Oxford Public Health Magazine Issue 5

The Magazine of the Oxford Public Health Global Network

Promoting Public Health Perspectives in Schools Lessons from Disasters

August 2016

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What we do to benefit Public Health We promote careers in public health, increase public health capacity worldwide, and integrate public health perspectives into the wider workforce, including but not limited to journalism, radio, television, film, law, policy, architecture, urban design, engineering, entrepreneurship, healthcare and academia.

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Schools The Teacher Matt Cone

Becoming a Global Citizen Ashish Premkumar

Surprising Narratives Kristen Lee

Rural Health in India Juliana Sierra

Public Health Entrepreneurship Eliza Filene

Challenges Occupying the Minds of the World’s Great Leaders

Disasters 7

Tweeting Ebola Tatiana Vorovchenko

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Using Local Networks

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Helping Decision-Makers

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A Career in International Humanitarian Response

Emily Lawrence & emBOLDen Alliances Claire Allen, Mike Clarke, Jeroen Jansen

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Professor Anthony Redmond OBE

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Bram Sable-Smith

Leadership Development Nadège Uwase

The Place of Books Allison Coffelt

Transforming Youth into Civic Activists

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Anne Flaker

Confessions of an Armchair Activist Glory Liu

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www.truehealthinitiative.org

LIFESTYLE AS MEDICINE. Our vision is a world where all people live long and healthy lives, free of preventable chronic disease.

Our mission is to create a culture free of preventable chronic disease by demonstrating and disseminating the global consensus on the fundamental, evidence-based truths of lifestyle as medicine.

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Matt Cone

Matt Cone teaches social studies at Carrboro High School--a diverse, progressive public school located within 15 minutes of booth the University of North Carolina and Duke University. Matt and his students reach out to guests from near and far in their effort to gain a better understanding of global health and global poverty.

Over the past five years, Matt's students have been fortunate to engage in dialogues with Jim Kim, Paul Farmer, Esther Duflo, Howard Buffett, Jeff Sachs, William Easterly, Ophelia Dahl, Dan Ariely, Peter Singer, Paul Collier, and many more. Matt studied Political Science as an undergraduate at UCLA and he received a Master's degree in Curriculum and Instruction from the University of WisconsinMadison.

“I am a better teacher when I am learning along with the students.”

What's your class and club all about?

Who are your students?

I teach a diverse public school, Carrboro High School (CHS). We have a higher percentage of African American students and Latino students than do most schools in our state and we have a significant number of students who are newly arrived from Burma. Despite this diversity at our school, the Global Issues class was almost entirely White when I first started teaching it six years ago. Over the years, I have been able to increase the enrollment of students of color in the class.

I teach a Global Issues class that contains an explicit focus on global poverty and global health. Rather than merely having students read articles/books and watch films, I try to connect them with speakers who have firsthand experience working on the issues that we study. Over the years, we have been fortunate to meet in person with World Bank President Jim Kim, Dr. Paul Farmer, Dan Ariely, Howard Buffett, Esther Duflo, William Easterly, and many more.

Similarly, we have Skyped with Muhammad Yunus, Laura Bush, Jeff Sachs, Colin Powell, Paul Collier, Chris Murray, and others.

Have any of the questions your students ask surprised you?

There are a few questions that stand out. Back in 2005, the first question to Dr. Paul Farmer was not about Haiti or healthcare but rather about the war in Iraq. Paul was clearly surprised by the question but he gave an eloquent answer in which he insisted that since the staggering majority of deaths and injuries in modern wars come from civilians, physicians have to be opposed to war. Another question that yielded an intriguing answer came when we spoke with Chris Murray last year. (Chris is the architect of the Global Burden of Disease project and the subject of Jeremy Smith’s terrific book, Epic Measures.) Chris was asked how he handles the perception that he is dictatorial in his management style. While acknowledging that his style could be harsh (“I have been known to ask, ‘Are you lazy or stupid?’”), Chris insisted that when people work on projects that matter, they don’t mind being pushed far harder than they would if the objective was simply to earn more money for their company.

What inspired you to set this up?

In 1995, I took a year-long trip through sub-Saharan Africa, the Middle East, India, and Indonesia. At that time, I was struck by how few people from the US I met during my travels. It seemed odd to me that a country which exerted such a profound influence on the world was so lacking in understanding of the rest of the world. By the time I reached home, I had the sense that I could play a role in making people from my country more knowledgeable and curious about global issues. Over the past two decades, I have been working on this task.

What are your top lessons for your students?

Two stand out. First, I want students to understand that addressing any big issue is inherently complex and requires insights from different disciplines. So, for example, in thinking about the post-earthquake reconstruction of Haiti, a student needs to grapple with Haitian (and American!) history, economics, anthropology, and the nature of the NGO system. The second big lesson that I hope that students absorb is that they should retain an open mind. I purposefully try to keep the students off balance by having them read books that argue for different worldviews. My sense is that in the long run, they are far better off.

How have your guest speakers or leaders you've visited responded to your students?

Our guests have been incredibly gracious. A common theme that the students hear is that they are more engaged and ask harder questions than do college 7

audiences. For us, this is a point of pride. We know that many people imagine that high school students have a superficial grasp of topics and so we rehearse precise, complex questions for hours before meeting guests. Here is a quick video clip (https://www.youtube.com/watch? v=GvkzKlJMQow) of Jim Kim talking about the group.

Towards the end, he calls the students “one of the most thoughtful and committed groups of young people I’ve ever seen.”

Here is an excerpt from an e-mail that I received from Anne earlier this week: “For the past two weeks, I've been meeting with teachers throughout Maharashtra, India to talk about literacy and how we can find more effective ways to teach kids to read.

Something extra special about this project is that we are working with blind students. I've never worked in the Marathi language before, much less braille Marathi, but the teachers here have a lot of great knowledge and they are happy to share. Matt, if someone would have told me in 2006 that by 2015 I'd be traveling the world working with teachers to make sure we can provide quality inclusive education to learners worldwide, I would have told them they were a liar... and yet here I am. Life is really good.”

Your work is extremely valuable in promoting public health perspectives in all sectors and careers. Public health is truly multidisciplinary. What are your student's career aspirations and how do you hope they will use what they learn in your class?

In terms of former students who are not visiting us this week, I can think of many who stand out. Ashish is doing his residency at UCSF. Bram, Spencer, and Kendall attended the United World College program. Glory is getting a PhD in political/economic history at Stanford.

Leah lived in Kibera and Togo for a year and is now becoming a nurse. Kristen should be in her third year on the UNC campus but she has only been there for a year as she has spent a year in Brazil and a semester in South Africa. Emily is wrapping up two years in Haiti with the organization Midwives for Haiti. Eliza helped found a start-up in China last summer. Amy spent two years in Madagascar and is now in business school at Michigan.

There are many more who are doing good work that was at least partially inspired by the class. Actually, one of my biggest goals for the class is to get students excited about the world and to give them a sense of agency in the world. I want students to have a sense that they can impact the issues that animate them. I worry that social studies teachers often leave students with a sense of fatalism and I would hate for that to be the case with my students. Having said that, I don't want students to be naive about the difficulty inherent in achieving change as I think that they will burn out if they are trained to expect quick success after quick success. So, I try to expose them to structural critiques while also aiding them in meeting with people who have brought about change.

Thus, I would be just as happy if Ashish became a math teacher or community organizer as if he became a physician.

This is a good question. When I first started doing this work, 99% of the students who became animated by it said that they wanted to become physicians. This was almost surely my fault because I exposed the students to too many sources who focused on the work that doctors do.

Over time, I have done a better job of giving the students access to economists, data geeks, policy wonks, NGO workers, and academics. Now, the students are much more sophisticated in thinking through what careers are a good match for their talents and interests.

Do you have any news from any of your alumni? How did your class help them?

I do stay in touch with many former students. In fact, on Tuesday of this upcoming week (at the time of writing), our Global Health Club will Skype with a former student, Scott, who is working in the Global Health Corps and who wants to talk with them about how they can support a piece of legislation (the Reach Act) that he is trying to build grassroots support for. On Thursday, my Global Issues class will Skype with a former student, Anne, who will connect with us from Afghanistan where she is working on a literacy project.

I wish that I had a better sense of how the class and the club have impacted students. Of course, I have anecdotal evidence to support the notion that this work has had a strong influence on many former students but this is a far cry from having the sort of evidence that might make it easier for my students and I to raise financial support for some of the trips that we hope to take. Perhaps a next step could be to get assistance from a researcher who could track down former students and do a more formal investigation of what these students are doing and how they feel that the class and club impacted their path.

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Credit: Matt Cone

What are your recommendations for other teachers interested in setting similar classes up at their school?

these mistakes and was able to modify what I did in future years.

Any final words?

I am a better teacher when I am learning along with the students. Thus, with the notable exception of Mountains Beyond Mountains, I rarely teach a book more than two or three times. So, I am always on the lookout for new books about healthcare, poverty, social justice, and economics.

Please feel free to send tips.

I have three tips. First, whenever it is possible to do so, teach about the issues that excite you as most students have a good BS detector and can distinguish between when a teacher is merely covering material and when she is passionate about material.

Second, feel free to reach out to guests who have expertise on the issues that you are studying. We reach out to everyone: Obama, graduate students, community members, academics, pop stars, journalists, etc. Most people say no which is why it is imperative to cast a wide net.

In terms of experiences, there are tons of folks with whom I would like my students to meet. I was excited to see Angus Deaton win the Nobel and I would be thrilled if we could ever meet him. Amartya Sen is a god--we might be too intimidated to speak to him. Nancy Birdsall does amazing work at the Center for Global Development. Paul Kagame has such fierce critics and gushing admirers that it would be intriguing to ask him about Rwanda’s development. I would love to have my students pick the brain of the Gateses as they have played such an important role in this work. Finally, Bono is at the top of the list. He gets a lot of crap from people but I think that he deserves immense credit for drawing so much attention to the field of development. Even his critics have benefited from the spotlight that he has been able to shine on the field. Plus, anybody who wrote “Where the Streets Have No Name� is good to go in my book.

Third, design units and projects that strike you as being ambitious even if there is a reasonable chance that they could fail. I was blessed to begin my career at a school, Rock Bridge High in Columbia, Missouri, in which teachers were encouraged to pursue work that mattered. As a consequence, I did many things in my first few years that did not work well. I had students read books that were too dry, create films without giving sufficient instruction about how to use a film to engage an audience, work on fundraisers that were ill-conceived, etc. Still, I learned from

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Dr. Ashish Premkumar

Ashish Premkumar is a third-year resident physician in the Department of Obstetrics, Gynecology, and Reproductive Sciences at the University of California, San Francisco. He was a member of the Seven-Year Accelerated Liberal Arts/Medical Education Program at Boston University. During his time in medical school, he completed medical anthropological research focusing on the perceptions of community leaders regarding reproductive health in low-income neighborhoods in Beirut, Lebanon. His research focuses are primarily in substance abuse in pregnancy; racial/ethnic disparities in preterm birth; periviability; humanitarianism and reproductive healthcare in Lebanon; and physician advocacy.

Three letters: on becoming a global citizen There are three small envelopes in front of a group of us. Each one contained a prompt, which we were asked to discuss by our teacher, sitting to the side of the room. The first prompt was a quote from Martin Luther King Jr.: “Injustice anywhere is a threat to justice everywhere.” We all took turns discussing the effects of inequality and suffering we had both witnessed and read about in books like The End of Poverty and Mountains Beyond Mountains. We all agreed with the statement, and began to think about our ethical obligations as global citizens to ensure injustice would not continue.

The answer to this continues to challenge me to this very day. Indeed, the only way I have found to answer this question is to reconsider what poverty, suffering, and inequality mean from different perspectives. By broadening the terms and analyzing their effects on reproductive health, I have found myself enmeshed in questions regarding identity, history, autonomy, and moral/ethical action within the realms of biomedicine, anthropology and philosophy.

The events I just described happened when I was eighteen years old, as a senior in high school in Columbia, Missouri. The group of us in the room were part of a small book club learning about current global affairs, and we would go on to become social workers, public health specialists, physicians, and, in one instance, a doctoral student in political thought. The teacher, Matt Cone, would also go on to be one of the most important and influential people in my life. Matt had ingrained in me, and in others, the importance of history and social studies in everyday life, not only to understand current events, but to understand how we, as individuals from one of the most privileged portions of the world, had a duty to remedy the inequalities that we saw – or, more likely, were made aware of by Matt– everyday. To this end, he would have us speak to and meet with people as varied as Paul Farmer, Noam Chomsky, and Jeffrey Sachs to understand not only their perspectives on topics as timely as HIV/AIDS and violence in the Middle East, but how we, as students, could impact the world by merely caring a bit more than the ordinary individual.

We opened the second letter. In it contained a paragraph from Bill Ayers, a former member of the Weather Underground. He described the rationale for targeted bombings and violence in the 1960s, likening the warmongering and exclusionary politics of the U.S. government to Nazi Germany. If dropped behind enemy lines in the 1940s, and knowing you could kill Hitler and stop World War II, what would you do to ensure that happens? The author’s question, provoking and critical, made us consider what we would do to end suffering.

Would we too consider violence as a means to end poverty? What were the costs? This question was not easy for us to answer, with many of us drawing on the revolutionary tactics of Che Guevara as forms of violence used to end poverty, whereas some of us turned to the nonviolent resistance measures (also a form of violence against the body) employed by Martin Luther King and Gandhi to achieve similar ends.

The final letter contained a simple phrase from Mahatma Gandhi: “Poverty is the worst form of violence.” Herein lied the rub for us as young thinkers – if injustice forced us to consider action to preserve justice, and violence could be construed as a form of that action, then would we employ such tactics to end poverty? What constituted violence – was it physical, or more subversive, taking on qualities of dissent and alternative modes of thought in a homogeneous society? Moreover, would the violence itself simply reiterate suffering and inequality?

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My goal to become a physician, and eventually work in the field of reproductive health, was part in parcel of the discussions I would have with Matt as a student and throughout the rest of my life. He always challenged me to think about the effects of global inequality on health, and my role in both understanding and (hopefully) helping to overcome them. As an undergraduate student at Boston University, I worked in a refugee camp in Zambia as a reproductive health educator and on labor wards in South Africa as a premedical student.

Credit: Ashish Premkumar

These exposures, along with my growing interest in anthropology and philosophy, built the framework for how I would understand the effects of history and policy on both the structure of healthcare provision and the very nature of how disease is interpreted and treated within the clinical space.

first introduced to me by Matt and used in the global context to understand inequality and suffering. The world of the labor floor, clinic, and operating room all benefit from this type of perspective – one that is both critical and diverse in scope. Ultimately, I hope that these re-interpretations of medical practice can be used to construct a new form of ethical inquiry into how we as biomedical practitioners and, in some cases, public health leaders, can use our considerable knowledge to impact long-standing issues in healthcare delivery and outcomes.

