Public Health Field Study

Public Health Field Study ePortfolio

Executive Summary

During June 18—July 29, 2018 I worked on a Community Engagement team with ECOSUR in Tapachula, Chiapas, México, working to promote understanding of and participation in the reduction/elimination of mosquito-borne illnesses.

Figure 1: Google Map showing the municipality of Tapachula (circle) within the region of Soconusco (red outline)

One method that is currently in development to reduce the quantity of disease-transmitting mosquitos is the Sterile Insect Technique (Alphey et al., 2010). By breeding and releasing large quantities of sterile male Aedes egypti mosquitos, the fecundity of this specific species of mosquitos should decrease without the need for broad exposure to insecticide fumigations. Therefore, the incidences of the diseases transmitted by these mosquitos should also decrease, namely: Dengue Fever, Chikungunya, and Zika Virus. However, there are many reasons one might not particularly favor an experiment in their community that involves releasing thousands of mosquitos nearby. That is why Community Engagement (Stuart, 2017) and the inclusion of these communities as members of our team are essential to the success of this project. Therefore, in order to maximally reduce exposure to mosquito vector-borne illnesses through the reduction of mosquitos, the team has focused on including the community in the development of the Sterile Insect Technique (SIT) for the Aedes egypti mosquito, educating all members of the community about mosquitos and SIT, and enlisting everyone's help in cultivating a local environment less prone to mosquitos in the first place.

Statement of Problem

In the state of Chiapas, this year has a particularly high incidence of Dengue Fever so far (Secretaria de Salud, 2018), with over twice the number of confirmed cases as of week 30 compared with last year. Week 30 is near the beginning of a typically steep upward slope in incidence during this time of the year, so I expect the incidence will unfortunately continue to rise. Children are the most vulnerable to this disease, with children ages 5-9 years experiencing the highest incidence of Dengue Grave or Dengue con Signos de Alarma (see figure 2).  All 4 serotypes of Dengue Virus have now been identified within Chiapas (see figure 3).

Figure 2: Heat-Map visualization of Dengue incidence in México as of July 30, 2018 (week 30)

Figure 3: Age Distribution of Dengue Fever incidence in México as of July 30, 2018 (week 30)

This endemic epidemic of Dengue Fever in and around Tapachula takes place in the aftermath of repetitive seasonal outbreaks of Aedes egypti transmitted illnesses including a severe outbreak of Chikungunya in 2014 (https://www.sciencedirect.com/science/article/pii/S1665114616300168). Attributed to an exposure-built herd immunity, there is now a low incidence of Chikungunya in this region, but several people who were previously infected still complain of chronic symptoms like arthritis in the knees or wrists.

All this is to explain that, year after year, illnesses transmitted by Aedes egypti mosquitos continue to take a toll on population health in South México. Whether by causing a child hemorrhagic shock or an adult chronic joint pain, the illnesses inflicted upon the people of Soconusco by mosquito-borne illnesses result in significant morbidity & mortality for this population, and the reduction or elimination of this burden is the rationale for this project.

Organizational Setting

INSP/CRISP
El Instituto Nacional de Salud Pública (INSP) or México's National Institute of Public Health is a large government-run and government-funded academic organization housed within México's Ministry of Health. The mission of INSP is to "contribute to social equity and the full realization of the right to health protection through the generation and dissemination of knowledge, state-of-the-art training of human resources, and innovation in multidisciplinary research in order to develop evidence-based public policies." This is a large organization, with locations in Mexico City, Cuernevaca, and Tapachula. It is also home to México's School of Public Health. Though I did not work directly within INSP, they were a sponsoring organization for my field study, provided me an identification card with their authorization, and are the umbrella organization for CRISP.

