available in this community. Often I find myself asking families,
“Tell me about your illness or what happened last night” and being told
something about drinking a cold drink while having a cold or eating ice during
a hot day. Certain foods are only eaten in certain weather due to intrinsic
properties within them. A bad back or heartburn is immediately blamed on eating
some kind of food that causes an imbalance in the body maybe because it was
eaten in the wrong weather or cooked in the wrong way. Health in this community
revolves around food and what food means beyond its typical nutrient value.

At Dartmouth, so many of us take off-terms that take us all around the world. Many experiences and stories get lost, forgotten or kept within a small group of people. It’s often the little things–the anecdotes, the frustrations, the process of writing itself, and the important aspect of being able to communicate with others—that lead to personal growth within the various societal, community, and even global atmospheres we all take part in.

For the past month, I have been working with the NGO “One!International” in the mainly urban outskirts of Mumbai to gauge changing cultural perspectives towards food and nutrition. The research constitutes a link between traditional small-scale ethnographical studies and macro-oriented studies of development.Throughout my study, I hope to share my experiences and stories in the field.

Mumbai, located in western India, is home to some of the richest people in the world as well the poorest. This fall, I am conducting ethnographic research on perceptions of nutrition and food in an outskirts town of Mumbai called Nallasopara. I am also working in the Khar area slum inside Mumbai. One! International is a Canadian NGO that has been in Mumbai for about 12 years. I am volunteering as a teacher at the two NGO schools in Khar and in Nallasopara teaching classes in English, Math, Exercise, and Health. I am also building relationships with the children and local families to conduct interviews and follow a small group of families in-depth during my three months in India. The dual roles seemed taxing when I first started, but I realized that I am researching twenty-four seven as I interact with the children, their parents, other volunteers, and NGO staff. Part of my project is to look at how perceptions of food and medicine, both traditional and what we call “Western” are changed by the presence of an international NGO.

One thing I have learned over the last month is that plans are made to be broken. The ethnography process is both challenging and low-maintenance in that it is observation: I’m not running an experiment in a scientific, methodological way with instructions. When dealing with people and participant observation, I have found they lead me to a goal or to a question through how they speak, how they behave, and what they tell me.

Many times I feel as if participant observation, especially in India, is a similar experience to being in a movie.I can just sit outside, overlooking a street, and hear a thousand different conversations in several different languages, see BMWs driving next to bicycles and smell both the fish market and Dominos from the same street. Ethnographic research is overwhelming at times because I want to capture what I hear, see, smell, touch—but I know that a picture, video, or even the most descriptive of words will never do justice to what it feels like walking through the inner mazes of some of the biggest slums in India. Field work is often frustrating for that reason and I find myself contacting my anthropology professor with questions and concerns on how and what and who I should be looking at, asking questions about—and his answer, although guiding, is always vague for which he just says is the nature of this work.

Fortunately, today we finally received good word about a student who had been in a kerosene fire accident about three weeks ago. One of the girls at the Khar school, Kolkila, had been cooking and something went wrong with the stove and she got burned. The flames engulfed her face and went all the way down to her waist. This incident occurred at 5 pm October 6— 35% of her body was burned. Her family immediately tried to get her to a hospital, but was turned down. They went to three different government hospitals, one being a hospital for prisoners and convicts. All of them refused to admit her. Her family immediately contacted One! Teachers, staff, and the director all banded together to see if they could drive her or get her into another hospital.

The wounds Kokila suffered continued to burn from 5 pm until midnight when one of the teachers made a phone call to his uncle. His uncle happens to be the MLA* of the district and because this uncle called the third hospital, Kokila was finally admitted–seven hours later. It took them another hour to take her into the ICU. By then, the percentage of her body burned had increased to 50%. Meanwhile, this girl was conscious and talking. When I heard that she had been waiting for seven hours, I almost hoped that she had lost consciousness so at least the pain would not be unbearable. At 1 am, Kokila was finally in the burn unit where an intern took care of six burn patients. There was no staff—no nurses, ward boys, or attending physicians. The intern had to change all of the dressings for each patient. Each dressing took two hours. He was working non-stop for 12 hours just to provide clean dressings, on top of all of his other responsibilities as a physician.

Walking into a government hospital can be compared to walking into a train station. The only difference is that the hospital has chairs. The school staff that was present when Kokila was admitted pushed her through the wards, transferred her onto the gurney, and wheeled her to her room. A burn patient is generally put into a sterile room, with little to no contact with others because of the risk of infection. Kokila had a possibility of sepsis, organ failure, and several internal infections. Her
entire family, the teachers, and friends were all allowed to walk in without
having to wash their hands or put on surgical clothes. On top of that, there was no air conditioning in her room. The place was unhygienic for a normal, healthy person, let alone a burn victim.

While all of this was going on, I couldn’t help but fixate on the fact that a
government hospital, whose purpose is to provide treatment and health-care for those that cannot afford it, turned away a 14 year old girl who has third degree burns. Although government hospitals are technically free, bribes are basically expected for admittance. Kokila, whose family lives in the slum, obviously does not have money for a hospital stay, let alone an additional bribe. Corruption is present everywhere in India: to refuse to admit a patient because they are too much of a liability is to say that the hospital doesn’t value human life. I know it’s a naive thought and I do not know what kind of pressures these doctors face, however, I just could not and still can not get over the fact that a doctor saw this little girl in excruciating pain, still burning, and refused to treat her. Money is always an issue, but there are also ethics that come along with being a medical professional. Kokila traveled to three different hospitals and if she had not been admitted when she was, she would have died that night.

