Health and Community

Spring 2008 Letters Home

Geneva, Switzerland - Letter Home
January 27, 2008

Composed by IHP Trustee Fellow Casey Welch

This is how we write the date in Genève. We write manz other things a bit differentlz, too, if we happen to be touch-tzpers and simplz cannot adjust to kezboards on which the ‘z’ and the ‘y’ have been switched. You don’t realize the rather high prevalence (or is it incidence?) rate of the letter ‘y’ until faced with such an obstacle.

Yes, launching this year’s Health and Community program in a foreign country has certainly added an extra element of cultural immersion to the usual orientation of the semester, which we feel has heightened the intensity and excitement of the experience for all of us. The prevailing sentiment voiced is that we were “thrown right into the thick of things”—culturally as well as academically and socially. This challenge has been taken up with gusto and we have managed, collectively, to hit the ground running. Seven days in Geneva has felt like weeks, despite having very limited free time to explore the city. After all, just getting back and forth to classes and attempting to feed oneself in a foreign place are sometimes challenging activities that have the potential to reveal much about the behaviors, ideology and values of the surrounding community.

Take transportation for example: In Geneva, public transport is ubiquitous and efficient, as one would expect from the Swiss. But the reasons for this go beyond merely the precise accuracy of timepieces in the country; another significant contributing factor that allows trams and buses here to operate without undue delay lies in the very functionality of the Genevese society itself. A city made up of 44% foreigners representing over a hundred different nationalities and ethnic groups, Geneva’s civil society relies on consensus in order to survive. That is, by and large people respect the agreements/rules that are made as far as responsibilities and acceptable conduct are concerned. So, while public transport is not free, there is no delay in service that might arise from any system of ticket collection upon entrance because there is none. Therefore, multiple sets of doors can be used simultaneously for both unloading and loading of passengers, who are in turn able to step in quickly because they are not required to present their ticket to a person or machine. Only on rare occasions might an enforcement official ever ask to see someone’s ticket, yet we are told that the honor system in place is seldom violated.

Perhaps the reason few people attempt to cheat the public transport system is because so many of them are wealthy. Based on the shockingly high cost of food and other necessities, we assume that much of Geneva’s populace is quite well off. A personal quest for lunch that wouldn’t break the bank was a daily struggle for most of us, but one which was usually rewarded with delicious and plentiful dairy products. Fondue de fromage was a big hit (at least during the consumption- if not digestion-phase) along with creamy brie, chevre, camembert, gruyere, gouda, and other delectable cheeses. Butter, yoghurt, milk, and cream-based desserts also rounded out a week in dairy heaven. And, throwing down $2 for a tiny hand-made chocolate truffle was undeniably worthwhile.

In addition to personal experiences of eating and getting around, we explored other facets of Swiss cultural behavior more explicitly in our first assignment from the Community Health Research Methods class. In small groups, students conducted field observations and wrote up reports on their findings in areas such as mobile phone use in public space, grocery shopping, and smoking. Julia Bienstock turned the microscope on our group itself, gathering quantitative data on instances of students (and faculty) falling asleep in class (or, exhibiting “the head-bob,” as she terms it). This study resulted in a lengthy in-class analysis of the myriad possible causes of head-bobs, including jet lag, sickness, the presentation style of the speaker, etc., and how one might cope with outcomes that may have similarly numerous confounding factors when creating public health studies. For example, by focusing on the variables for which interventions are actually possible instead of trying to determine each and every precise cause of a phenomenon, observation data can be targeted to become more useful.

Our group’s first attempts at ethnography were happily not our sole source of enlightenment on the life and times of the Genevese society. We were fortunate to have been hosted by locals who direct SIT’s academic program in the city, Dr. Earl Noelte and Anne Borrel. They guided us both literally and figuratively through our Geneva experience and shared their considerable contacts with us. The task of describing the person of Earl Noelte to you who have not had the considerable pleasure of his acquaintance was too daunting for me to face, so the description here transcribed has been supplied by a particularly talented and Earl-sessed member of our group, Miss Glencora Gudger: “Earl is not unlike the Swiss Alps—majestic, refined, and awe-inspiring. Not only did we admire his chic style accentuated by his immaculately tied scarves, but also his astounding intelligence that captured us all. Earl, also an avid figure-skater, effortlessly guided (glided?) us through the Swiss streets with poise and grace. He is not only a former diplomat who has worked in every department of the UN, but also fluently converses in eight languages. Earl’s experience served us well. He was able to provide us with an eloquent and extensive overview of Genevese culture, the UN, WHO and local hospitals. Just ask any IHPer, they’ll gush about every aspect of Earl.”

Truly, a stellar array of guest speakers and site visits were set up for us by Anne and Earl, and the IHP faculty team devoted a great deal of time and discussion to making sense of it all during daily synthesis sessions. With such a diverse student body, there are inevitably some members of the group that are able to follow a given lecture with ease and ask thought-provoking questions on the topic, while others struggle with concepts and new terminology, as their studies have focused on a different discipline entirely. We see this as a great strength of our group, and plan to utilize one another’s varied knowledge bases and skill sets for the benefit of the whole learning community as the semester goes on.

After our week in Switzerland, we now move into the India portion of our program armed with a much clearer overview of the major global players in the field of public health than any of us had had before. We’ve visited with experts at the European Headquarters of the United Nations, the World Health Organization, and the Hopitaux Universaires de Genève; we’ve spoken with people who represent such non-governmental organizations as ICTSD, FOSIT, and Médecins du Monde; we’ve waded neck-deep through a veritable river of acronyms while investigating such topics as the World Bank, WHO, GATT, WTO, IMF, SAPs, TRIPs, TBTs, GATS, UNDP, UNAIDS, UNCTAD, IGOs, NGOs, BRICs, and so many more. We feel we’ve had a good dose of the top-down view of international public health and are anxious to reframe our perspective in India to the bottom-up view, something we’re confident our activist coordinators there will be able to provide!