I spent a significant amount of time in Lebanon during medical school at Boston University, focusing on work in both Palestinian refugee camps on health-related programming and in low-income suburbs of Beirut on reproductive health perceptions. My first foray into the world of public health and medical anthropology was invigorating, not only because I could feel myself thinking about old problems, such as chronic disease and access to contraception, in new and interesting ways, but because I felt, for the first time, that I was becoming the type of person Matt had challenged me to become – a true global citizen, attempting to understand the world from different perspectives and trying to change it, hopefully for the better.

As a resident physician at the University of California, San Francisco, I have turned my attention towards how the global becomes local. By examining issues surrounding race/ethnicity and substance abuse in pregnancy from both a biomedical and anthropological framework, I find myself employing the same lenses 11

Ultimately, those three letters that Matt had placed in front of us as eighteen-year-old students in high school has created a trajectory that I am just beginning to realize. Beyond the ethics and morals surrounding poverty and inequality in reproductive health, the obligation to act – to not be neutral on a moving train, to paraphrase Howard Zinn – is something Matt taught me and is something I continue to bring into my clinical training and anthropological research. The importance of different modes of thought in improving the lives of those who have, unfairly, been damned to an unwinnable future through history and economics continues to awe me; not just because of the gravity of the violence present in the lives of those marginalized, but because of the potential for change that can improve the world.

Kristen Lee

Kristen Lee is a sophomore at the University of North Carolina at Chapel Hill and has grown up in Carrboro, North Carolina. She is interested in agriculture and urban planning and hopes to become a landscape architect.

“Every day, I listened and asked questions, piecing together a narrative – surprising narratives about the seasonality of water access and safety, alternate currencies in rural areas that can provide water security, and brave community members who defy the Tragedy of the Commons. ” I wanted to spend the summer traveling and learning whether or not I was interested in research. I soon joined a project at the Water Institute at my university.

The mission: gather qualitative data on water system sustainability in six different rural Zambian communities as part of a three-country sub-Saharan Africa study. At the time, I knew nothing about qualitative methods and interviewing, or post-construction support and water committees. With just a few months of preparation, I was on my way to Zambia with another student from my university. A seemingly benign curiosity to see more of this beautiful Earth and experiment with academia lead me on an adventure – one of both mesmerizing and troubling reality. One of my greatest mentors in high school often asks, “What surprised you?” Here are three:

to the borehole for their families.

Surprise 1: The Seasonality of Water Security

The rainy season seemed like a fairy tale. It was hard for me to imagine the dryness of the air and earth becoming liquid. There was something appealing, enticing about the idea of drinking the sky’s gift. I had idealized the charm of alternating seasons without realizing the unforgiving reality they bring. Each changing season presents a surprising ultimatum to some rural communities – time or health?

In great contrast, the earth comes alive during rainy season. Flowing and churning beside their houses, their shallow wells flood and spillover. In these months, women gather water just by scooping flowing water during the rains. However, the abundance of the rainy season carries a darker reality. Only borehole water, often sourced from 60 meters below, is sanitary. Due to open defecation and animals roaming, surface water is rarely trustworthy. This community has a saying – if the water is brown, don’t worry, still drink it. Nevertheless, when community members fetch water right outside their houses, a substantial amount of time is freed. On the contrary, the dry season forces community members to spend hours walking each day, but the water is almost guaranteed to be clean.

As I came to understand, the difference between the dry and rainy season is night and day. Zambia’s rainy season runs from January to April, and the dry season from May to December. In rural areas, which make up the vast majority of the country, the rhythm of life seems governed by these spells; interviewees for our study would remember events in relation to the timeline of the seasons. The translators would remark on how much the landscape would change from brown to green by the end of the year. Most noticeably, community members would discuss the differences in water accessibility by season.

One rural community in southern Zambia is a stark example. There is one borehole for a population of around 100 households spread across a radius of a one to two hours walk. In the dry season, water can only be found from wells dug around ten feet deep or pumped from the one borehole. In the driest times, wells are parched and the borehole battles with a low water table. Residents no longer choose between sources and many spend up to 6 hours a day walking

Surprise 2: Alternate Currencies The most recent model of providing a borehole in a rural sub-Saharan African community includes providing hardware (borehole drilling) and building software (a community management committee for the borehole).

This dual approach became the practice after a vast number of boreholes were found inoperable a few years after drilling. These management committees are often encouraged to collect money in preparation for borehole repairs and maintenance. However, in rural areas far away from urban centers built on cash, the formality of money is replaced by other currencies of time and energy. Whereas I had previously thought of money as the sole currency of formal exchange, I 12

Credit: Kristen Lee

area at any given time, the communities seem to fluidly compensate with an unformulated exchange of energy and time. Community members bartered and exchanged with water committees, their leadership, the borehole mechanic, and more in order to maintain a functioning borehole. The lack of formality makes it hard to pinpoint exactly how a community manages to keep its borehole functioning. However, I was surprised by the infinite ways to informally pay and be paid. These exchanges intertwine to create a net strong enough to solve a degree of water insecurity.

began to realize the tangibility of others.

There are examples of food – community members giving chickens or bags of dried maize to water committees who would then sell them in town for money. And there are examples of labor – whole communities working on someone else’s farm to raise money. There was the killing and preparation of a village chicken for the mechanic who would come to repair the borehole. Large swirling melons, wicker baskets overflowing with fresh raw peanuts. The communal work of building bricks. Dried fish purchased with maize. The preparation of a place to serve a meal.

The currency was energy and time. The energy and time needed to labor in the fields, cultivate food, build structures.

Surprise 3: The Lack of Tragedy of the Commons Since middle school, I was taught about the tragedy of the commons. A public good, a beautiful ocean or a green neighborhood space, can never be cared for and loved at its best by a collective community. There must be intervention, public policy, and protocol! Humans will fail at taking care of a collective gift; no one person will arise to take ownership. After listening to interviewees, I now believe there to be exceptions.

Even body language seemed to be a form of social currency. The bending and swaying, the slight nod and the intentional eyes. When greeting, community members would place their hand over their chest, acknowledging everyone who was present one by one with pats to the heart. Their motions suggested reverence, thanks, and acceptance. These movements could take the place of a welcome gift. When saying goodbye, a deliberate two palms together in front of the chest in a respectful posture and a slight head tilt forward. And there were genuine smiles, smiling eyes and smiling mouths.

Our interviewee asked us to bow our heads and say a prayer in Tonga. We quietly agreed. The soft crook of his nose, the curly stubble on his chin. He paused after most questions, often still thinking about them later. While he would be explaining another idea, he would ask to change his answer about a previous question. He stuck

Given the limited amount of money circulating a rural 13

out in my mind as someone who genuinely wanted to provide us with the information we sought. We found he also made sacrifices for the public good. The fifth community we interviewed was the most water insecure we had visited thus far. Their community was sparsely populated across a wide radius and had to walk significant lengths in order to reach the borehole. There was no financing structure in order to pay for repairs when needed due to the lack for financial resources in the area. No financing structure meant if the borehole broke down, it could stay broken. However, this man, a community benefactor, the treasurer of the water committee, compensated. He would sell his maize just after harvest and pay for the borehole repairs throughout the year so the community would have water as soon as possible. Only afterwards, he would begin asking the community for payments in order to cover his costs, something he knew was rarely successful. Contrary to the prescribed self-serving interests of individual humans, this community member craftily restores the borehole, the only clean water source in miles.

His eyes were largely light gray and the upper part of his face barely seemed to move. When we finally got around to interviewing him, he told a spectacular story.

Throughout the dry season, as mentioned above, the sun steals water from wells, increasing water insecurity.

About a decade ago, him and young men in the community had dug the deepest well around. The opening was around five feet across, and the depth perhaps around 15 feet. Over the years, they had put logs across the opening to prevent animals from falling in and tied a jerry can to a string to be able to collect water from down below. When everyone else’s wells dried up, he welcomed others to his without charge.

When we visited, there were young children there carrying small buckets, young couples with jerry cans, and a man with a plastic trough to be able to water his cattle. In the middle of a barren, dry landscape, this one man had been able to provide water to a community.

Rather than the usual narrative I had heard in school about the Tragedy of the Commons, I listened to stories of individuals willing to take ownership for a public good. Brave committee members agreeing to invest and sacrifice for their greater community. Given the prescribed formula for a structured water committee, I was pleasantly surprised to find water systems continuing even in instances of individual leadership.

In another rural community, the water committee had been disbanded after a misunderstanding with the village’s leadership. Soon after, the borehole began breaking down frequently and would lay dormant for weeks at a time. The community members would have to resort to drinking less-safe well water. To our special surprise, we found that the water committee’s caretaker began working to repair the borehole. Although publicly discouraged by the leaders and unsupported by the full committee, the caretaker would call the mechanic to fix the breakdown, a crucial step! The caretaker would encourage users to still keep the water system area clean. And the caretaker didn’t seem to ask for any credit, but rather contributed to providing water for his community under the radar. I began to understand that it often takes one extraordinary person to keep a water system sustainable and believe in ownership.

Surprises are opportunities to observe my former opinions and notions. Realms in which I can dive into what I’ve been taught and what I’m still learning, areas where I can recognize my expectations and their role in my life. While I had simply wanted to travel and experiment with academia, I fell in love with the chance to solely learn. Every day, I listened and asked questions, piecing together a narrative – surprising narratives about the seasonality of water access and safety, alternate currencies in rural areas that can provide water security, and brave community members who defy the Tragedy of the Commons. Public health research remains in my future as our team continues to process and review the past summer’s data. I have no doubt I will be surprised many times over.

In another instance, an elderly man proved to be the hero. During many of our interviews, he would fly by on

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Credit: Kristen Lee

Juliana Sierra

Juliana is in her final year at Elon University in North Carolina. She is obtaining her bachelor’s degree in International Studies with minors in Public Health and Poverty and Social Justice Studies. Born in Colombia, Juliana moved to the United States at the age of three. She grew up undocumented and with a single mom, who encouraged her in her education and passion to travel. Juliana was inspired to pursue a degree in International studies by her mentor and high school teacher Matthew Cone. Now a U.S. Resident, Juliana has traveled the world and continues to pursue her interest in Global Health by studying different health models and issues around the globe including Cuba and rural India. After graduation she will be working for a year in City Year in Washington D.C.

A Simpler Approach to Rural Health: What India Taught me.

India is home to some of the most impoverished communities in the world. Globally, India ranks highly for rates of several global health issues including maternal mortality, gender inequality, water sanitation and child malnutrition. With a population of over one billion people, the task of managing India’s public health issues is gargantuan, and though the economy is demonstrating steady growth, unfortunately India’s business boom has effectively widened the gap between those that do, and those that do not have access to basic necessities.

When I saw the opportunity to attend Elon’s course in India, I immediately jumped to apply. Not only had India been on my proverbial “bucket list”, but I was also fascinated by the culture and interested to learn how the large population rate was managed from a health perspective. In light of the Sustainable Development Goals (SDGs), I was curious as to how strategies were to be employed at a community level to tackle basic health needs such as sanitation, maternal health and gender equity. Honestly, I was expecting culture shock to an extreme degree, and other than that I wasn’t sure what to expect from a small town in rural India. There were so many questions running through my mind that I didn’t know where to start. Would we have running water at all? Or access to clean water? What would our diets look like? Will there be difficulty in terms of a language barrier? Will the rural communities be accepting with a large group of American students coming into their homes and observing them? These were only some of the hundreds of questions and concerns that were running through my head. I was so excited to learn from a community based health model and see first-hand its success throughout several communities. Having read the Jamkhed book before coming to India, I was looking forward to meeting some of the people featured, and to seeing the organization come to life. I had never been to this part of the world before and did not know what to expect, so with my list of concerns and questions in hand I packed my bags and got on a plane to India. What I did not expect was that Jamkhed would provide the platform for a life

changing experience, both personally and in terms of my global health education.

In the bustling rural town Jamkhed in central Maharashtra, lies a little slice of tranquility and safety in the form of a health professionals’ compound. The Comprehensive Rural Health Project (CRHP) was founded in the early 1970s by Dr. Raj and Mabelle Arole. CRHP works towards the development of sustainable community-based primary health care through empowering the disenfranchised men and woman of the community. The history of this organization is a story of the love, humility, empathy, faith and respect that Dr. Raj and Mabelle Arole had for each other and for the poorer communities they worked with. Both with high ranking skills and medical degrees, Dr. Raj and Mabelle Arole set forth started their marriage with a promise to commit not only to each other but to the betterment of their community. They vowed to devote their new lives together to the rural poor of India, creating an organization and model indicative of their egalitarian social beliefs, and heavily education-based. In using a human rights-based approach to healthcare provision, they brought back hope and justice to medicine and health development, demonstrating that there are more effective ways of bringing aid to a community than Western top-down charity models. It is through heart and a genuine interest in the communities’ needs and participation that you truly make a difference in the world. When there is equality and people feel they all have a platform to learn and access basic services, there is willingness to change.

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CRHP’s history is the root to its foundation and long term success today. Their broader education method is to teach by example – start by educating one group of people, have them become the worker and teacher and see them empower surrounding communities. This as well is a key component to making the CRHP model sustainable; inter-generational learning, and culturally relevant to India, inter-caste learning.

CRHP has developed programs that tackle health related issues not related to disease such as mental illness and domestic violence. These programs include the adolescent girls and adolescent boys program where youth from the rural communities learn about gender equality, personal hygiene, nutrition, and adolescent development. CRHP also runs a woman’s self-help group where woman from the project villages come together to share experiences, give support and learn from one another. The farmers club is where the men from the village come together to share knowledge with one another and support each other in agricultural practices. The village health workers are still a very active part of CRHP, also acting as a support system for young woman and girls in the villages in which they serve.

Credit: Juliana Sierra

Some of the most powerful moments of this experience were hearing the stories of woman like Lalanbai; who was one of the first Village Health Workers (VHW) to ever train at CRHP. Lalanbai was part of an outcast community, where she was considered untouchable.

She was appointed by the mayor of her village to go to CRHP and train to be a village health worker. Little did she know that her life was about to take a dramatic turn the next few years with this opportunity to serve her community. Uneducated, illiterate, and habitually shunned by her own village, Lalanbai looked at herself as incapable, untouchable and unwanted. She found herself sitting in Dr. Mabelle Arole’s training class, in the back away from the group with her head down, when Dr. Mabelle Arole told her to look at her and said “I am a woman, and so are you. If I can do it- so can you.” These words of encouragement and empowerment changed the way that Lalanbai saw herself and her life. She began to immerse herself in her CRHP training and went back to her community to work. At first she was rejected, and no one wanted to be touched by her, but to show her village the success of these health methods she practiced them on her family and herself. It was simple things like selfhygiene, keeping up to date with immunizations on children, fighting village superstitions such as not feeding a pregnant woman or a breast feeding a child the first few days after birth. She was able to change attitudes simply by being an example in her community and to her family. As she began to gain the respect and trust of the community, people began to confide in her.