Kokila fortunately received many donations from One! and this funding allowed for her to be moved to a private hospital, which is more like the hospitals people in the West are used to seeing. She has a full-time nurse, 2 doctors, and is doing well so far. For the last couple of weeks, the doctors continued to say that the next two weeks are crucial and she has a 50 percent chance of survival. Over the last couple of weeks, Kokila has received skin grafts from both of her legs. Now, she only needs a graft from the back of a leg transferred to her shoulders and back. The doctors say she no longer has any internal infections. With the success of this last surgery, she should be back home next week.

The kids at the school all made “Get Well Soon” cards even though they don’t know what that phrase means. They wrote messages that only children can write such as “Kokila, come back soon. I will never fight with you again over the red eraser” or “Kokila, I will share my lunch with you on Mondays.” The slum-area in Khar is a small community, so even the littlest children knew by word of mouth what had happened to Kokila. It really shook the school and getting updates is something that makes everyone feel that they still have contact with Kokila, especially since they have not been allowed to see her. Although we are all grateful Kokila is doing well, I still question how this situation was ethically handled by the healthcare system in India. In the next couple of weeks, the medical coordinator for One! and I will be touring area hospitals and hopefully that will help me better understand how government and private hospitals are structured and operated—shedding light on Kokila’s experiences.

*An MLA is a “Member of the Legislative Assembly.” He or she is elected by voters of a particular district to represent them in the state legislature.

“You need it to be hard, because otherwise you could get hurt while the men are pushing on you.”[1] These are the words of Agnes Munyiva, a 50-year-old woman in the Majengo slums of Nairobi, Kenya. She is describing the hard lumpy mattress in the small rented room she uses for work. On the other side of Majengo, she rents another room, slightly larger, where she lives with the three youngest of her five children.[2] Her children have never seen her other room. Though she never discusses her work with them, she is sure they know. Agnes Munyiva is one of Kenya’s numerous sex workers.

Her twelve-hour workday day begins at 6 a.m. everyday and ends before sunset. She begins with a wink and a sly smile, seated on a low three-legged stool in the alley outside her rented room. “Karibu,” she says, Kiswahili for “welcome.” If a potential customer stops, she invites him in to negotiate the prices; it is usually set between 50 and 100 shillings. The transaction is silent and swift; there are families in the neighboring rooms. When it is over and her client leaves, she cleans up with a cloth and a pitcher of water before returning to her stool. A dozen men later, she returns home with about 500 shillings (enough for food), and sets some aside for the children’s tuition and other expenses.[3]

Agnes recalls painful memories of losing her friends in the business to a strange disease she had once called “plastic,” named for the wrapping the city workers would cover the bodies with once the women had passed away. Beginning in the early 80s, some women began to grow thin and weak “with sharp coughs and white fur that coated their mouths and throats.”[4] At the time, most scientists were still unconvinced women were susceptible to HIV or that the virus could even be transmitted through heterosexual intercourse. Year after year, Agnes continues to test negative for HIV, though she has fallen ill to other (more common) venereal diseases. She is one of the five percent of women believed to have protection against the world’s deadliest virus.

About 30 years ago, Agnes and a group of 40 other Kenyan women unlocked a world of possibilities in the realm of research. These women were found to be “immune” to HIV. Despite consistent exposure to the virus due to their line of work, the women repeatedly tested negative for the virus.
Scientists believed these women had HIV-specific immune responses in their genital tract that could protect against HIV infection. It also appeared that their killer T-cells were more effective at identifying and eliminating the HIV virus as soon as it entered the system.

While a single exposure often does not constitute infection, scientists have ruled out all possibility of chance; many of these women have had “500-2000 sexual exposures to infected men when they weren’t using a condom.”[5]

Interestingly, researchers found that in instances when women took breaks from their work and later returned, they fell susceptible to the disease; continuous exposure was necessary to maintain immunity. Almost seventeen years later in 2009, scientists in Thailand developed and tested a vaccine based on research gathered from these immune Kenyan women. The vaccine displayed an impressive 30 percent reduced risk of HIV contraction. The vaccine was a combination of two earlier versions and was administered to 16,000 people, making it the largest trial for a vaccine of its kind. The participants were regularly tested for infection every six months for three years. Results showed the chances of contracting HIV were 31.2 percent less for those who had been given the vaccine. Seventy-four people who received the placebo became infected, while only fifty-one people who received the vaccine became infected.[6]

Thirty years after the study, Agnes is not much better off than when she first arrived in Nairobi. She is reimbursed with free health care for the occasional STD she contracts on the job and treatment for respiratory problems that result from air pollution in the slum. Other than that, her life is unchanged; she continues to turn about eight tricks a day so she can feed her family. Have researchers no obligation to better the lives of those they literally use?

