Monday, June 2, 2014

The Norovirus Hits Boston - Guest blogger: Cristina Pérez Rubio

Guest blogger Cristina Pérez Rubio is a 2014 graduate of James Madison University. In her own words, she is "A future nurse trying to find my purpose and way. The world gives us so many reasons to hate it, despise it, and give up on it. I don't know why, but I am still on a quest to find the good. I can't be alone in this. I love my dog, art, music, kids and babies, nursing, and anything inspiring."
While most people went to the beach or on a cruise to party hardy, I decided to spend my spring break doing volunteer work in Boston, MA.  I signed up for the week-long trip through James Madison University's alternative spring break program and was thrilled to spend time at a homeless shelter making a difference.  I, along with 8 other JMU students and 1 faculty member, embarked on the 9 hour drive to Boston early Saturday morning (March 8).  You can imagine how uncomfortable the journey was since the 10 of us were packed into a JMU service vehicle, you know, one of those big white vans with four rows of seats.  The drive up was fun, though, because we started to bond and get to know each other.

We stayed in Cambridge at a church right off of Harvard's campus.  Within this church there was a nursery/day care, located on the third floor of the building, and a homeless shelter in the basement.  The homeless shelter was operated by Harvard students who would volunteer  to spend an entire night, every night, cooking meals and offering the available bunks to the homeless in the area.  We slept in sleeping bags on the floor of the nursery/day care classrooms on the third floor.  When it came to meals,  we shared the kitchen with the Harvard kids in order to prepare our "asb family dinners".

Our mission on this trip was to volunteer at a homeless shelter in Boston, which was just a T (metro) ride away from our home away from home in Cambridge.  The New England Center for Homeless Veterans (NECHV for short) is a shelter that specializes in offering men and women from the armed forces a place to stay and rebuild their lives.  The majority of the veterans at NECHV suffer from some type mental illness, most commonly PTSD.  While each veteran's story is different, the majority of them  turned to alcohol or drugs to deal with the undiagnosed mental illnesses.  One way or another, these individuals found themselves homeless and suffering.

NECHV is a unique combination of a homeless shelter and a detox program.  It does not just offer a roof over their heads, it helps give the veterans the tools to go back into society as working "normal" individuals. While veterans do not have to comply with the rules, the shelter demands full sobriety of its residents as well as constant meetings with housing counselors who help them search for housing.  The shelter also offers classes for the vets to take to get certified as bus drivers, security officers, mechanics, etc.  NECHV uses a multifaceted approach to helping the vets better their lives.

So where did we JMU dukes come in?...

Sun 3/9 9AM
We showed up at the shelter early Sunday morning ready for orientation at the center.  We were told that we would be assigned to go through the storage rooms in the shelter's basement.  Here, they stored all sorts of things that they would sell at the shelter's store.  This "store" was for the veterans to pick up anything they needed from toiletries to new interview-appropriate clothes, jackets, underwear, etc.  We would have the chance to sit and talk with the vets at lunch, because the shelter was offering us free daily lunches.  I, personally, was offered the opportunity to volunteer upstairs alongside the nurse, instead of downstairs in the storage rooms.  Since I want to be a nurse, this was a unique opportunity for me to interact with a current nurse, as well as the vets, and to see how things were run at the shelter from a medical point of view.

Mon 3/10 8AM
Monday morning we commuted into Boston via the T and began to work.  While my fellow asb-ers went downstairs to organize things, I sat outside Irene the nurse's office, excitedly waiting to meet her.  20 minutes passed and she finally showed up visibly out of breath and in a hurry.  "Sorry I'm late! I had to run up and see some sick vets.  I think the norovirus is going around.  I had 7 confirmed cases today."
...........um WHAT?! Don't get me wrong, I didn't show any visible signs of distress, but holy shit was I freaking out internally when she said that.  I had flashbacks to the entry I made for this very blog about the cruise ships and the norovirus outbreaks.  *gulp*  I swallowed hard, reached for her desk-size hand sanitizer, smiled, and asked her what we had planned for the day.
The day went on, I was learning so much and having fun.  I reconnected with the other volunteers at lunch when we all buddied up to sit with the vets.  I met two ex army medics who told me stories of combat and ER shifts.  The first day at NECHV was going pretty well!