Au revoir!

Finally, I leave you with some superlatives we came up with after some rather non-technical polling in the airport departures lounge:

Best food in Geneva: a tie between cheese fondue and chocolate

Biggest cultural faux pas committed by one of us: Our collective lack of fashion in such a fashionable city

Favorite speaker: Dr. Bernard Hirschel, Division des Maladies infectieuses, unité VIH/SIDA, HUG. This rather frank and jovial pathologist explained to us the biological mechanisms by which the virus infects, as well as various treatment regimes and their side effects, all whilst wearing this classic, long white lab coat and coming off as an incredibly professional cartoon scientist.

Greatest misadventure: That would be the failed attempt at going to France (which is visible from where we were staying) during our only afternoon off which was endeavoured upon by at least half the group. Nyon was as far as they got, where one student, who wishes to remain nameless, decided to leave behind his/her jacket (with passport inside) when they returned to Geneva. Student X, accompanied by Brooks, managed to re-travel the round-trip train journey in time to successfully retrieve the estranged document, though barely. (They caught the last train of the night coming back from Nyon, on the night before our 7:15 am departure for the flight to Bangalore…) The amusing post-script to that tale was the part where Glencora and Claire were dispatched on a high-speed mission to inform me of the situation and got on the tram going the wrong way. They then proceeded to wait, speedily, at the next stop for the tram that would carry them in the right direction and by that time ended up on the same car that the others they had left were on.

India Letter Home
January 28 - March 4, 2008

Composed by Casey Welch, IHP Trustees Fellow

When you are told your new time zone lies ten and a half hours ahead of EST, you begin to suspect that you are entering a very special sort of place. When a large, unhurried cow is found blocking the path of your vehicle in the heart of downtown Bangalore, an urban center of 6 million people, your suspicions are totally confirmed. (A seeming contradiction to the belief in the holiness of cows, these animals, lacking adequate grass in the city, are usually seen consuming piles of garbage that contain organic matter in addition to plastics of various exciting shapes. Which begs the question: just which stomach does this refuse get stuck in? And while we’re on the subject of animals in roadways, it is also not uncommon to find goats and dogs alongside the cows, with the occasional elephant or camel thrown in for good measure.) Even when you come to India with the expectation that it’s absolutely going to blow your mind, you find that it does not disappoint.

This is a land of stark contrasts: delightful aromas of onion utthapam and coconut chutney intermingle with those of burning plastic fumes; women in flowing sarees of every possible eye-bending shade stroll along dusty, littered streets where 3-foot-deep holes in the sidewalk threaten to swallow them; the addictive melody of the Bollywood hit “Om Shanti Om” competes with a cacophony of horns (not to mention the reversing-music each car seems to personalize here, not unlike the way we do with cell phone ring-tones. You know, so you can hear the dulcet tones of “We Wish you a Merry Christmas” one last time before someone backs over you.) Beyond these sensory extremes, we are simultaneously spiritually enchanted and emotionally assaulted.

Intellectually, we are “crazed out,” as one student put it. One day, five chapters into Yunus's Banker to the Poor, the Grameen Bank is discovered as the be-all and end-all of eliminating poverty. But the next day a compelling feminist guest speaker whose lecture moves us to the point of tears happens to disagree fundamentally with the very idea of microcredit, and we are left reeling. If two such eloquent, compassionate and righteous people can disagree so, then what hope do we have of figuring it all out? As seekers of truth and justice, we desperately resent the impossibility of discovering neat solutions and infallible guidelines for these confounding issues.

It would be futile to attempt to explain in this letter all that we’ve seen and learned in India, but a few dominant themes stand out. First, we gained an appreciation of the issues surrounding access to water in Bangalore by visiting low-income neighborhoods (aka slums) at dawn to see for ourselves what it looks like when 3,000 people share four spigots that only work for a few hours every other morning. Thanks to translation by our friends at the Environment Support Group, we were able to hear accounts from women who start to line up at 2 AM to be sure to obtain their water for the next two days. We then followed the path of the water to its ultimate destination at a secondary wastewater treatment facility, which is a sort of dubious open-air sludge Jacuzzi, as we contemplated the fact that 80% of the problem of water contamination in India is due to untreated domestic human sewage. While enjoying an outdoor classroom at the hotel where we concluded the program, we had to pause five or so times for the noise from the large truck engines laboring up the hill—carrying our water. Meanwhile, at the government Ayurvedic hospital we’d visited in town, we were informed that they were only able to function at half their 100-bed inpatient capacity due to a shortage of water. Some students opted for a bucket bath that night. Others considered it and took a blissful hot shower instead. But they tied this self-awareness into our discussions of public health interventions which revolve around changing people’s behaviors—we understand now that knowledge alone is often insufficient.

