Student stories

{***Pause/Music***}

{***Noah***}

Coming up on Harvard Chan: This Week in Health…

Student stories.

{***Alice Han Soundbite***}
(The first paper that I read reported that the rates of violence against women in Brazil were over 50%. And when I thought back to my time working in Brazil, and I thought that one out of every two women I passed on the street had experienced this problem, I need I wanted to explore this problem further.)

In this week’s episode: Three graduates from the Class of 2018 share why they chose to work in public health—and how they’re looking to make the world healthier and safer.

{***Pause/Music***}

{***Noah***}

Hello and welcome to Harvard Chan: This Week in Health, it’s Thursday, May 24, 2018.

I’m Noah Leavitt.

{***Amie***}

And I’m Amie Montemurro.

{***Noah***}

This week more than 650 students from dozens of countries graduated from the Harvard Chan School.

{***Amie***}

Each graduate has their own amazing story—with powerful reasons for pursuing public health.

We can’t share them all—but this week we’re sharing three stories.

{***Noah***}

These graduates are addressing a range of issues, including violence against women, health care inequities, and the health challenges posed by cities.

You’ll learn why they pursued public health—and how they’re hoping to make an impact after graduation.

{***Amie***}

First up—a doctor who’s trying to change how we think about violence against women and girls.

{***Alice Han Soundbite***}
(My name is Alice Hahn. I’m a Canadian-trained obstetrician and gynecologist and instructor of obstetrics, gynecology, and reproductive biology part-time at the Harvard Medical School, an adjunct lecturer at the Department of Obstetrics and Gynecology at the University of Toronto, and a staff physician at the Dimock Center here in Boston, Massachusetts. And I’m just wrapping up my MPH here at the Harvard Chan School of Public Health.)

{***Amie***}

Alice Han’s interest in global and public health has been informed by the time she’s spent working in health care around the world.

{***Noah***}

A six-week seminar in Vietnam during her undergraduate years focusing on maternal health.

Later a health equity internship in Brazil aimed at reducing health gaps between the rich and poor.

And work with Partners in Health in Rwanda, where she and others tried to strengthen rural health systems and address inequities.

{***Amie***}

These experiences showed Han the importance of the intersection between public health and clinical medicine.

In Rwanda Han learned about the complexities of delivering health care in a resource-constrained setting as well as the barriers patients face in accessing care.

{***Noah***}

She says it was a challenging and humbling experience.

{***Alice Han Soundbite***}
(As a physician, I felt so ineffective and unable to provide help where it was needed. I remember seeing a need to give blood to a patient. But there’s no blood available. Tests that needed to be done, but the equipment needed for the tests wouldn’t be available. The challenges that patients had in getting care, challenges they had in arriving, walking days to arrive to the clinic. Also being in a rural area where there was not a lot of other support from other clinicians. I trained in a tertiary care center in Toronto where every support possible was available. So moving from this to a rural area with very little support was challenging. But also things like I remember being in the operating room and the lights going out at one point, or needing to do a procedure but there would be no sterile gloves in my size, which made manual dexterity very challenging. So on all fronts, just so many challenges in trying to work within that setting.)

{***Noah***}

It was this experience that led Han to decide she wanted to develop more formal skills in public health to address the health care challenges patients in Rwanda were facing.

{***Amie***}

But these field experiences also broadened Han’s perspective on social justice. And in recent years she’s worked to draw attention to violence against women and girls.

{***Noah***}

In a 2017 Ted Talk she called it a global pandemic.

{***Alice Han Soundbite***}
(A hidden disease is threatening everyone in this room and everyone watching. One out of every six people in the world, more than a billion people, will be directly affected by one form of disease in their lifetimes.)

{***Noah***}

Han found that violence against women and girls—or VAWG—is an area of public health that was greatly overlooked.

{***Amie***}

She explained why she views violence against women as pandemic and what can be done to address it.

