Community-focused programs in Nepal

Enjoying the fresh air while attending a nutrition workshop in Balthali

Hello again, this is Ellina Wood. As the summer is quickly fading and my internship is coming to an end, I have been reflecting on my time spent in Nepal over the past three months. I have the great fortune to complete an incredibly fulfilling and rewarding dietetic internship with Helen Keller International (HKI) on Suaahara II: a project that has been implemented in Nepal since 2016 and partners with local stakeholders to address the health and nutritional status of women and children across 42 key districts.

Green leafy vegetables, pulses, and eggs to be shared at a swasthya aama samuha (health mothers’ group)

I agreed to the internship with the premise that I would engage in cooking demonstrations, analyze the nutrition content of existing recipes, make recipe recommendations to bolster the micronutrient profile, and write success stories to be shared in the annual report. Although some of my time has been spent on these objectives, a larger aspect of my internship has been spent on other tasks. While collaborating with a local dietitian and the Ministry of Health and Population (MoHP), I conducted literature reviews to develop a new national nutritional management protocol to aid in the recovery of moderate acute malnourished (MAM) children using nutrient-dense foods in place of imported formulated supplementary foods. Whilst there is currently no international guidance that endorses the use of local foods for the treatment of MAM, emerging evidence suggests that providing local foods may be comparable to formulated supplementary foods for recovery rate and weight gain so long as quality sources are used for the appropriate duration. In fact, the World Health Organization (WHO) is in the process of developing an international guideline, focusing on locally available food, for the prevention and treatment of moderate wasting in children presenting at health facilities with acute illness. It is the MoHP’s goal that any learning generated through monitoring and evaluation of the rollout of the new nutritional management protocol will be a valuable addition to the evidence base for the WHO guidelines.

Materials used during growth monitoring and promotion pilot testing

I also provided technical support to my team as they conducted pilot testing for an upcoming revision to Nepal’s Growth Monitoring and Promotion (GMP) guideline. The field-testing process meant that I had the opportunity to travel to different regions across Nepal to meet with the municipality-level governments and to support my team in training/ observing health care providers at Outpatient Therapeutic Centres (OTCs) and Non-Outpatient Therapeutic Centres (non-OTCs). Following each GMP pilot test, my team conducted exit interviews and focus groups with participating health care workers and mothers. Our observations and the following discussions ultimately guided our revisions for the GMP protocol and model recommendations for local and national government-decision making. Being able to travel to several districts not only gave me the chance to engage in monitoring and evaluation exercises with various government agencies and communities but it also allowed me to gain a deeper understanding of the region-specific customs and beliefs (trying new foods and getting glimpses of new, breathtaking views was a bonus!). I gained knowledge about the value of adaptability, how to effectively communicate in a culture that differs from my own, and how to be receptive when my worldview is challenged.

Although it is difficult to leave, I do so knowing that I am far better equipped to handle public health challenges. Overall, my internship has left me feeling inspired to continue working in the global health space.

-Ellina

A Practicum ending and a Pilot beginning

Hello! It’s Maria Esposito, again. Here with a practicum update!

A little bit of Jamestown, NY.

I wrapped up my practicum in the beautiful and peaceful Jamestown, NY while visiting family. My practicum was focused on a soon-to-be implemented study examining differentiated care models for transgender people in Johannesburg, South Africa regarding their HIV care, led by Dr. Audrey Pettifor and Dr. Tonia Poteat in partnership with UNC and Wits Reproductive Health and HIV Institute. As part of this practicum, I reviewed several journal articles, interview questions, and compared clinic checklists on LGBTQ+ health and their quality of HIV care to assist in the creation of my practicum products: a facility-level checklist, and two interview guides (one focusing on patients at local clinics, and the other focusing on key informants – clinic providers and supervisors). The trickiest part of creating these products was figuring out the proper wording of questions and cutting down questions to make the interview shorter. I also received feedback from Wits IRH folks, which was extremely helpful considering they have more insight than I do about transgender folks in Johannesburg, South Africa.

More Jamestown, NY.

However, the study isn’t over but just beginning. Dr. Pettifor and Dr. Poteat will be sending out my practicum products to be assessed by clinic supervisors and folks at Wits IRH before implementation begins. The study is expected to be piloted this Fall – but it may start in the New Year. And I am excited to see where it goes!

With that being said, I am thankful for this practicum opportunity and the mentorship Dr. Pettifor and Dr. Poteat provided. Before starting this practicum, I knew I wanted to re-engage with research again, specifically qualitative research. This experience has only confirmed that I find qualitative research extremely compelling and informative of a person’s individual experience. I am excited to see what the next step of my Public Health journey will be!

Maria

The U.S. does not have universal safe sanitation, and we’re not doing enough about it

Jordan Lake

Wrapping up the summer, I feel exhausted but fulfilled and excited to put the work of this summer into use in the future. These past months have been filled to the brim with various projects, the largest of which of course being my practicum project, but also my Haitian Creole (kreyòl) courses and my work with the Humanitarian Health Initiative.

There are a million and one things I would like to say about my practicum, and what I’ve found researching the barriers, risks, and social determinants related to poor sanitation in the United States. I would like to rail against the injustice that is a high-income country that allows millions of residents to rely on, for example, straight pipes, the system by which waste is directly conveyed, untreated, onto adjacent land or into nearby surface water (though, to be clear, the United States is not the only high-income country home to such methods.) I would want to highlight how many communities lack safe sanitation, a basic human right as delineated by the United Nations Resolution 64/292 (and common sense), because they are afraid of revealing their documentation status; how many communities of color still lack municipal water and sewer services due to under-bounding, the municipal annexation equivalent of red-lining, even though, in some cases, water and sewer pipes run through their neighborhoods to serve majority white neighborhoods.

Price Lake

But if I had to select a single thing (and, really, I don’t, because I’m currently writing a literature review on these barriers, risks, and social determinants!) it would be that there are indeed sanitation issues in the United States. In my readings, I came across a quote from a law review, that states: “indoor plumbing and sanitation are taken for granted in developed countries. … approximately 43 million Americans are in rural areas unconnected to public supply systems, but are nonetheless able to rely on clean water … and utilize on-site sewage facilities such as septic tanks for sanitation” (Hartley & Van Meter, 2011). This is an all-too-common misconception. Millions of Americans simply cannot “rely on clean water” and safe access to sanitation. In fact, Catherine Coleman Flowers, an eminent environmental justice advocate, calls the state of sanitation in areas of Alabama “the final monument of the Confederacy.” And lack of safe sanitation will become an increasingly pressing problem as climate change increases flood risk and incidence, leading to septic tank malfunction and increased spread of possible pathogens in flood waters. This is an issue that can no longer be ignored by various levels of government, by public health professionals, by our nation as a whole. I look forward to continuing this work as an Environmental Justice Graduate Research Fellow with the UNC Institute for the Environment this upcoming academic year.

Paddling on Jordan Lake

Other than compiling this work, I’ve enjoyed my six weeks of Haitian Creole (kreyòl) classes through the Florida International University, where I had the amazing opportunity to take basic and intermediate kreyòl and a course on Haitian culture (kilti Ayisyen). I hope in the future to visit Haiti (Ayiti) and work with community-based organization working to address the environmental justice and sanitation issues wrought by centuries of colonization and US occupation. And, finally, I’ve loved getting to know some North Carolina lakes! See y’all in the fall, or, in kreyòl, n a wè talè!

Amy