Mon 3/10 2:30PM
At the end of the day, all 10 of us to the T back to Cambridge while discussing that night's plan for dinner.  While on the T, Carter, a junior poli sci major, suddenly gripped her stomach and confessed she felt nauseous.  "DEAR GOD IT'S HAPPENING" was my instant thought.  Of course, I didn't say that.  "Carter you might have the norovirus," I said calmly as I noted her ashen sweaty face.  "The what-?!" everyone asked.  I, along with another future nursing student, described the symptoms to everyone and I explained how Irene had mentioned to me that there were confirmed cases at the center.  "Oh there's no way! Shut up, stop trying to freak us out, Cristina!" ...no one believed me and I secretly hoped I was wrong in my suspicion...

Mon 3/10 6:00PM
There I was, with a bucket of clorox bleach and yellow gloves up to my elbows, cleaning up the chunks of Carter's vomit in the sink.  She didn't make it in time to the bathroom and no one else on the trip wanted to clean it except for me and Alexis (the senior future nursing student I mentioned earlier).  Carter was en route to the emergency room because she was blacking out from dehydration.  We had already stopped by a local CVS and bought her some Pepto, Gatorade, and saltine crackers, but she couldn't keep any of it down.  She needed to get IV fluids stat.  You better believe everyone's hands were raw from scrubbing them after having witness Carter's misfortune.  Before she left, I slipped into the bathroom to see how she was doing.  The poor thing was on the toilet, diarrhea and all, with her head in the trashcan, vomiting.

Other volunteers were still going through the "what ifs" of the situation and how the ER doctors would "surely diagnose it as food poisoning.  There was no way it could've been the norovirus."  After 7 hours in the ER, Carter came back with the diagnosis... norovirus.  There I was panicking yet throwing a party in my mind.  My suspicion was right.  I used my health education and common sense to prematurely diagnose her and I was validated by the ER team.  On the other hand, if anyone was exposed to the super bug it was me and my fellow volunteers.  Still, I held on to a naive sense of "it won't happen to me"  I'm the nurse in this situation.  Alexis and I were the ones calming everyone down.  We couldn't get sick... there was no way.

Tues 3/11 8:00 AM
7 of the 10 of us showed up to the shelter Tuesday morning.  Carter was quarantined into her own bedroom (aka a separate classroom within the nursery), and the other two volunteers who accompanied her to the ER were asleep.  It had been a very long night.  I met with Irene as scheduled and she explained how she had to email the Massachusetts Department of Health because they had a full-blown outbreak of the norovirus.  "Funny story.." I told her about Carter and how she got sick.  Irene had me help her make flyers for the veterans about the norovirus and how hygiene was a huge preventative and protective factor.  The day went on as planned, including a couple hundred trips to the bathroom to wash my hands.

Tues 3/11 6:00 PM
I was getting used to the routine we had going and found that I enjoyed sharing the kitchen with the Harvard kids to make dinner for our group. That night we decided on having a group "brinner"... breakfast for dinner.  I made everyone pancakes while other people made omelets and bacon.  I even made Carter her chicken broth and bonded with some Harvard students who were nonchalantly describing how they were going to med school next year (cue the eye roll).  The dinner was delicious and I enjoyed three of the hearty pancakes I had worked so hard on.  I remember thinking I had overeaten and that I was suffering from a major case of food baby.  I also had a terrible headache for which I had to take four 200mg ibuprofens.  I also ended up chugging almost 1 liter of water because I thought the headache may have been a result of dehydration.  The headache went away, but I still felt uncomfortably full and bloated.

Wed 3/12 2:30 AM
We went to bed late Tuesday night because we had spent so much time talking about our day's events.  We were excited Carter was feeling better and she was telling us all about what she had gone through.  I usually sleep through the night and only wake up to pee (since my bladder is the size of an acorn), so I was surprised to wake up at 2:30 feeling burpy and a sense of gurgling in my gut.  This is way too much information, but the only reason I woke up was because I had to fart, and for some reason I had the feeling that this was one of those farts you just know you shouldn't trust.  So off to the bathroom I went hoping and praying that my worst fears were not about to come true....