The ethics of science today require that these women receive counseling and condoms: an education that tells them that what they are doing is dangerous and unhealthy. Yet rather than being helped to pursue higher levels of education or training in another trade, these women are merely given condoms to make their occupation “less detrimental.” As a result, these women continue to live lives of shame in a desperate attempt to provide for their children.[7]

Ninety percent of Kenya’s poorest prostitutes find themselves infected with HIV.[8] Simultaneously, 33 million people in the world suffer from HIV worldwide.[9] Researchers face one of the greatest ethical dilemmas of all time: sacrifice the lives and well-being of some in the hopes of a preventative vaccine, or even a cure, for countless others. Should we ignore the suffering allowed, and in some ways encouraged, by a research community that gives so little for the well-being of those studied? Is it permissible to employ human beings as lab rats for the overarching cause of a cure? Is it even that simple?

A cure or a vaccine would be a world-changing discovery that could save millions of lives. But even today when we find ourselves with an effective tuberculosis vaccine, the disease still plagues developing countries where the governments cannot afford the medical technology needed to control and eradicate the bacilli. As of 2007, 2 billion people—a third of the world’s population—were infected with tuberculosis. Since 1990, the number of TB infections has increased four-fold in countries that are heavily affected by HIV.[10] Ultimately, it is likely that a vaccine for HIV, once developed, would not be readily available to those in the poorer countries; the very people without which there would be no cure in the first place.

1. Nolan, Stephanie. “Staying Alive: The Women Who are Immune to AIDS.” The Observer: 27 May 2007. Guardian News and Media. 4 May 2010. <http://www.guardian.co.uk/world/2007/may/27/aids.features/print>
2. ibid. p 13.
3. ibid. p 3.
4. ibid. p 5.
5. ibid. p 8.
6. “HIV Vaccine ‘Reduces Infection.’” BBC News: 24 September 2009. <http://news.bbc.co.uk/2/hi/8272113.stm>
7. Nolan, Stephanie. “Staying Alive: The Women Who are Immune to AIDS.” The Observer: 27 May 2007. Guardian News and Media. 4 May 2010, page 5.//8. Purvis, Andrew. “Cursed Yet Blessed.” Time: 6 December 1993. Time Incorporated. 4 May 2010 <http://www.time.com/time/magazine/article/0,9171,979763,00.html>
9. As of 2007. CIA. “TB and HIV/AIDS| Factsheet.” Centers for Disease Control and Prevention. January 2008. < http://cdc.gov/hiv/resources/factsheets/hivtb.htm>.
10. CIA. “TB and HIV/AIDS| Factsheet.” Centers for Disease Control and Prevention. January 2008. <http://cdc.gov/hiv/resources/factsheets hivtb.htm>

Photo Credits: http://apimages.ap.org

South Africa was under apartheid less than 20 years ago.  While 20 years may seem like ancient history to Dartmouth students, it means almost every adult in the country has some memory of that era.  Considering the state of urban segregation in the USA almost 150 years after our Civil War, the implications of South Africa’s very recent political reforms are clear.  For a month last spring, I lived in the town of Plettenberg Bay on the Western Cape of South Africa.  If you never left the town center, Plettenberg Bay would appear similar to many other beautiful beach towns, equipped with fancy restaurants, surf shops, hotels, and million-dollar vacation homes.  But just a 5-minute jog from the city center, I reached thousands and thousands of hand built, wood and tin shacks with no running water.  These two communities inhabited different economic worlds, and they were almost entirely segregated by race as well; blacks and coloreds lived in the “townships,” while foreigners and white South Africans lived in the urban center and along the coast

Now consider HIV and AIDS.  In 2008, the World Health Organization estimated that between 15.4% and 20.9% of the population of South Africa had HIV.  Almost a fifth of the population had a disease with no cure and no vaccine, and the government only started national antiretroviral drug distribution six years ago.  Consequently, much of the population still does not get the treatment they need.

HIV/AIDS is an extremely socially situated disease; stigma, misunderstanding, poverty, and other diseases exacerbate it. I worked for a month with an organization called Plett Aid, which provides home-based care to the townships in the region and helps coordinate the government’s HIV/AIDS response.  I would go out in the mornings with one of the home-based care workers, Margaret, and visit patients around the community.  One of the most powerful aspects of home-based care is that it trains people to care for other people. Margaret was an effective caregiver in Kwanokuthula, the township she lived in, because she spoke the languages necessary (English, Xhosa, and Afrikaans) and cared deeply about her community. We would make sure patients were taking their antiretroviral drugs, check blood pressure, check glucose levels, change bandages, and make sure everyone knew how to take his or her medications. Margaret also was a friend to many of her patients.  Before Margaret measured blood and glucose levels, patients usually invited her in, offered her a drink, and chatted with her.  While HIV/AIDS was a focus, caretakers were responsible for taking care of any other mental or physical problems the patient was experiencing.

The stigma surrounding HIV is enormous. Many patients never tell their families or friends, so their care worker may be the only person who knows their “positive” status.  Since Plett Aid provides chronic healthcare to everyone (even old ladies who get bitten by dogs), neighbors who see care workers walking into a home don’t necessarily think, “he or she must have AIDS.”   These patients were not easy to classify due to a lot of overlap among different conditions. One woman we visited was getting treatment for tuberculosis, and as we were leaving, Margaret told me she probably was suffering from AIDS as well, but had not been tested.

