Family Matters

Most people here don’t have health insurance; several don’t even know what it means. One person I talked to said that American Samoans don’t need it, since their families ARE their insurance.

Since coming here I’ve understood what he meant. Family is very important here- what affects you affects the rest of your family as well. There is no sense of a nuclear family- a household is not only made up of parents and their children, but of parents, children, grandparents, aunts, uncles, and several cousins. You are not necessarily even raised by your parents; I wouldn’t be surprised if the phrase “it takes a village to raise a child” originated here.

As a part of my research we are solely surveying mothers of infants on their feeding behaviors. This eligibility criterion is probably the biggest source of missing babies in our study, since the person coming in with the baby is often a grandmother, aunt, or sibling. Since some of our questions are about the pregnancy and breastfeeding, we can’t include these other caregivers.

Adoption is also very common here, but not in the way we are familiar with in the United States. Siblings and cousins often adopt each other’s babies, and there are times in which blood siblings are raised by different family members. Families being as fluid as they are, everyone ends up being your sister, brother, cousin, aunt or uncle, even if it’s not biologically true.

In one story we heard, there was a woman and her husband who really wanted children but couldn’t seem to bear any. The husband’s extended family called together a family emergency, and the husband’s brother and sister-in-law volunteered to have the couple’s first child. A few years later, the husband’s other brother and sister-in-law volunteered to have his second. The reason they volunteered? The woman was “meant to be a mother”. Even though the two girls are biologically the husband’s nieces, there is no question in the family’s mind that these two are the couple’s daughters.

Another example of the value of one’s family is the concept of fa’alavelave, monetary donations to family members. Whenever a family member is born, is sick, graduates school, or dies, the rest of the family is expected to donate significant amounts of money to the person in question. However, these expenses add up- since “family” is almost a small community, there are often contributions that need to be made. In return, you expect the same charitable spirit if anything happens to you. Being a part of a family turns into a small-scale health insurance plan.

While this is a great system for some of the islanders, fa’alavelave is starting to create some problems for others, especially the younger generations. The donations that need to be made are quite a large part of an individual’s salary, and are sometimes for occasions that are of no consequence to you- a grandmother’s sister’s death in California for example (in the most loose sense of “grandmother” and “sister”). Other times there are no donations for an occasion much more important to you, like paying for your college education off-island (these donations seem to become less mandatory once you leave the island, but then again, so do your returns). Concerns about fa’alavelave include pressure to participate and restricting economic movement, and while you have some say over your health insurance plan, you have no choice in your familial obligations.

Despite the issues that arise from this system in American Samoa, the strong sense of family is something to be commended and to be learned from. As my time in American Samoa draws to an end, I’ve been told by my co-worker’s family that if I were ever to return their home is my home, since I am a part of their family now (without the pressure of fa’alavelave, of course). And knowing how much they value family, this is an honor.

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Summer in the South Pacific: A Recap

I can say without a doubt that this summer was the most exciting adventure I have ever had. I learned a lot about the societies and cultures of the Pacific, what it means to work in global health, and myself. I also learned I am not very good at keeping blogs. I’ll focus mostly on my time spent in the Solomon Islands studying a post-flood outbreak of diarrheal disease. Sorry it’s long!

Working Hard
A great deal of the research I did in the Solomon Islands was quite simple. I remember Mayur telling us early on in Epi I, “Epidemiologists count!” and that is what I did this summer. In a cramped WHO office, I poured over piles of outpatient register books, tallying diarrhea cases from the past year. Though tedious, I learned to appreciate how good surveillance data is often not available, especially in a country like the Solomon Islands. You can know how to do all the fancy analyses and regressions we learn in Biostats, but if your data is crap, your results are meaningless. I think we often overlook this fact in our classes. In the end, what I enjoyed most was traveling to each of these clinics, having conversations with the nurses, and seeing how people reacted to the flood emergency. Pretty much all of the nurses were always willing to help me with my research and seemed excited to be a part of my project. I owe a lot of my findings to their diligence.