Wed 3/12 4:00 AM
There I was on the floor of the bathroom, convinced I was dying a slow death.  I had the norovirus.  How was I so sure?  Somewhere between violently and projectile vomiting and diarrhea-ing at the exact same time I knew.  Let me just make this clear... anyone who dares say they have the norobug but are able to get up, vomit, and later, have a bowel movement, is WRONG.  The norovirus makes you expel copious amounts of liquid from both ends at the same time.  I was literally shitting my insides out, legs shaking and dangling because I was too short to touch the floor and the toilet was high off of the ground, while throwing up pure bile and probably the lining of my intestines.  In between dry-heaving and flushing the toilet I found myself so desperate for help and relief, that I was praying to any deity out there willing to listen.  I was weak and out of it.

I cleaned off all of the surfaces, washed my hands profusely and left the bathroom.  I found myself in the hallway with Steven, the JMU employee and our chaperone on the trip.  Listen, I know I was not looking gorgeous at that moment, but boy did he look like crap.  "Are you...?" "YES" I cut him off. "Me too." He said.  Another volunteer had woken up and realized what was happening and grabbed our stuff.  Carter was up as well.  Steven and I were now excommunicated from the group and put into our own quarantined room. In less than 36 hours, our group went from 1 sick person to 3.

Wed 3/12 11:00 AM
Steven and I stayed behind and did not go back to the shelter.  Quite frankly we were so dehydrated we probably should have gone to the hospital for IVs too, but instead we slept it off.  Steven kept throwing up while I only had diarrhea.  We would both wake up moaning in pain, curled up in the fetal position.  It felt like I had ninjas in my abdomen attacking my intestines.  From the constant fits of vomiting and diarrhea my insides were beyond empty and I was feeling the pain.
Steven and I got a call from the group which had gone in to volunteer that morning and they reported that two more people from our team were feeling ill.  Surprise, surprise...

Wed 3/12 11:00 AM
Steven and I stayed behind and did not go back to the shelter.  Quite frankly we were so dehydrated we probably should have gone to the hospital for IVs too, but instead we slept it off.  Steven kept throwing up while I only had diarrhea.  We would both wake up moaning in pain, curled up in the fetal position.  It felt like I had ninjas in my abdomen attacking my intestines.  From the constant fits of vomiting and diarrhea my insides were beyond empty and I was feeling the pain.
Steven and I got a call from the group which had gone in to volunteer that morning and they reported that two more people from our team were feeling ill.  Surprise, surprise...

Wed 3/12 5:00 PM
Since Steven and I were in and out of sleep (especially Steven because he had a low grade fever) we didn't really notice when Alexis, my fellow senior bio major and future nurse, snuck into the room after having been excommunicated from the group.  Alexis got sick while at the shelter and suffered through what must have been an agonizing metro trip back to Cambridge.  Steven and I welcomed her into our "sick room" and filled her in on what the next several hours were going to be like for her.

Wed 3/12 11:30 PM
At this point, Alexis' violent vomiting fits had subsided and she finally fell asleep.  I woke up at this time and was surprised to see a body within a sleeping bag, contorted in the fetal position, lying next to me on the floor.  There was moaning coming from within the sleeping bag and blonde hair sticking out of it.  Caroline, a sophomore poli sci major, was the fifth person from our trip to appear in our sick room and come down with the norovirus.

Thurs 3/13 9:00 AM
I woke up feeling much better.  It had been a little over 24 hours since I initially gotten sick and the vomiting stopped.  The good news was that the norovirus ends almost as quickly as it comes.  It's probably the sickest I have ever been, but it went by quickly.  At this point in the trip I had only ingested two cans of gatorade and a slice of white bread.  The JMU asb team back in Harrisonburg was in contact with our group in Boston.  They told us not to go back to the shelter and that it would be best for us to leave.  They tracked down an extra van to rent from Enterprise which was dubbed the "sick van."

Thurs 3/13 2:30 PM
The healthy people from our group helped us sick folk out by making trips to CVS for us.  They bought us Depends (yes, the adult diapers), gatorade, white bread, face masks, gloves, and trash bags.  Around 2:30pm, we evacuated Cambridge and left for home.  The healthy and sick vans caravanned home and made it back to Harrisonburg by 2:00am.