Along with access to water, we looked at access to healthcare, both in urban Bangalore and in rural, tribal areas of Karnataka and Tamil Nadu. After receiving a lecture on how the Indian healthcare system is supposed to work, which sounded pretty reasonable in theory, we had a panel discussion with some working poor about where they go when they fall sick, and what their experience is like. The panel consisted of a young auto-rickshaw driver (who worked two other jobs besides, catching intermittent naps totaling roughly four hours of sleep per day), an old ex-farmer, a house maid, and a security guard. The phrase “dehumanizing treatment” appears boldly in my notes. In theory, those who fall below the poverty line—set at 10,000 Rs per year, about $250—are supposed to receive a “yellow card,” which entitles them to free healthcare. Ignoring the fact that a significant percentage of farmers (coincidentally?) earn about 10,500 Rs, or $262 per year, this yellow card sounds like a good idea. In reality, the difficulty involved in obtaining the card deters many who would be eligible, as they would have to miss precious income-earning workdays to wait in line to get it. Even those who obtain the card have difficulties, as it only covers the official, legitimate costs of treatment. As we learned from this panel, there exists an informal but insidious system of “tipping” which must be followed or service is denied. Tips must be given to the person who registers you, to the person who cleans the toilet, to the person who pushes your wheelchair. You must tip to get a decent bed. God forbid you don’t tip your nurse immediately, or she will be intentionally ungentle when finding a vein—or nerve—with her needle. As we were told by a former “Vigilance Director,” of the ten sectors of government for which corruption is analyzed, healthcare is second only to the police, and there are even stories of people being refused urgent life-saving procedures until the doctor’s bribe is paid.

Outrage began to percolate. Dr. Tekur informed us that only 1.3% of India’s GDP is used for healthcare. We also heard that thanks to globalization and Monsanto, 18,000 Indian farmers are committing suicide every year. (That’s one every half hour or so, and those who don’t swallow pesticide are leaving the land in droves.) Madhu Bhushan, a woman’s rights activist, told us that every day in Bangalore, three women die of unnatural causes within the institution of marriage. And here’s the thing with IHP: we could have read these disturbing statistics from the comfort of our college libraries; instead, we learned in our Indian classroom that 60% of women here are anemic and then accompanied a midwife on her rounds and actually saw the yellow eyes and weakness of each woman, in the flesh. We’ve all read before that sanitation and dysentery are major problems in poor areas, but it’s suddenly a lot more real when you walk past the slum a few blocks from your upper-middle-class homestay and actually see a small child experiencing his diarrhea, right there on the sidewalk, outside the atrociously maintained public toilet block. Bearing witness to people living out these statistics cultivated the sort of empathy that will keep us from giving up when problems seem too daunting.

Thankfully, after weeks of grappling intellectually and emotionally with the health challenges facing India’s poor, we were able to spend several uplifting days doing case studies of projects which are managing to affect positive changes in areas that previously lacked adequate healthcare. The personal commitment and dynamism of these projects’ founders inspired us all and provided the glimmer of hope that we needed to go forward. Each has a story as remarkable as the next, but here is one example:

Dr. Sudarshan was a successful urban physician who chose to move to a tribal area that had no access to western medicine. He lived in a small hut while he visited each family in the region, having tea or dinner and chatting with them about everything except health. He learned the ways of the community and slowly gained the people’s trust. After a few men with severe wounds allowed him to suture them, people realized the efficacy of his healing techniques and began to allow him to treat other health problems. He proceeded to eradicate leprosy in the area, and is well on the way to doing the same for polio. In the course of his work, Dr. Sudarshan listened to the community members and altered his own outlook on the appropriateness of care as dictated by the western system. For example, he realized that it is actually for the doctor’s comfort—not the mother’s—that women deliver lying on their backs on a table. In this tribe, women prefer to squat and hold a rope. So there is an option for this at his hospital, which has grown to hold 20 beds and serve many thousands of Soliga tribals. He also realized that the health of a community is inseparable from other aspects, such as education and economic self-sufficiency, so he started a school from which 4 of the 6 students in the inaugural class now hold post-graduate degrees.

While we were exhilarated and heartened by all of our case study hosts, not all of our confusions were put to rest. People in each of these places, in their wisdom, adamantly refuse to hold their methods up as models for successfully aiding communities in need. A cookie-cutter approach is inherently flawed, as every community will have its own unique set of issues and cultural norms which will determine the success or failure of any attempt to intervene. For example, we learned from the Karuna Trust that it is tricky to implement a health insurance scheme when the very concept of planning for the future is absent from the culture. Likewise, it is hard to get proper consent for care of a pancreatitis when the patient you are explaining it to is not aware that he or she even has a pancreas. We are realizing how important cultural understanding really is when it comes to communication, which begins with knowing what the right questions are before seeking answers. To elucidate this point: when given an opportunity to ask us any questions of their choosing, a group of tribal women who had been trained as nurses wanted to know, “What crops do you grow?” We are leaving India with a whole new level of humility as we accept the fact that we are ignorant of many things we may not even be aware we are ignorant of. In a way, I think this is the most valuable knowledge one can gain.

Wow, this is way too long already and I haven’t even gotten to the part about the wild tusker charging us during our journey to Wayanad, when we realized why people dig massive trenches and erect electric fences around their land… Or the bit where we got a flat tire on the way to the Gurukala Botanical Sanctuary and walked the last mile or so, meeting a tea farmer along the way and stopping to chat. He mentioned the price for his tea has been falling, and when a student asked why, he responded with one heavily accented five-syllable word: “glo-ba-li-za-tion.” I didn’t tell you about holding a morning yoga class outside our classroom and having a random dog walk up, stand in the circle, and proceed to stretch himself in an exaggerated fashion… Or the time when we did the hokey pokey with a group of tribal women and life became at once sublime and surreal… I never got to describe our traditional market scavenger hunt, or the silkworm auction… Or the way each virus is represented by a goddess and has its own temple (like the plagueamma and AIDSamma temples)… Or about how the waiter at S.L.V., due to strong personal aesthetic objections, wouldn’t let Michael eat naan without gravy. As in refused… Or the fact that Leo Saldanha, our coordinator, could not be with us for the last two weeks, due to legal action against him as a result of his involvement in a protest to save children’s artwork from bulldozers… Or our visit with the tribal community of Kanavu who celebrate life each night with song and ecstatic dancing, which they managed to elicit from every last one of us...
And don’t even get me started on the food. Oh sweet mercy, the food. This deliciousness was provided, most often, by our incredibly gracious host families, who not only fed and housed us but who also served as invaluable cultural brokers in the wilds of Bangalore. They taught us how to cross the street, how to eat with one hand, how to wear a saree (or a doti, aka manskirt), how to arrange a marriage (applications are involved), how to play cricket, how to consume pani puri, and how wonderful Indian people are. We will miss them, along with Leo, Bhargavi and the amazing staff of ESG.

