Using High Quality Royalty Free Symbols for Public Health

A few months ago my boyfriend, Eric Ferraiuolo, showed me a website called The Noun Project. The website has a large library of symbols that are—as their website pledges—”Free”, “Simple”, “Fun” and of the “Highest Quality”. The symbols are all Scalable Vector Graphics (SVG), which means that they can be displayed at any size and still appear crisp around the edges. I recommend browsing through this site as their are many interesting symbols. For example, a funny yet communicative symbol is the mammogram. I also appreciate that someone created a symbol for public health.

My Mom recently asked me if I could make signs for her for an upcoming medical trip she is leading to Bolivia through Remote Area Medical Volunteers. I immediately thought of The Noun Project. On these trips, she travels with Family Medicine Doctors, Dentists, and Optometrists from Canada to remote villages in Bolivia where medical care is not easily accessible. The last time I made signs for her I hand drew them. The process was a bit more labor intensive and the signs were not high quality. Below are the three signs that I put together using The Noun Project to denote where each doctor is located in their makeshift clinics:

You may notice that at the bottom of the glasses symbol there is an attribution. The reason why this is under the glasses symbol, and not the tooth or the doctor, is that the creator of this symbol listed the license as “Attribution” while the other two listed the license as “Public Domain”. In the image below, you can see where to find the preference that is listed by each symbol designer:

The Noun Project’s mission, “sharing, celebrating and enhancing the world’s visual language”, fits perfectly with my Mom’s international trip, and it is a great free resource to find well designed and scalable symbols.

Book Review: Social Entrepreneurship What Everyone Needs To Know

My brother, Eric Verploegen, loaned me Social Entreprenuership: What Everyone Needs To Know by David Bornstein and Susan Davis. Eric has recently been doing a lot of thinking, talking, and reading about how he and others effect the world around us. This includes topics such as energy consumption and global warming, the misguided use of growth as a metric of success and prosperity, and population growth.

One of the themes that my brother has been drilling into my head is the importance of social entrepreneurs, which is the reason he loaned me this book. Eric has been impressing upon me that I am an entrepreneur even though I do not currently have the desire to start my own public health organization or initiative. Everyone involved in a social entrepreneurship is themselves a entrepreneur, even if they are not the big picture thinker.

This book provides a plethora of examples of organizations that got it right and how they were able to achieve social change. The book reads fast and defines the who, what, where, when, and how of social entrepreneurship’s. The short answers to these questions as defined by the book are anyone, for any socially productive cause, anywhere, now more than ever, through increasingly interesting and innovative channels and methods. Many of the themes in this book include seemingly common sense advice that is difficult to achieve in practice, such as having an open mind and thinking outside of the box. The book also encourages collaboration and cooperation between fields and the integration of knowledge sharing and partnerships between not-for-profits, for-profit businesses, governments, and academic institutions.

A subject that I have been thinking a lot about is the importance and desire for socially minded organizations to achieve sustainability. I particularly like how the authors of Social Entrepreneurship addressed this:

“…the idea of sustainability can be considered in two ways: the sustainability of an institution and the sustainability of ideas or values. The way we speak about sustainability usually refers to individual institutions. This is limiting. It’s like speaking about the lives of trees rather than the lives of forests. Both are important, but just as trees fall and are absorbed into the ground, institutions go through cycles of growth and decay. Some find ways to renew themselves; some die off. In thinking about sustainability, it is key to focus on the forest.”

This spoke to me. While I whole heartily believe that organizations should have good business sense in order to be efficient and successful, it is also important that organizations remember their goal. The goal of the organization should not necessarily be sustainability of the organization itself, but sustainability of the core mission.

A great example that Bornstein and Davis provide in this book is Jeffery Hollender, the founder of Seventh Generation. Seventh Generation’s goal is to increase the use of environmentally friendly household cleaning products. While Hollender had his own company to run and compete in the household cleaning product market, he also provided unpaid consulting services to Walmart. Since Walmart is a massive distributor of household products around the US and the world, Hollanders impact on the environment would be greater if was successful at reducing the impact of this retail giant – even if they were not selling Seventh Generation products. “At the highest level, success for a social entrepreneur is not about building the biggest or best organization in the field. It is about changing the field.”