For a moment, it is worth considering what care looks like in the region around Plettenberg Bay without home-based care.  There is a clinic in each of the townships, each of which is generally open to everyone, but all of which are crowded.  More importantly though, the clinic in a township like Kwanokuthula may be up to a mile away from patients toward the edges of town.  The people who need to walk that mile are the sick or the hurt ones: patients with AIDS, TB, or who are severely injured.  I saw very few cars parked outside houses, and the ambulance (which you have to pay for) will take you only to the nearest hospital about 30 minutes away.  All of these factors add up and create a serious barrier to care for a large portion of the population, whether in terms of cost, distance, or time.  By comparison, home-based care is a service that bridges these barriers.  A 2009 study in Uganda compared clinic-based care with home-based care.  It found that home-based care significantly lowered the access cost for users and slightly reduced operating costs.  Operating costs are relatively unaffected because the cost of drugs stays large and stays the same between the two delivery systems.  So on an economic level, as well as a personal level, home-based care is a powerful healthcare delivery system.

However, home-based care service was not the standard health care system in Plettenberg Bay.  Plettenberg Bay is located in Western Cape province, one of the first and best provinces for antiretroviral treatment. Yet even within the Western Cape province, the poorer communities (such as the townships surrounding Plettenberg Bay), still depend on state-funded public health solutions like clinics and home-based care. The provincial or national government funds much of the home-based care, although Plett Aid supplements that funding with grants and fundraising efforts.  In contrast, the residents of wealthier communities stick with private medical care and are less affected by changes in public health care.  Overall, I found home-based care to be a compassionate and effective way to provide quality public health care in resource-limited settings, especially to patients infected with HIV or suffering from AIDS.

In the mountains of Costa Rica, the people in the rural village of Chinampas live in dire conditions unimaginable to the majority of students at Dartmouth.  The locals live in a spread-out community along the side of a mountain.  Until 2006, they lived without running water or electricity. Children walk in the fields and on the dirt roads with no shoes to protect their feet from tarantulas and scorpions.  The closest healthcare facility is miles away, making immediate aid virtually impossible.  Yet despite the absence of life’s basic amenities, the people of Chinampas do not struggle to find happiness.

In the summer of 2006, I joined a team of 15 students and traveled to Chinampas with the hope of constructing a water system for the village. Previously, children walked over three miles up the mountain in order to collect fresh water in old soda bottles.  However, they could never gather much water in just one trip.  They had no other choice but to make the trip up the mountain several times a day to provide water for their families.  I needed to make this trip twice each day, once in the morning and again in the afternoon.  Each time, my team and I struggled to climb and carry our tools to reach our work site.  It was unbelievable that children half my age had to make this trip multiple times a day.  In addition, making multiple trips kept these children from being able to attend school.  As a result, many families opted for an alternative; instead of gathering clean water, children gathered water from the closest water source, a source contaminated with animal feces and bacteria.  They were forced to choose between their health and their education, a decision no human should ever have to make.

My team and I worked for three weeks, digging trenches and laying pipes in order to connect the fresh water source to a cistern in the center of the village.  The task was difficult due to the daily downpours characteristic of the rainforest.  Most days, we had to wait hours before we could resume our work, only to find that much of our progress had been destroyed as a result of shifts in the mud which caused the trenches we had already dug to fill up with clay.  Various other factors inhibited our progress.  The three-mile hike up the mountain that we completed twice a day had a physical toll on our bodies and took away valuable time that we could have spent working.  Additionally, the lack of decent food and cold water (we had to boil all of our drinking water) combined with the inability to access showers made our task even more difficult.

We worked side by side with many of the locals, many of whom gladly spent their free time joining the effort to obtain a healthier, more accessible water source.  One day while we were working in the forest, a man accidentally sliced his head open with a machete while clearing tree branches from our path.  The cut was deep and bled profusely.  Yet, medical care was miles away and there was no form of convenient transportation.  The man had no choice but to walk over ten miles to reach the closest clinic in order to receive sutures.  Surprisingly, he was working alongside us the next day, unable to spend time resting because he was determined to provide for his family and community.

Despite all of these hardships, however, it was rare to find someone with a frown on their face.  The children appreciated what little they had, spending their free time playing on a dirt soccer field after school.  Even though there was only one poorly constructed goal post on the field, the kids still enjoyed playing.  Families spent a lot of time together, and most attended church 2-3 times a week.  They rejoiced and thanked God for what they had, rather than dwelling on what they lacked.  Their joy is so contagious that my team, struggling to adjust to an unknown lifestyle and culture, was able to smile even during the toughest of times.

The living conditions in Chinampas are extremely modest.  Basic provisions that we take for granted on a daily basis are sparse.  Yet the people still manage to find joy in their lives.  They have a surprising appreciation for one another and the little that they do have.  Their outlook on life is vastly different from ours.  After spending just three weeks in their village, I had a greater appreciation for the simple things of life we often take for granted.  Every time I take a sip of water, flip a light switch, take a shower and tie my shoes, it is hard to forget just how fortunate I am.  I will never forget the people of Chinampas.