We thank them all, and we thank you, our families and friends back home who support us from afar.

p.s. In the spirit of hope, I’d like to leave you with a couple of quotes from Swami Vivekananda, or, as some students call him, “the man”:

“Give me a few committed youths, and I will change India’s destiny.”

“Be not afraid of anything. You will do marvelous work. The moment you fear, you are nobody. It is fear that is the great cause of misery in the world. It is fear that is the greatest of all superstitions. It is fear that is the cause of our woes, and it is fearlessness that brings heaven in a moment. Therefore, Arise, Awake and stop not until the goal is reached.”

p.p.s. Please check out the wonderful work being done by some of our case study hosts, coordinators, and guest speakers here in India:

Letter Home from China
Student observations compiled by Casey Welch, IHP Trustees Fellow

Driving into Beijing from the airport we are greeted by uniform rows of trees lining the roadside, straight as fences, and I wonder if I’m looking at a metaphor. Are the residents of this famously Communist nation forced into similar submission by a controlling government that allows no space for the organic chaos of nature or dissent? After a few days in the city I seek refuge in a park, hoping for a green softness to take the edge off the glass and metal skyscraper cityscape and what do I find? The park is essentially paved. As my reactionary indignation begins to gestate, I look to my left, to my right, behind me, and realize: I am surrounded by wheelchairs. The elderly are everywhere—wheelchairs cluster around the mah jong tables, other folks are using the primary-colored upper body public exercise equipment in the corner, more are tracing slow circles around the fountain with their walkers. My indignation retreats sheepishly as it dawns on me that it is the very paved-ness of this park that makes it a place that can be enjoyed by China’s disproportionately large aging population, --million strong. Oh, the lenses we wear.

Recognizing how easy it would be for me to write our whole group’s “letter home” from China solely from my own terribly personalized perspective, I’ve decided this time around to share the words of others on this wild ride we call IHP. Here is what one particularly eloquent participant had to say:

"Beijing is new and massively designed: every boulevard as wide as a freeway – 3 lanes in each direction plus another wide lane for bicycles, lined with enormous brand new high rises mile after mile after mile, huge emporia, billboards, luxury apartments, university campuses, subway systems. It's also shiny and clean, if you ignore the strange and menacing forms of air pollution: the noxious, choking fogs, the winds blowing toxic sandstorms from Inner Mongolia, the strange grey construction dust that covers everything inside the house even with the windows closed. And yet, I am told, this is nothing. This is a 60% improvement over 10 years ago (gov't statistic, hmmm). In preparation for the Olympics most factories around the city have been relocated elsewhere, subway and bus tickets have been halved to encourage public transit use, and older diesel trucks are only allowed into the city at night.

Great expense has been taken to make the city what it is – a modern, world-class city – and everyone is terribly proud and excited about the future. This summer’s Olympics are the crowning achievement -- international recognition of China's entry onto the world stage as an equal player. All signs of poverty have been swept away somewhere, there is not a beggar to be seen in Beijing, not even a migrant worker in torn clothing, and yet most of China's citizens outside the city live near the poverty line of $2/day…"

Others had sunnier outlooks, of course. Some highlights of home life with host families and exploration in the city included: Aleefia and Nikki teaching their parents the “Soulja Boi” dance, Rachel asking if she could wash her hair and her Mom taking it upon herself to wash it for her, Brooks and Michael sharing a bed with pink pillows that say “Love Story,” the boys teaching English to local teachers who sang back to them “You Are My Sunshine” and having the story and photo printed in Beijing’s largest daily newspaper, Kyle being told her kite was sub-par before being given a sweet one and taught to fly it by old men in the park, Hoi See eating 40 handmade dumplings in one sitting, one of our guest speakers serenading us with a classic Chinese ballad after her lecture, Dana learning that the literal Chinese translation of AIDS is “the loving capitalism disease,” Brooks coming late to tai chi class because he had to help push the broken-down public bus, the tai chi class witnessing one neighbor’s daily goose-walking routine, Sando and Nikki discovering that there is a multi-tiered pricing structure for SIM cards depending on the phone number’s degree of auspicious vs. inauspicious numerology, Rachel realizing after an exhaustive bookstore search that the Lonely Planet’s Beijing guide book is actually banned in mainland China, and so many more…

I think all would agree that some of the most significant learning here in China took place during case study week, when groups of 5-9 students were provided with a short list of contacts and a couple of English-speaking Chinese college students to act as translators and were sent off on their own to investigate different topics of interest. Here are a few words from each:

“With my group, I got a further look into senior care issues. We traveled to a local nursing home where we sang and were sung to by lively, smiling residents, and later interviewed a popular journalist for an elderly health newspaper and a medical research professor about the difficulties the country is facing as it increasingly becomes an aging and elderly society. We also took a trip to a nearby park one morning and observed older community members doing Tai Chi (some groups with swords and fans and practicing Chinese calligraphy on the cement sidewalks using an enormous paintbrush and a bucket of water. The data we collected affirmed that China’s shifting demographics will amount to a huge problem in the very near future. The government’s political persistence with the One Child Policy is beginning to leave more and more of the nation’s elderly without enough family support to provide for their needs (a 4:1 ratio of grandparents to grandchildren.) Additionally, the opening of China’s market to the global economy has introduced a sense of capitalistic individualism which has done everything from pulling younger generations away from their families to pursue their own lives and careers, to increasing the privatization (and thus, the cost) of health care facilities and services, to introducing a drastic and unforeseen inflation in the price of everyday necessities. With policies that demand a decrease in family size for population control, and modernization which undermines Confucian emphasis on familial piety in society, traditional values are being replaced with a new-age way of life that leaves the elderly behind.”

“At a particularly poignant field visit to an NGO which advocates for migrant laborers’ rights, we learned that conditions in China’s factories can be brutal. For example, when it gets close to the Christmas shopping season, a worker’s shift might be 5 days long, or until s/he passes out from exhaustion and is quickly replaced on the line by another laborer so that all the eyes can be sewn onto the teddy bears that will unwrapped by children overseas on Christmas morning. This moving slideshow piqued the interest of a handful of us who were eager to study the issues around occupational health of migrant workers as our case study. We came up with a list of questions and hit the streets with our translators, finally interviewing about 30 migrant laborers in professions ranging from construction workers and maintenance workers, to shop keepers and restaurant owners. As you can imagine, we received quite a range of responses. Basically our conclusion was that the term "migrant workers" comes with a slew of false expectations and preconceived notions that do not hold true in Beijing. Most migrant workers here said that their situation was "so-so" and they "accepted reality." While many of our respondents affirmed that they were always paid on time and all of them were legal and had a permit to be living in the city (and that this was actually an easy process), others noted that very little consideration is given to health when applying for jobs, and few were covered by health insurance. While some were reluctant to speak to us, others were thankful for our research, happy that someone was taking an interest in the issues they were facing.”

From the group who studied the impact of Traditional Chinese Medicine on reflexology and its market: “Unaccustomed to the freedom granted, we approached case study week with both fear and excitement—would people censor their responses? Would we be able to arrange hospital interviews? All these fears were soon allayed as people eagerly talked to us, completed our surveys and agreed to interviews after chance meetings. While some interviews were difficult to get, such as the one conducted at the Beijing Reflexology Department, after an hour of bureaucratic clearances we had an enlightening conversation with the doctors about reflexology and the changes it’s undergoing. Reflexology, which is the physical act of applying pressure to the feet and hands, is based on a system of zones and reflex areas that reflect an image of the body on the feet with the premise that such work effects a physical change on internal organs. Case study week definitely had its perks—especially employing the embodied approach (i.e. getting a reflexology massage!)”

“Our case study on the One Child Policy was a constant but intriguing challenge. We ran up against much reluctance to voice opinions about the policy and were often met with blank stares when we asked about the policy’s impact on family health. We agreed with our informants’ answers that most of the changes in health were highly influenced by changes in socioeconomic development, but we continued to push to find out how the one-child policy changed the scene in China. We tried to dig deeper with less straightforward methods, such as asking people to draw what “family” meant to them. Though one person told us “I don’t want to draw people, I want to draw furniture!” we collected a very interesting assemblage of drawings, some representing one-child families, some still showing two-child families, and others interpreting the prompt in metaphoric terms. Since we can’t show you their sketches in this letter, here are a few quotations we gathered:

“I ate one meal a day—without meat—so that my 15-year-old son could change his cell phone.”
Q: “How long should the One Child Policy last?” A: “That’s the government’s business.”
“The One Child Policy gives parents more time for romantic life.”
“There is more time to be a weirdo… more time to talk to myself.”
“We sacrifice for China and for the world.”
“The U.S. has a large population and will have to enact a similar policy.”
“If there was no One Child Policy, China would eat all of America’s rice.”
“I wouldn’t have had a second child if the first was a boy… A second child is a burden.””
“During our China case study we examined the role of various organizations in prevention of HIV. Organizations that we visited were governmental and nongovernmental and ranged from international (Medecins Sans Frontières, Red Cross, etc.) to local. We examined the barriers that organizations faced working in China, the main ones being stigma towards HIV, lack of support from the Communist government, and lack of funding. We also learned about various programs that organizations had implemented, including fundraising and education for AIDS-affected children, outreach and education in gay bars, and hotlines for AIDS-related information. In the process, we ourselves ended up helping formulate ideas and strategies for the PTE organization (Prevention Through Education) that focused on educating school teachers. Our major finding was that organizations fall on a spectrum with two dimensions: government to NGO and domestic to international, with each facing its own unique challenges depending on its specific position yet also all having to overcome the same challenge of working within the Chinese context. This was a valuable learning experience which we feel will positively affect our future endeavors in the field of public health.”

“My case study group aimed at uncovering the causes of the relatively high abortion rate in China. In the short time available, we collected data regarding the cost of various types of abortions and the details of the national sex-ed curriculum, but in reality it was not the information gathered that enriched our education so much as the process of investigation itself. How unique it is to be able to have conversations about abortion with elderly Chinese women in the park, university students between classes, nurses who think you’re considering an abortion yourself, or a doctor at a community health clinic. I never thought I’d be sneaking around the abortion wards of public and private hospitals in Beijing, or that I’d have a dozen old women surrounding me in a park, all speaking to me in Chinese about their thoughts on abortion and pre-marital sex. It’s these simple and everyday interactions that have become so common on our travels, but still leave me in awe at the end of the day. Partly because of the taboo around abortion in the U.S., we were hesitant at first to approach people on the street about this subject, but it was being pushed beyond our comfort zone that made this experience so valuable.”