I also liked how the authors related the needs of new entrepreneurial social ventures to new business ventures. They discuss how the riskiest part of any venture is during the growth phase, and this is no exception for social or non-profit ventures. Scaling an idea that was successful as a small model many times fails to take off in different settings with different parameters surrounding the need or demand.

This book did a great job of relating the social entrepreneurial world to the average for-profit businesses. While there were many real world examples provided for each point made in the book, I feel that the authors overused a number of organizations that they are affiliated or familiar with. It would have been nice to learn about a wider breadth of organizations and businesses in this social entrepreneurship category. All in all, Social Entrepreneurship: What Everyone Needs to Know was a worthwhile quick read that provided interesting ideas to continue thinking about.

More Access to Electricity than Toilets in India

I have recently been working on an evaluation project at the Center for Global Health and Development at Boston University where I have been working with a dataset from Karnataka, India. The evaluation is of an HIV/AIDS cash transfer project, and two of the demographic variables collected to assess poverty level were access to electricity and access to toilets. It was shocking to find that 83% of families in this study have electricity but only 16% have toilets. The percent of people in this study who have toilets includes both indoor plumbed toilets as well as pit latrines. This means that the 84% of families who do not have toilets are defecating in the open, which is a serious sanitation and public health concern.

Since I don’t know much about Karnataka, I decided to dig a little deeper. Using USAID’s Demographic and Health Survey (DHS) STATCompiler I looked up the statistics for toilet and electricity access in all of India. Below is information that I compiled into a table from the most recent DHS India data in 2006:

	All of India	Urban India	Rural India
Toilet (%)
Flush or Pit Latrine	43.8	82.1	25.3
No Facility	55.3	16.8	74.0
Electricity (%)
Yes	67.9	93.1	55.7
No	32.1	6.9	44.3

A few days later I was forwarded an article from NPR by my colleague, Erin Morehouse. This article addresses a similar issue – more people in India have cell phones than toilets. The article points to the lack of the Indian government’s ability to organize and provide public services to a rising middle class. Although an individual or a family maybe able to afford a cellphone, the task of building a pit latrine or installing a toilet that is attached to working plumbing has many barriers.

This concept relates to public works on any level. No one person or family wants to pay for the street lights or stop signs in their neighborhood, but without them the community is collectively less safe from crime or traffic accidents respectively. Without the Indian government’s assistance to set up plumbing infrastructure in many parts of India, many people will not want or be able to pay for what is necessary for indoor plumbed toilets and collectively everyone is more likely to be exposed to the spread of infectious disease.

While working in Uganda last summer, I helped promote the construction of pit latrines in rural Iganga through the Uganda Village Project. While they do not require large scale government investment in infrastructure, pit latrines are not a piece of cake to construct and require maintenance. While surveying sanitation facilities my team found that when people did have pit latrines some were not built properly and were at risk of caving in or not dug deep enough. Pit latrines need to be dug at a certain depth, have supports on the sides and at the top where a person stands, and have a structure above the latrine to keep out animals (for the most part) and for privacy. Serious manual labor is required, as well as a devoted piece of land away from potable water sources.

While sanitation and access to toilets are health priorities, electricity and cell phones can be business priorities that aid in development. Additionally, electricity can be essential to providing certain healthcare services, and mobile technology is increasingly being used to improve international public heath systems in incredible ways. The economic and health value of electricity and cell phones do not make the need for toilets and better sanitation less important; however, it is interesting to note the increase of access certain technologies over toilets. The rate at which and how countries develop varies greatly, as do priorities. It will be interesting to see how trends like these continue to evolve.

The Difficult Task of Global Health Decision Making

A resounding lesson I have learned through classroom education and work experience is that decision making is not only difficult in international public health but it can be agonizing. Yesterday, I attended a panel discussion at the Boston Public Library organized by Médecins Sans Frontières titled At Any Price? Negotiating Access to Crisis Zones. The panelist were seasoned humanitarian aid and human rights professionals. The stories shared and lessons learned conveyed that it is nearly impossible to have unwavering moral standards when working in crisis zones. In order to gain access and save the lives of civilians, it can be necessary to negotiate with the abusers or provide resources the criminal organization. If you are unwilling to negotiate and compromise, people will suffer and many will die. Unwavering morals can cost human lives.

