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The Latest News from the World of Public Health

Profiles by Mike Field

NIGERIA
Olugbenga Obasanjo

It is Africa's most populous nation, and, in many respects, its most important. It is an oil-producing state and often a major voice within OPEC. It is geographically central, politically centrist, multicultural, and economically diversified. Nigeria is all these things and, if Olugbenga Obasanjo (MPH, PhD '99) can help achieve his dream, his homeland will be one other thing as well: Africa's leading force in the fight against AIDS.

Nigerian AIDS prevention programs must be as diverse as the country's terrain, which runs from sub-Saharan desert to savannah and tropical jungle.

"We're in the forefront of HIV programs right now, but across Africa the problems are enormous," Obasanjo says. At present, government statistics put the AIDS infection rate of Nigeria's 120 million people at 5.8 percent. The World Bank estimates that this rate will double within the next three to four years. Unofficially, many experts acknowledge that Nigeria's AIDS population—and its rate of infection—may be much greater than estimated.

In April of 2001, Nigeria brought heads of state from the Organization of African Unity together in the Nigerian capital city of Abuja to address the crisis of AIDS and other infectious diseases confronting the continent.

Olugbenga Obasanjo is part of a major AIDS prevention effort in his native Nigeria.

The African summit coincided with the launch of APIN—AIDS Prevention Initiative in Nigeria—a partnership of the Nigerian government, academia, and the Bill & Melinda Gates Foundation created to control the spread of AIDS in Nigeria. Obasanjo joined the effort this year as a research associate at the Harvard School of Public Health to help design, manage, and coordinate AIDS-related projects already under way in the country, and study how the government's efforts can be made more effective. "Right now the national program is not as coherent as it should be," he says, "but the population is huge and Nigeria is going to be a big player in how Africa responds to this crisis."

Obasanjo has special insight into the country. In 1999 his father, Olusegun Obasanjo, returned to power as Nigeria's first freely elected president in 15 years. President Obasanjo pledged strong support for AIDS prevention in Nigeria, a position his son helped promote.

The tremendous diversity of cultures and traditions within the country means that AIDS prevention campaigns in each of Nigeria's 36 states must be specifically tailored to indigenous populations. "Nigeria is a country that ranges from nomadic peoples in the sub-Saharan desert in the north, to savannah, to tropical jungle," Obasanjo observes. "To prevent AIDS transmission our approach must be multifaceted, because the same diversity of terrain is also true of its people."

The challenge is mostly, he believes, a matter of bringing all levels of government together with a common goal in mind. "I find as far as best practices, people just don't know. It's not that they're not ready to know—they lack knowledge," says Obasanjo. "That's what we can do: give them the information and say, 'Now, how can we help?'"

JAKARTA, INDONESIA
Bhavna Patel

Bhavna Patel, MPH '99, offers a lesson in developing economies: Just because the government says something is there on paper, she warns, don't necessarily believe it's so. In Indonesia, where she is stationed as a field office director for Catholic Relief Services, a case in point is the national system of village-based health clinics known as Posyandus. In theory, at least, every village has one. They are meant to offer basic medical services to villagers and spearhead the national effort to control infectious diseases.

Bhavna Patel enjoys a rare vacation with her brother Ravi Patel.

In the more remote rural areas, however, the reality is often far different. "Most people aren't using the Posyandus," she says, noting that many Posyandus lack the basic equipment, drugs, and supplies necessary to do business. "Since the [Asian] economic and political crises, government programs have suffered. In Indonesia, a lot of infrastructure on paper is not functioning on the ground."

Catholic Relief Services works indirectly to attack such problems. "Rather than provide services ourselves, we work with partner NGOs to help build local capacity and develop local service infrastructure," she says. Currently, her office supports two rural projects in western Indonesia: a community-based health program designed to improve utilization of Posyandus, and an agricultural project that documents and disburses best farming practices, including integrated pest management techniques.

"We work at the local level to create Posyandu-based health teams, which are in the process of identifying the unique health priorities of each village," she says of the three-year pilot health project. "Then we will provide specific training tailored to those priorities."