Follow Up... What Did We Do? 

So we decided to evacuate because.... A) Considering that we were supposed to stay in Boston until Saturday, we ran the risk of having our entire 10-person group contract the norovirus.  We also risked giving the virus back to the vets who gave it to us at the shelter.  People who had already had the virus, like Carter for example, could easily get sick again.  I'm all for sharing, but the norovirus is NOT something you want to share.  B) Considering that we were staying at the church, we ran a huge risk of spreading the virus to many other people including the children who use the rooms we were staying in, the Harvard students we shared the kitchen with, and the homeless population who used the same showers we used.

We ended up wearing face masks to protect other people.  This protection was more mental than physical, since the norovirus is transmitted via the fecal to oral route, not through airborne droplets.  Although if I coughed after having just vomited, I could have spread the bug to my surrounding area.  But hand washing was the main form of prevention and quarantining ourselves.

Don't get me wrong, I thoroughly enjoyed the trip.  I bonded with these strangers over the norovirus and community service. Within days of knowing each other we were cleaning up vomit and confessing of having shit our pants.... yes, it happened THRICE on the trip. I kid you not.  I was lucky enough not to have any poopy pants, but out of the 5 of us, a couple of people did.  We became instant friends and if given the opportunity to relive the experience, norovirus and all,  I would be first on the sign up list.  It's funny because I had a friend going on a cruise and I gave her such a hard time for not returning her ticket for a refund.  I thought for sure she would get sick with the nrovirus.... touché universe, touché.

So in conclusion, WASH YOUR HANDS, WASH YOUR HANDS, AND FOR GODS SAKE WASH YOUR HANDS!!!!! Also, never doubt your god given talents and abilities.  I never thought I could puke and poop simultaneously, but boy was I very wrong.  I am quite talented indeed. =)










Friday, April 18, 2014

#923 (Guest blogger, Rachel McAuley)

Guest blogger Rachel McAuley with her co-leaders and
NGO coordinators in Guatemala, 2014. 



Guest blogger Rachel McAuley is a senior health sciences major at James Madison University. She recently coordinated a service abroad trip to Guatemala.









"To hell with good intentions, this is a theological statement. You will not help anybody with your good intentions. The third largest US export is the US idealist, who turns up in every theater of the world; the teacher, the volunteer, the missionary, the community organizer the economic do-gooders." 

Ideally these people define their role as "service." Actually they end up "seducing" the "underdeveloped" to the benefits of the world of affluence and achievement. Perhaps this is the moment instead to bring home to the people of the US the knowledge that the way of life they have chosen is simply not alive enough to be shared.

Suppose you went to a US ghetto this summer to help the poor "help themselves." People offended by your pretentiousness would hit or spit. Soon you would be made aware of your irrelevance around the poor, of your status as a middle class college student on summer assignment. You would be roundly rejected no matter if your skin is white, or black or brown.

I am here to entreat you to use your money, your status and your education to travel to Latin America. Come to look, come to climb our mountains to enjoy our flowers. Come to study. But do NOT come to help."
-Ivan Illich in "To Hell With Good Intentions" an excerpt from a  speech to the conference on inter-american student projects in Cuernavaca Mexico

As volunteers walking through the Mayan village I felt more an alien, like we were shiny new toys on display.

Then 923 happened...923 stoves. 400 blocks of cement. 300,000 less trees. 12 volunteers.

923 reasons how I can prove Ivan Illich wrong. 

Shards of glass, nails and various debris spawned the surface of  cobble stone streets slanted at a steep incline. Walking through this Mayan village was no match for my Nike sneakers, spandex pants, and clean white cotton t-shirt.

"Un ave" she said pushing an armful of trinkets upon me. "Un ave" once more. I cringed as I watched her walk barefoot on the cobblestone. I felt so blonde, so American, so disgustingly exposed and ugly.

She was old, small and worn. You could see her years in her face, smell it in her breath and feel it on her scaly hands as she touched my arm. "She's old," I thought to myself, reflecting on the age of my own grandparents and their good health. What did she do in life to lead her to beg at such an old age? Why doesn't she bathe? Where is her family and home? Does she have a home? What is the government situation like? It saddened me to learn she was only 55. She looked as if she could have been 70.

