I get around is one of our regular series. Every month, Association members tell stories of where they are, what they are doing, who they have met, and why they believe or hope they are doing valuable work. This month we have Seva Khambadkone writing from Nicaragua, telling us about her gap year in the community of Fila Grande, working as a research assistant.
Managua, Nicaragua. This gap year has been an experience unlike any Ive had so far in my junior career in public health. At university I worked with several public health organizations serving both Columbus, Ohiowhere I went to schooland Nicaragua, but these were extracurricular pursuits I had to manage alongside daily coursework and lab-based research. Though I minored in public health and development economics, the gap between the textbook and real world experience is immense. After class I would seek out this real world immersion, rushing to a free clinic or local school to volunteer and coming back to campus for meetings of various health and development-oriented activism groups. Co-leading the Ohio State University chapter of US-based nonprofit Project Nicaragua, I would work to organize student involvement and fundraising toward our causes on campus, coordinate projects with Nicaraguan partner organizations, and lead service trips to Nicaragua for two-week trips. I squeezed public health in between classes, while experiments were running in lab, over school breaks, and sometimes at the expense of classwork. Through this partial immersion, I developed a passion for health care for the underserved and a collaborative, holistic view of health. I knew, however, that before I entered graduate training in this field, I wanted to have the sort of immersion experience that the rigor of university would not allow me.
My need for immersion and consequent decision to take a gap year was rooted around the idea of perspective. The reason I am going to medical and public health school is to serve the underserved, to do my part in furthering the human right to health. In light of this life aim, I did not want to approach years of advanced medical training with only the perspective of the sheltered, upper middle class, American college student I was fortunate enough to be. I cannot escape my privileged identity. Nor do I want to; rather, I will utilize that privilege and the education and resources and opportunity that come with it toward my goal of addressing health disparity. But knowing that I will focus my health career on marginalized populations, likely in Latin America, it was only logical to enter medical school with better understanding of their perspectives. I thought that a yearthough even a year is shortof living and working in Nicaragua with such populations would supplement my classroom education in my development as a public health servant. As I said in my first I Get Around column last September, Id hoped it would help me mature beyond good intentions into a more capable partner in the collaborative global effort toward social justice and equitable health.
As I near the end of my time in Nicaragua, Ive been reading past writings like that column, using them as an external compass to gauge my development over the past months. While it is easy to checkmark a list of skills that Ive learned or projects Ive done, this method has additionally allowed me to recognize a subtle but profound shift in my perspective toward community-based public health from needs-based to strengths-based, dynamic, and utterly complex.
Being one of the younguns in WPHNA, its part of my duty to keep you abreast of whats trending in Generation Y. One such trend is the idea of first world problems. The rationale behind first world problems is innocent and even seemingly self-aware. Its a way for privileged people to lament about the relatively minute inconveniences of their lives in a way that recognizes just how minute and silly these inconveniences are, packaged into a self-deprecatingly charming 160-character tweet. One would think that as a proponent of equity I would appreciate this new societal consciousness, and for a long time I couldnt articulate exactly why the trend bothered me so much. That is, until I read an article in The Atlantic that explored the same question. Nigerian-American writer Teju Coles critique was so shatteringly precise that I feel compelled to quote it directly:
I dont like this expression First World problems. It is false and it is condescending. Yes, Nigerians struggle with floods or infant mortality. But these same Nigerians also deal with mundane and seemingly luxurious hassles. Connectivity issues on your BlackBerry, cost of car repair, how to sync your iPad, what brand of noodles to buy: Third World problems. All the silly stuff of life doesnt disappear just because youre black and live in a poorer country. People in richer nations need a more robust sense of the lives being lived in the darker nations. Heres a First World problem: the inability to see that others are as fully complex and as keen on technology and pleasure as you are.