Before she knew it the village wanted her to run for mayor. “I began my journey afraid of the mayor and what he wanted from me, and it turned into the mayor being afraid of me.” Lalanbai is still a very important part of the CRHP community, now retired she inspires young interns and students like myself through her life testimony and her unlimited wisdom.

Today CRHP has branched out to develop several programs separate from the primary health care focus of VHW training and placement. As the link between social structures and health is better understood,

As a keen 21-year old college student, eager to go out into the world and change it with my newly gained knowledge and experience, India taught me a lesson I will never forget. Never did I imagine at the beginning of this trip that Jamkhed would also become like my own little safe haven. I am humbled and blessed to have been able to come here and learn such a simple, modest and effective way to aid work. Jamkhed brought me back to myself, it strengthened my faith in humanity and reminded me why it was that I fell in love with Global Health and International Development to begin with. It isn’t about my own self worth, or to say that I was able to make a difference in this world. It was to be able to pass on my skills and knowledge to others so that they may be able to do the same. If I learned anything from India, is that if I am able to help empower one person- I have already made a difference in the world. I know my time in India isn’t over, and I look forward to returning back to Jamkhed one day and continue to learn from such an empowering and humble community.

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Credit: Juliana Sierra

Eliza Filene

Eliza Filene is a sophomore Innovation Scholar at the University of North Carolina at Chapel Hill, majoring in Public Policy and minoring in Entrepreneurship and Chemistry. Eliza works as an undergraduate research assistant at the UNC AIDS Clinical Trials Unit. She is also a student delegate to UNC Faculty Council, where she works to bring the student perspective to university policy-making. After working at a start-up company in Shanghai, she became interested in how entrepreneurship and public health fields can address health disparities in the U.S. and abroad.

“Most Likely to Save the World …,” But Not Really Feeling It: How Public Health Entrepreneurship Offers New Opportunities for Students to Make Change Upon arriving to UNC-Chapel Hill’s campus as a firstyear student in 2014, I experienced a shift. I just wasn’t grabbed by the same causes. I found myself walking past fundraising bake sales and ignored Facebook invites to health-related events. Instead, I found myself focusing on issues closer to home. I spent my days working with physician researchers to hone my research skills, writing papers about HIV-positive prisoners, coercion in prisons, and HIV screening practices. I became fascinated with UNC campus policies, and became heavily involved in student government. I went to talks and events, and (on the pre-med track) devoted seemingly endless hours to introductory chemistry courses.

How can students make change? How can they handle the internal and external pressures to “save the world?”

Prompted by serious feelings of doubt about my place as a change-maker in the field, I explored new ways of thinking about change in public health, and realized that activism takes on many forms.

A formative dinner conversation In ninth grade, my social studies teacher, Matt Cone, emailed Howard Buffett, a famed philanthropist, asking him to Skype with students about his work in developing countries. Mr. Buffett instead offered to fly 17 students to his home in Decatur, Illinois, to discuss global development, economics, and poverty. This offer sparked a rigorous two-month process led by Mr. Cone, in which students arrived at school at 7:00 A.M. every Wednesday to discuss books, meet and Skype with experts on global health, and develop our opinions.

Over dinner in Decatur, Howard Buffett challenged us to use our knowledge and understanding of global poverty to take action.

Wake-up moment One of my clearest memories from my freshman year of high school is of watching a TED talk by the controversial ethicist Peter Singer about what he calls “effective altruism.” In the video, Singer argues that our proximity to suffering and poverty has no relationship to our responsibility to help alleviate it. Clearly walking by a dying child in the street is wrong; therefore, Singer says, so is ignoring the suffering of those oceans away.

I remember vehemently thinking: “Duh!”

Upon returning home, I co-founded the Carrboro (NC) High School Global Health Club. In four years, we raised $133,000 for organizations fighting for global health equity in developing countries. The global health community that I came to know through this work awakened me to the extent of health inequity and helped me see healthcare as a human right. At the same time, it taught me that health disparities, though complex, can be addressed and that I have both the responsibility and ability to help address them.

Five years later, I watched this same video for an ethics class. My reaction to Singer’s video was more complex and oddly dulled. I felt distant from his fervor—I wasn’t making any real sacrifices like the men and women he points to as exemplifying his ideas. I debated with myself over my change in response to the talk. I thought to myself: Am I no longer an activist? If not, what am I?

A shift In high school, my identity revolved around my commitment to combatting inequality across the ocean.

For Christmas and Chanukah, I asked only for donations to the Global Health Club fundraiser. I sent people emails at 1:00 AM instead of doing my AP U.S. History homework. I won “Most Likely to Save the World” in our senior yearbook.

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Recently, I grappled with this feeling over breakfast with Matt Cone. I choked up when I told him that I had recently stumbled upon a campus chapter for the global health organization for which I had fundraised in high school. The fact that the group was not on my radar was telling. I felt I had broken the promise I’d made to myself in high school—to always be a part of the

movement for social justice. But Matt saw it otherwise, saying “You don’t need to fundraise to make change in public health.” He pointed to thinkers, activists, scientists, and businesswomen who all impacted health disparities in profound ways. He helped me see that “the movement” is made up of many—people can contribute with different skillsets in different ways at different moments in their lives.

strengthen existing ones.

Public Health Entrepreneurship A particularly intriguing bridge is public health entrepreneurship. Public health entrepreneurship has taught me new ways of problem-solving. It is thrilling to explore small, concrete solutions to the same big problems I once found overwhelming. In this transition time, the field has shown me how to hold on to my passion and drive for “change now” by tying it in with my “training for change” skills to create sustainable ventures.

Peer Perspectives There I wondered if other students were experiencing a similar dilemma about their role in social change. I spent one Saturday afternoon asking my peers two questions: Do feel that you have the responsibility, ability, or both to make change? Is there a community of change-makers at UNC? If so, are you a part of it?

Public health entrepreneurship can be a powerful bridge for students, a way to bring together the scientist and the person holding up a sign. Almost all students have both capacities within them. Public health entrepreneurship can help connect their “pools” of interests.

I was surprised by the answers that I received: almost everyone felt obligated to make change. As put by a young woman majoring in business and hoping to go into finance, “I feel the continuous need to pay forward everything that I have been given.” However, few seemed content with their performances thus far. A friend involved in many activist groups on campus relayed that she feels like she is “making demands, but not making change.” There was palpable tension during these conversations. I realized I wasn’t alone in my doubts: we all have our uncertainties and frustrations about how to help others.

It isn’t simple. “Entrepreneurship” is increasingly becoming a buzzword, with projects and programs popping up on campuses and cities across the country.

Stereotypes abound: entrepreneurs are either all about making money—the capitalist in the suit; or too cool for school—the hipster in Silicon Valley. Additionally, “entrepreneurship” can be interpreted as discovery of new ideas. But as we learn in our entrepreneurship classes at UNC, “new knowledge” is the least likely source of innovation (Drucker, Peter. Innovation and entrepreneurship. Routledge, 2014.) In short, entrepreneurship is about a whole lot more than the next coolest app. It is not even just about starting new stuff—it is a way of problem-solving.

I began to notice patterns in the answers I was receiving. There appear to be two approaches to making change as a student. The first is to engage in “now change.” From posting on Facebook to holding up signs in the Pit (our central campus gathering area) to hosting campus forums, this method of activism is often spurred by charismatic leaders and builds a powerful sense of participating in a social movement.

At UNC and across the country, there is a push to broaden the definition of entrepreneurship to include diverse students and academic fields. The increasingly popular Minor in Entrepreneurship at UNC, fondly known as the “E-Minor,” has introduced entrepreneurship “tracks” in areas that just ten years ago may have seemed tangential—including public health, design, sports, and scientific tracks.

On the other hand, students also spend time “training for change.” This method often includes more behind-the-scenes work. These students focus more on building their capacity for future endeavors, gaining and refining skills through research and learning. For instance, the young woman planning to launch her career in finance sees herself launching a socialchange venture after she has the skills to run a business. Others may use knowledge they gain in a lab setting to make scientific advances later.

Impact and Potential Best of all, it’s working. As the field takes shape, boundaries seem to be breaking down. My Wednesdayevening public health entrepreneurship class illustrates this field’s ability to bring a wide array of people together.

Sitting on my left in the class is a business major; to my right is a young woman going into a physician’s assistant program; the owner of a small business in Chapel Hill audits the class. We all listen attentively as our professor explains frameworks for addressing public health issues and as guest speakers describe how they started their own health-related ventures.

I like to think of these two methods as wading pools.

People move between them often; some prefer to stay in one pool more, but there are countless bridges allowing for communication and collaboration. These bridges are especially valuable to the field of public health, a field that is by nature interdisciplinary. In fact, I feel that a key to success for the field of public health will be to build new bridges and to sustain and

Teaching this class is Dr. Alice Ammerman, director of the Center for Health Promotion and Disease Prevention 18

The result is a general curiosity about the world. “Public health people are not linear thinkers,” MacMillan reflects.

“Otherwise they wouldn’t come to a field that engages so many different fields.” To prepare to thrive in this world, Ms. MacMillan, counseled taking the long view. “It’s good to make investments in your ability to be effective later.

Recharging your batteries periodically and building diverse skillsets is important to long-term success.” In a world where policies can take decades to pass, having the skillsets to make incremental yet impactful change can be critical.

and a professor in the department of nutrition in the UNC Gillings School of Public Health. Dr. Ammerman does not wear a suit. Nor does she don hipster glasses, yet she is a pioneer in the reframing of entrepreneurship.

Speaking with Dr. Ammerman is humbling. She pushed for innovative thinking in public health spaces before it was cool, when “entrepreneurship” connoted only profitseeking. As Dr. Ammerman says, “For a long time, I used the notion of sustainability to appeal to people in the public health world, because “entrepreneurship” suggested no concern for the common good.” However, ways of thinking have changed tremendously. Dr. Ammerman reports, “Public health entrepreneurship is helping to bridge the gap between researchers, policymakers, and activists.”

The Bridges to Come To echo Matt Cone, Alice Ammerman, and Julie MacMillan, there is no one right way to be involved in public health. The endless avenues for change can seem overwhelming to those of us who are still figuring it all out.

And through speaking with both students and “grown-ups,” I’m realizing that almost no one has! My college experiences are helping me to evolve past worrying about having a planned path to “save the world”—I’m ready to just get working on it. Whether my efforts are focused on “training for change,” “change now,” or both, being open to the inevitable twists in the road will be a key to success. I look forward to crossing bridges that I cannot yet see.

I heard a similar message about connectedness when I spoke with Julie MacMillan, the managing director of the Research and Innovation Solutions team at the Gillings School of Public Health. Ms. MacMillan discussed the public health field’s inherently innovative spirit. “People in public health tend to be entrepreneurial whether they like the term or not,” she said. “You have to consider the economic and social contexts of your [public health] project in order to be successful.”

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Credit: Eliza Filene

Bram Sable-Smith

Bram Sable-Smith is lead reporter on the Health & Wealth Desk of public radio station KBIA in Columbia, Missouri. His reporting has been honored by the Online News Association, Radio Television Digital News Association, and the Missouri Broadcasters Association, among others. He's an alumnus of Washington University in St. Louis, Waterford Kamhlaba United World College of Southern Africa, and the Salt Institute for Documentary Studies.

“Engaging classrooms full of teenagers in the same challenges that are occupying the minds of the world’s great leaders.” health journalism and one telling jokes on a stage began with a teacher who exposed me early and often to the world of global public health.

This time last year I was sitting in the living room of a young, expectant mother named Leah. This was going to be Leah’s seventh child, and the 27-year-old was hoping for a boy. She was also hoping this would be the first of her pregnancies to go full-term. It was a hope shared by her mother and by her caseworker who sat across the room on a couch.

One simple way to describe Matt Cone’s teaching style would be to say he aims very high, but that description doesn’t really do him justice. I was Matt’s student soon after the United States went to war in Iraq, for example, and he brought in an Iraqi former nuclear engineer to guest lecture in our high school classroom and answer our questions.

Seventeen percent of children born in the region of the United States where Leah lives are born premature. If this were a country, that’d be among the highest rates in the world – about on par with Congo, Indonesia and Gabon.

When the George W. Bush administration announced a major HIV/AIDS funding initiative, Matt arranged for his class to interview the First Lady of the United States on the topic via a satellite feed. On a recent trip to Washington D.C., his students sat in a boardroom of the World Bank and picked the mind of its president, Dr. Jim Yong Kim.

The region’s infant mortality rate is also among the highest in America: 10 babies die out of every 1,000 born. In the African-American community, that rate is 16 babies out of every 1,000 born.

On a smaller and much more personal level, Matt aimed very high with me. In my wisecracking teenage energy he saw a thoughtful enthusiasm that could be channeled into a style of learning that was not merely academic, but compassionate, humane and, at times, humorous. His challenge was to make me see that too.

I interviewed Leah for a series I was reporting on this region of America known as the Missouri Bootheel. The region is home to some of the most productive and lucrative farmland in the United States, as well as some of its poorest people.

I wasn’t the best student when I was fifteen. To be fair, I wasn’t the worst either, but I was far more interested playing sports and watching television than in studying for my classes. My grades lingered in the B to B+ range.

Together with a colleague, I’ve made several trips to the Missouri Bootheel this past year documenting the health and wealth disparities of the region, which offer an emblematic snapshot of the challenges facing rural America: high unemployment, severe medical provider shortages, insufficient health insurance coverage.

When I walked into Matt’s world history class in 2003, that’s how I saw myself as a student. That impression didn’t change a whole lot until he offered our class an extra credit assignment, which I took because, frankly, I needed the extra credit.

As a public health reporter, my goal is to lift the veil on seemingly forgotten places like the Missouri Bootheel in the hopes that voices of people like Leah might be heard by the policymakers who hold the power to effect change.

The assignment was to watch a screening of a documentary on the Rwandan genocide – a country I never knew existed – and to write a reflection on seeing the film. In my essay, I wrote that I was devastated. How could this be allowed to happen? If the violence was being broadcast on televisions across the

It wasn’t long ago, however, that my great ambition in life was to be a stand-up comedian.

For me, the difference between a career in public

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globe, how could the international community do so little to respond?

When Matt returned my graded essay, he expressed in no uncertain terms that those were the thoughts I was capable of thinking, the questions I was capable of asking, and, from that point forward, those were the standards he would hold me to inside and outside of the classroom.

He made good on that promise when he got wind of my family’s plans to travel to South Africa after school let out that summer. Not every 15-year-old has the opportunity to travel abroad and he was determined to help me make the most of it.