By Michelle Lee

Orphans walking to school

Shahana, a young girl from Bangladesh, used cloth rags during her menstrual cycle.  One day, she washed the rag and dried it outside to prepare it for reuse. Without her knowledge, a parasite slipped into the rag.  When she used the rag the next day, the insect entered her vagina and infected her body.  After a week’s worth of stomach pains, she died.
While Shahana’s situation is an extreme case and menstrual-health-related deaths are not ubiquitous, unsanitary methods do result in various urinary and vaginal infections.1   Complications regarding female menstrual health have long remained problematic and unaddressed by both governments and non-governmental organizations.  These serious health effects impede girls’ access to a valuable education and limit female potential to contribute fully to their communities.
Kenyan Naisiae Tobiko is a first-hand witness to this unjust situation.  While she attended school, she noticed the consistent absences of girls from poorer families every month.  She learned that the girls could not attend school a few days each month because their families could not afford sanitary napkins.2  Expensive international brands of pads and tampons comprise an inaccessible market of sanitary products the average person cannot afford.  Females who cannot afford these products are forced to resort to subpar, unsanitary methods instead, such as using dirty rags or bark.3

Cases like the story of Shahana persist because local communities are reluctant to address issues regarding menstrual health.  Monthly menstrual cycles are stigmatized in many communities worldwide, oftentimes associated with cultural and religious taboos concerning blood.  In parts of central Uganda, some people consider menstruation a taboo topic and rarely discuss ways to improve hygienic practices.  In Bangladesh, there is a belief that menstrual blood is “the greatest of all pollution.”  Another cultural taboo exists in Sierra Leone, where some believe that using sanitary napkins may cause infertility.4

Discussion of menstruation-related issues at the local level is minimal, and communities are able to avoid initiating efforts towards addressing this consistently overlooked aspect of women’s health.  This issue also remains unaddressed at the global level as well; governments and non-governmental organizations alike have dedicated minimal time and effort to making sanitation products affordable and sustainable.4   This ill-fated deficit of education regarding hygienic menstrual practices, as well as the lack of funding toward constructing hygienic facilities, has far-reaching, detrimental impacts.

Not only has this unfortunate situation resulted in harmful health effects for females, but it has also spurred negative socioeconomic effects in local communities. Women must manage 3,000 days of menstruation in their lifetime, and 450 of those days coincide with the years of basic schooling.1  Each year, millions of girls and women do not attend fifty days of school or work because of their periods; many of them drop out of school or the workforce entirely.3   Education is key to solving many global issues such as gender-related injustices and economic inequalities.  A report released by Goldman Sachs Economic Research states, “There may be no better investment for the health and development of poor countries around the world than investments to educate girls.”5   Educated women are more likely to participate in the workforce, and there is a link between high education levels and low fertility rates. Statistics prove that female education correlates with higher national economic productivity and higher returns to investment.5

Fortunately, some people have recognized the importance of keeping girls and women healthy and in school.  Social entrepreneurs are using their compassion, innovation, and resolve to pioneer solutions to menstrual health issues, creating organizations such as Forum of African Women Educationalists (FAWE), Bangladesh Rural Advancement Committee (BRAC), and Sustainable Health Enterprises (SHE).  FAWE in Uganda encourages open dialogue about menstruation and related hygiene via locally run discussion workshops, which has led to an increased distribution of sanitary napkins.  FAWE is currently fighting for legislation in Uganda to supply sanitary napkins to female students without charge.  BRAC is working on a project to produce sanitary napkins locally, which keeps the products accessible and affordable.5   SHE’s market-based approach strives for sustainability, because as their website states, “Donations don’t work long-term.”  SHE’s mission is to empower women to be vehicles of social change in their own communities.  SHE provides education, training, and resources to women in developing countries to support entrepreneurship in producing and distributing affordable, eco-friendly, locally-produced sanitary pads.3

These initiatives, among others, provide hope that new and continuing efforts will address menstruation-related hygiene and health.  Permitting women to suffer preventable burdens of their menstrual periods is unjust and has far-reaching implications socially and economically.  The success of organizations such as FAWE, BRAC, and SHE are keeping girls in school, allowing them access to education and future opportunities.  Education is a crucial vehicle to harness the untapped potential in girls and women worldwide so they can contribute socially and economically to their local communities.  Women’s health, specifically menstrual health, is something that should no longer be overlooked.  Period.

SOURCES:
1Ahmed, Rokeya and Nahar, Qumrun. “Addressing special needs of girls challenges in school.” September 2006. South Asian Conference on Sanitation. 28 Apr. 2010 <http://www.wateraid.org/documents/plugin_documents/addressing_the_special_needs_of_girls.pdf>//2Friedman, Thomas. “Cellphones, Maxi-Pads and Other Life-Changing Tools.” 6 Apr. 2007. The New York Times. 28 Apr 2010. <http://select.nytimes.com/2007/04/06/opinion/06friedman.html?_r=3>//3“Sustainable Health Enterprises”. April 28, 2010 <http://www.sheinnovates.com/>.//4Ten, Dr. Varina Tjon A. “Menstrual Hygiene: A Neglected Condition for the Achievement of Several Millennium Development Goal.” 10 Oct. 2007. Europe External Policy Advisors. 28 Apr. 2010 <http://www.eepa.be/wcm/component/option,com_remository/func,fileinfo/id,26/>//5Lawson, Sandra. “Women Hold Up Half the Sky.” 4 Mar. 2010. Goldman Sachs Economic Research. 28 Apr. 2010. <http://www2.goldmansachs.com/ideas/demographic-change/women-hold-up-half-of-the-sky.pdf>