The idea of problems being First World or Third World creates a caricature of the spoiled, latte-drinking, Ray-Ban-wearing, FaceTiming Millennial. But, worse, it creates a one-dimensional, static, and dehumanizing image of poverty. It shifts the emphasis of poor person from person to poor. Something like closet full of clothes but nothing to wear!!! #firstworldproblems implies an awareness that much of the world really doesnt have much in terms of wardrobe choices. But what this so-called awareness fails to recognize is the universally human desire to take pride in ones appearance. The effort and angst I put into the silly problem of looking cute in high school is matched by the teenage girls I work with in remote rural Nawawasito, teenage girls who also deal with much more serious challenges than I ever faced. Human beings have been born into billions of life situations, have faced billions of unique challenges of differing magnitudes, but each of these humans is just as silly, just as complex, just as human.
Young women in Banco de Sikia trying and failing to pose seriously for a picture.
It is so easy to take a near-solipsistic view of the world. Trapped within yourself, it is so easy to recognize your own complexity but view the rest of the world as inert characters in the play that is your life. Can the human mind even comprehend 7 billion others as vast and intricate as itself? This failure of empathy becomes easier the more removed and disparate the life of another person seems to your own. As well-intentioned and paper-perfect my perspective toward public health as a collaborative uniting of effort across socioeconomic strata, cultures, and academic disciplines seemed, I too was guilty of an oversimplified outlook centred around my own experiences and strengths.
What is incredible and beautiful to me is how easy it is to shift this outlook. Through human connection, whether by an empowerment-based qualitative research technique like PhotoVoice or a meal shared between new friends, we can reach across our disparate selves toward mutual recognition of complexity, dignity, and equality and, with that, a truly collaborative approach to public health and development that utilizes the experiences and strengths of each of us to better life for all of us.
My work partners U.S.-born son, Tiago, and health promoter Ismaels daughter, Maria, holding hands while playing. An example for us all!
13 and pregnant
The majority of my focus in the past couple months has been in the Southern Atlantic Autonomous Region (Región Autónoma del Atlántico Sur, or RAAS), specifically in the area of El Ayote. In the words of my Nicaraguan co-workers, El Ayote can best be described as the Wild West of Nicaragua. A violent Contra stronghold during the Sandinista-Contra struggles, the region, once inhabited by indigenous populations, was overrun by people displaced by Nicaraguas political and environmental instability. Even more than in many other parts of Nicaragua, the rural communities we partner with here have large numbers of youth, low education and literacy rates, and high teen pregnancy.
In February and March I spent three weeks within two of these communities, Banco de Sikia and Nawawasito, to work with community members and AMOS staff on sexual, reproductive, and early childhood health. In each community, gynaecologist Brenda Pereda and I ran three focus groups: young women, older women, and men. The premise behind a focus group is to create organic discussion between participants that not only sparks the revealing of individual experiences and viewpoints but also allows insight into interpersonal community dynamics. This is a factually accurate but utterly dispassionate description of the memories and stories and ideas that came forth slowly but soon brimmed and bubbled in our groups.
Asked about sexual health education and services, the youngest girls, giggling behind their hands, first appointed their braver friends to speak in hypothetical situations. Soon, questions began pouring forth. What does beginning menstruation mean? How can I talk to my partner about contraception? Until what age can pregnancy occur? Our groups had sixteen-year-old single mothers, toddler children in tow, learn for the first time the physiology of conception. One of these girls stayed after the session one day, chattering with me about her friend problems and music tastes in the way my little sister would, in a way that made me remember that a sixteen-year-old with a child is still a sixteen-year-old. After a couple hours she took me aside, whispering about a problem down there. Her shyness and shame and the leap of faith she took in trusting me, a community outsider, about her potential STI was heartbreaking and so very humanizing. The girl, suffering for weeks, hadnt sought help from the communitys health promoter. But of course she didnt want to ask the adult male promoter about her female issueswhat teenage girl would! Speaking to another new young mother, I learned more about the WHO-discouraged practice of giving infants water in addition to breast milk. Of course an inexperienced but well-intentioned mother would believe that infants, like adults, need water!