Human rights organizations have to be careful how far they go to expose the truth of what is going on in a crisis zone, even though justice and bringing awareness is their mission. If a human rights or humanitarian aid organization exposes a sovereign state’s leadership of wrong doing, they may not be allowed back in to provide much needed assistance.

An agonizing story described by one of the panelist was the unintended consequence of repeat rapes enabled by aid that was provided in a crisis zone. Doctors were repairing obstetric fistulas and providing mental health services to women who were victims of violent rapes. Unfortunately, the fact that the women were able to return to relatively normal lives left them yet again vulnerable to rape.

All decisions have consequences and reverberations — many which are unforeseen. In global public health decisions often mean life or death. I was lucky enough to be taught by Bill Bicknell during my time at Boston University. His lectures commonly included the theme that international public health is “the business of who dies when and with what degree of misery.” While this is not the altruistic message I was thinking of when I wrote my admission application to BU, it a way of thinking about the field that I am glad I was exposed to. No situation has one correct answer or a perfect solution. There will always be resource limitations, many people will not receive lifesaving or pain mitigating interventions, inefficiencies are inevitable, and serious compromises will have to be made. The job of global health professionals is to problem-solve, make evidence based decisions, and strive to save the most lives and reduce as much misery as possible.

Book Review: The Invisible Cure by Helen Epstein

While in Uganda this summer, I encountered misconceptions about the spread of AIDS in Africa. Some people assume that HIV/AIDS prevalence in Africa has to do with high levels of promiscuity. I knew this was not the case and had remembered reading information to the contrary, but I didn’t know what reason to give for why AIDS spread more rapidly through Africa than other regions of the world.

A few weeks later, when I returned to classes at Boston University, I was assigned Helen Epstein’s book The Invisible Cure: Why We are Losing the Fight Against AIDS in Africa. This easy to digest book that reads almost like a mystery novel provides a well developed answer to the efficient spread of AIDS in Africa. Epstein takes you through her experiences of working on AIDS in Africa and introduced me to the concept of concurrent relationships.

The network of sexual relationships that is created by concurrent relationships, as opposed to serial monogamy, shows how a sexually transmitted disease can spread rapidly through a population. In many places condoms are viewed as most necessary to be used with risky partners. But people in concurrent committed loving relationships most likely do not view their partners as risky. An STI can spread more rapidly within a network of people with more than one relationship at a time even if those who have concurrent relationships have less lifetime partners than serial monogamists.

Epstein’s book goes into more detail with other valuable information from her journey on an uphill battle to fight AIDS in Africa. However, this explanation of concurrent relationships was the most revealing information I garnered from the book.

Recipe: Prossie’s Cabbage

There are many wonderful foods that I tried while in Uganda this past summer. My favorite is this deliciously sour cabbage. Prossie, who prepared six of us three meals a day for two months, would cook this cabbage for us at least a couple of times a week. I am not sure how ubiquitous this dish is around Uganda, but it is prepared in a similar way to sukumuwiki or doh doh, the shredded greens that appear in almost every meal in restaurants. I am a huge fan of sauerkraut, creative coleslaws, and cabbage in hearty soups. This is my new favorite way to prepare cabbage.

Ingredients:

• 1 head of cabbage shredded
• 1 large carrot diced
• 1 green pepper diced
• 1 medium yellow onion cut in half and sliced
• 2 tomatoes blanched and skins removed. (Prossie would rub the back of a knife across the skin of the tomato and remove them by hand, but blanching them is a much easier method)
• 2 cloves of garlic minced
• salt (a lot of salt!)
• pepper
• vegetable oil (I generally cook with olive oil at home, but in Uganda people generally cook with vegetable oil. Either type works well.)