While the rest of the students in his class got to chose their own topics for a final research paper, mine was given to me: the modern history of South Africa. He assigned me chapters from Long Walk to Freedom, from Guns, Germs, and Steel, and from King Leopold’s Ghost so I would know something about the country’s history before I visited. It was an assignment for which I will be ever grateful.

It was the first time I realized the true potential of using my schoolwork to inform the way I experienced the world. It meant I had enough context to begin to grasp the significance of seeing Nelson Mandela’s cell on Robben Island, or of visiting the townships outside of Cape Town.

Reflecting on it now, I see this is as the first stone on the path to my career as a journalist.

When I returned home, Matt challenged me not to view the trip as a vacation or as an experience unto itself. Instead, he taught me to think of my time in South Africa as a springboard to be inquisitive of the world outside the one with which I was familiar.

As Matt’s pupil, I read Mountains Beyond Mountains, Tracey Kidder’s nonfiction masterpiece about Dr. Paul Farmer and the global health organization Farmer co-founded – Partners In Health. Our class’s capstone to reading the book was to raise money for that organization.

We were graded not by the amount of money we raised but on our efforts and our journalized reflections.

Our class went door-to-door in our neighborhoods collecting donations. We hosted fundraiser dinners for our parents and family friends, and even pitched our friends to divert some of their lunch money to this organization whose impact was a world away. In the end, our small class of students raised thousands of dollars in only a few weeks.

I read my first health ethnography when I was sixteen, also because of Matt. At a time when my other classroom syllabi included mostly fiction books like Frankenstein and The Scarlet Letter, Matt assigned me Infections and Inequalities – the aforementioned Paul Farmer’s look at how and why infectious diseases disproportionately afflict the world’s poor. When I was finished reading, I was tasked with presenting to my classmates on the challenges of

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An HIV/AIDS campaign sign, Mali, 2007. Credit: Bram Sable-Smith

treating multidrug-resistant tuberculosis in Haiti.

former students who would say the same thing.

The purpose of Matt’s assignments was always about something more than our grades or our classroom. He was insisting that to truly be citizens of a globalizing world, we had to make the extra effort to try to understand and to relate to the people who inhabit it.

Read the extra book, have the extra conversation, travel the extra journey.

Steadily, Matt is educating a generation of globally conscious young adults. His students have traveled the globe doing everything from volunteering in refugee camps, advocating for children’s rights, and founding non-governmental organizations. They have gone on to become doctors, journalists, researchers, activists, consultants and more.

It was a lesson I took to heart.

There aren’t many American high school students who have excitedly posted selfies with the president of the World Bank to social media – as Matt’s students did.

There aren’t a ton of American high school students who are aware the World Bank even exists. I submit that a disproportionate number of those who do shared this same teacher.

When I was seventeen I moved to Swaziland to pursue a two-year International Baccalaureate diploma at Waterford Kamhlaba United World College of Southern Africa. Matt wrote my reference.

At university, I studied international studies and anthropology, and focused my research on poverty, health and development. Today I’m a journalist spotlighting stories of inequalities in health, wealth and opportunity.

That’s the real accomplishment of Matt’s style of teaching – engaging classrooms full of teenagers in the same challenges that are occupying the minds of the world’s great leaders.

Matt’s finger prints can be found all over the trajectory my life has taken so far. There are many, many of his

Thirteen years ago, I was lucky enough to be one of Matt Cone’s students.

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Senegal. Credit: Bram Sable-Smith

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Nadège Uwase

Nadège Uwase devotes much of her time volunteering in her community. As a Rotarian, she is the President-Elect of the Rotary Club of Columbia and co-sponsor for Interact. She is mostly involved in social justice issues with a particular emphasis on genocide. She is an Advisory Board Member of Step Up! American Association for Rwandan Women, and spends time speaking about her experiences as a genocide survivor to raise awareness about the issue. Nadège has a Bachelor of Arts in Political Science and Minor in French from the University of Missouri-Columbia. She also earned two certificates from the Truman School of Public Affairs —Grantsmanship and Nonprofit Management. Additionally, she has a Professional Fundraising Certificate from Boston University.

GILD volunteer, Dana Burris, contributed to the writing of this article.

“I learned to see the struggles people are met with as symptoms of greater problems in the world. ” At GILD, we believe that young people understand their responsibility to their communities and are often willing to roll up their sleeves and help out. We encourage them “to live in a way that respects and enhances the freedom of others,” as the late Nelson Mandela said.

GILD does this by setting up after school clubs in high schools called Global Issues Clubs, in which students identify a current global plight to study and do something about. As an organization, our role is to help Global Issues Club members locate, identify, and access resources that will teach them about global issues. Our organization especially values first-hand knowledge and experience and so we regularly set up captivating speakers to talk to the students about their chosen topic. A speaker is an example of resource. We do this because we want to help build a new generation of leaders and citizens that are civically engaged at a local and international level.

People are like seeds on the wind. Just as a single event can lead people in different directions or bring them together, so too can a single breeze keep the progeny of a plant together or set them on journeys apart. And when a plethora of different seed species settle in a place and grow they build a beautiful land; the same way people, despite differences can come together to create something awe-inspiring. To me, a truly awe-inspiring creation is one that empowers people to meet their own greatest potentials so the landscape of life grows healthier, stronger and more beautiful. This is what I hoped for when I founded the non-profit organization Global Issues Leadership Development (GILD).

The story of how GILD came to be begins with my life in Rwanda where I was born and raised. When I tell people about my homeland I often describe it as a tiny country beneath the equator, in Central Africa.

My childhood, until I was seven years old, was spent the same way most children across cultures and continents spend their time. I went to school, giggled with friends, and climbed mango trees. I felt that my neighborhood in Rwanda exemplified a time and place best described by the ending salutation of the NPR show The News from Lake Wobegon, where “all the women are strong, all the men are good looking, and all the children are above average."

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Both of my parents worked hard to provide for their children. I went to private schools and spent many evenings with expensive tutors. My father traveled frequently and we received clothes and toys from his expeditions abroad. I was not aware of our wealth. My mother took it upon herself not to raise ungrateful children. On Sundays, our house staff was off and we

With that new philosophy wedged in my mind, my college years were a haze of social activism—advocacy days at the Capital, die-in protest on campus and t-shirts sales for various fundraisers. I enrolled in a community development class and learned about how to start an organization. Later that year, I submitted my proposal for an organization to the Global Engagement Summit. GES is a student run organization at Northwestern University. At the conference, for the first time in my life, I felt like I belonged. It felt as if I had heard of these people. People huddled in masses, all certain of their path in life, and full of confidence in their ideas. They knew their facts and could hold their weight in any conversation. I was slightly intimidated and also enthralled. All of a sudden, I knew this was my calling.

Unlike anyone else in my family, I would take the road less traveled and be an activist instead of just being charitable. I left GES without all of the answers, but I knew that choosing to lead the life my peers at GES were also embarking on was going to be the hard. I did not know how I could explain to my parents, who spent their lives working hard to amass wealth that I would not do that, not even to use it as charitably as they did.

It would fundamentally shift our relationship.

did the cooking and cleaning.

From an early age my parents taught me how to be charitable through their example. My parents frequently opened their checkbooks for weddings, funerals, school tuition, and medical bills. On many occasions, my mother would donate clothes right off hangers in our closets. I am not sure of all the influences that led my parents to be so generous. My mother has talked of observing my great-grand father and his wife giving away extra goods from their farm to the people that came from all over to tend their crops. Her family was well-off and never went a day without a roof over their heads, clothes, or food.

I was very young at the time but over the years I have come to realize that perhaps their benevolence was mandated by our culture. I have heard numerous stories where one family member does well, and then helps everyone else. I suppose that both of my parents always had the autonomy to say no and send people on their way. Perhaps it was honor. Regardless, each day they got up at the crack of dawn and knew that their hard earned money would support their family and friends.

Fueled by a deep sense of justice and my passion to change the world I live in, I graduated from the University of Missouri in 2009 without consideration for a job or graduate school. Instead I holed up in Daniel Boone Regional Library for the summer with my close friends and together we created GILD. Those summer months are vividly etched in my memory. Anxiety always overtook me as I prepared for our meetings. I would meticulously map out our agenda and task lists. I would arrive early to stake claim to a table with enough chairs for everyone. After each meeting, I left feeling fulfilled. I felt that I had walked in thirsty and left after drinking five gallons of water! I was overflowing with the energy I needed to cultivate my project and bring it to the world. Instead of taking apart my half-baked idea, my friends encouraged and nurtured it and were willing to roll up their sleeves and work for its success.

Together we labored and soon GILD emerged. GILD became active in its first high school that fall.

The next chapter of GILD's story takes place in Columbia, Missouri where I attended Rock Bridge High School. As a student there, I joined Model United Nations and Global Issues Club, both of which were sponsored by Matt Cone. It was there I learned to see the struggles people are met with as symptoms of greater problems in the world. For example, I grew up with a cousin who was born HIV positive and years later the death of an uncle was discussed in my family in hushed tones because he had HIV. Before Cone’s class I understood HIV as a disease my family members succumbed to, but not as a pandemic.

Cone’s clubs helped me begin thinking of people’s problems as more than just single stories. I learned to understand them as systematic global issues, both pervasive and oppressive. At that point in time, I feel I started to branch out instead of keeping up with my own personal experience of life.

27 Credit: Nadège Uwase

Credit: Nadège Uwase

The Belize Water Project was led by Jack Maxwell throughout Rotary District 6110. Students raised money to purchase water filters for homes and schools in Belize. Maxwell selected Sawyer water filters which use Hollow Fiber Membranes, a technology developed for kidney dialysis. The filters have tiny "U" shaped micro tubes that allow water to enter into their cores through micro pores. The pores are so small (0.1 micron absolute) that no bacteria which cause cholera, typhoid and E. coli, protozoa, or cysts can get through. These filters were chosen because they are also cost efficient and easy to maintain. With the fast flow of water, families can use them for drinking, cleaning, bathing, cooking, and much more. Knowing that a donation of $100 purchases three water filters, students raised $3, 350 and 100% match was made by the Rotary Foundation for a total of $6,700.

In just six short years, our students have traveled to Belize, raised money to support other nonprofit organizations, and learned about many global issues.

In 2015, we started collecting stories from our alumni and we feel rewarded to see that the seeds we planted are being nurtured. Most of Global Issues Club alumni went on to college. Although they majored in various degrees, all of them are public servants and they are still passionate about leading lives that respect and enhances the freedom of others, whether they are doctors or social workers.

Two of our schools have helped Belize. Belize is a small country in Central America bordering Mexico and Guatemala with an east coastline on the Caribbean Sea. The country is a former colony of Britain and was known as British Honduras. Belize was granted full independence in 1981, although it was self-governed since 1964.

Our Rock Bridge High School Global Issues Club decided to learn about lack of access to clean water and its impact on the health of people, their communities and the world. The lack of safe drinking water can often lead to death. The Centers for Disease Control and Prevention (CDC) says that pathogenic microbes from contaminated water can cause diarrhea, cholera, hepatitis, and much more. For example, CDC reports that 80% of diarrhea cases worldwide are linked to unsafe water, inadequate sanitation, or insufficient hygiene and result in 1.5 million deaths. In partnership with various Rotary Clubs, Global Issues Club members worked on the Belize Water Project.

The Southside High School Global Issues Club traveled to Belize. The club members wanted an immersing international experience serving their peers in another country. Current teacher and Southside High School alumna, Meredith Southworth, serves as our club sponsor. As a sophomore in college, she went on a trip to Belize which helped shape her philosophy as a teacher.

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“I have learned that kids need to connect to something, they want to connect to something outside of themselves. They don’t really get that opportunity in school other than connecting with each other; they don’t really get the opportunity to connect with people outside their country. I think anything that gives them that

Credit: Poster ads designed by Dana Burris

opportunity is really positive,” said Southworth.

they are going through.” GILD has many more example of how the experience helped the students develop empathy.

After Global Issues Club members convinced their School Board to allow a trip to abroad, Meredith returned to Belize November 2014 with her students.

Club members spent the first part of their trip building picnic tables for Toledo Community College in Punta Gorda, a secondary school, with students around the same age as club members.

Over the course of my life, I have had wonderful teachers and a family that set a great example for how to be a good citizen of the world. My friends and I came together and created something awe-inspiring that I feel has greatly enriched the landscape of life for all involved. There are still many plans in the works for GILD’s future. We are working to expand our activities to many more schools while always being supporting our current club members’ goals and ideas. With GILD our students have a safe space to learn and grow and the tools and encouragement to be proactive in their local and global communities.

After the trip, we followed up with our students, who all had great things to say. One student attendee, Brian Scott told us that international service is important because it provides a cultural exchange and the opportunity to see other peoples’ points of view.

Another, Keegan Wiggins, agreed and said, “If we go and we help other people, we can see their position.

We are more understanding and sympathetic to what

To learn more about GILD and support our work, please visit http://gildhumanrights.org/

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Students building tables. Credit: Nadège Uwase

Awaken the social entrepreneur in you 30 Order on Amazon today

Allison Coffelt

Allison Coffelt lives and writes in Columbia, Missouri. Her work has appeared or is forthcoming in the Los Angeles Review, the Crab Orchard Review, museum of americana, Prick of the Spindle and elsewhere. She was a finalist in the John Guyon Literary Nonfiction Prize and the San Miguel Writer's Conference Contest. In 2015, her work won the University of Missouri Creative Writing Program Essay Prize. Currently, she works for True/False, a documentary film fest.

Website: http://www.allisoncoffelt.com Twitter & Instagram: @allisoncoffelt

The Place of Books I pulled my bare feet under me as I sat on the couch, promising to put on socks when I finished this chapter.

This was how I spent winter break my sophomore year of high school, reading Mountains Beyond Mountains, and journeying to the world of Paul Farmer and his work in Haiti. Outside my window, brittle, frozen tree limbs stood against gray air. Inside the pages, Caribbean heat simmered. This book by Tracy Kidder has influenced me more than most, which is to say a lot, and I think this has less to do with what it’s about and more to do with the experience of reading it.

Matt Cone taught global health to high school students through stories. I had him as a teacher at a time when sincerity was social suicide. It was cool not to care, but I — and more likely, we, so many of his students — longed to be part of something bigger than ourselves. Whether it was Paul Farmer and Partners in Health, Mohammed Yunus and the Grameen Bank, or Jonathon Kozol and the American public schools, the texts Matt chose placed suffering on the same map as the plentiful.

Mountains changed the way I saw the world because it came at a moment when I was open to exploration. It altered my trajectory. “To travel far,” wrote Emily Dickinson, “there is no better ship than a book.” I first read this quote in Spanish, on a canvas bag in a bookstore when I was studying abroad in Costa Rica. She was right, I thought. Books can take you anywhere: imaginary lands, places of the past, even forward in time. They can steer you anywhere, too. If I hadn’t read Mountains I did in high school, I may not be standing in that bookstore.