On mission trips in the past, I've pitied these people, and remember feeling overwhelmingly sad in their presence. This time however  I noticed disparities unfolding before me as we walked deeper into the community. Instead of feeling bad, I felt angered and conjured questions I couldn't solve. Clean water? Education? Access to medical care? Death rate? Diet? Who? What? When? Where? 

These were questions I was constantly asking myself and Cameron the head of the ONIL stove foundation. He considered himself a native Guatemalan although he was born in America, and having moved to Guatemala when he was 5 he experienced a time of civil war and government strife in this country. His response to most of my questions about this old women were...simply... "she's a women." Thats it? Cameron mentioned her husband had a 3x better chance of survival. Then laughing he said "and if he's still alive, he's either working for $1.50 a day or drinking away the afternoon."

$1.50 a day.

But it wasn't just this old women. I watched as two little girls played jacks in the street, giggling and chasing each other. The second they caught a glimpse of our group it was as if that moment of childhood was broken and they transformed into begging prodding sales women, asking for 1 quetzal in return for a bracelet. (I stupidly couldn't resist.) It was as if the generational gap didn't exist, as if I was looking into the eyes of an old beggar in these little girls. It seems like this life was all these Mayan women were capable of.

Juanita, happy with her new stove.
Photo by Rachel
McAuley, 2014.


A women named Juanita proved to me they were capable of so much more.

In Ivan Illich's speech, he talks about how American's often take these trips for themselves, for their own realizations and betterment. Sure, it's hard not to reflect on how much we take for granted in our own lives when having experiences like this. Food, water, clothing, shelter all entities we as Americans have in abundance. However the one thing I had never EVER taken for granted or thought about....my kitchen stove. 

The number one killer of Mayan women are their stoves. Over 3 million people in developing countries burn traditional biomass fuels as a source of household energy, with no ventilation to remove the smoke. Mayans have the highest rates of emphysema, bronchitis, asthma and lung cancer which are almost never diagnosed until they are too late. This accounts for the largest number of deaths among Mayan women, and it's hidden amid skewed health data in these hard to reach mountain villages.

Juanita's was the first stove we reconstructed.

An overwhelming amount of dust and debris was emitted into the air as we cleared an area for filtration in Juanita's home. 80 year old Juanita stepped in and helped, not fazed by the surrounding smog. "She's used to is" Francisco said. Us volunteers fled the scene in search of fresh air reprieve. How ignorant of us to leave, as 80 year old Juanita stood unflinching, not bothered by the amount of dust.

For several mornings after the stove building was complete we coughed up a grey phlegm, blew black snot out of our noses and had sore throats and coughs. This was after only a few days of being in this work environment, I can't imagine breathing this air for a lifetime.

We proceeded to build 6 stoves, and donated even more to the ONIL stove foundation. After the completion of Juanita's stove we thanked her for her hospitality and turned to proceed to the next home.

"Wait we aren't done yet!" Cameron yelled.

He handed Juanita a thick black marker.

"Tu puedes escribirlo" You can write it! He said.

Slowly, meticulously,  in big black thick bold letters Juanita wrote...#.....9.....2......3. Signifying her stove being the 923rd built.

923 stoves.

923 healthier lives.

923 less trees.

Did we make an impact?

The problems that are rooted in the Mayan culture are not a quick fix, but that's the ambiguity in the term "make an impact." No one in this world, whether your a college student on a week, or a 6 month long trip has the ability to change the world around. Surely we can paint schools, or build homes and fences that will last a lifetime, but in my opinion the largest impact we can make must be something SUSTAINABLE. It's not us that's going to make a change immediately but rather instill our knowledge to perhaps better the lives of these Mayan women and their community for future generations. We showed Juanita the importance of the filtration system we drilled into her tin roof, encouraged her to spread to word on ONIL stoves to her friends and opened her eyes to the harmful effects these stoves had on her health.

Education is KEY.