Directions:

In a large saucepan over medium heat add a few table spoons of oil. Once heated add the onion, carrots, green pepper, and garlic. Season with a bit of pepper and a generous amount of salt. Let these ingredients soften for about 5 minutes.

Add the shredded cabbage to the pan and toss with the other cooking vegetables. Add a few more tables spoons of oil and more salt. Cover and let it continue to cook over medium heat for about 10 minutes. Add the tomatoes to the pan, stir, and cover to let cook for another 10 to 20 minutes.

Stir the cabbage well. The tomatoes will start to break apart. Add more salt and oil if needed. The combination of the salt and the tomato creates a sweet, sour flavor in the liquid created from the vegetables. If you do not taste this flavor then keep cooking and add more salt – its hard to over cook or add too much salt or oil.

Serves about 6-8 as a side dish.

Prossie would generally serve this cabbage with rice, beans, and potatoes.

Below is my favorite picture of Prossie:

Sustainable health intervention – what does this mean?

I am supposed to be writing a 20 page Culminating Experience for my masters degree right now. A first draft is due on Friday, but instead I am procrastinating by writing a blog post. The paper questions the definition and use of sustainability so I am not too far off of my topic. Additionally, writing this post has helped me to explore the idea. Do not get too excited though. I have not figured out the end of my paper yet, so I don’t have answer to the title of this post.

Sustainability was a high priority while I was working in Uganda this summer — if it would not last after the organization is gone, the we could not provide it. The idea is that creating a cycle of dependency on a donor organization can be dangerous and counter productive once the organization has left. I believe strongly in thinking long-term as opposed to creating short-term results that make people happy and do not last. However, does it actually benefit the long-term to work under the assumption that we can only implement things that will be sustained if we leave in the short-term?

It’s well-known that teaching a person to fish is better than giving them a fish. When teaching someone to fish, is it okay to provide them with the fishing rod? Or should they be required to find the resources for the pole, string, and hook? Before teaching people how to fish you now have to teach them how to construct a fishing pole with locally accessible materials. They need to learn how to whittle the pole into the proper shape and thread the string. What if hooks are not locally available? It is not sustainable to provide manufactured hooks to people who are unable to get more if the hooks are lost or broken. A sustainable way to create a hook, in this hypothetical setting, is for people to learn how to create a hook out of wood or stone. Now, even before teaching people how to construct the fishing pole you have to teach them how to make the hook in order for the fishing pole to work. Teaching someone how to fish has become a much more daunting task than it first appeared. Teaching a community to make hooks could take a decent amount of time, let alone teaching the rest of the fishing techniques. How much time is appropriate to spend in the act of teaching people how to fish before they actually catch the fish and feed their hungry families? Some of the people learning how to fish might get frustrated and look for someone else who can help their family.

In many places in Africa, similar to where I was in Uganda, there are a plethora of NGOs. The NGOs that give away free things may be less sustainable, but are certainly more interesting to the average villager. A good compromise, and a method to keep people’s attention, might be to go ahead and give someone a fishing pole to teach them how to fish. However, what if they catch one fish and then the second fish gets away with the hook? They are left with a pole that has no hook and cannot catch any more fish. This is pretty much the equivalent of giving someone a fish.

The proper balance between getting things done efficiently (maximizing time and resources) and maintaining sustainability is crucial to creating an effective and lasting health intervention. Unfortunately, balancing these two competing factors isn’t an easy task. I wonder if the definition of sustainability as lasting after we are gone is the best way to look at this ideal? Maybe their is a better lens for sustainable health interventions.

Ndala na Ndala Team in Bulumwaki

At my mom’s request, this is a post about the team I am living with in Uganda this summer. We decided to name our selves “Ndala na Ndala” which means “One by One” in Lusoga. There are multiple meanings for this, but the more profound is that we want to help make a change in the villages we are working in one by one. The less meaningful and more fun part of the team name comes from when Simonpeter was asking if he could kill the termites living in our wall one by one with his fingers (you can read more about this in my post titled Bug Invasion on Several Fronts).

My team consists of 6 people – two Ugandan Interns and 4 International. All four of the International Interns are from the US. Simonpeter is the Ugandan Team Leader and I am the International Team Leader.