Stacks of Outpatient Registers or The Diarrhea Diaries!
Stacks of Outpatient Registers

I also had the exciting chance to be a part of several outbreak investigations while in the Solomons. While I was there, the country had outbreaks of diarrhea, measles, and meningococcal septicemia. Getting to help in a buzzing office and out in the field with WHO employees and global health professionals to contain these diseases is the coolest work I have ever done. Riding into Makira Province in a helicopter to bring antibiotics and investigate several deaths from a “mysterious disease” was a cocktail of fright, sadness and excitement. These experiences made me more certain that someday I want to join the EIS (Epidemic Intelligence Service).

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Helicopter Ride to Makira
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Testing Stools for Cholera and Rotavirus

“Paradise with a Bite”

As for leisure, there was a quite a lot of fun to be had, especially since I have friends who had been there for some time before me. The Solomons do not have a prominent tourist industry yet so one had to be active about finding your next adventure. Some of the things I will never forget doing:

Snorkeling, campfires, rope swinging, and good times with friends in Central Province

SCUBA Diving inside WWII shipwrecks

Hash Hikes on Mondays and Ultimate Frisbee games on Tuesdays

Karaoke with a rock band at the local Filipino Bar, “Cowboys”

Weekly “Chicken through the Fence” meals (barbecue chicken on the side road, handed to you through a fence)

Watching the World Cup under a tarp at my neighbor’s house with a crowd of locals

Fourth of July Party at the US Ambassador’s home

“Friday Night Drinks” (expat invasion of a different bar every Friday)

I will never forget the friends I made within the expat and local communities. I already miss you all if you are reading this.

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I lived there!
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Village in Maravagi
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Maravagi
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Ultimate Frisbee Gang

Australia, Fiji and New Zealand
Getting out of the Solomons proved challenging. On the day of my departure, all flights between the Solomon Islands and Fiji (my next destination) were cancelled indefinitely due to arguments between the two governments. I did a last minute switch to Brisbane, Australia, spent the night on an airport couch, and flew to Fiji the next day. It was a very bizarre and brief return to the developed world.

In Fiji, I was reunited with my counterpart of Team Diarrhea in the Pacific, Jordan Emont. I spent 2 weeks writing up a manuscript, creating figures, and giving a small presentation. Jordan and I also got to eat lots of cake, drink kava and beer with local friends and even go diving with bull sharks!

Team Diarrhea
Team Diarrhea!
SHARKS!
BULL SHARKS

Lastly, I spent a week and a half with my relatives in New Zealand, mostly catching up and sharing stories. Very happy I got this brief chance to see them on the last leg of this journey.

Lessons Learned

So overall, what I got from this summer:

Data collection can be a pain, but someone has to do it.

When considering whether to ask something that might be slightly socially awkward, always remember, “They won’t punch you”

I spend way too much time on the internet. I was much happier not having as much access in the Solomons.

The Pacific is composed of a diversity of rich cultures and should be given more attention by the global community. These countries are much more than vacation destinations and have some serious health, social, and environmental issues to be addressed.

Epidemiology is awesome. Not sure what my next step will be after my masters, but I like how things are going.

Kichina in Tanzania: Part 1

I’m going to be very honest here.

Like any other girl who’s managed in a resource-poor setting, I have laughed, I have cried innumerable times and I have rolled my eyes at most men (and women) on the street who have bellowed “KICHINA”, “CHING CHONG CHANG”, and even hee-hawed at me unceremoniously. I really don’t know where the hee-haw comes from. Does Mandarin really sound like a donkey’s bray? I will never know.

Living and managing a project in Tanzania meant having to get used to a few things: 1) People staring at you because you look fairly different to the rest of the populace 2) Learning to speak Swahili 3) Acquiring a whole set of project management skills to execute your study from ground zero.

1) Being different. In Mwanza, I believe that people here are not accustomed to seeing Chinese females walking around town by themselves. There are a lot of Chinese men who come here to work in construction and mining, but I have not seen any women. It is quite different to Dar es Salaam in this respect, where I was left alone to my own devices most of the time. In Mwanza, I always get heckled on the streets. My office manager told me that this is mostly affectionate: “we like mzungus (foreigners)”. Although I do understand the rationale, I will admit that the name-calling took some getting used to given that I don’t possess Kardashian levels of narcissism. Some people were quite friendly in their loud greetings, but some were just plain mean, especially teenage boys and market vendors. However, I sense that it has come to the point where the excitement at this Oriental girl walking around town alone has tapered off. Just at the point where I’m leaving. Go figure.