JOHNSTON ISLAND
Gregory Zaar

Gregory Zaar can't talk long on the telephone. He explains that a recent accident severed the submarine cable serving Johnston Island, leaving the 1,000 or so inhabitants of the remote Pacific atoll just seven telephone lines in, 14 lines out. As a result, calls are kept short. Zaar, MD, MPH '90, a physician by training and the island's chief medical officer, gets right to the point.

"This island has seen it all," he says of the tiny, previously uninhabited U.S. territory located about 800 miles southwest of Honolulu. Discovered accidentally in 1807 by British sea captain C.J. Johnston, the coral atoll formation of two neighboring islands is about a half-mile wide and two miles long and only a few feet above the sea. In 1856, the U.S. laid claim to the island for its rich deposits of bird droppings—guano—used for fertilizer. Since then, it has been fortified as a World War II military airfield and submarine base; irradiated with plutonium during a missile launch failure; contaminated with Agent Orange supplies bound for Vietnam; and, most recently, equipped as one of several sites devoted to destroying a portion of the U.S. chemical weapons stockpile.

"The island has a runway down the middle, with the living quarters on one end of it, and down on the other, this huge incineration plant," Zaar says. "When I first got here in June of 1999, they were still destroying old mustard agent shells. At the time the project finished up in November of 2000, they were destroying anti-personnel land mines filled with VX nerve agent."


Above, Gregory Zaar; right, a speck in the North Pacific, Johnston Island will soon become a bird sanctuary.

The operation was performed by civilian subcontractors (including many laborers brought in from the South Pacific), overseen by U.S. military personnel. Workers would punch and drain the weapons, then burn the liquid agent in a furnace at 1,500 degrees Fahrenheit. The emptied shells, mines, or other devices would themselves be melted in an even hotter furnace, leaving nothing behind but ordinary scrap metal.

In addition to his regular medical duties, Zaar mastered a list of specific protocols that had to be followed whenever one of the island's chemical sensors sounded an alarm signaling potential contamination—a frequent occurrence that would send workers to the clinic for testing. Luckily, there were no serious injuries to workers during the 10-year operation, which has been responsible for destroying about 6 percent of the U.S. chemical weapons stockpile.

Workers are now disassembling the chemical agent disposal system and, piece by piece, destroying it in the furnace. Zaar will leave the island as the last workers depart in December 2004.

"One is always amazed at the millions spent on building and now destroying these weapons," says Zaar, a civilian under contract to the Defense Department. "What could have been done [with the money], possibly with more benefit, for example in areas without clean water and sanitation? How do you 'buy security'?" Still, he says, he is glad to be helping to return Johnston Island to its original state—it will become a bird sanctuary after the last buildings are destroyed.

"A place like this allows a lot of time for introspection," Zaar says. "When you're out here it's absolutely beautiful and phenomenal. There's a 50-meter pool in my backyard. I walk everywhere I go and swim two miles every day. Where else can you have that?" He pauses momentarily to consider. "Still," he says, "I wish there were more people to talk to."

SOUTH ASIA
Dina Borzekowski

Dina Borzekowski and her friend Grover

A little girl named Meena is creating a stir in South Asia. With her brother Raju and her talking parrot Mithu, Meena takes on the real-life challenges of girls from Bangladesh, India, Nepal, and Pakistan in 15-minute animated adventures. She confronts issues like equal access to school and proper nutrition and health care, and battles child labor, wedding dowries, and early marriage practices. While serious in theme, Meena's messages are communicated through light-hearted stories.

Dina Borzekowski's job is to ascertain how effectively Meena is delivering her message. A leading researcher into how health messages are conveyed to the public—particularly children—Borzekowski, EdD, an assistant professor in the Department of Population and Family Health Sciences and the School's Center for Communication Programs (CCP), recently returned from a trip tracking Meena's impact across Bangladesh, India, and Nepal. "I was surprised to see the enthusiastic acceptance of Meena," she says of her first investigational visit to the subcontinent. "Young mothers would bring their daughters to Meena screenings and they would both watch together. Sons seemed to like her, too." The makers of Meena, she says, "appear to be successfully reaching many audiences, including children, adults, and community leaders."

Created in the early 1990s as part of a United Nations initiative aimed at improving children's rights, Meena is the work of Hanna-Barbera Studios (which created, among other cultural icons, Fred Flintstone and Scooby-Doo). The UNICEF-funded Meena Communications Initiative uses film, radio, and print media to convey messages about girls' equal rights to educational, medical, and social resources.