{***Alice Han Soundbite***}
(So in my mind I conceptualize disease as an abnormal condition with a cause that affects an organism. So for problems of violence against women, I see the normal condition as the violence. And I see that there are root causes of violence against women. So unlike viral diseases, the root causes of violence against women are sociopolitical in nature, like gender inequality and unequal power relations between men and women. But just like the viruses that cause diseases like the flu or smallpox, the ideas that lead to violence against women, they can spread, and they can infect populations. And they pose a threat to societies.

I initially explored this area during my residency training. A mentor suggested the topic of looking at reproductive health outcomes of violence against women in Latin America and the Caribbean. And to be honest, I was at first hesitant to explore it, because as an obstetrics and gynecology resident, I had previously not been exposed to this topic nor had given a lot of thought to it.

But the first paper that I read as background knowledge for that topic reported that the rates of violence against women in Brazil were over 50%. And when I thought back to my time working in Brazil and I thought that one out of every two women that I had passed on the street had experienced this problem, I knew that I wanted to explore the problem further.

So what I found interesting was that my colleagues who study cervical cancer or preterm labor or gestational diabetes are never asked this question. But people always ask me with a bit of hesitation, why are you studying this. What’s your what’s your personal story? So that begged the question to me, why is it that violence against women is not seen as important enough of a problem to merit the research and advocacy by the medical community, regardless of whether someone has a personal story or not. So given the magnitude of the problem and also the devastation that it exerts on women around the world, their communities, their families, and economies, I felt that this was an attitude that urgently needs to change.

What I’ve seen is that this framework pushes people to view the problem in a new light. So I feel that often, it’s a problem that people see as too messy. It’s messy. It’s complicated. And it’s really difficult to do anything about.

So what I think this framework does is highlight that it can be approached, just as we approach diseases. So we can identify a root cause. And then we can target that root cause for prevention efforts and then work to address the harmful effects of those that are affected.

I can extend the analogy and say that just as we can vaccinate against diseases, we can think of vaccinating against violence against women. We can identify the root cause as, say, gender inequality as one of the root causes. And then we can use interventions that are aimed at that root cause.

In my TED Talk, I give the example of a study that was held in Uganda, where community leaders worked with both men and women to learn how to equalize power dynamics over three years. And eventually, this succeeded to cut a woman’s risk of physical violence by half.

We know that there are interventions that work to prevent and reduce violence against women. And they don’t take generations to produce results, but they work within the programmatic timelines of just a few years.)

{***Amie***}

Han says there is still much work to be done to better understand violence against women—and develop ways to prevent it.

{***Noah***}

She says that it’s critical to use epidemiological tools to collect data to better understand the problem and the potentially unique cultural issues at play. Then, Han says, it will be critical to scale up targeted interventions that are region and culture specific.

{***Amie***}

As for her next steps, Han is still exploring options, but wants to continue her public health work.

She plans to continue being an advocate in calling for health systems around the world to respond to violence against women.

{***Noah***}

A key part of this she says, is engaging more doctors and health care providers to join her and be part of the solution.

{***Pause/Music***}
{***Garang Dut***}
(So, my name’s is Garang. And I study MPH 45 in health policy in management. Most recently, I moved here from Australia, Melbourne.)

{***Noah***}

That’s Garang Dut—and his path to public health and medicine has been remarkable.

{***Amie***}

Dut is a doctor and most recently completed a surgical residency at the Alfred Hospital in Melbourne.

{***Noah***}

He spent most of his early life in refugee camps.

Dut was born in South Sudan and grew up in a Kenyan refugee camp, eventually moving to Australia when he was 17.

{***Garang Dut Soundbite***}
(Having been born in South Sudan, pretty much in the middle of the Second Civil War and had to move to Ethiopia initially and then subsequently Kenya. And that’s where I grew up. So I was saw so much need for medical care in the setting that I grew up, mostly in a refugee camp. And that spanned a period of about 17 years total.)

{***Noah***}

It was in these camps that Garang saw not only health challenges and inequities—but he also saw how difficult it was for governments or nongovernmental organizations to address these issues.