But here is something: I never reread it. I doubt I will.

Texts, be they books or films or music, are indeed ships carrying or launching you elsewhere. But what if they are also destinations in and of themselves? What if a book is not just the vessel by which one arrives elsewhere, but an elsewhere? That is, a place one creates just by reading.

We feel this when we go to a theatre and watch a film, and

Texts, be they books or films or music, are indeed ships carrying or launching you elsewhere. But what if they are also destinations in and of themselves? What if a book is not just the vessel by which one arrives elsewhere, but an elsewhere? That is, a place one creates just by reading.

We feel this when we go to a theatre and watch a film, and in those few hours we all view something together and we create a place, a memory, that we cannot return to, not exactly, again. What if text is both a journey and a destination?

Perhaps one reason I refuse to reread Mountains is because I know I can never go back to that afternoon with cold feet where my understanding of the porousness of borders began. Books are a way to travel, yes, but they are also a trip in its entirety, a place that, once beheld in a particular moment, one can never return. Like a trip to somewhere new, be it a different town or foreign country, the place text creates is a point on the map that makes you. Texts can change us if we let them. The best books, I think, comprise our compasses.

When I pick up my copy of Mountains after a decade, I notice it’s earning that old-book smell from browning pages.

Its age stands in opposition to my feeling that just a few months ago, or maybe a year, I first cracked open its spine.

This book has moved with me nine or ten times at least.

When I drug around that paperback to college in rural Missouri or an internship at Partners In Health or FACE AIDS in northern California for student organizing, I wasn’t just bringing a vessel to somewhere else. I was bringing the memory of having gone somewhere else, like a vacation photo, that had irrevocably shaped where I was heading.

Now, as I write my own first book about the eventual trip I took to Haiti and the connectedness we simultaneously share and deny, I think a lot about guides. I admit part of my stubbornness about returning to Mountains is rooted in fear.

What if rereading is like buying strawberries from the store after my first time picking fresh ones? Full of memory, and not as sweet. Perhaps I’m not giving the book enough credit; there is probably still magic in it. But I will never be 31

15 again, open and searching, about to return to class with a teacher who paired research with action.

I read a study once about how each time we access a memory, the brain alters it. The mind does not return to a single experience, encased in glass, but rather remembers remembering it. You recall the last time you brought up that particular memory, and the brain brings that version to mind. We reshape the thing every time we touch it.

It’s beautiful in a way, this repurposing of the mind’s repertoire. It forces me to consider that my refusal to reread might be about more than the fear of never replicating. Tolstoy wrote, “True life is lived when tiny changes occur.” I believe this–but I also know how soon we forget all the tiny changes, the micro adjustments that lead us to who and where we are. It’s simpler to stick to the big-picture: I read a book; it changed my life. This straightforward cause and effect is more alluring and easier to map. It doesn’t require the calculations–and patience– that come with adjusting by degrees, and in so doing, seeing the ship shift course years later.

This is not to say there is not truth in the bullet points: I did read a book; it did change my life. All of the texts I’ve read went into my decision to go back to school for creative nonfiction. In my current role at True/False, a documentary film festival, I daily use what I’ve learned in other nonprofit work. The public health perspective I began cultivating early ripples helps me connect the dots of our Fest’s educational programming. For years, our organization has offered an array of options—we’ve reinvented seasonal

programs, hosted field trips to our cinema, provided teachers with class talks from visiting filmmakers, pulled together a free, district-wide student screening at the Fest for over a 1,000 tenth graders, and more—each seemingly discrete in its attempt to reach students.

As we enter our next phase of educational programming, I’ve worked to secure a funding for a permanent partnership with the school district that will pull in administration and systems, as well as the individual relationships we’ve cultivated for years. Our next step in the schools is building and incorporating a structure to train and teach media literacy.

Our collaboration with the public schools, a foundation, and our cinema and Fest is unlike anything in the field. We’ll work with teachers, trainers, and existing institutions to incorporate films and the critical thinking skills to view film as text into both curricular and extra curricular activities. Over several years, we’ll transition our training and the cost of materials to the school district with the guidance of our district administrators who have been partners from the beginning. We must maintain relationships with teachers and students on-the-ground while building a structure that serves them. This transition to systems support and strengthening is a balancing act. How do who move from blips to patterns, from stars to constellations?

And so maybe this is what Mountains teaches me now, still, after all these years: to lean into changes and uncertainty; to be open to guides. The will-I or won’t-I is not as important as the unsettling unknowing of what could happen, what might happen if. It’s the challenge of recognizing the course we’ve charted while navigating the next change.

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Anne Flaker

Anne Flaker is an international development practitioner specializing in education with particular interests in literacy acquisition, school management, and women’s education. She has worked on literacy assessments and programming in Africa, Asia, and Latin America, evaluated child protection programs along the conflictafflicted Ecuador-Colombia border, and researched women’s rights in education in South Asia. Anne is a Returned Peace Corps Volunteer and received her Master’s in Global Human Development from Georgetown University.

Sorting Out the “How:” How the Global Issues experience transforms youth into civic activists current events and project design. They brought up everything from the role of women to communication barriers, and community involvement to security threatsparticularly around a recent beheading in one of the southern provinces. To be honest, they really challenged my own understanding of development- a field to which I’ve devoted my career. When our call ended, I had to shake my head and smile a bit. If that’s what the next wave of leaders looks like, we’re in pretty good shape.

It was 6:15pm on December 8th and I was stuck in traffic in downtown Washington, DC, frantically trying to make it to a rather significant meeting only to find that a motorcade had shut down the streets encircling the White House. Of course, my destination was swallowed up by that radiusseeing as it was located just two blocks from the landmark.

As I watched the minutes advance, I ditched the cab, opting to walk 12 blocks through the city rather than deal with the gridlock. Rushing to the building entrance, I tugged at the pizza place’s door just as the throng of high schoolers started to file out. I groaned to myself. They were the guests of honor- and I had just missed our meeting.

A couple weeks later, when Matt emailed to say his students would be in DC- my home base- and asked if I’d like to meet them in person, I jumped on the opportunity. I know Matt and his teaching style well. And after a conversation with his students, I was certain a pizza place reunion would bring lively discussion- especially considering the class’s all-star itinerary while in the city. They were meeting with Jim KimPresident of the World Bank, Arne Duncan- US Secretary of Education, US Senators, and development economists. I was sure those encounters would leave them bursting with thoughts, and I wanted to be there to take it in.

Let me back up for a moment. (And in a few paragraphs, I’m going to ask you to let me back up even farther.) Three weeks before that pizza place encounter, I had skyped a classroom full of students from Carrboro High School in North Carolina. I was on assignment in Kabul at the time, helping develop literacy assessments as part of a government contract. Matt Cone found out about my work and asked if I had a few minutes to talk to some of his students. A handful of them had been reading Fawzia Koofi’s book “The Favored Daughter,” based in Afghanistan, and Matt was certain a first-hand account would deepen their understanding.

Today, I am a development practitioner specializing in international education, but my ties with Matt’s Global Issues class run much, much deeper than a few skype calls and run-ins with his students.

As we skyped that November day, I was struck by their thoughtfulness and how well-versed they were- not only in the core debates of the development world- but also in

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Jefferson Memorial, Washington, D.C.

Credit: Anne Flaker

Twelve years ago, I was a sophomore in high school just getting ready to enroll for the fall semester’s courses. The Global Issues class (then called “Contemporary Issues”) was listed as an “electives” options. I read the description closely and talked to some of the upperclassmen who had taken it the previous semester. The verdict was unanimous: This was the most demanding class they had ever taken. They worked non-stop- always reading some new book or interviewing people about international health issues. Most of the topics were things we had only heard brief mention of on the 6 o’clock news. Yet for all its intensity, Global Issues was also the class that people talked about the most. And more than that, it was the students coming out of Global Issues that I respected the most. Even at the age of 16, I could tell that they saw the world differently. Their questions were more nuanced and their responses more informed. I did not know exactly what all the buzz was about, but I

investors, ultimately they are most interested in the business case o

wanted to be a part of it. I wanted to learn about the world and engage with it. So in the fall of 2005, I stepped into my first Global Issues Class led by one Mr. Matt Cone.

This class has profoundly impacted over a decade’s worth of high schoolers as they enroll to reshape the way they contextualize the world. And in the four walls of that classroom, something truly remarkable begins to take form. Once a group of teenagers finds out how much they can accomplish independently, they will go to outstanding lengths to achieve their goals. Matt Cone has witnessed, encouraged, and inspired those young adults as they set up booths at fairs, walked 10 miles in the dead of winter, and created videos for their causes.

I even seem to recall Matt and a group of teachers shaving their heads during one school assembly to raise awareness about HIV/AIDS. It is a contagious environment. And the more the Global Issues class gets involved, the more the whole school begins to jump into the dialogue.

The class was not quite what I expected. I had always been a good student. I took assignments seriously, I participated in class, and I prepared well for tests. But this was nothing like English Lit or Biology. The semester was broken into blocks- each addressing a different crisis of the year (e.g. - the HIV/AIDS pandemic, the War in Iraq, student-selected issues we found on the news). Our discussions were framed around news clippings and books from activists around the world. Each day was a dialogue- not a lecture- and for the class to move forward, everyone had to participate. Taking a strong stand on issues was difficult- and supporting your argument was even harder. But that was what we did every week for the whole semester. In fact, if there is one thing Global Issues taught me, it was how to look critically at the world, not accepting it for what it is, but asking why it is that way and what could be better. Mr. Cone taught us to take that curiosity one step farther though- never stopping at “what could be better,” but also mapping out “how.”

Mr. Cone’s Global Issues class emboldens students to take their enthusiasm to the next level. I cannot even begin to count the number of letters I wrote requesting interviews that semester. We started with the obvious: local leaders and politicians. When those were exhausted, we expanded our reach, asking for a bit of time from Colin Powell, Howard Buffet, Paul Farmer, and Bono. (To my knowledge, Bono still hasn’t responded, but if he ever wants to chat, I’m sure there is a very enthusiastic classroom in North Carolina that is willing to give up a couple minutes of their time to skype with him.)

In retrospect, that final step was critical in my own personal development. It taught me how to be an active and engaged citizen of the world; and whether it was picking up a shift at the neighborhood foodbank, or writing a letter to my senator about antiretroviral therapy in the Caribbean I learned that most of the world’s problems- if not immediately solvable- are actionable.

Mr. Cone taught his students to look at the world and ask “how?” “How can we make it better?” “Where is there room for change,” and “How do we get there?”

During the HIV/AIDS unit, the class conducted interviews of local community members- not just students, but parents, neighbors, and strangers alikeasking what they knew about HIV/AIDS. We shared our own knowledge with them at the end of the interview, we told them about an organization called Partners in Health (PIH), which seeks to bring modern medical treatment to the most destitute communities. The interviews were a challenge in themselves. Students had to have all their facts straight before leading anyone into a conversation on the issue. But taking it to a new level of activism (and discomfort), students asked if the interviewees would consider making a donation so PIH could prevent and fight HIV/AIDS in Haiti and around the world. The Global Issues class taught us it was not enough just to ask what the problem was. Regardless of age, we are free-willed individuals who have the agency to make change-if only we choose to act.

Going into it, these endeavors felt like a long shot. I was already awe-struck when a state senator showed up in our high school classroom. But then to make such bold requests of these international power-houses?

After all, I was just a teenager who wanted to talk about bed nets and clean water in sub-Saharan Africa. Why would Dr. Paul Farmer want to talk to me? I was wrong.

We got one lead. And then another. Soon, we were talking to people in all spheres of influence and they actually cared about what we had to say. Talk about empowering.

That class put the world into new focus for me. It made me believe that change really was possible- in global health and in other areas, too. I started thinking about all the injustice in the world- landing soundly and enthusiastically on international education. With so many kids out of school, it is no wonder families struggle to keep food on the table and children growing strong across the globe. Educating mothers has proven to positively impact children’s health. And elementary reading skills instill a new degree of selfreliance and ability to control one’s own life among women and men worldwide. And basic math skills?

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You can become a savvy entrepreneur at your local market and beyond. In education, I found a cause that drove and inspired me just as much as the Global Issues class’s HIV/AIDS unit inspired an entire high school to act against the pandemic.

class are cross-cutting. Rarely do I feel like the most competent person in the room- nor should I. But I can ask questions of people who know the situation better than me. I can talk to local teachers and administrators. I can reach out to education economists and literacy experts. I can listen and engage with them as we try to sort out the “how” of improving education.

Moving forward, I knew how to act. I had experienced operating out of my comfort zone and knew first-hand what a “big ask” looked like. More importantly, I knew that it was okay to ask. If someone says “no,” it is not the end of the world; and when they can, people actually like to say “yes.” And when they do say “yes,” you can bet your life that Global Issues taught us how to prepare for those conversations- reading up on everything from the news to seminal works in the field.

I was no longer afraid to ask tough questions- even from the likes of the most technical economistsbecause Global Issues taught me that everyone has something to bring to the table.

It is almost surreal now to think that two short months ago I sat on my computer in Afghanistan skyping the next wave of Global Issues students- telling them what I have experienced since leaving that classroom in 2005.

Everything comes full circle. The very issues I studied are now the initiatives I grapple with for my career; and the students on the other end of the line are already taking up the torch and pushing me to think harder about the challenges of our time.

Flash back to December 8th. I push open the door to the pizza place- the most important meeting of my week- because those teenagers are absolutely the change makers of tomorrow. And today. My immediate reaction, upon seeing them file toward the exit, was to kick myself for being so late- believing that I seemingly missed the meeting. But if there is anything those young adults have taught me, it is not to be surprised when people surpass expectations. For the next two hours, a small group of high schoolers passed up their evening of free time to sit around the pizza place with me- talking about the problems of our time with such enthusiasm that it reminded me why I got into this business in the first place. They are the future. And the future looks pretty darn good.

So here I am, twelve years after perusing that first course catalog, trying to add a drop in the bucket, improving education internationally. By a stroke of good fortune, I get to travel to some uniquely wonderful pockets of the globe. I meet with local educators and hear about their biggest struggles in the classroom. I work with Ministries of Education to improve reading assessments. And I collaborate with local organizations to design reading projects around the world. That alone, is wilder than anything I could have dreamed up as a 16 year old.

I may have strayed a bit from the initial health perspective, but those lessons from my Global Issues

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www.epiprev.it/INPHET/home

Glory Liu

Glory Liu is a PhD Candidate in Political Science at Stanford University. Her research focuses on the history of political and economic thought, public beliefs about economic inequality and social justice. She holds a BA from the University of California—Berkeley, and an MPhil from the University of Cambridge.