Here's what I have to say to YOU Ivan Illich:, we were not "imposing" our American ways, we were not trying to change the way these communities functioned or persuade them to change thousands of years of practice. We were instilling something much more useful. I can communicate with these people fluently, and have studied their culture and way of life. Personally there is something about global health, about that old woman and child begger, about the black phlegm in my lungs, about Juanita's hospitality that captivates me and inspires me to share what I know to try and create a change. Sure there are problems in America just like this, but the magnitude of governmental injustice to these Mayan women and indigenous tribes as a whole made our nation seem sickeningly privileged. Change isn't going to come by reconstructing years of governmental strife, but rather through small individual action.

On this trip we built a fence around a Mayan playground, planted over 2,000 trees, however above all this stove project taught me profound impact something like education can have on these communities. Passion for change extends beyond just a "do gooder" mentality Ivan Illich. Besides, what's wrong with wanting to do good? Perhaps if more people recognized this passion, inside and out of the US, the world would be just a little bit more of a better place.

You have to learn to crawl before you run.

The power in 923, the power in one...can be immense.

"Everything you do in life is insignificant. But it's very important that you do it." -Ghandi

Monday, February 17, 2014

Guest blogger Spencer Pelfrey: A Field Study on Traffic Injuries

Spencer Pelfrey is a senior Health Sciences student at James Madison University, in Harrisonburg, Virginia. He is from Amherst, Virginia, and has been accepted to a master's program in university administration at the College of William & Mary this coming fall. Originally published as a class assignment, October 2013.




I had actually never heard of this until taking this course, but there is such a thing as "injury epidemiology" (the effect of preventable injuries within a population). It wasn't until we had a guest speaker, Mr. Edrisa Sangyang, speak to us all the way from The Gambia that I began to take interest in injury epidemiology.

You know that feeling when you learn something for the first time it becomes much more apparent to you in daily life? It's like a deliverance from ignorance--you understand more of the little things around you or you're more observant of your surroundings. I'll give an example, because I'm starting to get a little "out there."

I decided to go to the JMU-William and Mary football game this weekend with some of my friends. As we were pleasantly riding down 64-E taking in all the beautiful scenery that Fall has painted on the mountains, it struck me how dangerous it was to go 70+ miles per hour in a vehicle weight more than ton next to vehicles doing the exact same thing. We passed by Staunton and as we were continuing towards Waynesboro, about 2 cars up from ours a tractor-trailer started to merge into the left lane (I'm still confused as to why--it seemed completely unnecessary). The car continued to stay in his blind spot causing me to verbally express how concerned I was (in a very non-professional way). My passenger shrieked in terror too, but somehow the truck knew exactly his time and place in the moment and tucked his way cozily into our lane. My roommate piped up and said "wow... that was incredibly dangerous." My response was literally: "go watch a traffic video from Russia and get back to me."

Later in the car ride, I noticed one of my passengers not wearing her seatbelt. I made some sassy remark how I was going to prove to her seatbelts were a good thing and she understood that I was ridiculing her for the sake of her safety. After I ran over a couple rumble-strips on the shoulder, she obliged to "make me happy."

Fast-forward about 2 hours and we arrive in Williamsburg. Unfortunately for us, it was William and Mary's Homecoming weekend, so there were people EVERYWHERE. I carefully drove through downtown avoiding pedestrians better than a middle school girl avoiding her parents at the mall. It struck me that maybe we could improve how we do things... even if we aren't as bad as Russia, India, The Gambia, etc.

What this weekend taught me was the varying levels of traffic safety we take for granted everyday. My generation has grown up with seatbelts, most of us wear them everyday and it's become a habit (which is great!) for us to wear them--they'll save your life. We have crosswalks, we have turn signals, and we have rumble strips. We're actually pretty blessed to have the safety that we have although we may not be excited when we get a ticket for not following the traffic laws. More specifically, since learning was injury epidemiology is, and more specifically, traffic injury epidemiology, I've become more in tune with how well-off we are in America, but how there's still room for improvement.

We may never get to the point where we have zero injuries from traffic issues, but that shouldn't stop us from attempting to reach perfection.