PICTURE CREDITS:

http://www.orphanages.ws/images/GIDCCO/orphans%20walking%20to%20school.jpg//http://www.newstimes.com/mediaManager/?controllerName=image&action=get&id=93698&width=628&height=471//http://www.sishope.com/storage/inequalityphoto.png?__SQUARESPACE_CACHEVERSION=1269718128569//http://blogs.nationalgeographic.com/blogs/intelligenttravel/475-trip-lit-0912-school-girls-thumb-500×368.jpg

Gold mining in the Congo

The destructive extraction of gold is a major source of public health risk worldwide and has caused a high degree of environmental complications as well as societal problems. The negative impact of the “global gold rush” on humanity is particularly witnessed in developing countries that are heavily overwhelmed by poverty and weak economies. Destructive extraction of gold is particularly prevalent in African countries such as Tanzania, where extraction is not only a hazard in mining areas, but also contributes to downstream problems and negatively impacts the ability of communities to earn income.

The amalgamation of gold is a simple extraction process that entails the separation of gold from the gold-mercury amalgam by burning. It produces a vaporized form of mercury that people are exposed to via inhalation.1 This mercury accumulates in the food chain and becomes even more toxic when it transforms into methyl mercury. Methyl mercury pollutes soils, sediments, and lakes, which consequently contaminate fish and other food sources. Fish are a staple food for many developing countries. Over time, mercury becomes absorbed and heavily concentrated within protein-enriched meals and ascends the marine food chain. Community residents consume the fish, resulting in high toxic exposure to mercury. It is estimated that more than 100 million people around the world are exposed to mercury from small-scale mining.2

Gold mining in Burkina Faso

With the current gold mining process, methyl mercury in the food chain is becoming an invisible epidemic. The deleterious effects of mercury on the human body are well documented and have grabbed the attention of concerned humanitarians worldwide. Exposure to mercury as an adult can cause damage to localized areas of the brain, causing paresthesia (an abnormal tingling sensation), ataxia (a loss of full control of bodily movements), and other sensory abnormalities.4 Mercury poisoning has an even greater detrimental effect on pregnant women. Prenatal exposure to methyl mercury has adverse effects on a child’s cognitive and neuromuscular development.4 Effects are even seen in children breast-fed by mercury-contaminated mothers.

Due to the unstable Tanzanian economy, large mining companies own more than 90% of the mineral-rich land in the Geita region.2 Difficulty in attaining micro credit and money forces poor citizen groups to partake in hazardous and illegal gold mining. In 2007 and 2008, the President of Tanzania urged large mining companies to work in cooperation with the indigenous people. Cooperation would encourage improvement of technology and development of safety protocols that would diminish the hardships being inflicted upon poor small-scale miners. The ultimate goal would have been to combat both the economic shortcomings of his people and reduce health hazards for everyone.3 However, no action has been taken as of yet.

Ironically, some mining companies have switched from using mercury to cyanide.3 Unlike mercury, cyanide does not bioaccumulate. However, it is an extremely dangerous toxin, and it may pose an even greater health risk than mercury. Is this really the best solution? Are these mining industries really concerned about the people of Tanzania?

It is imperative that the public becomes more aware of the implications of small-scale mining in developing countries. Without increasing awareness, the enactment of laws and legislation is unlikely. Mercury contamination due to gold mining not only affects Tanzania, but also affects many other mineral-rich developing countries impeded by industrial exploitation. The onus is not only on industries to change gold amalgamation processes, but also on developing countries to protect the health of current and future generations.

Picture credits: http://blogs.reuters.com/mark-jones/2009/07/02/finbarr-wins-best-photo-in-diageo-awards/;http://blogs.reuters.com/africanews/2009/09/28/can-gold-save-burkina-faso/

1) Onyemaechi et al. “Modern Environmental Health Hazards: A Public Health Issue of Increasing Significance in Africa.” United States 2008.

2) Veiga et al., 2005 “Reducing mercury and responding to the global gold rush.” 2005, pp. 2070–2072.

3) Spiegel, Samuel J. “Occupational health, mercury exposure, and environmental justice: learning from experiences in Tanzania.” American Journal of Public Health, 2009 Nov.

4) Mozaffarian et al. “Fish Intake, Contaminants, and Human Health-Evaluating the Risks and the Benefits.” American Medical Association, 2006 Oct.

By Taylor Sipple

Despite the recent passage of President Obama’s landmark Health Care and Education Reconciliation Act of 2010, America is far from its goal of health equality. One striking indicator of this disparity is the difference in life expectancies between socioeconomic groups, which has grown from 2.8 years in the early 1900s to 4.5 years by the turn of the century.[1] Parts of the United States have health conditions worse than the developing world.  From the prevalence of unhealthy food to the distressing conditions in America’s urban populations, health inequality goes far beyond access to care.  To approach health equality, these factors must be addressed alongside a strong emphasis on preventative care; we should make health a lifelong and continuous process rather than a series of disjointed applications.