Confessions of an Armchair Activist grip the life preserver that kept me afloat—the life preserver that asked, “What are you doing to alleviate poverty? What are you learning that might change the way you think about global issues?” But the more I sought truth through history, economics, political science, the more I despaired. I had taken urban studies classes on global poverty and development theory, TAed classes on the historical political economy of imperialism and globalization, and gave up believing in the idea of altruism and good intentions. I was probably one of the most cynical members of my undergrad honors thesis class who scorned “development” projects. I rolled my eyes at my classmates’ “do-gooder halos” and verbally tore up their “evaluations” of projects in various developing countries.

I wondered how I ever thought I was doing the right thing when I started reading books about global poverty with Mr. Cone.

I begin with a confession: I am probably the least likely candidate to be writing in a public health journal. As former classicist, an aspirational economist, and a current political theorist, my days are spent attempting to cut cubes out of the fog of abstract normative theory and historical texts. But when I step back into my high school shoes, I would have found it even less likely to imagine myself where I am now— studying dead languages and eternal truths—and I think Matt Cone would agree.

I first met Mr. Cone—I still can’t call him “Matt”—when I was a sophomore at Rock Bridge Senior High in Columbia, MO. I was a bright-eyed, bushy-tailed high school student with ambitions to become a diplomat or lawyer, and naturally gravitated towards the new Model UN team which Mr. Cone was supervising. He coached me through my first two Model UN conferences that year and the following year, and must have seen some promise beneath my over-achieving and over-preparing attitude. My senior year he asked me and a handful of other students if I was interested in starting an independent studies reading group on “global issues.” At that age, the concepts “global justice,” “categorical imperative,” or “paradigms of development” might as well have been nonexistent—or if they were, I couldn’t grasp them or how they would shape my life. But I remember my feeling and thoughts exactly when I answered in the affirmative: I have to do this because this is seems like the right thing to do.

I devoted the first few years of my graduate career to studying how people think about poverty, inequality, and social (in)justice throughout history; I had clung to the hope that by piecing together some sort of genealogy of social justice, I might finally arrive at a good understanding of how we ought to think about and address issues of poverty and inequality today. But four years and elbows-deep into political theory I felt even more disenchanted about the prospects for truth—not because it wasn’t out there, but because it was so disconnected from real people and real action. I had these burning questions, big ideas that I couldn’t do anything with because I was too concerned about historical and philosophical rigor.

We devoured books. Tracy Kidder’s biography of Dr. Paul Farmer, Mountains beyond Mountains was the first on the list. We read Bill Ayers’ gripping autobiographical tale of extreme activism. We struggled through Jeffrey Sach’s The End of Poverty. We wrote letters to Bill Gates. We fund raised for Partners in Health initiatives classroom-toclassroom, using all of the verbal coercion we could muster from our awkward adolescent selves. We drove to Kansas City to hear Paul Farmer at the end of the year, the highlight being when Paul Farmer agreed to sign my yearbook.

After this deep dive into global issues, mostly through the lens of public health, I was ready to swim through the storm that usually sinks most college-bound kids: choosing a major. I ultimately settled on a double major between Political Economy (“something practical”) and Classics (“something beautiful”), but desperately tried not to lose my

Enter Hasso Plattner Institute for Design, better known as the d.school at Stanford. I had actually taken my first design thinking class in 2013 and was hooked. The mantras of the school were simple—have a bias towards action, defer judgment, fail faster and bounce back—but the application of design thinking to actual problems was where the challenges lay. It was the perfect dose of reality and empathy-driven strategies to problem solving that balanced out my now-instinctive habit to think about either increasing my survey sample size, or come up with a new thought experiment.

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In 2014, I participated in a highly competitive class known as “Designing Liberation Technologies.” The course

brought together top talent from academia, computer science, and industry at the faculty level, and students from all schools and fields at the student level. The premise of the course was this: Kenya was on the cusp of a technological revolution; mobile penetration rates were higher than any other country in East Africa, mobile money was taking off, and while most residents in slums didn’t have toilets, they did have mobile phones. How could we harness this kind of technical power to improve the lives of those living in extreme poverty?

how to wade through rough intellectual waters—like the Sacs -Easterly debate on how to end poverty. One said, pour money into state-backed investment spending while the other said, give anti-malarial bed nets directly to local organizations. You weren’t wrong for subscribing one or the other, nor were you wrong for saying that there were merits to both. The point was that if you wanted to do something that would change peoples lives for the better, you had to first recognize that you weren’t going to be the only one trying.

More importantly, you have to prepare yourself to defend your opinion, “fully, fearlessly, and frequently” (to borrow from John Stuart Mill) in face of the opposition.

I worked with a team of three other students on a project that was focused on increasing vaccination compliance rates. During our time in the field—once over spring break before the course began, and another trip after the course was over—we learned that there was both an information and an “impetus” gap that posed a barrier to low-income mothers following through with multi-stage vaccines, or even single vaccinations.

The second lesson is that the goal of “saving the world,” is a bad goal to set oneself up for not because it isn’t a noble cause, but because it is poorly defined. It’s one thing to say, “I just want to help people”—and you can get into a lot of trouble trying to do that—and another thing to say, “I want to find a way to convince governments to increase the percentage of GDP spending that goes to foreign aid,” or “I want to find a better way to help mothers get more information about vaccines in rural Kenya.” Clearly-defined goals are more focused without pre-empting a specific solution, though they aren’t necessarily easier to achieve.

However, they do open up the space for us as individuals to interrogate the reasons why we choose the path we do, and that process is beneficial not only for those we’re trying to help, but also for our own personal growth. I recall a profound moment in one of the conversations my high school classmates and I had with Dr. Paul Farmer. He said simply, “I think it would be a problem if everybody wanted to become me.”

Our in-person interviews were corroborated by larger-scale studies published in medical journals, and the research suggested that something as simple as a text message reminder—a mobile “nudge”—might positively influence compliance rates. So our team pitched a simple, focused solution: send personalized text messages to mothers that tell them three key pieces of information: (1) that their child is due for a vaccine, (2) where that vaccine would be delivered, and finally (3) what disease the vaccine prevents, in descriptive terms. On the night of our class pitches, our team received accolades from a wide range of high-profile attendees—acclaimed economists, employees from Apple University telling us that our team needed funding and that we were going to do amazing things. Our partners at the University of Nairobi—computer science students—were ready to build anything and everything to get this mobile app working. Our team received a small grant to fly back to Nairobi to work with two partner organizations and determine the long-term plans of our project.

Which brings me to my last lesson, which is actually a question: what amount of responsibility, right, and agency do we have to affect change in different arenas? I didn’t think about the answer to this question until I began working on the most recent mobile health-focused project in Kenya, when it dawned on me how different my answers could be.

On the one hand, my training as a political theorist and political scientist told me there was something wrong with imposing or even nudging people to behave or act in a way that some outside actor—myself, my design team—deemed “better.” How can I really prove that a particular belief about poverty, equality, liberty, or justice would improve peoples’ lives? On the other hand, it seemed so obviously true that telling people to vaccinate their children to prevent deadly diseases is the right thing to do when it comes to individual and public health outcomes. There seemed to be so much clarity in defining the responsibilities, rights, and degree of agency that one has when talking about public health issues, and I often envy those in the health profession for that very reason. But rather than allowing myself—or more worrisome, allowing others like me—to resign to the position of “armchair activist,” I have hope: that we might empower ourselves and others more effectively by identifying and acting with the agency we do possess in any situation.

But even with the best of plans and the best of intentions, our project never got off the ground. I could write at length about the reasons why we failed—everything from the promises and pitfalls of design thinking in developing contexts, long-distance brainstorming and prototyping, and the enormous gap between a great idea and a viable, sustainable one—but those are subjects for a different article and a different journal. Here, I would like to share a few lessons learned from a failed attempt at public health activism.

The first lesson is that there is no one savior, no single silver bullet, no unique pill completely solves a problem, public health or otherwise. One reason Mr. Cone was so adamant about having us read so much—and from opposing points of view —was to implant in our young and (over)active minds that everybody has an answer, and nobody has the answer at the same time. We were taught 37

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Tatiana Vorovchenko

Tatiana has just completed a Master of Science by Research in Clinical Medicine at the University of Oxford, focusing on the use of Twitter during the recent Ebola outbreak in West Africa. She is a motivated young dentist, and spent her early career serving in a public hospital in Ulyanovsk (Russia) where she gained experience with a wide range of populations. Tatiana expanded her skillset beyond dentistry by serving as an intern at the Ministry of Health of the Russia, and as a consultant at the WHO. Tatiana also received a Master of Science in Global Health Science at the University of Oxford. Tatiana is a co-founder of the Russian Association of Dental Students and Young Dentists, the largest non-governmental organization for dental youth in the country. She aims to become a world leader in global health, serving both her native Russia and the international community.

Ebola and Twitter.

Why is social media important for public health?

Why Social Media?

At the beginning of August 2014, after the first Ebola case was diagnosed in Nigeria, a Nigerian student posted a tweet urging the public to drink vast amounts of salty water in order to avoid catching the Ebola virus.

Later the World Health Organisation (WHO) reported that two people died and twenty were hospitalised in the country because of excessive consumption of salty water. On the 8th August the WHO posted their tweet saying:

Despite the level of poverty in the countries most affected by the Ebola outbreak, the use of tablets, computers, and smartphones in these regions is increasing. For example, Nigeria, the most populous country in Africa, has approximately 2 million Twitter users. Social media platforms enable both misinformation and accurate information about the disease to be disseminated quickly and widely. The opportunity to reach the public via this channel of communication has already been recognized by large health organisations such as the WHO, CDC (the US Centers for Disease Control and Prevention), and MSF (Doctors without Borders). Social media was successfully used by some of them in previous diseases outbreaks (swine flu), or other public health emergencies (Japan tsunami 2011).

“Bathing with salt and warm water, drinking water with salt does NOT cure #Ebola� and provided a link to a web-page with the facts on what helps manage the disease. This tweet could have potentially prevented more deaths.

This is an example of how social media can become a dangerous medium where rumours and misinformation can be spread quickly and widely, and how important it is for public health authorities to fill this medium with the accurate and timely information.

This is why my research at the Global Health Network, Nuffield Department of Medicine, University of Oxford was focused on the investigation of the ways in which social media was used during the West African Ebola outbreak by the general population, as well as by public health organisations.

What is Ebola Virus Disease?

Ebola virus disease is a severe and often fatal disease in humans that causes haemorrhagic fever. The virus is transmitted to people from wild animals, and is spread in the human population through human-to-human transmission. The estimated average case fatality rate of the disease is estimated to be as high as 50%.

How can we study social media data?

I decided to use Twitter data for the reason that both real-time and historic Twitter data are publicly available.

The study sample resulted in more than 60 million tweets covering the period of 17 months from the beginning of the outbreak in December 2013 to May 2015. To analyse this huge amount of data I used Splunk, a platform for machine data, a time-series optimised NoSQL data storage, analytics and visualisation software.

The West African Ebola outbreak has been the most complex and the largest since the discovery of Ebola virus in 1976. Its first case dates back to the 26th of December 2013. The outbreak is not over by the end of February 2016. The most severely affected countries are Guinea, Sierra Leone, and Liberia. There have been more than 28,000 reported Ebola cases and more than 11,000 deaths worldwide. According to the UN, more than 22,000 children lost at least one parent to the disease. So far there is no Ebola vaccine or treatment approved by the WHO.

What was the pattern of Twitter use in the general Twitter population during the West African Ebola outbreak?

The dataset included tweets in 149 languages with 83% 42

of tweets in English, followed by Spanish, Portuguese, French, and Indonesian.

coming from West Africa at the beginning of the outbreak, before the first Ebola case was diagnosed in the USA.

Geographical mapping (Figure 1) of the tweets demonstrated that most of them were posted from North America, Europe, and Latin America with a substantial proportion (approximately 14%) of tweets

Figure 2 represents the frequency of tweets over the whole study period and its correspondence with Ebola news events.

Figure 1. Geographical distribution of Ebola tweets.

1 December 2013 – 12 May 2015

22 March 2014- 30 September 2014

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Figure 2. The overall temporal tweet frequency distribution (by day) and key news events that influenced it.

1. 22 March 2014, Guinean health officials received confirmation that the mysterious haemorrhagic fever was caused

by Ebola virus.

2. 25 July 2014, Nigerian health officials announced that the first Ebola virus disease case was diagnosed in Lagos, Nigeria.

3. 30 September 2014, U.S. Centers for Disease Control and Prevention announced the first diagnosed Ebola virus disease case tested in the USA.

tweets?

The Twitter conversation started at the end of March 2014, when a mysterious haemorrhagic fever in Guinea was confirmed as Ebola, which was followed by the release of the first WHO report concerning the Ebola outbreak in West Africa. The frequency of tweets grew at the end of July 2014 when the first Ebola case was diagnosed in Nigeria. It rapidly increased further when two US missionary workers infected with Ebola were evacuated to the USA from Liberia at the beginning of August 2014 and when the WHO declared the Ebola outbreak a Public Health Emergency of International Concern. Tweet frequency reached its peak at the beginning of October 2014, after the first Ebola case was diagnosed in the USA on the 30th of September 2014 and demonstrated significant peaks throughout October 2014. Then, the first Ebola infected patient died and three more Ebola cases were diagnosed in the US. 40 million out of 60 million tweets of the dataset were posted during October 2014. Twitter conversation started to gradually drop since the beginning of November 2014 when Ebola topic stopped dominating news headlines.

The possibility to use Twitter data in order to detect and track the spread of a disease was widely demonstrated in case with influenza. Twitter activity was found to track the scope and extent of influenza outbreaks.

However, the Ebola case was different, as the Ebola Twitter conversation was driven by news events. My study demonstrated that in such a case public health organisations can use Twitter data in order to identify these events, track the information being spread on Twittersphere about them, and make sure to provide accurate information on the topics of interest.

These events can be distinguished in seconds with the use of big data analytics tools by evaluating the topics of the most shared articles within the tweets of interest.

For example, on the 8th of August 2014, one of the peak days in the dataset, most of the top shared articles were about the news that the WHO declared Ebola outbreak a Public Health Emergency of International Concern. Public health organisations could use this topic in order to draw public attention to the positive sides of this decision, as well as to highlight important public health information (such as the way the disease is spread, what the first symptoms are, and what people should do if they have them).

What can public health organisations learn from these 44

Who were the key players involved in the Twitter discussion surrounding the West African Ebola outbreak and why is it important for public health organisations to know it?

Twitter engagement, most likely due the high number of followers and reputation they have on Twittersphere, which also demonstrates their potential to spread the information during public health emergencies. Many UN organisations already collaborate with celebrities, appointing them as goodwill ambassadors in order to attract attention and focus the world’s eyes on the organisation’s goals.