Spencer

Saturday, January 25, 2014

Global Minds, Global Health: A concerto for change in three movements

http://library.thinkquest.org/05aug/01006/peacocks.htm


The India of my dreams is
   at once
gleaming brash hot-moist elegant purple and blue and
    a peacock’s green
Raucous shoving curried blaring jasmine-sweet
     shimmering
The peacock, his enormous burden of a tail,       

dragging behind, screams, 
    “to love, to die!”
-- Anne Wallis



A concerto is a musical composition usually composed in three parts, or movements, in which a solo instrument is accompanied by an orchestra. The concerto changed its form somewhat after the early 20th century. when modern composers began experimenting with ideas like a more frequent use of modality, exploration of non-western scales, the development of atonality, and the use of polyrhythm and more complex time structures. Concertos for orchestra use different sections of the orchestra as solos. This talk is organized as a concerto for orchestra. First: The strings, viol 1 and 2.


From Bartók's Concerto for Orchestra, 
as annotated by Georg Soti  
bookhistory.harvard.edu
The following is excerpted from my keynote speech on 4 November 2013, that served as prelude to the student-run Washington & Lee University Global Health Symposium. The remainder of the week included student panels on maternal and family health, water, and comparative health systems. 

Prelude

Who am I? 

I am a product of a classical, liberal arts education. I majored in history and studied literature, philosophy, political science, biology, and music. I came to love the scientific method, I learned about fetal and infant health and development and, in my 30s, landed at the Johns Hopkins University, Bloomberg School of Public Health, studying reproductive health. I then taught for 10 years in the Department of Epidemiology at the University of Iowa and I was part of the multidisciplinary, undergraduate program in Global Health at the UI.

I have led study abroad trips to Romania and India and my current research is based not only in the US, but in Romania, Serbia and Croatia, the Gambia, and India.

My goal tonight is to talk about the application of liberal arts thinking and studies to the seemingly intractable problems of global health. I can tell you that maternal mortality claims the lives of at least 1000 women per day; I can add that cardiovascular diseases, diabetes, and cancers are the biggest killers in the developed world; and I can confuse you by telling you that India may soon lead all countries in its prevalence of diabetes, while still leading much of the world in rates of infectious disease.

The world today is filled with paradoxes and enigmas.

We know something about how to improve the health of young children – vaccines and better nutrition have saved millions. We know that healthy drinking water is key to survival for everyone on the planet. It is very, very scarce for some; tsunami-terror for others; and poison for too many. We know that traffic injury is a leading killer of people of all ages, especially in the developing world.

We also know that many of the strategies we use to improve health are temporary or unsustainable or simply do not work. We have spent literally billions of dollars in Africa, South Asia, Latin and South America, and in less fortunate parts of the US and Europe, for a few successes. 

At all points, we face the notion that solutions are not easy and that we need some Big Ideas. We face the corruption of dictators and local politicians. We face a serious brain-drain from the less developed world – people who leave for a better education with the full intention of returning to help their people, but soon come to believe that it is nearly futile.

I have a few ideas that I hope can provoke a new conversation in academia about how to grow a new global health intelligentsia.

I want to start out with a couple of basic problems – one is maternal mortality and the second is extreme, persistent, deep, widespread poverty.


1st Movement

Maternal mortality: the death of woman while pregnant or within 42 days of termination of pregnancy. Maternal and infant deaths are sentinel events that tell us about the strength of a health care system and overall population health. Women die every day of severe hemorrhage, unsafe abortions, eclampsia, obstructed labor and indirect causes like malaria and anemia. There are as many as 500,000 maternal deaths per year – about a thousand a day. The picture below, taken by a Reuters news photographer of an Afghan family that lost its mother a few months prior, lists some of the many sequelae of a maternal death.



Fully 99% of maternal deaths occur in the developing world, but it happens here too. Black women in the US have three times the risk of dying of pregnancy-related causes when compared to white women and we have one of the highest maternal mortality ratios in the developed world.

Infant mortality: death in the first year of life – most often occurs in the first hours and days after birth. Like maternal deaths, infant deaths often go unrecorded. Infant death is most common in the developing world, particularly south Asia and in sub-Saharan Africa; in Afghanistan, the infant mortality rate is about 120 per 1000 live births. In the US, the IMR is presently about 6 per 1000 live births – but before getting too comfortable with that fact, please bear in mind that the US IMR is not the best in the developed world – in fact, it sits at about 26th on the list of industrialized countries. Worse than that, we have incredible disparity in the US – poor, black communities in the US have rates as high as 10-15 per 1000.