Concerning nutrition, America faces a striking paradox unlike anywhere else.  Globally, poverty is commonly associated with being underweight; but American children in low-income families are at a higher risk of obesity than children of a similar age in middle to high-income families.  Adult men and women of lower socioeconomic status are 50% more likely to be obese than their better-off counterparts.[2] One reason obesity is especially prevalent in the United States is due to the availability of unhealthy food through food stamps and subsidies.  These food prices are often kept down by the use of highly subsidized corn syrup, which is used as a substitute in many food products.  Moreover, an unsteady food supply can also lead to obesity through binge eating at the availability of food, which causes large weight gain. [3] In particular, childhood obesity is a problem that has far-reaching consequences for an individual’s entire life.  These consequences include: diabetes, hypertension, sleep apnea, fatty liver disease, and life-long damage to the cardiovascular system that can result in premature cardiovascular disease.[4] In adults, the most costly effects of obesity are high rates of cardiovascular disease and diabetes.  With 30% of American adults obese and 34% more overweight, America needs to take another look at its approach to nutrition.

Another tragic component of health inequity is the disproportionate contraction of HIV/AIDS.  According to Newsweek, HIV rates are higher in some parts of the United States than in parts of Africa.[5] In Washington, D.C., 1 in 30 adults are infected.  This exposure occurs mainly among impoverished communities; unprotected sex and drug-usage have taken the disease to a seemingly inescapable place in urban society.  In addition to increased HIV/AIDS prevalence, poverty and unemployment are also associated with higher rates of unintentional injury, infectious disease, suicide, and general mortality in both men and women.[6]

The solution to these problems begins with addressing the need for rigorous preventative care, an issue the health care bill will hopefully start to address.  By giving Americans access to yearly check-ups, people will begin to have conversations with their doctors and change their approach to personal health.  Americans will begin to learn of disease before it nearly kills them, and they will have access to knowledge about nutrition that will help stave off obesity.  Preventative care is the first step in diagnosing American health inequality.  With rigorous commitment, America has an opportunity to reverse its growing disparity in life expectancy and increase its overall health.  As it stands, America needs to take a hard look at itself; at a time when more and more Americans are focused on issues of global health abroad, we must not forget that America itself is a part of the global community.  When looking in the distance, we must remember never to forget what is right in front of us.

Morrill, Allison, and Christopher Chinn. “The Obesity Epidemic in the United States.” Journal of Public Health Policy 25.3/4 (2004): 353-366. Web. 30 April 2010. <http://www.jstor.org/stable/3343494>.

Hofferth, Sandra, and Sally Curtin. “Poverty, Food Programs, and Childhood Obesity.” Journal of Policy Analysis and Management 24.4 (2005): 703-726. Web. 30 April 2010.

Daniels, Stephen. “The Consequences of Childhood Overweight and Obesity.” Future of Children 16.1 (2006): 47-67. Web. 30 April 2010. <http://www.jstor.org/stable/3556550>.

Cunningham, Jaime. “HIV Still Plagues the U.S.: Some Areas Have Higher Rates Than Africa.” Newsweek 26 Feb 2010: n. pag. Web. 30 April 2010. <http://blog.newsweek.com/blogs/thehumancondition/archive/2010/02/26/hiv-still-plagues-the-usa-some-areas-have-higher-rates-than-africa.aspx>.

Muntaner, Carles, John Lynch, Marianne Hillemeier, Ju Hee Lee, and Richard David. “Economic Inequality, Working-Class Power, Social Capital, and Cause-Specific Mortality in Wealth Countries.” Political and Economic Determinants of Population Health and Well-Being: Controversies and Developments. 1st ed. 1. Amityville, NY: Baywood Publishing Company, Inc., 2004. Print.

If four years ago somebody told me that by the spring of 2010 I would be a trained First Aid provider able to take care of injuries all across Europe, I would look at him or her with disbelief.  Prior to enrolling at the Red Cross Nordic United World College (RCNUWC) in Norway, I was never involved with rescue teams, mainly because the Czech town I come from is actually quite small and does not provide many opportunities to get involved in free time activities. But during my two years at the international boarding school in Norway, I got the chance to explore the field of emergency medical help, and it was love at the first sight.

The RCNUWC was founded in 1995 as one of the schools of the United World Colleges (UWC) movement. The dream of Nordic college was made possible because of efforts of the UWC movement, Nordic countries (Norway, Sweden, Denmark, Finland and Iceland all contribute to the budget of the college), and the Norwegian Red Cross. The cooperation between the Red Cross and the RCNUWC staff and students is represented through extracurricular activities, and the recent (2009) establishment of the Red Cross Certificate for students who get especially involved in the Red Cross-related events serves as a shining example of the healthy partnership.

Of all activities, the First Aid Team is most probably the most popular among the students. Many students come to the College with the intention of becoming the member of the Team, and even more become interested after they learn about the Team’s existence and activities (this was my case).  However, becoming a member is not easy and requires a lot of dedication and time commitment. First of all, all first year (juniors of high school by the USA standards) students have to complete the compulsory 12-hour training program provided by the second year members of the First Aid Team.  During the course, the students have to prove both their passion and dedication for first aid, and demonstrate that they are able to master the life-saving skills and teamwork. Usually about 75% of the hundred first-year students apply to join the team, but usually only 30 to 35 spots are open. Needless to say, the competition is tough, but always friendly.