News organisations achieved the highest level of engagement with the general Twitter public over the period of the outbreak, suggesting that the general public was sharing news stories and actively sought information on Twitter. This also supports the fact that the Twitter Ebola conversation corresponded with news events, and highlights the importance of Twitter as a tool for rapid communication and information sharing during epidemics. Therefore, in future outbreak scenarios, it is important for public health organisations to closely track the information provided by news organisations on Twitter in real time and collaborate with them.

Public health organisations should collaborate more closely with news organisations, Twitter celebrities, celebrities, and humour accounts that have such a high reach and level of engagement with the general Twitter population during public health emergencies; especially in the periods when the public expresses high levels of anxiety in the case of humour accounts.

How did governmental and non-governmental organisations fit in the Twitter conversation related to the Ebola outbreak?

Interestingly, humour accounts also achieved a high level of engagement during the Ebola outbreak.

Humour accounts’ activity was especially high during October 2014 (when Ebola cases were diagnosed in the US). Although there are a number of humour accounts that have millions of followers on Twitter, some of the most retweeted ones were created during the outbreak, with Ebola as a specific focus of their tweets.

The accounts of the WHO, UNICEF, CDC, and White House were among those that achieved the highest level of Twitter engagement. This suggests that Twitter users turned to them in order to seek the information during the Ebola outbreak. Whereas the WHO and UNICEF accounts were the sources of information for the global community, the accounts of the CDC and White House provided the information targeting the US public.

Humour accounts’ popularity might be explained by the general popularity of Ebola as a topic for Twitter conversation, and by the increased concern of the general public and Twitter users on this issue. Reading and sharing humorous content on Twitter might have acted as a means for relief and for tackling anxiety, as it is known that humour, even dark humour, is used in stressful situations as a buffer. However, these accounts did not always post humorous content. For example, one retweeted a public health information tweet posted by the CDC, and received a higher number of retweets than the most retweeted tweet posted by the CDC itself.

However, none of the tweets of these organisations managed to receive the highest levels of attention among all Ebola tweets.

The most retweeted WHO and CDC tweets were posted on the day when the first Ebola case was diagnosed in the USA (the 30th September 2014). The WHO tweet contained an emotional personal story and was retweeted more than 3,000 times. The most retweeted CDC tweet contained public health information and was retweeted more than 4,000 times.

Interestingly, the most retweeted tweet in the whole dataset was posted by a Twitter celebrity, who had just around 2,500 followers. This tweet contained a political statement expressed as a joke and was retweeted nearly 63,000 times. Considering the relatively low number of followers that the account had, this tweet was likely retweeted due to its controversial content that attracted people’s attention. This suggests that the combination of emotional content with important public health messages could help public health organisations to achieve even higher levels of engagement with the Twitter public.

Twitter celebrities and celebrities also achieved a high level of engagement with the general public during the West African Ebola outbreak. Twitter celebrities are the accounts of people or organisations that are not famous outside of Twittersphere, but have a high number of followers on Twitter. Among them were health specialists, journalists, or bloggers, who actively use Twitter for communication with the public. This suggests that they have high influence in the Twittersphere during the outbreak periods.

Accounts of celebrities also achieved a high level of

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In conclusion

Health authorities need to consider the use of big data analytics tools in order to quickly gain insights from social media data to inform their communications strategies, as this project has demonstrated.

Health authorities would benefit from building their Twitter presence because people turn to the accounts of these organisations in order to ask questions and obtain accurate public health information in public health emergencies. Twitter provides a unique opportunity for public health organisations to listen to their audience, and to share scientifically accurate information.

Acknowledgments This material is based upon work supervised by Dr. Francois Van Loggerenberg and Dr. Proochista Ariana. The work was done within the The Global Health Network group (www.theglobalhealthnetwork.org), Nuffield Department of Medicine, University of Oxford, and supported by Splunk4Good, corporate social responsibility programme of Splunk Inc.

Public health organisations may benefit from employing humorous and emotional content, and collaborating with accounts with a high level of Twitter engagement, such as news, humour, Twitter celebrities, and celebrities. It is also important for them to monitor how accurate the information posted by these accounts is, and this would be most helpful in real time.

Figure 3. Most retweeted of the WHO, CDC, and overall in the dataset.

Most retweeted WHO tweet (retweeted more than 3,000 times)

Most retweeted CDC tweet (retweeted more than 4,000 times)

Most retweeted tweet in the dataset (retweeted more than 63,000 times)

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Emily Lawrence

Monitoring & Evaluation Specialist, emBOLDen Alliances

Emily Lawrence brings over five years of experience working in international development and public health throughout Latin America, South Asia and the United States to emBOLDen Alliances. As a former Peace Corps Volunteer in Honduras and Health Educator with Clinica Family Health Services in Denver, she has an intimate understanding of the challenges small non-profits face during program implementation and evaluation.

Paired with her public health research experience and MPH training in Monitoring and Evaluation, Emily is committed to helping organizations reach their full potential through research, evaluation, and strategic learning. Emily completed her BA in International Relations from the University of San Diego and her Masters in Public Health from Boston University. When not working, Emily can be found enjoying the great Colorado outdoors, biking, hiking, skiing and camping.

Using Local Networks in Humanitarian Disasters On 25 April 2015, a 7.8 magnitude earthquake with an epicenter in the Gorkha District of Nepal caused severe destruction in 14 of the country’s 75 districts. Two weeks later, on 12 May, another quake of 7.3 magnitude hit with a more eastern epicenter, and worsened the humanitarian situation. According to the United Nations Dispatch, the earthquake and subsequent aftershocks affected approximately 5.6 million people, killed 8,891 people and displaced approximately 2.8 million.

This is the story of several exemplary Nepalese who acted immediately to help their fellow citizens. Their response assisted countless individuals and invaluably directed international aid efforts.

The Earthquake The day of the 7.8 magnitude earthquake in Nepal, Ang Tshering Lama, owner of Ang’s Himalayan Adventures, was about to launch off on a river trip on the Trisuli River about three and a half hours from Kathmandu, when everything around him began to shake, rocks started to fall from the cliffs above, and brown clouds of dirt filled the air. The earthquake continued for a seemingly long time with continuous aftershocks. He immediately packed up his crew and clients and rushed back to Kathmandu. On the drive back, Ang and his rafting crew had to clear through landslides as the massive destruction caused by the earthquake became clearer. “It was dark at night, there was no electricity, it was just with the lights of the car, but I could see [the destruction].”

Within days of the earthquake, relief flooded into the country and an estimated 100 international search and rescue and medical teams immediately dispatched to provide emergency relief and to help prepare for recovery. As the earthquakes affected predominantly remote mountain villages, rescue and humanitarian operations took place in extremely challenging terrain.

Local knowledge and networks were critical in minimizing further death and damage and maximizing delivery of life-saving resources.

47 Ang (left) and Jiban (right) meeting about Person2Person4Nepal before the second earthquake on May 12.

Temporary hotels for 40 children attending Syabru Bensi of Rasuwa District

Recovery in Kathmandu

When he was finally able to get through, he learned that everyone in his small village was fine, but many people had lost their homes and were in need of medication and daily essentials. Sherap started by going to the local market in Kathmandu where he bought 20 tarpaulins, rice, cooking oil, and plastic containers for water. However, he had no idea how to transport the supplies as the roads were buried, and it was impossible to even hike to the village. Then he received a call from a friend who flies for Dragon Air who said that his friend who worked for Search and Rescue Technical Rescue (SRTR) in China was flying into Kathmandu to help. Could Sherap meet them at the airport?

Ang arrived in Kathmandu at 1:30AM, and after ensuring that his mother, who had been alone in his apartment, was okay, he quickly realized that although none of his neighbors were hurt, no one had eaten. Ang had been expecting a big earthquake to come at some point and had kept a store of emergency food. He fed 15-25 people that night with Wai Wai (Nepalese noodles) that he cooked on his camping stove. As a mountaineering guide, he had extra tents and parachutes to use as shelter for those who had lost their homes or were too frightened to sleep inside due to the many aftershocks. He felt scared at times, but he tried to stay calm. “ I couldn’t stand seeing the plight, I knew I needed to help.”

Meanwhile, Ang’s response effort was also quickly escalating. He started to work closely with his good friend from Nepal Kayak Club and within a week after the earthquake hit, he had started to make trips out to Sindhupalchok District with other outdoor trekking guides to bring food and supplies. “We had this whole team of kayakers, rafting guides, mountaineers, so we blended in. If we had to climb a mountain, we did it.”

Through his connections with the mountaineering world, he connected with Person 2 Person 4 Nepal, a national grassroots movement and with emBOLDen Alliances, a non-profit based out of Colorado, to transport duffle bags filled with temporary shelter and supplies up to remote villages in the mountains. They called themselves the “Grassroots Gorillas”.

To the Mountains In the days after the earthquake, money for relief efforts began trickling in to Ang. Previous clients and Nepali friends living abroad started to send money to him and said: “Go. Your people need your help.” Then more and more people started sending money, and in Ang’s words, “then, we went big.”

Sherap Sherpa, owner of Wild Tracks, also knew that he had to get to the mountains to help his fellow villagers. Sherap lives in Kathmandu, but he is from a small village of 26 households 148km north from Kathmandu, near the Tibetan border. He tried calling his family for five days after the earthquake.

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Then Ang received a call from Ming Serpa, a Nepali American Nurse associated with a Nepali-American Nursing Association who said that her organization wanted to send four nurses from the United States.

With those nurses as well as local Nepali nurses, Ang and his team of mountaineers and river guides, travelled to 15-20 villages in Sindhupalchok, where they provided medical care, distributed food and supplies and trained villagers on proper hygiene. This work required traveling to very remote villages, negotiating challenging terrain, and executing helicopter evacuations of wounded patients. But, for Ang and the Nepalese medical team, they took these obstacles in stride with focus and determination.

the Person 2 Person 4 Nepal effort, agreed: “I would say [that a] bigger organization has bigger issues [which] means red tape. But we had smooth supply [chain] without any disturbance. To be honest, I was very fortunate as [a] Nepali to support my people on behalf of our team whom we worked together without borders & boundary twenty four-seven.”

Because of their work in the tourism industry, all of these men had contacts in and direct knowledge of the affected areas. For Sherap, he would call hotel owners that he knew from motorcycle tours and ask them what they needed, how badly people were affected, and if there was an accessible road for them to get there. He would then post that information on Facebook to let others know. Within the next three to four days, he would get supplies from friends in India, who were also a part of his same motorcycle club, Friends of Royal Enfield (FORE), and he would be off to the villages in need with the supplies and with Nepali members of his club.

Meanwhile, Sherap was headed for the districts of Nuwakot, Sindhupalchok and Rasuwa with SRTR. Through SRTR, Sherap met another international relief organization that he assisted with medication and supply deliveries. While assisting this organization and coordinating with several other international organizations, Sherap was also able to deliver the first round of aid to his own village and its two neighboring villages using helicopter and road transportation.

Understanding of the culture and language of Nepal also played a huge role in their nimble response.

According to the 2011 Nepalese Census, 123 languages are spoken in Nepal. Sherap speaks 9 of these, helping him to communicate quickly with those in need. Additionally, knowledge of the complex caste system in Nepal helped Sherap and his friends identify priority towns, know with whom to speak within communities, and identify those who may be voiceless.

For example, when Ang learned from his local connections that a delivery of rice had been given to a household that already had significant stockpiles, he had the rice recalled and given to a household that had none. Most agencies may have just walked away, checking the household off their distribution list off, but here, local insight directed this limited resource most appropriately.

Sherap also helped to build temporary learning centers in Syabru Bensi of Rasuwa District in-coordination with Head Master Madhav Lamichhane of Shri Shyame Wangphel Secondary School. With help from another international organization, he brought tents to setup a temporary hostel for 40 resident kids in the same school, setup clean drinking water facility for the kids, and provide solar rechargeable lamps. Without Sherap to guide these international resources appropriately, the school children may have suffered waiting or may never have been reached.

Local Networks Both Ang and Sherap work in the tourist guiding industry and have a deep understanding of the complexities of Nepali culture and language. Their knowledge and skill helped them to respond to the April earthquake with flexibility and speed. “For westerners, it’s hard, because they have to do a lot of logistics, they have to do the research first, and that takes time you know. Whereas I go on word of mouth from people whom I know and trust: ‘This many people are killed, this many are injured and this is all gone’. Then we say: ‘Okay we are coming,’ and this is how we do it. We don’t have to have a team go and do all of that scrutiny first…you know, write it down, evaluate the situation, etc. We knew that everything was gone, everyone’s homes are gone,” explained Ang. He continued: “In Nepal, it is not like America, it’s through word of mouth.

‘Do you need our help? Okay, we are coming’.”

Continuing On Both men are still working on projects in affected areas.

Sherap and his motorcycle club are working to rebuild a health center in Dubachour. The previous health center was devastated in the earthquake, and after speaking with the locals, it was clear that they wanted a primary care center. They already had the land and an agreement signed with the Ministry of Health, however due to the current political crisis and boarder blockade from India, his team cannot get supplies across the boarder to build the center. Sherap also plans to work with an international relief effort to bring in engineers from Macau and rebuild 27 homes in Thalo village of Sindupalchok.

Ang too is hindered by the current political crisis. He is working in Sindhupalchok to rebuild a school and has

Jiban Ghimire who also worked very hard with Ang on 49

Jiban Ghimire and several of the many community members who worked tirelessly to distribute life-saving supplies during the emergency.

They mobilized resources from clients and partners around the world to effectively and efficiently deliver aid to those most in need. As a final word of caution for the next disaster, Jiban states: “We have to have basic supplies ready to move first [during an emergency]. You guys should collect money rather sending unusable stuffs. I found [that overall from everything I saw come in], 35% of relief goods coming from USA could not be used. [It seemed that] some people were just clearing out their garage.”

all of the materials ready, but due to the fuel blockade, he cannot yet transport the materials.

Both men were motivated by a great need to help their fellow countrymen: “I couldn’t stand seeing people suffering, I tell you…I am not religious, [but] for me, religion is helping people [laughs]. At the end of the day, it gives me good sleep,” says Ang. For Sherap, he feels that if we don’t help, no one else will. He feels the government is practically hopeless in Nepal. “We have to help, because these our people, they belong to our country…if we don’t help them, who will?”

Acknowledgements Emily Lawrence, Ang Tshering Lama, Sherap Sherpa, Jiban Ghimire, Liesl Clark, Julie Hull, Jake Norton, Bill, Rohs, Matt Murray, Patti Bonnet, Neena Jain, and ALL of the scores of individuals who contributed to the P2P4N and emBOLDen Alliances’ Nepal response.

Lessons Learned Local knowledge, generosity, local language and culture, and deep-seated compassion are priceless in any situation, and particularly during disasters. Ang, Sherap, and Jiban were able to spring into action the moment the earthquake hit using their connections and knowledge to understand where the most affected areas were and what was needed.