2) Swahili. People have told me that Swahili is really easy to pick up. Fair enough, it’s not as difficult as some other languages, but when people speak to you at a 100 words per second, it most certainly is. I’m proud to say that my Swahili isn’t as bad as I thought it would be after 2 months. Just don’t ask me to direct a light opera.

3) Project management. I came to Mwanza with the sole purpose of exploring drug abuse in the city. A lot of blood, sweat and IRB edits later, my team and I managed to pull off interviewing 480 subjects for my cross-sectional study. I came with absolutely zero expectations and I was prepared to be completely disappointed. Hope for the best, expect the worst. It turns out that the lower you set your expectations, the happier and more pleasantly surprised you will be.

However, the fact that we were able to reach out to 480 people in 6 weeks of data collection means that – while this makes for an extensive HIV risk behavior dataset – there is a terrible drug abuse problem that is completely hidden from the rest of society here in Mwanza. Just 5 minutes ago, I spoke to an aunty who told me outright, “Oh, you will find that drug abuse here is not a problem, not like in Dar es Salaam.” An American doctor at Bugando Hospital also asked me, “Wait, I thought drug abuse wasn’t a big deal here?”

I later found out that she is unaware of the drug abuse situation because she has very few patients who come in to see her who have had telltale signs of drug abuse. There are some cases that I have heard from medical students where patients come in with “marijuana-induced psychosis”, but we concluded together that was because marijuana here is often laced with heroin. I have seen this with my own eyes: kokteli (cocktail) joints are frequently made with marijuana and sprinkled with freshly “cooked” heroin. 

We also discovered anecdotally that drug users spend 80% of their daily income on drugs, thus most do not have any money to go to the hospital if they have any problems. We provided plasters, alcohol pads and Dettol for those who needed it. Further, there is inadequate access to healthcare for many people, not just drug users. Bear in mind, though, that the drug users I speak of are mostly socioeconomically disadvantaged. Many of them sleep on the streets, on their fishing boats, in the fish market located near a beautiful affluent neighbourhood. In this neighbourhood, I have seen Jaguars, shiny designer bags and a multitude of servants per home. In restaurants, a meal can cost up to 30,000TSH. On the streets where we carried out interviews, a massive plate of rice and beans costs only 1,000TSH.

The inequalities are, as always, stark and vulgar.

Surviving Macondo

As day 69 draws to an end, I realize that I am mentally preparing to return home to Yale. Yes, home to Yale. In less than a year, Yale has become a home away from home; YSPH ’15 is now officially stamped with the status of family. Yes, the countdown back to Yale has begun. 8 more days of surviving Macondo.

Macondo, the fictitious town from Gabriel Garcia Marquez’s One Hundred Years of Solitude is based on Aracataca, a city 80 kilometers from Santa Marta (where I am currently living). Macondo: Best described as “shorthand for the bizarre, magical-realist things that happened all the time in Latin America but seemingly nowhere else.” Maybe that is stretching it too far, but after living in Colombia, majorly in Santa Marta for almost 10 weeks, I know what Gabo was talking about.

So, how do I go about describing my version of Macondo? It is a daunting task: For one, Macondo, with all its chaos, is beautiful; in an attempt to translate it into words, it is very easy to portray it in negative light. Secondly, Macondo for most part is inexplicable.