For those accepted, the true training begins. The members of the First Aid Team meet at least twice a week: for an afternoon training and scenario session (which from my experience usually takes the entire 2.5 hours allocated to it), and shorter squad meetings during which the squads plan scenarios and practice the first aid skills. The other obligations of the teams are 1) to provide around-the-clock first aid coverage for the campus of the RCNUWC, 2) to provide first aid coverage to the RCNUWC and local events such as marathons, 3) to provide the basic First Aid training for the students of the RCNUWC, as well as for the local Norwegian elementary and high school students. On top of that, thanks to the involvement of the RCNUWC First Aid coordinator David Robertson, the members of the RCNUWC First Aid team help with training of Serbian National First Aid Team for the annual European First Aid Championship (FACE).  To exemplify the quality of the training: since the Serbian team has started training at the RCNUWC five years ago, they have won FACE every year, becoming the first ever First Aid team that has won the competition four times in a row.  Sadly, Serbians will not extend their streak since this year, since FACE is set to take place in Serbia this year and the hosting country cannot send a team to compete.

My experience in the First Aid Team of the RCNUWC was invaluable.  As I already alluded to, I never got the chance to be involved in the emergency medicine before RCNUWC.  Through my 1.5 years on the team, I learned a lot about this field.  I have also improved my group-work, planning, coaching and lecturing skills. But most importantly, I got the chance to interact with injured people and help them in securing their speedy recovery.  During my tenure on the team, while having several emergency situations, we never had to deal with anything severe.  But even through the limited amount of encounters, I have learned how crucial is a skilled, calm and reassuring first aid provider for the well-being casualty.

While I was not able to get involved in the EMT here on Dartmouth due to time constraints, I still keep up with the Team in Norway.  If everything goes as planned, I will be able to meet some of my friends from the team this summer in Beograd, Serbia, at the FACE 2010.

The incredible success of Nicholas Kristof and Sheryl WuDunn’s Pulitzer Prize winner (and best-seller) Half the Sky helped focus American attention on the worldwide problem of obstetrical fistulas. Largely eradicated from Europe and North America with the advent of increased bridal age, delayed child-bearing age, and improved prenatal and delivery care, obstetrical fistulas—essentially tears near the vagina generally sustained in childbirth–continue to afflict at least two million women globally, according to the World Health Organization. WHO estimates a minimum of 100,000 new cases annually, nearly all in the developing regions of Africa and Asia. However, women’s advocacy groups point out that the WHO data are from 1989 and probably represent significant under-reporting of the true extent of the problem, due to poor record-keeping and to the shame attendant upon the condition.

Many factors contribute to the development of obstetrical fistulas. Kristof and WuDunn, like many of the international organizations working to prevent and treat the condition, trace fistula development back to the poverty and low status of women. Because girls in some traditional societies are not valued highly, they receive less nurturance and less actual nourishment than their brothers do. Malnourished, they are married early in puberty, their skeletal structure having had neither the time nor the nutrition needed to mature fully. As a result, the pelvis is often stunted, dramatically raising the risk of obstructed labor when a child is born.

Obstructed labor is frequently also prolonged labor. Contractions continue, but the narrowness or malformation in the pelvis does not permit the baby to pass through the birth canal. Instead, its head presses on the pelvis, sometimes for many days. The pressure cuts off the blood supply to delicate tissues. It is not uncommon, in such cases, for both the mother and infant to die if an emergency Caesarean section is not undertaken. Even if the mother is ultimately able to deliver successfully, in 90% of cases the infant will not survive. For the mother, the extended period of tissue “blood starvation” means the vaginal tissues will subsequently die and fall away. The woman is left with a hole between her vagina and her bladder or between her vagina and her anus. Urine and feces commonly drip from this hole. Ulcerations result. Infections have easy access to the internal organs. The kidneys are often affected, particularly since women desperate to limit the leakage may drink very little and consequently become seriously dehydrated. It is also very common for the duration of pressure during delivery to damage nerves in the legs and lower back, sometimes leaving women unable to walk. Nearly always, women who suffer long-standing, un-repaired obstetrical fistulas are unable to become pregnant.

Their infertility is one reason the victims of this preventable trauma are “social lepers” discarded by their families. Other reasons, however, also contribute to their isolation. The urinary and fecal incontinence is not only embarrassing and debilitating to the women themselves, but also causes them to exude a foul odor that leads to shunning by others. Half the Sky recounts histories of women cast out of their homes, lying in their own filth, unable to fend for themselves, and lacking the knowledge of the availability of medical treatment and the means with which to seek it.

For such women, the medical sequelae of obstetrical fistula are only part of the problem. The humiliation and social exclusion from family and community are just as devastating. Generally, victims are not allowed to prepare food and may be forbidden to participate in prayers or other religious activities. Furthermore, most are grieving mothers who have lost a newborn and know they will never be able to give birth again. All of these circumstances exacerbate the physical torment of the condition itself.

Organizations such as Campaign to End Fistula emphasize that obstetrical fistulas are treatable, generally for as little as the equivalent of $300 USD. Plastic surgery is effective, yet beyond the means of most women suffering from the condition. Not surprisingly, those working to raise awareness of obstetrical fistulas seek donations from wealthier nations, but they also stress the fact that treatment is not the ultimate goal. Prevention– through education, through empowerment of women, through improved access to medical care, and perhaps most importantly, through addressing the underlying poverty and oppression of women– is considered essential. Only 58% of women in developing countries give birth with the assistance of a physician or a professional midwife. Since an average of 15% of all births (including those in which pelvic stunting and other poverty-related conditions are not a factor) require emergency medical intervention, the risk for obstetrical fistula is clear and frightening. Entirely preventable, this affliction has been too long ignored.