* * *

Looking back on what I’ve compiled here, I realize that China does not in fact speak with but one voice, just as our students do not. And in light of the government’s concerted efforts to prevent any deviation from the well-ordered party line (or the fastidiously planted line of trees), that is remarkable. This is, after all, an incredibly vast country that has somehow been shoe-horned into a single time zone—that of the capital. This is also a nation where, in 2007 alone, 200 million pieces of “harmful information” were removed from the internet by a team of 35,000 censors staring at computer screens around the clock in what my colleague refers to as “The Great Firewall of China.” The news that is considered fit to print here is not only printed but is posted on boards behind glass in front of most parks and many other public spaces, just to make sure cost is no barrier to the people getting their daily dose of official spin. But somehow, despite all that, the Chinese manage to view their world from 1.4 billion individual perspectives, many of which are highly critical of the things we take for granted as right and true from our vantage point in the “democratic” West. On the whole, I believe we are all leaving China with a richer understanding of the concept of perception than we arrived with a month ago.

IHP Health and Community
Letter home from South Africa

Composed by Casey Welch, IHP Trustees Fellow, on May 9, 2008

Dear family and friends of IHP Health and Community program participants,

I am tempted to just tell you all that there won’t be a “letter home” this time, since by the time you get this we’ll be back, and instead of reading my version of events you should find a comfortable sofa, put on a large pot of tea, take the phone off the hook (or at least set it to vibrate) and settle in for a long, multi-layered rendering of the IHP experience in South Africa as told by the person who has returned to you. But surely you will do this anyway, and I am just searching for an excuse not to have to attempt the impossible: to do justice in a few pages of text to the profound journey we have just completed. Of course, our 33 students were recently asked to accomplish just as daunting a feat for their final projects—3D models of globalization’s effects on health and community—and they succeeded with flying colors, so I suppose I shouldn’t cower from the task of a little letter-writing. I feel I should mention at this time that one of those final globalization models evolved into an epic installation/performance art piece incorporating a near-assault on every sensory organ and requiring scavenging trips to the scrap-metal yard, more than a Honda-ful of materials (buckets, pipes, boards, wire mesh, cardboard, a life-sized fist made of twine, sand, rocks, plants, incense, a rusted 55-gallon Shell Oil drum, light fixtures, Nutella, and an incredible “book” whose every-textured “pages” presented perhaps all of the various aspects of globalization’s weighty reach). This piece even had a gravity-fed water element, a killer soundtrack, hand-stenciled uniforms, and an interactive response area. It is about as hard to describe as our semester, so I ask that you refer to the attached video file.

Hmm, it appears I have just begun at the end, which is perhaps not the most sensible way to explain to you what we’ve been up to this past month. Let’s rewind to the beginning of our South Africa program, which brought us to Zwelethemba, an all-black township of about 22,000 people that played a significant role in the anti-apartheid struggle in the 1970s and 80s (and is the TB capital of the world!?!) The township’s physical location is in the Western Cape region, only about 90 minutes away from Cape Town by bus, but about a world away from Cape Town’s dazzling display of the “good life” that mesmerizes new visitors at their first glimpse of majestic Table Mountain and the slick, modern properties overlooking the sea. Californians get a distinctly South Central LA vibe from Zwelethemba, whereas the gorgeous, pastel-colored administrative capital to the south is reminiscent of San Francisco. Our arrival in Zwelethemba happened to coincide with school vacation, which coupled with a fairly high rate of unemployment and fantastic, sunny weather led to a preponderance of folks simply hanging out in front of their houses and in the streets at all hours of the day and night. Loud and lively music emanated from every home: hip-hop, reggae, and traditional African rhythms made up the festive soundtrack to one’s daily walk to the far end of town for classes at the local library—a walk which was most often accompanied by a half-dozen neighboring children vying over prime hand-holding positions next to IHPers en route. After a cold, grey, and nearly childless month in Beijing, the new mood amongst the group was positively buoyant; a majority of us mark Zwelethemba as one of the most enjoyable weeks of the semester.

It was not only the dancing, barbecuing, socializing, lively church services, and hair-braiding by little hands that made us fall in love with this community; we were also captivated by numerous field visits and enlightening discussions with panels of locals who generously shared stories of apartheid days, their experiences with accessing the healthcare system (which is free, really) and other serious issues. Our once-sketchy knowledge of recent events in South African history was quickly brought up to speed by watching an excellent documentary on apartheid, reading the published memoirs of our host Thembsy Ngcechwe who had been quite an active organizer in her day, and talking with other host families whose stories of hardship and hard-won victories both shocked and inspired. I for one didn’t know how to feel upon hearing about the peer pressure that accompanied the 1976 children’s struggle. Apparently, when the bands of youth came around to gather for the protests, worried parents could not try to protect their children by hiding them inside the house because if they did so then the next day those same young freedom fighters might put two tires around your child, douse them with petrol and light them up. Yet at the same time, and continuing to this day, doors in Zwelethemba are rarely locked, and any random child wandering into any house will be fed and cared for without question. If you asked an IHP student how many kids lived in their homestay, the answer was probably, “I’m not sure—at least two but sometimes more like seven.” Community ties and networks of extended families run deep here.