A protégée of one of Sesame Street's creators, Borzekowski says, "Much of my education in children and media came from the stories of Sesame Street's challenges and successes."

The Meena videos are well-produced and engaging for children, according to Borzekowski. She should know; her Harvard doctoral advisor was Dr. Gerald Lesser, one of the original creators of the children's TV show Sesame Street. "Much of my education in children and media came from the stories of Sesame Street's challenges and successes," she says.

Meena, however, faces some distribution issues that Grover, Cookie Monster, and other denizens of Sesame Street never had to contend with. She appears on state-run television in some places, but "in others, it literally means strapping a generator, a monitor, and a tape player on a donkey and taking this equipment up into the mountains," says Borzekowski. Her multinational evaluation, which will entail household and community-based surveys of parents, children, and opinion leaders, will be conducted in the coming months, and will entail further visits to the region, including Pakistan. In the meantime, she has some preliminary observations of her own. "Meena is a hero over there," she says. "I can only speak anecdotally at this point, but I observed that she is a role model for both boys and girls. In places where there is an ingrained cultural belief that girls are a burden to a family, Meena champions the idea that girls are a blessing."

AHMEDABAD, INDIA
Mirai Chatterjee

Each morning before work, the women gather to pray. Sitting cross-legged on the floor, Hindu beside Muslim, they offer an all-faiths prayer devised originally by Mahatma Gandhi. These women are the front lines of a unique effort to organize the poorest of India's poor — organizers and administrators of the 285,000-member Self Employed Women's Association (SEWA) based in the western city of Ahmedabad, in the state of Gujarat.

Further to the west, the India-Pakistan border teeters on the brink of war. In Gujarat, sectarian violence between Hindus and Muslims has claimed more than 1,000 lives in recent months; rioting and arson have destroyed countless businesses and homes. Hanging over all is the specter of nuclear war. And so the women of SEWA pray for peace and unity.

After prayers, there is time for some yoga and brief exercises. And then the women get to work. About 300 women, drawn from across India's communities, work from this office, directing a network of health centers, medicine shops, and mobile health camps in Ahmedabad City and 11 districts of Gujarat state.

On a SEWA mission, Chatterjee (far right) meets with a young woman and her child.

"We never have a typical day and nothing goes as planned," says Mirai Chatterjee, MHS '85. Coordinator of SEWA's social security team responsible for organizing health care, child care, and insurance services for poor women, Chatterjee shares with all her colleagues responsibility for both leading and implementing SEWA's services. "One morning I may be in Delhi meeting with [national Secretary of Health] A. R. Nanda. The next day I'm in the slums working with our barefoot doctors," she says. Since its inception as a labor union in 1972, SEWA has organized women workers of the informal economy, providing financial services (including "micro-loans" of less than $100), medical care, child care, and insurance to Gujarat's poorest. Women become members of SEWA to obtain services as well as their economic rights through the union.

The task is an enormous one. In India, "informal workers"—those with no fixed employer/employee relationship and hence, no statutory protection to guarantee pensions, sick leave, insurance, and other basic rights—constitute 93 percent of the workforce, according to Chatterjee. They are the small and marginal farmers, the street vendors, the day laborers, and piece-rate home manufacturers. Most are very poor; many live on the edge of financial catastrophe.

Chatterjee (left) welcomes SEWA members and midwives at the opening of a SEWA health center.

For them, the possibility of injury or illness is a constant threat. According to studies, about a quarter of all Indians hospitalized each year fall below the poverty line as a result. A decade ago, SEWA began offering basic health insurance to its members to help protect their families from financial ruin. Known as "micro-insurance," the policies cost between 85 and 400 rupees (approximately US$1.50 to $8) per year and provide hospital benefits, life insurance, and assets coverage of from 2 to 10,000 rupees.

"Recently, we were told that ours is one of the largest micro-insurance programs in the world," says Chatterjee.

Sometimes, their needs run deeper than mere finances. Chatterjee and colleagues have been documenting the effects sectarian violence has had on Hindu and Muslim SEWA members. Many need to express their grief at the loss of a loved one, or destruction of their business or home. SEWA offers an opportunity to share their pain across cultural divides. Says Chatterjee: "We are just together as workers, as women, and mothers."

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