Photo Credits Person2Person4Nepal, emBOLDen Alliances, Sherap Sherpa

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Claire Allen

Claire Allen is the part-time Operations Manager for Evidence Aid. She worked for Cochrane for 18 years, and has a B.A. (Hons) in Communication, Media and Culture.

Claire’s background is in administration and finance. She was appointed to the post of Knowledge Manager in August 2011, moving to Operations Manager in September 2015.

Her main tasks relate to the overall operations of Evidence Aid, including management of information to ensure that evidence can be readily accessed in the format that is most helpful to the user, bearing in mind the potentially difficult circumstances in which this evidence will be needed.

Mike Clarke

Mike Clarke is one of the founders of Evidence Aid, and now voluntary Research Director and Chair of the Board of Trustees. He has extensive experience in the evaluation of health and social care and is Director of the Northern Ireland Hub for Trials Methodology Research at Queen’s University Belfast. He has worked on some of the largest randomized trials in specific areas of health and on dozens of systematic reviews in a wide range of areas, and has a strong interest in increasing capacity for the conduct and use of systematic reviews.

Jeroen Jansen

Jeroen Jansen has been engaged in a wide variety of sectors, issues and working environments, mostly in management positions. He worked for Médecins Sans Frontières (MSF) in Afghanistan, Liberia, Darfur and several other contexts. He has been successfully employed in the private sector, managing the deployment of humanitarian aid and working as a head of department for MSF in the UK. Although he started as an engineer, he later obtained a Masters in International Human Rights Law and worked for Marie Stopes International. This wide variety of experience has exposed him to different actors and developed his ability to bridge divides between cultures, industries and topics.

Helping decision-makers before, during and after disasters and other humanitarian emergencies Hundreds of millions of dollars are spent each year on disaster relief and humanitarian aid with the intention of improving the lives of those affected and reducing the impact.

Evidence from health care has shown us that no matter how good the intentions, some interventions are useless or even harmful. This is no less true for the humanitarian sector.

Interventions that are not based on evidence can waste vast resources and hinder effective approaches that would speed up recovery and improve health outcomes.

You’re responsible for a humanitarian organisation and as news of another disaster reaches you, the cogs in your machine start turning. Pictures and stories of devastation start arriving, exposing an overwhelming need for humanitarian aid, and you have to act soon.

Although you don’t yet know what the priorities will be food and water, healthcare, shelter - you know that some interventions and actions will be better than others. You also know that some that sound plausible may actually be harmful. You need a way to tell them apart – what do you do? Who can you turn to for help?

There is increasing recognition that the choices we make in our lives and work should be based on reliable and robust evidence. In the case of humanitarian interventions and actions, available evidence about the effects of the interventions need to considered when aid is being delivered and when writing guidelines, standards, and policies.

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COPYRIGHT TASHI SHERPA, Nepal Village after the earthquake in 2015.

Reliable and robust evidence will help those making decisions, developing policies and standards in the humanitarian sector to know which interventions work, which don’t work and which remain unproven. And, for those interventions that work, people need to know how effective they are, so that they can choose the most appropriate and effective intervention in a specific circumstance.

research and makes best use of the investment in that existing research. This should be no different for disasters and other humanitarian emergencies [1].

Evidence Aid was established after the Indian Ocean tsunami of 26 December 2004, by members of Cochrane, the world’s largest organisation dedicated to the preparation, maintenance and dissemination of systematic reviews of healthcare interventions.

Between 2004 and 2015, Evidence Aid sought simply to help people involved in disaster risk reduction, planning, recovery and response to access a reliable evidence base. However, much more is needed if people and societies affected by disasters are to really benefit from reliable and robust evidence. So, during 2015, Evidence Aid developed a five year business plan to inspire and enable those guiding the humanitarian sector to apply an evidence-based approach across their activities and decisions. This will ensure that those in need receive humanitarian aid in the most timely, effective and appropriate way possible.

One of Evidence Aid’s first successes was to inform psychiatrists and psychotherapists responding to the Indian Ocean tsunami that counselors should not use ‘brief debriefing’ (a single-session counselling service designed to prevent psychological trauma) as a means of preventing post-traumatic stress disorder, or PTSD. Cochrane evidence had shown that this intervention is not effective, and, if anything, might be harmful. This decision not only led to better health for the affected population but also allowed scarce resources to be used for the deployment of more effective interventions.

Since then Evidence Aid has created specific bundles of knowledge for earthquakes, most recently responding to the Afghanistan and Pakistan earthquake in 2015, windstorms, and the Ebola outbreak.

The organisation has grown to include partnerships with many different types of organisations (e.g. aid and U.N. agencies, government departments, non government organisations, and academia) and individuals working in disasters and other humanitarian emergencies. This allows us to cover the broad spectrum of people working throughout the humanitarian sector. Since inception in 2004, Evidence Aid has championed the evidence-based approach in humanitarian action, and is now also concentrating on

When it comes to identifying and using robust findings of research to decide what is likely to do more good than harm, the healthcare sector recognises the need for evidence to come from the synthesis of all similar studies, often called systematic reviews. This avoids undue emphasis on the findings of any single study, minimises bias, maximises the power of existing 52

creating and satisfying an increasing demand for evidence that will improve the impact of humanitarian aid. It will do this by stimulating and supporting the use of an evidence-based approach.

The most recent course, held in Dublin, Ireland in association with the Centre for Global Health, Trinity College Dublin was in December 2015. Twenty-four people signed up to the course from various geographical locations including France, Italy and the US, as well as the UK and Ireland, and from many diverse humanitarian organisations and academic institutions. These include (but are not limited to) Plan International, Save the Children, Action Against Hunger, Loughborough University, University of Galway, and the Uniformed Services University of the Health Sciences - USUHS (USA). Professor Steve Waller from USUHS said of the course “The Evidence Aid systematic review course is a gem in my toolkit now, and my participation in future systematic reviews will be greatly enhanced by my experiences in Dublin” [7].

Evidence Aid‘s work has four objectives: 1. Establishing Evidence Aid as the influential ‘go-to’ organisation for the evidence-based approach towards humanitarian action.

2. Upholding and promoting the value of evidence in health outcomes across sectors.

3. Identifying the gaps in evidence for humanitarian aid and building the resources and networks to address them.

4. Raising the capacity and commitment of those who guide the humanitarian sector to implement an evidence-based approach.

Supporting the identification of gaps in evidence in the humanitarian sector continues to be important. To start this process, Evidence Aid held a Priority Setting meeting in 2013, bringing together those who influence and guide the sector [8].

To date, Evidence Aid has held three international conferences to promote the use of evidence in the humanitarian sector, one in Oxford in 2011 (supported by the Centre for Evidence-Based Medicine, University of Oxford), one in Brussels in 2012 (supported by the Belgian Red Cross, Flanders) [2], and the last in Hyderabad, India in 2014 (supported by the South Asian Cochrane Centre). All three conferences were well attended by a diverse mix of participants and reports are available on the Evidence Aid website: www.evidenceaid.org [3-6].

Approximately 30 high priority research questions were identified under ten themes that could be addressed by systematic reviews in the area of planning for or response to natural disasters, humanitarian crises or other major healthcare emergencies. There was a particular focus on topics of particular relevance to low- and middle-income countries, where the health impact of disasters may be greater than in high-income settings. Some of these gaps have been taken up by the Humanitarian Evidence Programme and other individuals. When the reviews are available they will be included with the more than 250 systematic reviews that are already freely available from the Evidence Aid resources.

Evidence Aid enables maximum impact on investment in the organisation, by running an agile organisation, with a scientific approach, capitalising on a robust and responsive network. To raise capacity and commitment, Evidence Aid also provides training opportunities for those in the sector who wish to learn about evidence.

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Conference in Hyderabad

Credit: Evidence Aid

Conference in Oxford

Credit: Evidence Aid

References

Through Evidence Aid’s first eight years, nearly 1.6 billion people were affected by disasters globally, with the estimated total cost of damages totalling over $1.3 trillion (USD) for the same period(2005-2013) [9].

Looking to the future, Evidence Aid’s work should help to make the evidence-based approach ‘the norm’ in the humanitarian sector. This would mean that those who guide the humanitarian sector will use evidence to substantiate their policy and guidelines with improved effectiveness of humanitarian action; and that evidence will be accessible to all actors whose interventions contribute to health outcomes in the humanitarian sector.

1. Gerdin M, Clarke M, Allen C, Kayabu B, Summerskill W, et al. (2014) Optimal Evidence in Difficult Settings: Improving Health Interventions and Decision Making in Disasters. PLoS Med 11(4): e1001632.doi:10.1371/journal.pmed.1001632 2. Vandekerckhove, P., Clarke, M.J., De Buck, E., Allen, C., Kayabu, B.. Second Evidence Aid Conference: Prioritizing Evidence in Disaster Aid. Disaster Med Public Health Preparedness. 2013;7:593-596.

3. http://www.evidenceaid.org/evidence-aid-symposium-2014/ 4. Allen C (2014) , A resource for those preparing for and responding to natural disasters, humanitarian crises, and major healthcare emergencies. Journal of Evidence-Based Medicine 7 234–23. doi: 10.1111/jebm.1212

Evidence Aid believes that those in need have the right to receive humanitarian aid that has been proven to be effective and not harmful. If evidence exists, such as that on brief debriefing after the Indian Ocean tsunami, it should be used to guide activities. Related to this, the increasing demand for ‘value for money’, proof of impact, and effectiveness in the provision of humanitarian aid, makes it essential to ensure that such decisions and activities are evidence-based to ensure funds are not wasted. Evidence Aid and those who guide the sector need to work together to ensure that we do no harm and that humanitarian activities are as effective, timely and appropriate as possible. We can do this by identifying existing evidence, filling gaps in the evidence, and facilitating collaboration between those who understand and provide evidence and those who ensure its application.

5. Lisam, S. (2014), Minimum initial service package (MISP) for sexual and reproductive health in disasters. Journal of Evidence-Based Medicine, 7: 245–248. doi: 10.1111/ jebm.12130 6. Mahapatra, P. (2014), The need for evidence-based public health response in disasters. Journal of Evidence-Based Medicine, 7: 238–244. doi: 10.1111/jebm.12129 7. http://www.evidenceaid.org/evidence-aid-training-course-7-8 -december-2015/ 8. Evidence Aid Priority Setting Group EAPSG. Prioritization of Themes and Research Questions for Health Outcomes in Natural Disasters, Humanitarian Crises or Other Major Healthcare Emergencies. PLOS Currents Disasters. 2013 Oct 16 . Edition 1. doi: 10.1371/ currents.dis.c9c4f4db9887633409182d2864b20c31

If you would like to find out more about Evidence Aid, or to get involved, contact us by e-mail: callen@evidenceaid.org, or follow us on Twitter (@EvidenceAid), Facebook, LinkedIn (Evidence Aid) or online (www.evidenceaid.org).

9. The Centre for Research on the Epidemiology of Disasters (CRED), which maintains The EMDAT (Emergency Events Database). http://www.cred.be/

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Professor A D Redmond OBE

MD DSc(Hon) FRCP(Glasg) FRCSEd FRCEM FIMCRCSEd DMCC

Anthony (Tony) Redmond qualified in Medicine from the University of Manchester where he also completed his postgraduate training in Emergency Medicine. In 1994 he established UK-Med www.uk-med.org an NGO that provides international emergency humanitarian medical assistance and which now hosts the UK International Emergency Trauma and Medical Registers. He is currently Professor of International Emergency Medicine at the University of Manchester where he co-founded the Humanitarian and Conflict Response Institute at the University of Manchester (www.hcri.ac.uk). This is a joint venture between the Faculties of Medicine and Humanities and researches into the background to, and consequence of, humanitarian crises. The HCRI runs Masters programmes in humanitarianism and conflict studies, international disaster management and a bachelors programme in global health.

A Career in International Humanitarian Response You have been involved in the public health response efforts for several disasters around the world. Can you name some of these?

services in Manchester, UK. The SMART team responded to earthquakes in Armenia and Iran, as well as the Kurdish refugee crisis on the Iran/Iraq border. SMART members also attended the Lockerbie air disaster.

Directly involved in earthquake responses to Armenia 1988, Iran 1990, Kashmir 2005, China 2008, Haiti 2010 and organised response to Nepal 2015.

We worked in Sarajevo but the work demanded a broader national response, so I established a new national non-governmental organisation, UK-Med.

Worked in Bosnia, Macedonia, Croatia, Serbia and Montenegro in the civil war 1991-1995 and Kosovo 19992000 and civil war in Sierra Leone 2001.

What were the most challenging decisions you had to make as team leader during disaster response?

Responded to a cholera outbreak in Cape Verde during a volcanic eruption 1995.

To invite volunteers to join a mission where the risks were very high because of snipers and shelling.

Responded to the Typhoon in the Philippines 2013.

Who else was in your team?

Surgeons, anaesthetists, emergency physicians, nurses, physiotherapists, occupational therapists.

I was seriously injured during the typhoon in the Philippines and incurred fractures of T11 and T12. I was quite incapacitated so couldn’t respond directly to the Ebola crisis and Gaza but organised things from the UK.

How do you or your team engage with other sectors as part of the public health efforts for disaster preparedness and response?

Are there any common features to the public health preparedness and response to these incidents?

The media is important. They may be new to these circumstances so taking the time to explain the true needs and true risks can help get accurate information out to the affected population.

The affected population in a sudden onset disaster have an unreasonable fear of disease outbreak associated with the unburied dead, often fuelled by the media and sometimes by health care workers who are unaware of the true risk. This leads to unnecessary burning of bodies in the street and mass graves - with all the emotional horrors and legal nightmares that produces for the survivors. Of course if the disaster is an infection and the organism remains contagious after death (e.g. Ebola, cholera) then dead bodies are a risk; but not after earthquakes etc.

Throughout your experience, have you witnessed or been part of exceptional leadership or innovation as part of disaster preparedness and response?

I have witnessed altruism, professionalism, commitment and courage in all my teams and I am immensely proud of them.

What made you decide to establish UK-Med? I established the South Manchester Accident Rescue Team (SMART) which started life as a local medical team, acting in support of the rescue and ambulance

What made you decide to pursue this career pathway?

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It is an extension of emergency medicine.

What is your top advice for anyone considering a similar career?

Any final words?

There are no “natural� disasters; only natural phenomena. The disaster that follows is a result of human action/inaction/neglect that leads to vulnerability and it is always the poor that are most vulnerable. But poverty is a product of politics and economics and can therefore be changed

First complete specialist training so as you have an expertise to offer. The work is not for you to learn but to offer skilled help to those in terrible need. Then learn more about the context and skillsets required – do a DTMH/MSc/ MPH. 56

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