{***Garang Dut Soundbite***}
(So initially, it was very visible that preventable diseases are claiming a lot of lives. But in the immediate sense of violence from war, there were a lot of other priorities as well, including physical safety. And so within the confines of displaced camps, international law applied differently, because you are within your birthplace. And that’s different from when you engage with the international agencies across international borders. And so you’re now a refugee. And you can get more services from NGOs once you have crossed the border.

So that made the difference in terms of access to health care, but still very significantly having challenges to do with preventable diseases. And so coming into medicine, I had that intention to still work at the societal level to try to have preventative care and improve access. But fundamentally in those settings, health care is much more delivered by things that are beyond clinical medicine, such as infrastructure to do with sanitation as well has just the logistics of getting medications to people.

So I remember immunizations being given under trees, pretty much in open spaces where people had been displaced. And it could be in middle of the desert. And so there would be a lot of NGOs coming in, say, UNICEF. And they would just do mass vaccination of children. There would be weighing of children as well to try to track and gauge malnutrition. And that would be used by humanitarian agencies.

So I got a different experience of what medicine is like prior to coming into medical school in Australia. And so I’ve had a different lens as to what medicine should be able to provide or health care as a whole. And so I’ve carried that lens through as what eventually led me down the route of pursuing studies in public health as well.)

{***Noah***}

Dut’s pursuit of public health actually has grassroots origins.

{***Amie***}

He started by simply reading what he called “forgotten” books in the library—about core public health subjects, such as Melbourne’s sewer system.

{***Noah***}

But Dut also developed an interest in more modern concerns, such as inequities in health and access to care, particularly among indigenous Australians.

{***Amie***}

Dut says there’s often a gap between what the evidence may show in a particular area and the actual process of making policy to address that.

He’s hoping his training at the Harvard Chan School will help him that in Australia.

{***Noah***}

One key lesson from the School: it’s critical to understand key stakeholders and their priorities and then developing policies that balance often competing interests.

Dut says this is especially important when you consider that the communities that may benefit from an intervention or policy change may not be well-organized—such as lower-income groups.

{***Amie***}

Once Dut graduates he’ll be putting that into practice working on health care policy issues in the Department of the Prime Minister and Cabinet in Australia.

{***Noah***}

Going forward Dut eventually wants to return to clinical work, while still working on ways to improve health care for lower-income or underserved groups.

And as he does this work he’ll take lessons he learned at the Harvard Chan School, including the power and importance of collaboration.

{***Garang Dut Soundbite***}
(I think the most important lesson I’ve learned is the power of working with people. So nothing can really happen, however much you can do or however much you know, working with others. And so it’s the power of network and being able to collaborate with others across disciplines as well as across nations to make things happen.)

{***Pause/Music***}

{***Amie***}

The final student we’re profiling is helping to re-imagine how we think about cities and public health.

{***Noah***}

Jon Jay is graduating from the Doctor of Public Health program and we spoke to him via Skype from his home in New Haven, Connecticut.
{***Jon Jay Soundbite***}
(My work in the Dr.PH program has focused on urban health, particularly using data science and looking for specific applications for local governments to reduce risk in cities.)

{***Amie***}

Jay brings a wealth of different experiences to his work on cities and urban health.

{***Noah***}

He trained as a lawyer, studied philosophy at Georgetown, worked in biomedical ethics for the Division of AIDS at the National Institutes of Health, and worked in global advocacy for universal health coverage.

{***Amie***}

And all of these varied experiences in global health inspired his research into cities

{***Jon Jay Soundbite***}
(What I saw there was that there was a longstanding focus on rural areas in developing countries. And that’s a huge issue. But it seemed to me that there weren’t enough people thinking specifically about the issues that we confront in urban environments, which are important in developing countries, where we see megacities with tens of millions of people and also in the US, where most people live in cities of various sizes.)

{***Amie***)

And the health effects of cities can be seen in many areas, ranging from infectious diseases to noncommunicable diseases.