Talking about my project is a good place to start. I am researching Chagas disease in the indigenous tribes of Wiwa and Kogui in Sierra Nevada de Santa Marta. From the go, it has been disaster control and improvisation with further improvisation. My not-seemingly-complex study overwhelmed us on field, and my study was reduced to bare skeleton. Yes, fieldwork is difficult. Field work in a developing country – even more so. In addition to being faced with lack of resources, logistic difficulties and the now-familiar more-talk-and-less-work, I was faced with the human factor. Human factor – it is a funny thing really. Wiwas and Koguis have a history of being at war with each other. We had our own war within the research team; all my efforts at playing mediator between the two fronts were in vain. Lack of communication, compounded with the misfortune of our manual centrifuge breaking down just one week before we started the project led to unavoidable delays. Add to that the frustration of the indigenous communities at having innumerable researches over time draw repeated samples from the kids, without any resulting treatment: it took repeated negotiations and meetings to convince them that our interests lay in treating the children. After nearly 1.5 months of just waiting and hoping, we finally made some progress. Yesterday, I wrapped up my data collection and said goodbye to the children who have become dear to me. Children who have become dear to me. My biggest achievement this summer. This internship has taught me to be kid-friendly, if not anything else!

Life in Santa Marta has been difficult. I have a room in an apartment, provided by the university my mentor teaches in. One miraculous day, I lost gas supply to the stove, only to never regain it. It has been 5 weeks. We tried contacting the concerned people at the university, turns out they were very busy fixing another tragedy: the second floor of the university building had unexpectedly collapsed. Macondo.

Water is another problem. There is water supply 4 days a week, and sometimes if misfortune chooses to strike you, even fewer days. Among more bizarre things: 1. I have air conditioning in my room (who the hell has air conditioning in a global internship???!!) 2. The AC spews off ice crystals on to my bed at night (never have I seen something so weird). Someone I know here had his bank account frozen by a random caller; apparently the caller had lost his credit cards and had given the wrong account number by mistake (how does that happen??!!). In another instance, the vegetation surrounding my mentor’s estate caught fire; some random guy had thrown a cigarette (luckily, it was not a big fire and was controlled easily).

Where is the beauty in the midst of all this chaos? The beauty of Macondo lies in the undying spirit of people here. Throw any misfortune at them, you will still find them enthusiastic, full of life, eating their big hearty lunches and dancing away every evening. Ever-smiling. Never losing the opportunity to start a conversation. “De donde eres?” has been the most common opening line for some of the most interesting conversations I have had in the past 2.5 months. “Eres muy linda” – not by way of being flirtatious, just a matter-of-factly-passing-by-compliment. “¿Tiene muchos amigos aqui? Soy otro amigo. Pero my english very bad.” “¿Te gusta Colombia?” “¿No es Latina? Como?” – Common conversations with cab drivers.

Living in Macondo, you are bound to fall in love with it. You are bound to end up laughing at the chaos and misfortunes. You are bound to leave with a little part of the undying spirit that this place thrives on. I have had the opportunity to visit some stunning places here, and have met some fantastic people along the way. There are no pictures to document many of these moments, because life happens, with or without a camera. I leave Colombia with a relatively small dataset, but a heart filled with irreplaceable memories, inexplicable experiences and lessons that no other place could have taught me. I have friends for life here, and Colombia will see me again.

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The Waste Land

“You cannot say, or guess, for you know only
A heap of broken images, where the sun beats,
And the dead tree gives no shelter, the cricket no relief,
And the dry stone no sound of water.”

 Landscape

This will be my last post on this blog. It’s going to be filled with real talk, and will probably be less logical (and more personal) than I want it to be. It’s a rough draft of bigger ideas and burning memories. You’ve been warned.

Throughout this summer I’ve been able to go on some amazing weekend trips all over KwaZulu Natal. It’s been a luxury and I’ve had some adventures I’ll never forget. Last weekend, I was barricaded in Tugela Ferry. The community went on strike.

Water and power shortages have plagued the area for a few weeks, and many of the outlying villages have reached their wit’s end. Combine no water with a lot of very sick people, and you get a recipe for death—even above the usual “death is around every corner” or “life is crazy” threshold I’ve gotten used to. There’s a one lane bridge over the Tugela River. Strikers put boulders, bricks, tree branches, anything they can find on the only roads in and out of the town. They marched down the streets and closed down the local stores.

Monday morning came and nothing changed. There’s still no water; the roads were cleared. Life goes on. Life always goes on. I went to the store and bought a half gallon of milk and that night I had a hot shower behind the barbed wire fence that protects the hospital. As I showered I almost forgot that this water might be better used for a dying person. Should I feel guilty? I don’t know. I didn’t stop showering.

