Field Work on the Thailand Burmese Border

Josh Havumaki

This summer I was working with the US Centers for Disease Control and Prevention and a French NGO called Première Urgence – Aide Médicale Internationale in Mae La, the largest Burmese refugee camp in Thailand. Due to political hurdles, the camp does not have the same infrastructure as surrounding Thai villages. This creates unique public health concerns. For example, there have been 4 cholera outbreaks in the past 7 years. The CDC and the Thai Ministry of Public Health are currently preparing to give Shanchol, a new oral cholera vaccine to most of the ~50,000 residents in the camp and follow them for three years as part of a prospective cohort study to assess characteristics of vaccination failure (e.g. are young people less likely to respond vaccine?).

My project consisted of providing a local staff of incentive workers with personal digital assistants (PDAs) to collect demographic data and track the residents in the camp.  PDAs will potentially replace the current paper based system that has been in place for years. There are pros and cons to each system, but the accuracy and efficiency required for data collection in the upcoming prospective cohort study is not met by the current system.

Part of the current paper based system. This is how 50,000 residents are tracked each month.

There are numerous technical and cultural barriers to design a program for a local staff of camp residents with little computer and English skills. I was working with American government employees, French NGO workers, Thai programmers and Karen and Burmese camp workers. Needless to say cultural and language barriers were a continual concern. Therefore, a large part of the project was recognizing political hurdles to accomplishing our goals. For example, speaking with the elected camp government about different ways to identify people in the camp. There is no identification system and residents are apprehensive about being identifiable by the Thai government due to their status in the country.

Pictures from the Thailand Burmese Border

Josh

Apologies for my extended absence. I wanted to share a few pictures loosely related to public health from my time in Mae Sot, Thailand – just over the border from Burma. I am here for a summer internship with the Centers for Disease Control and Prevention and the Ministry of Public Health Thailand.

Sign in Burmese presumably warning against bird flu

Stop Human Trafficking – on The Thai-Myanmar Friendship Bridge

A quick PubMed/Google Scholar search could not support this claim – in Bangok, Thailand (see references below)

Milk and Stress:

1. Peuhkuri K, Sihvola N, Korpela R. Diet promotes sleep duration and quality.Nutr Res. 2012 May;32(5):309-19. Epub 2012 Apr 25. PubMed PMID: 22652369.
2. Blass EM, Shide DJ, Weller A. Stress-reducing effects of ingesting milk,sugars, and fats. A developmental perspective. Ann N Y Acad Sci.1989;575:292-305; discussion 305-6. Review. PubMed PMID: 2699193.

Enjoy your summer!

Positions on Global Health

Josh Havumaki

With the republican primaries in full swing and super Tuesday right around the corner, it is worth considering how the leading candidates would impact global health if elected.

Rick Santorum

If Rick Santorum were elected president, his global health policies would follow in the steps of George W. Bush. Contrary to what you may expect, this IS NOT necessarily a bad thing. Santorum believes that the U.S. should play a strong role in international health. He is the only candidate that wants to expand Bush’s plan for humanitarian aid to Africa which has included initiatives like the Presidents Emergency Plan for AIDs Relief (picture from here).

Bono has even praised his strong antipoverty policies. A potential drawback is that his pro-life and anti-drug views may isolate organizations and government agencies such as USAID. USAID has global health and capacity building initiatives around the world.

Mitt Romney

A Mitt Romney presidency would most likely result in a reduction of global health spending. In August of last year he expressed his views on borrowing money to support global health.

“At a time when we are borrowing money to pay for things, I’m very reluctant to borrow lots more money to be able to do wonderful things, if those things can be done by people making charitable contributions or by other countries that are wealthy.”

Even with his implimentation Romneycare, Mitt sees the U.S. playing a lessor role in global health initiatives.

Regardless of political affiliation, it is worth noting these issues as the primary season continues and beyond. Ultimately, global health will become more topical as technology and the globalized economy make the world a smaller place.