For example, overcrowding can increase transmission of tuberculosis or dense, low-quality housing can lead to a greater risk of fire and burn injuries.

{***Noah***}

And urban environments have also been linked to lifestyle shifts, Jay says. So, people are increasingly living in environments where they are more sedentary—it’s harder to walk and they’re in vehicles more often—which can increase risk for conditions such as heart disease or type 2 diabetes.

Jay saw this play out firsthand during a winter immersion program in Mumbai, India.

{***Jon Jay Soundbite***}
(We were working there with a health center based in the Darabi slum, which is one of the world’s largest slums, almost a million people living there. And it’s the extreme end of urban concentrated poverty. And so working on tuberculosis there, it’s like this is one of the characteristic problems of crowding and lack of resources in urban environments.)

{***Noah***}

Jay says this is an exciting time for his research because cities are now generating so much data.

{***Amie***}

The information ranges from public records about homes and property to Google Street View data, which provides detailed photos of urban environments around the world.

{***Noah***}

And Jay put this data to work with his dissertation, which used city property data to analyze fire risk in Portland, Oregon.

{***Jon Jay Soundbite***}
(The data that the city has on your house, like how big it is, when it was built, how many bedrooms, those kinds of data are strong predictors of the potential fire risk. So working with the fire department there and with David Hemingway, we were able to predict risk for every property in the city of Portland. We did that using data from 2012 through 2015.

And we knew what had happened in 2016. So we made those predictions for 2016 and we were able to compare them to the actual fire outcomes and found that we predicted them much better than if you were to go about it by random chance, which actually is how most fire departments operate. They will do inspections based on alphabetical order or something like that. And so prioritizing building inspections and home safety visits can make those programs much more efficient.

Fire engineering is actually a really well-developed field. And there’s been much less work looking at the spatial distribution of fires within cities, because it’s totally non-random. We think of fires as these random or sudden acts of god when, in fact, they are strongly correlated with various factors, particularly when you look at fire injuries. So the types of people who die or get severely injured in fires tend to be people who are more vulnerable across a range of social indicators. So there’s really an important connection with other issues.)

{***Noah***}

After graduating Jay will be using this approach to cities and data to address gun violence.

{***Amie***}

Jay will be completing a postdoctoral fellowship with David Hemenway, director of the Harvard Injury Control Center.

{***Noah***}

The HICRC is part of a consortium based at the University of Michigan to prevent child firearm injuries, which are the second-leading cause of death among children in the U.S.

{***Amie***}

Once again, Jay will be using city data to identify trends and hopefully develop solutions.

{***Jon Jay Soundbite***}
(The same kind of disparities that we see for other health outcomes, we see very, very strongly for firearm injuries in cities. So there are, even from block to block in a given city, you see differences in injury risk. And then certainly at the neighborhood level, within any given city, there are some neighborhoods where you’re very, very unlikely to be injured by a gun and others where you are much more likely to be injured by gun. And there’s also a strong racial component to those disparities too.

I’ve been working with satellite images and Google Street View images and using machine learning to use those data sources to better understand the physical environment. And so that’s kind of the key aspect of my work now, is to think about, what do high-risk places look like in terms of the physical environment. And what does that tell us about how we might be able to change the physical environment to reduce risk?

Even down to the individual street corners that are dangerous. What would happen if we put a park in instead of that empty parking lot that nobody uses? Is it possible that that would reduce violence?)

{***Amie***}

That was Jon Jay talking about his work on integrating data science and urban health.

{***Noah***}

Thank you to Jon, and also Alice Han and Garang Dut for taking time to talk with us during this busy graduation season.

{***Amie***}

And if you want to read more about the recent Harvard Chan convocation, you’ll find much more on our website, hsph.me/thisweekinhealth.

{***Noah***}

That’s all for this week’s episode. A reminder that you can now find us on Spotify, so if you’re a fan of this episode or any others, be sure to share with your friends.