Things are rough here, but not that rough. South Africa is a middle-income country, and there are enough roads, hot water, cell phones, and Coca Cola signs even in Tugela Ferry for me to have lived quite comfortably. After getting internet and power back I read up on Gaza and Israel, plane crashes left and right, and Ebola doctors dying. Hey, at least here people are organized and civilized enough to go on a strike; it’s not a war zone. At least here, there’s a hospital, not the burnt up remnants of bombed medical facilities. Living here has made me appreciate New Haven, and hearing about Congolese refugee camps has made me appreciate Tugela Ferry. It’s all relative. I’m struggling to balance gratitude and discomfort; I have no idea how to contextualize my experiences.

I suppose that means it’s time for one last attempt to paint a picture with words.

At the bottom of South Africa there is a place called Cape Agulhas where the Indian and Atlantic Oceans meet. It’s a line in the water at which two worlds collide. This summer, I’ve walked that line every day.

Tugela Ferry is the Wild West, untamed and unruly and unpredictable. Driving down the road, and you hit a child? Talk to the police. Driving down the road and you kill a cow? Run (or drive) for your life; the vigilante “livestock police” will be out for vengeance if they ever get wind of your doing. Cows are money generators; children money drains.

Tugela Ferry is also modernizing, quick—and not always in the best way. Taverns are extremely popular, as is drinking. To excess. Any evening. Then driving drunk, getting in fights, and ending up on the street. French fries are served everywhere, and Coca Cola has planted its feet firmly into the rural landscape. The intricate Zulu beadwork is being replaced with mass produced plastic; authentic “Zulu cuisine,” as someone told me, is “eating whatever you can get.” That, and fermented milk (don’t try the fermented milk).

Everything clashes. The area is developing, yet poor, losing tradition, yet gaining very little of the positives of “modernization.”

It’s easy to point out the problems, easy to throw out buzzwords. Look at me go. Easy to say that the double burden of disease is so high due to the vicious cycle of poverty and food deserts. The infrastructure needs overhauling. Financial incentives to receive proper medical care aren’t overcoming the stigma of HIV. If only we had a few more startups, a few more NGOs, a lot more money, and perhaps dialysis for the god-forsaken patients that come in with kidney failure…

Is this too bleak? Maybe. I think I’ve realized bleakness inspires me. Because while things may not be efficient, while there may be too many problems to count, while everything seems like it’s on the brink of collapse, it is better than it was before. It takes time, so much time—the smallest of baby steps and the refusal to look back. Bringing about change is the process of water wearing down a rock or two oceans mixing. It’s about dedicating your life to a cause or a person or a reason and then realizing you may never reach that finish line, or tick the checkbox, or cross off the to-do list fully. No matter. Reflect, try harder, keep going. The contributions still count None of us individually does enough, but all of us combined make up the grinding gears of progress.

Almost done here. I’ll miss it and I won’t miss it at all. I’ll move forward and I won’t look back.

“What have we given?
My friend, blood shaking my heart
The awful daring of a moment’s surrender
Which an age of prudence can never retract
By this, and this only, we have existed
Which is not to be found in our obituaries.”

-T.S. Eliot, The Waste Land

Nothern Charm and Southern Efficiency – the tale of DC

Global Access to Fun
Global Access to Medicines team in our office.: Left to right: Me, Derek, Kelley – the interns – Burcu, Peter, Steve (top) – The staff, Alberto – the fellow. Oh and notice Burcu’s book – Out Sept. 25th in US.

Washington DC is a magical place to find yourself as a policy-nerd YSPHer. Every week there are events to attend both within and outside your field, happy hours galore, and people from all different types of fields to speak with. This year has been especially awesome with futbol (soccer) games to watch at at happy hours everywhere!

So far, I’ve had quite the summer experience. Working with Public Citizen has been a dream. I’ve been writing reports, working on advocacy materials, attending meetings, and following up on different campaigns with us and many other nonprofits I’ve worked with somewhat in the past.