Why I do it with (Mathematical) Models

Josh Havumaki

Apologies to our friends in the bio-stats department. There is a definite need for statistical methods in public health. Many of the tools that biostatisticians use are well established and necessary for things like causal inference. However, there are certain questions that aren’t sufficiently addressed by statistical techniques. Therefore, dynamic mathematical models have become more prominent in epidemiology and other branches of public health.

Here are a few public health issues that can be explored more effectively using dynamic mathematical models.

1) Figuring out the best way to vaccinate a population. If GAVI allocates enough influenza vaccine to the government of Indonesia to inoculate 10% of the population, where should the prevention efforts be focused to ensure maximal coverage (e.g. rural vs. urban populations)?

Past literature has focused on sharing the worlds vaccine or antiviral stockpile. For example, if the wealthiest countries share only a fraction of their influenza vaccines with the developing world, the effects would be much greater than expected. As the strategy becomes more cooperative, the containment efforts become more effective – even for the countries sharing their vaccine or antiviral stockpiles.

2) Building multi scale representations of how disease progresses and spreads. The beauty of dynamic modeling is in its modularity. It is possible to combine a cellular model of influenza pathology with one of transmission dynamics at the population level. This can provide information about interplay between levels.

3) The right kind of dynamic model (i.e. an agent based model) can grant insight into the stochastic (random or unpredictable) nature of pandemics. If a small influenza outbreak of occurs in Southeast Asia, what is the threshold that needs to be reached before it becomes a pandemic. This can factor in things like herd immunity and heterogeneity of susceptibility in the population due to immunity.

The major caveat is that accurate and quantitative data to validate and inform dynamic models can be difficult to find especially in lower resource countries (where many pandemics start). However, data quality is ever improving and organizations are becoming more strategic about collecting and synthesizing large amounts of information as seen in fields like health informatics.

Taking Notice

Josh Havumaki

As part of the International Health track of the Epidemiology program, I often forget that direct impact can be made locally through simple means. In fact, anyone can “practice” public health through top-down or bottom-up approaches. Some examples of the different approaches are discussed in the first 3 paragraphs here.

Due to the struggling economy, tent cities are cropping up all over the states. In fact, just a short distance from SPH, is a homeless community called, Camp Take-Notice (CTN). Renown intellectuals, Cornel West and Tavis Smiley recently visited the camp as part of their Poverty Tour of America. Last week, a couple of friends and I decided to take an impromptu trip to the area to speak with the residents and understand their daily lives.

Travis (left) and Sabri (right) preparing to fix the stairway leading to CTN

The camp is cozily nestled in the woods between two major highways on the outskirts of Ann Arbor. Each of the fifty or so residents have private tents and sleeping bags. Heaters are provided in the winter – though most residents migrate somewhere warmer. There is a common area with a large tent complete with propane stove and kitchen supplies. Another tent on a wooden platform provides additional tools for maintaining the camp. Most of the residents are either working part-time or actively looking for work and a few have been able to save enough money for an apartment in town.

Once we arrived, introductions were made and we were put to work fixing-up a dirt stairway leading from the road to camp. Afterward, we were invited to join the residents for dinner – provided by a local church. When dinner was finished, we took a quick tour of the camp and joined their weekly meeting. The meeting is a chance for residents to air grievances, praise each other for helping out and make requests for necessities. Overall, it was fascinating explore this alternative to homelessness and how community can alleviate suffering.

Travis and I on the stairs

Most businesses in Ann Arbor don’t hire homeless people. The residents of CTN have stability, community and a semi-permanent place to live. Additionally, the skills they develop through their work maintaining the camp are transferable. However, the stigmatization of homeless people is difficult to contend with and employers will not consider hiring them without a proper address.

Regardless of background and future career goals, all of us here at SPH have the opportunity to look at both the global and domestic determinants of health. Public health issues exist everywhere - so stop by, help out and above all take-notice.