Site visits in the area included a trip to a local sangoma (traditional healer who treats everything from stomach cramps to court cases) and to a workshop for the blind and an institute for the deaf. Some students experienced an intimate form of communication with a man who neither hears nor sees, but can understand speech by placing his hands on your lips and vocal chords. We were later treated to a tour of the Rooiberg winery as well as the massive De Doorns grape farm by its charming Afrikaaner owner who let us ride in the back of his pick-up and gave us all a package of delicious export-quality seedless grapes to take home. His claim that the pesticide usage on his land was not at all harmful if proper precautions were taken was later balanced by the views of a panel of grape farm workers back in the township. Those women neglected to feed us grapes, but described for us the conditions in which they must work, including having no provision for maternity leave (if they get pregnant “it’s not the farmer’s problem,”) not being allowed to use the bathroom for half the day, not being paid for sick days, suffering from ailments of the chest from constant inhalation of sulphur in the packing house, and having to strip off all their clothes outside their houses upon coming home from work if they have an infant inside, on account of the chemical residue’s damaging effects on babies.

Zwelethemba residents also proved to be valuable resources outside the classroom, when IHPers undertook a community health survey of new mothers as part of the public health course. With the help of Xhosa-speaking homestay family members, students got first-hand practice at conducting public health field research, and with Karunesh’s expert guidance they presented a quantitative analysis of their survey results. Their posters and graphs were impressive, but I preferred their stories of the actual interviewing process—particularly Emma Lawrence’s, who was greeted at the front door by a completely topless interviewee. She was reassured that yes, she was expected, and this was a perfectly convenient time to do the interview, so Emma proceeded to ask the entire series of questions to a woman who was wearing nothing above the waist. {Emma's field research continued to be memorable during case studies a few weeks later, when she, Allison, and Sando arranged an interview with the host of a health-themed show for 98.2 FM Radio Zibonele in the township of Khyelitsha. They were to be guests on the Saturday morning show, but five minutes before airtime there was still no sign of the host. One of the girls wondered aloud, “If Joyce didn’t show up and we had to host the show, that would just be so IHP.” Which, of course, it turned out to be. The radio debut of the child health case study team ensued, with kids calling in with questions about nutrition as well as requests that the Americans sing them “Happy Birthday.” Fortunately, our omniscient country coordinator Chris Colvin got this all on tape.} In addition to their maternal health surveys, students also got real-world public health experience when a 24-hour ailment marked by intense nausea and vomiting hit the group and rapidly managed to afflict half of its members. Students charted the progress of our mini-epidemic (noting its speed of dispersion and observing that its scope included 70% of households) and attempted to trace its possible source and mode of transmission.

The move to our final homestays in Cape Town’s Muslim Bo Kaap neighborhood provided students with an inside look at so-called “coloured” families’ attitudes toward South Africa’s governance and social structure. Most sensed a tangible resentment towards the ANC from their city hosts, whereas citizens of Zwelethemba had tended not to complain about current politics. Smells of Cape Malay cuisine, sounds of prayer being sung from the nearby mosques, and sights of bright multi-colored paint jobs on every Bo Kaap dwelling provided a feast for the senses that may (or may not) have made up for the emotional challenge of living in a city where muggings are all too commonplace. Cape Town, while beautiful and populated with a diverse citizenry enjoying a high quality of life, is tainted by an undercurrent of fear. The collective perception of risk dominates the psychological landscape: though the city is not under any actual siege, it is a place where electric fencing and expensive security systems are the norm, where no one leaves anything of value visible in their cars which never have their windows down and which lock automatically after starting up, where one must carefully plan every trip to the ATM, where most people won’t walk alone at night, and fear of having one’s property taken away by some armed predator pervades daily life. Country-wide it is commonly accepted by everyone, including police, that red lights and stop signs need not be heeded after dark so as to reduce the risk of car-jacking. (As for the 2008 Health and Community students: other than one minor break-in, we are pleased to inform you that our precautionary lifestyle adjustments—i.e. constant vigilance—paid off and we ended up making it out of Cape Town completely unscathed!)

Our proximity to the University of Cape Town afforded us the opportunity to receive lectures from some fascinating academicians. Dr. Andrea Rother opened our eyes (literally) to issues around pesticide policy and labeling that many of us had never considered before. She told us about the bureaucratic challenges created by the lack of communication between different branches of government, such as in the case of lindane, a substance found to be so harmful that it was banned by the Department of Agriculture for industrial application but still remains the key ingredient in a lice shampoo commonly used on children’s heads, because this product falls under the jurisdiction of the Department of Health, not Agriculture. Dr. Rother engaged us in a revealing experiment whereby she passed out samples of the new labeling symbols for dangerous chemicals and asked us to indicate what we thought they meant. We were also asked to rank order what we believed to be most to least hazardous designations in South Africa’s color-coding system for pesticides, and more than half of our college-educated group mixed up the order. It is now pretty easy to empathize with the possibly illiterate population that must actually use these products, especially considering the added fact that 12% of males here are potentially colorblind. Another favorite lecture came from Professor Howard Phillips, whose historical perspective on epidemic disease helped us understand the current trends of AIDS and TB in another light. (Michael Kolbe’s journal entry recalls Professor Phillips as “a totally sweet man who confidently rocked the overhead projector in an age of crazy technology.”) He made us realize that just as we are undertaking a comparative study of HIV/AIDS along a spatial axis by traveling to Geneva, India, China, and South Africa, that likewise there is much to gain by looking for patterns in epidemic disease in one country along a temporal axis. Certain elements prove constant across time and space. For example, every major epidemic is accompanied by society’s tendency to want to assign blame. When the plague hit in 1901, black harbor workers were first to contract it since it spread via fleas on rats coming off of ships. Blame affixed, infected blacks were forcibly removed and isolated into the earliest South African townships, and even after the plague subsided they were not permitted to leave these areas. In the early phases of the AIDS epidemic in the 1990s, the government stopped accepting blood donations from all black people because they were seen as more likely to have HIV; meanwhile blacks were calling AIDS the “Afrikaaner Invention to Deprive us of Sex,” and therefore deprive them of the ability to increase their numbers and power. Professor Phillips also demonstrated how lots of young men on the move provided the means of dispersion of nearly every South African epidemic, with the combination of migrant workers and rail travel being a particularly potent means of spreading Spanish flu as well as TB and STDs.