Public Citizen Office
The Public Citizen banner on our DuPont Circle Office. I’ve really grown to love this sight every morning. Could not be happier!

A little background on what I’m doing here. Every year around 10 million people die because they cannot afford medicines that exist in the market and could treat or cure their ailments. Public Citizen works on this issue by helping change the rules that allow medicines to be priced so high. This means not only advocating for new law and incentive regimes for research (trying to remove the rhetoric of more profits = more research), but also by working with countries to know and use their rights to obtain cheaper medicines for their people.

I’m working on projects more based on the first point there. I’m using data from health and safety, clinical trials, pricing, and others to help form arguments we’ll use to try to remove barriers to competition and lower the price of life saving medicines.

This type of work I’d classify as “incredibly DC.” Access to medicines is a very niche field, without a ton of actors – maybe 20 NGOs or so that really work on these issues. And with that, being an intern means I’m actually making an impact. I’ve also had the opportunity to network with amazing people. I’ve met public health officials from Europe, State Department big wigs, and heads of nonprofits. I even met, through a related experience, the former president of the board of the Sierra Club. This has truly been an experiment in networking and professional life, and I have to say I love it.

All in all, even though the experience has and will continue to teach me so much, I am also very happy with DC. My other DC YSPHers can probably concur that this has to be one of the best cities in the world! With jazz in the garden on Fridays, brunch on Sunday, a zoo with Pandas (don’t even get me started… haha), too many museums to count, and happy hours to boot, there’s no place like it.

Simply put: if you’re ever thinking about working in Health Policy, you’d be crazy not to find yourself in DC over the summer.

 

 

A Geography Lesson

American Samoa is actually made up of five islands; the largest, Tutuila, contains the majority of the population as well as the capital, Pago Pago, and the hospitals and clinics where I work. Aunu’u is Tutuila’s next-door neighbor. A few weeks ago my co-worker, her family, and I decided to take the trip over to Aunu’u to see what the rest of American Samoa has to offer.

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Turns out, not much. There is clearly a reason why most people live on Tutuila. We drove to the wharf on the other side of Tutuila and I saw that it wasn’t so much of a boat ride over as it was some sort of motorized raft ride. We all climbed onto the boat and zoomed across the fifteen-minute stretch of Pacific Ocean between Tutuila and Aunu’u.

Our boat and captain
Our boat and captain

When we got there the first thing we had to do was announce our arrival at the island government building, which I’m pretty sure was just somebody’s house. The man we talked to offered to show us around the island, so we jumped in the back of his pick up truck and took a ten-minute drive around Aunu’u. During this entire time everyone was talking solely in Samoan, so I didn’t realize we were taking a tour until well into our drive. I clearly have not picked up any Samoan during my time here.

If someone thought Tutuila was unpopulated and rural, they clearly have not seen Aunu’u. It didn’t take long to see the entire island- most of it is farmland and very few people live there; however, the landscape of Aunu’u is slightly different from Tutuila. Apparently there are species of sea life found only around the island, and often residents of Tutuila go to Aunu’u for its beaches. We also found a lot of quicksand, which I hadn’t seen anywhere on Tutuila.

Quicksand!
Quicksand!

Our entire trip took about four hours, a lot of which was spent driving to and from the Tutuila wharf. I’m told the other islands of American Samoa are similarly unpopulated; however, they are a bit too far for me to check this for myself. Manu’a, possibly the next most populated island after Tutuila, is about an eight hour boat ride away- farther away than the country of Independent Samoa.  While I may never go to Manu’a, the island is a source of pride for many American Samoans, since, as legend has it, this is where the first people of the world came from. Samoans who are from or who have family from Manu’a are quick to point out their direct ties with the island. Many Samoans also seem to have family in Independent Samoa, a former territory of New Zealand. Independent Samoa doesn’t seem to receive the same love as Manu’a; in fact, many people I’ve met are quite antagonistic to the country. In several weeks when I get the chance to visit Independent Samoa we’ll see if the feelings are mutual.

View of Aunu'u
View of Aunu’u

The Yale School of Public Health Class of 2015 Summer Internship Diaspora

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