Though my organization focused on community-based health, I still thought about health challenges from the institutional perspective I had been trained in. But the focus groups and the friendships that followed allowed me to transcend to some degree the nonprofit-community gap toward a human-human level of understanding. The PhotoVoice technique we used in our last week in the communities further developed this bond by promoting communication through the visceral medium of imagery. Armed with a camera and guided by broad questions, the initially shy girls I worked with became the authors of their own lives. Beyond using photos to present the problems they faced, they created stories weaving these problems with passions, strengths, and potential solutions. In one photo they presented a young woman handing a teenage mother birth control, explaining that community women should utilize their experiences to counsel and support one another. In another they showed a community midwife shaking hands with a physician from the Nicaraguan Ministry of Health (MINSA), illustrating the collaboration and local capacity building needed to improve mother and child outcomes in their remote rural area.
Box 1: PhotoVoice
An example of a PhotoVoice picture taken by my team in Banco de Sikia.
For the PhotoVoice aspect of our work, we selected four or five volunteers from each focus group in both communities, creating six teams total of young women, older women, and men. Armed with basic photography knowledge and four guiding questions on sexual health strengths and needs that were developed through our many focus group sessions, the participants took photographs and wrote stories that brought these strengths and needs to life. Above is an example of the types of photos taken by our participants. I feel privileged to be able to share a translated version of the story accompanying this picture, written by Dayling (red skirt) and Maria Ledy (blue top).
Title: MINSA and female facilitators from the community need to train women in sexual and reproductive health
Story: Dayling is a teacher in Banco de Sikia. Here she is giving sexual education classes to women who are in adult secondary school, the minority of the women in the community. All women need to be trained in sexual health, but the majority of the community women arent able to attend adult secondary school. With the help of MINSA, female facilitators from the community like Deyling could have the support to teach special sexual health classes to all the women in the community.
Photos and stories like this, so powerful in the voice that they give community members, played a huge role in creating a strengths-based, collaborative action plan between the communities, AMOS, and MINSA.
My team of young women from Nawawasito showing off their PhotoVoice pieces.
Through these photos, the participants demonstrated the needed external support from organizations like AMOS and MINSA while pledging their own investment in and contribution to addressing local health needs. On our last day in the communities, we scheduled a meeting with the local branch of MINSA and community representatives. As community members presented their photos and stories to MINSA and MINSA members responded with their own perspectives, I could almost see the tendrils of tentative human connectionthe same ones I had experienced over the past several weeksspring and intertwine throughout the room. Meeting with community members in this capacity forced MINSA members to see the community members as complex humans rather than the synecdochical litany of STDs, teen pregnancies, malnutrition, etc. that it is sometimes so easy for health professionals to reduce their patients to. At the same time, the community members were able to see the MINSA representatives as well-intentioned allies in health rather than the huge, terrifying institution MINSA is sometimes seen as within communities. This meeting was a concrete example of the three-way partnership between community, government, and institution that AMOS exists to facilitate. Recognizing each others humanity, we were able to truly collaborate in a strengths-based and honest way. By the end of the meeting we had created a plan to address local sexual health challenges as equal partners, in which the young girls I had worked with played as great of a role in improving female health education and access as the physicians at MINSA and AMOS.
Three-way partnership in action: Community members presenting their PhotoVoice pieces to AMOS staff and the Ministry of Health to illustrate local needs in sexual health education and services.
Stirring the Pot
Back in AMOS headquarters in Managua, I worked with our Primary Health Care (APS) team to organize a one of the three health promoter trainings held each year. In addition to monthly on-site monitoring and evaluation of health promoters, AMOS brings the health promoters from each of our communities to Managua three times a year for a weeklong idea exchange and capacity building session. A week prior to the training in March, we had the opportunity to work with physician Roy Shaffer, a father of community-based health care. Shaffer grew up in Kenya to missionary parents, learning Masai along with English as a child. After training as a physician in the U.S., he returned to Kenya to teach medical students at the University of Nairobi and work with the African Medical and Research Foundation. Easily relating with both community members and health professionals, Shaffer recognizes the importance of the communitys role in public health. In his book Beyond the Dispensary, he addresses the balance between the community and the institution, urging us to move from an institution-centric pill for every problem and needle for every need perspective of health to one that understands and utilizes community strengths.