2nd Movement 

The elephant in the living room – cue bass violins; the thrumming monotone beneath the violin solos:

1.2 billion people in the world live in what is called extreme poverty, meaning that they live on less than 1.25 USD per day.


We know that health and wealth are linked. Extreme or deep poverty leaves people susceptible to premature death from infectious disease and injury.

The UN recently announced (see my blog entry, "Is there any way to end extreme poverty?" on poverty and an article in The Economist, "Poverty, not always with us?") that world poverty seems to be decreasing. That may be a matter of definition and semantics. 

If half of all extreme poverty has been eliminated, then how is it simultaneously possible that urban slums are growing in nearly all cities in the developing world? About 1 billion people worldwide live in slums (and this is almost surely an undercount) - these urban and peri-urban "communities" are marked by makeshift housing, no running water, open sewage, and crowded living conditions.


In Planet of Slums (2007), historian Mike Davis argues that slums are not only growing in numbers, but also in squalor. He notes that in slums, unsanitary food and water are concentrated at greater levels than at any other time in history. Clean water and toilets must be shared by thousands. Poor sanitation is coupled with chemical pollution. In Latin America, 90% of sewage flows untreated into streams and rivers. Slums also raise special issues for women. In Mumbai, women band together to go to the public toilets between 2 and 5 in the morning for privacy and to avoid sexual assault. 

So even as the UN and others congratulate themselves on eliminating the problem they label "extreme poverty" it seems that relative poverty, persistent poverty, and deep poverty may be far less tractable and require more resources and ingenuity to solve. 

There are ideas out there about how to improve slum life. Some propose relocating slum residents into new housing, an idea which may not work because people live near the city center to be close to work, and besides - slum or not, their home is their home. In fact, relocated slum residents often sell their new property and move right back into their old homes. Alternatives can improve rehabilitation and legitimization of existing space, that may lead to improved infrastructure and security of tenure - UN HABITAT has developed a slum upgrading program that shows some promise, but really - we don't have the answers.

3rd Movement

What then must we do?


From The Year of Living Dangerously (Peter Weir)
This is the question people asked Jesus (Luke 3:10), and it's a question Tolstoy asked in his book of the same name. Tolstoy was so upset about poverty that he went out one night into a poor neighborhood in Moscow and gave all his money away. He concluded that it did no good - giving away even a large amount of money would just be a drop in the ocean. In The Year of Living Dangerously, Billy Kwan asks the journalist Guy Hamilton the same question about the poverty they see in Jakarta. Guy sees giving money away as a futile gesture; Billy says, "you do what you can about the misery that's in front of you. Add your light to the sum of light."

There is no easy answer to this question.


My view aligns more closely with Tolstoy's, but mixed with more than a teaspoonful of Billy Kwan's karmic sensibility.

We need structural, large-scale solutions to the problems of poverty. Building a single well, sending a cheque, supporting an NGO may add to the sum of light, but they do not represent a strategy.

Finale
The power of public health solutions is the power to save millions. If we want to reduce malaria, why are we so invested in a malaria vaccine or even in research to genetically modify the mosquito? Yes, these technologies may contribute to understanding the problem, but the REAL problem is upstream. Until we can rid the circumstances - by which I mean physical and social environment - in which malaria thrives, then we will not end malaria. If a vaccine reduces malaria's threat, a new disease that breeds in poverty will move in to take it's place.




Washington & Lee University, candlelight memorial,
December 2013, photo: W&L
Undergraduate, multidisciplinary global health programs can take many forms. They may be vertical – that is, they may exist within a department of health sciences, but a far better idea is to formulate them as HORIZONTAL cross-cutting programs. There need not be a specific department designed just for pre-meds or others interested solely in “health” -- departmentalizing the health sciences appears to result in narrowly trained minds. Instead, the idea should be to grow interest in global health piece by piece, by stimulating students via a variety of disciplines - anthropology, economics, history, literature, biology, politics, and art. 


Real solutions can only happen when we understand the complexity of these phenomena that play out on the global stage, in local communities, and in families. How can we understand immigration patterns and civil unrest without understanding their upstream predecessors: historical conflicts, oppression, colonialism, climate. And culture.