And now, you knew it was coming and here it is: the obligatory HIV paragraph that no letter home from a public health course in South Africa can be without. While HIV/AIDS has been a theme of study intentionally incorporated into every country we’ve visited, nowhere does it manifest itself quite so prominently as here in S.A., where the adult prevalence rate reaches 20%. The virus’s epic proportions actually make it much easier to talk about with locals than it was in India or China—perhaps too easy, as illustrated in one group’s visit to a men’s HIV support group called Khululeka in the community of Gugulethu. During introductions, one man gave his name and then said that he did not have HIV, whereupon Phumzile, our coordinator’s right-hand man and all-around sweetheart, interjected to finish the joke: “Yeah, he has AIDS! Ha ha! He’s in the final stage!” Good-natured joking such as this may be precipitated by the sheer omnipresence of HIV here, or perhaps it owes to the fact that the triple combination therapy antiretrovirals in wide use have been so effective in keeping people alive that AIDS seems to have transitioned from a fatal to a chronic condition. Either way, this topic that can be considered semi-taboo in other locations is firmly entrenched in everyday discourse in South Africa. The verb “condomize” has made its way into the vernacular of Zwelethemba, where when someone suggests that you “take some sweets” they are referring to the bowl of condoms on the counter. During a speech for Human Rights Day by the former mayor of Cape Town to a secondary school in another township we visited, Nomaindia Mfeketo spoke about freedom and HIV practically in the same breath—reminding the students that if they want to be president, or a lawyer or doctor, that they must be alive to do so and that they should protect themselves. The murmured reactions from the thousands of teens crowded into the auditorium made it obvious that they hear this message every day. But just because there do exist groups like Khululeka and the Treatment Action Committee wearing bright, bold “HIV Positive” T-shirts, and a church in Khayelitsha that has a banner reassuring people that they are still brothers and sisters in Christ no matter what their HIV status, and that the 74-year-old woman sitting next to you will tell you she is HIV+, does not mean that stigma has been erased. In fact, HIV+ mothers (who are provided by the clinic with six months worth of free infant formula to reduce the risk of transmission via breastfeeding) will choose to breastfeed when in public because bottle-feeding is tantamount to disclosure. Many women are terrified of the repercussions of even going in for testing, having heard countless stories of men beating or abandoning their women for tarnishing the couple’s reputation in the community. A woman might travel a hundred kilometers to a community where no one knows her in order to keep the clinic visit confidential. Going beyond didactic public health campaigns that order people to “abstain” or “be faithful” to ones that instruct them to “condomize” will still fail to be effective if people (especially women) cannot advocate for safer sex with their partners. Females are 5% more likely to be infected than males, and in some parts of the country the prevalence rate for women is as high as 60%. A group of journalists in their twenties offered us this startling perspective when asked what they saw as the biggest problem facing Zwelethemba: “AIDS. And it’s not a problem of awareness. People have the education but they are just arrogant. They don’t want to die alone so they go around infecting others.” Fortunately, we then had Chris’s class on behavior change to sort that all out for us.

For a bunch of budding doctors and public health practitioners, I suppose it is a good thing that we’ll be returning home knowing that there is much work to be done. Over the course of this semester we’ve been disturbed, humbled, shocked, confused, awed, and filled with hope in turns, and all of us acknowledge that we have gained far more than we have given back. But I hope that those who have helped us along the way enjoy the knowledge that they have opened eyes, touched hearts, and kicked every last bit of apathy out of this particular group of 33 American students from 22 different universities (picked to travel the world….) To Phumzile, Thembsy, Chris and family, and all of our guest speakers and gracious hosts, we thank you for bringing South Africa and all of its issues alive for us in a way that other travelers barely glimpse as they flit from backpacker hostel to wine tasting to wildlife center. Take it from me, I’ve been doing just that for a week now and the contrast to the IHP experience has reminded me just how special this program is. Reports from other members who have extended their travels in Africa confirm that collectively we now have a hard time looking at tourist attractions in quite the same way as everybody else. (There is now a tour guide in the Kango Caves who will be submitting a complaint to the province’s “Public Protector” that the working hours of employees at the Caves are unconstitutional.) So thank you all, students and faculty, and those of you at home who have supported us—it’s been quite a journey.

All the best,

Casey Welch, for IHP Health and Community Spring 2008

p.s. We had lunch with Archbishop Desmond Tutu. And pounded it out.

IHP office interpretation for those not on the program:
According to the IHP Health and Community group, “pounded it out” indicates a sort of modern-day handshake which simultaneously conveys deep respect and jocular familiarity.

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Credits: 16

Duration: Spring, 16 weeks

Program Sites:
United States, India, South Africa, Brazil

Prerequisites: None. Coursework in public health, anthropology, biology, or related field recommended.

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