Dr. Shaffer and his wife, Betty, receiving AMOS t-shirts from AMOS Medical Director Dr. Laura Parajón and Primary Health Care Team Coordinator Dr. Roberto Martinez.
Though AMOS already operates under a collaborative model of community-based health, Shaffers experience in navigating the gap between nonprofits and communities was immeasurably helpful. During a week of training for our Primary Health Care team, Shaffer used a Training of Trainers methodology and gently guided our supervisors toward a problem-posing, inductive style of community engagement. He reminded them to not only have confidence in themselves but also in the abilities of the community members they work with. We practiced tools of community engagement like using drawings and short skits as triggers for discussion, adding them to methods like focus groups and PhotoVoice already in our collaboration toolbox. The next week, Shaffer helped facilitate as the Primary Health Care team used his techniques to lead health promoter training. It was incredibly exciting to see the immediate impact of this learner-centered training. The room was filled with an indescribable energy, and by the end of the week even the quieter promoters were actively participating.
It was obvious that this method of engagement, conscious of the strengths and complexities of each participant, worked when the promoters began using it themselves to communicate with each other and with us. One of my favorite moments of the week was listening to Timotea, an experienced health promoter, teach younger promoters about plant-based, natural treatments for illnesses during a training break. Not only were the women using Shaffers engagement tools, but even the subject of their conversation was about community-based strengths and resources! Timotea began the conversation through a discussion trigger, something Shaffer dubs a starter, and carried it through a question-based and example-heavy discussion filled with mutual respect. In response, other health promoters joined in and started sharing natural methods used in their own communities in one of the more organic grassroots idea exchanges that Ive ever witnessed. Totally unprompted by us, the health promoters are now thinking of putting together a guidebook of natural remedies that they can use in combination with conventional medicines within their communities.
Timotea Romero, health promoter from Laguna de San Onofre, Boaco stirring the pot with her discussion cucharón, or spoon.
By engaging community members as whole, capable persons and partners in health, we can do what Shaffer calls stirring the pot, a cooking metaphor that transcends cultures. Imagine cooking porridge. Would you stir around the outer edges or just in the middle? Stirring around the edges, scraping the sides of the pot, is required to cook the porridge evenly. Shaffer asks who are the people at the edge of the pot? When we stir the metaphorical community pot we are striving to make sure we reach beyond the leaders and the people at the centrethe youth, the women, and the people at the margins of the community. Engaging entire communities through problem-based learning and opportunities for mutually respectful idea exchange is necessary to sustainably improve health care in places where there is almost no access. At the end of the week the promoters left the training with new skills and the motivation to scrape the sides of the pot and reach the most marginalized and least heard people within their own communities.
AMOS Primary Health Care team staff receiving certificates for completing Dr. Shaffers training.
My teachers here in NicaraguaLaura Parajón, Brenda Pereda, Roy Shaffer, and, especially, my teenage PhotoVoice girlshave helped me to identify my own unconscious biases toward collaboration. Now more than ever, I recognize the strength of the people I serve beyond the challenges they face. Trained in focus groups, PhotoVoice, and problem-based community engagement, I am further developing the tools to utilize these strengths and combine them with my own in true partnership towards better health.
In my most recent WN article, I mentioned Carl Taylor, a giant in community-based health and founder of Johns Hopkins Universitys Department of International Health. On my laptop I have a well worn, stained sticky note with a quote from him that explains, in one pithy sentence, our challenge and pursuit. This plus the mental refrain Ive developed over the past monthswe are all just as complex, we are all just as human, we are partners in bettering our liveshas become a mantra for me whenever I find myself returning to the comfort zone of oversimplification and self-centrism. It is:
Real change occurs when officials and people with relevant knowledge and resources come together with communities in joint action around mutual priorities.
My post-Nicaragua plans are becoming more and more concrete. I was thrilled to be accepted to my first choice medical school, Johns Hopkins. This fall, I will begin medical and public health studies at this mecca of community-based health care, where idols of mine including Dr. Taylor himself have centred their careers. Through the next steps of my path, I will carry with me the philosophy and skills of true collaboration that I learned here in Nicaragua.
The views expressed here are those of the authors and should not be taken to be those of the Association.
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