Simonpeter is the only man in the house and he makes sure we are well taken care of by negotiating transport, getting us to our destinations safety, killing spiders and other miscellaneous bugs, and being a patient translator. He has worked with Uganda Village Project (UVP) for the last three years and is our point of reference for Busoga culture, language, and guiding us around Iganga. Simonpeter is from Iganga, the district we are working in, but went to University in Kampala. When in Iganga Town with Simonpeter it is impossible to keep track of him. He seems to know every 5th person who we walk past, and this had its perks. He has been able to get us the best chickens in town by using his contacts wisely. He is hoping to attend Dar es Salaam University in Tanzania for his masters and he wants to become a counselor – which will be an excellent career for him.

Bernadette, who we call Bernie or Benna, is a super fun ball of spunk. She has this crazy curly hair that fits her personality perfectly. She has something to say about everything and makes us all laugh. Not only is she funny, but she is also very smart, perceptive, and a captivating public speaker. Benna is getting her Undergraduate degree at Makerere University in Kampala in Public Health. She is from Western Uganda and speaks mainly Luganda; however, she is very good at communicating in Lusoga, which is a similar but different local language.

Amanda is our team member who is prepared for anything. She has a disinfectant, first aid tools, and art supplies for any situation. We tease her about the amount of things she carries in her back pack, but then are pleased when we get a cut, have some unexpected down time, or really want fresh tomatoes from street markets. Amanda has just applied to medical school and I can imagine her as a very patient and attentive doctor.

Hannah is our expert on HIV and STIs having had experience working with injection drug users and youth. Hannah keeps us entertained in the village with her many exciting stories or by starting a six person dance party in our small living room. We are all very happy that she brought her iPod and travel speakers. Hannah is also not shy about giving our condom distributors a lot of detail about proper condom use or using a wooden penis to demonstrate how to put on a condom.

Julia is our engineer and also the person on our team who is most in shape. She recently booked a trip to climb Kilimanjaro after our program is over and she has been running or biking everyday since. She is also our resident expert on safe water and is determined to build a fence around our trash pit and a plate stand before we go home. Julia is the queen of “Two Truths and a Lie” and is a very good story teller.

We have a great team. Everyone is smart, hardworking, and has their own skills to add to our work. I am really happy to be working with these five people who are dedicated to making a difference in our villages this summer.

Beautiful Uganda

Uganda is such a beautiful country! Both the people and the landscape. The countryside is a brilliant green with a contrast of rich red soil. The people here are also amazingly gorgeous. When working in the villages we have come across some people who could be supermodels back home. Both the men and women have stunning features. There certainly is poverty and issues with sanitation where we are living; however, it can be easy to see past this when traveling down rural roads and looking out at expansive green landscapes of rolling hills.

What am I doing in Uganda?

I realized that I started blogging about being in Uganda before explaining what exactly it is that I am doing here this summer.

For two months I am volunteering for the Uganda Village Project (UVP) in the Iganga District of Uganda. I am one of 41 volunteers who are split into groups of 6 and living in 7 different villages in the district.

My team is living in Bulumwaki, but we are also working in two other villages, Nabitovu and Walukuba. Our team is following up on these three “Healthy Villages” which were started by UVP in 2009. The Healthy Village Program works with each village for three years in the hope of setting them up with sustainable health improvements that they can continue once we are gone. It is important that we interact with the villages in a way that is sustainable. This means no hand outs to cute kids, no allowances for people who help us in the work we are doing, and we can’t provide services or teach technology that cannot be continued without our help. This makes our job challenging, but hopefully allows our short time in the villages to make a longer lasting impact.

In the villages we are working with Village Health Teams (VHT) who are unpaid volunteers from the village and have an influence in their community. The villages that my team is working in this summer are in their last year of the program. Our main goal in this final year is to make sure the VHT is taking over the responsibilities of what UVP was previously doing.

Below is a poster Amanda on our team painted to present the work our team did in the first month in Uganda:

If your interested in more information you can read more about the Healthy Villages Program on the UVP website at http://www.ugandavillageproject.org.