Google Streetview image of the entrance to the INSP/CRISP campus in Tapachula, MX

El Centro Regional de Investigación en Salud Pública (CRISP) is a component of INSP dedicated to infectious diseases, and is located within the Tapachula campus of INSP. The mission of CRISP is to "generate knowledge, train human resources, innovate health systems and develop services for the community in the southern region and border of México." With a local focus on understanding and preventing infectious diseases, CRISP has a number of interesting projects and partnerships that go beyond my scope of mosquito-borne illnesses. Dr. Rogelio Danis is the Director of CRISP and was my primary contact upon arrival to Tapachula. His help was monumental in setting up this field study.

Me (left) and Dr. Rogelio Danis at CRISP in Tapachula, MX

ECOSUR

El Colegio de la Frontera Sur (ECOSUR) is a federal/public multi-campus university along México's southern border with sites located in the following cities (states) of México: Campeche (Campeche), Chetumal (Quintana Roo), San Cristóbal (Chiapas), Tapachula (Chiapas), and Villahermosa (Tabasco). The mission of ECOSUR is to "contribute to the sustainable development of the southern border of Mexico, Central America and the Caribbean through the generation of knowledge, the training of human resources and the linkage from the sciences social and natural." The Community Engagement team I worked with primarily during my field study was based in the ECOSUR campus at Tapachula, consisting of Dra. Ariane Dor, Sra. Ana Laura Pacheco, Sr. César Moreno, and Dra. Roberta Causa.

Some photos of the ECOSUR campus in Tapachula, MX.

Hospital General de Tapachula
The local public hospital in Tapachula, available to anyone free of charge, but with very limited resources. The hospital receives most of its funds from the state and municipal governments, in addition to reimbursement for services that are billed correctly through the insurance program Seguro Popular. Here I worked with Dra. Daenna Romero, an epidemiologist (which in México is a field that physicians can choose to specialize in). In the afternoons when I had time, her and I and other students would document cases of certain illnesses that are tracked by the federal government, particularly Dengue Fever. This entails visiting each patient and logging their symptoms and signs of diseases, as well as tracking their laboratory values and clinical status over time. That information is then sent electronically to a federal database.

Dra. Daenna and myself outside of Hospital General de Tapachula

Place of Project within Organization

This Community Engagement project takes place within a collaborative project to control Aedes aegypti mosquitoes through SIT. The collaboration includes ECOSUR, INSP/CRISP, the Joint FAO/IAEA Division of Nuclear Techniques in Food and Agriculture in Vienna, Austria, and the people of the communities of Ejido Hidalgo and Rio Florido. The first sterile male mosquitos will hopefully be released in September 2018 within Ejido Hidalgo and then next year within Rio Florido, both communities within the Soconosco region of Chiapas, MX. Preparation for this has taken place over the past several years. In addition to developing technical processes for effective application of SIT, the preparation for this project has included Community Engagement, as it is essential for these communities to be on the same team as the researchers conducting this experimental attempt to control the mosquito population and prevent disease. Without Community Engagement, the researchers and the communities could easily become opposed to one another, preventing progression of the project. The Community Engagement team was primarily composed of faculty, staff, and students (including visiting students like myself) of ECOSUR. This Community Engagement component to the project has humble stability. Being a university, there are many ongoing projects and a constant stream of students coming and going as they begin new programs or finish their degree programs. But Dra. Ariane and Sra. Ana Laura have both been involved for many years, and their relationships with the community members are developed and strong. This is equally important to funding, as having trusting relationships with the communities involved represents the foundation of this project. That said, there seems to be stable funding as well, as control of mosquito-borne illnesses is a national & international public health priority.

Core Public Health Functions

Needs Assessment
Program Planning
Program Evaluation
Health Outreach/Development

Skills Developed

Literature Review
Data Collection
Program Implementation
Data Analysis
Coalition Building

Examples

This is the Biofabrica, next to Rio Florido, where the sterile mosquitos will be reared. We had a meeting here with the Promotores de Salud. I elicited the Promotores' definition of SIT in their own words and transcribed this for further analysis.

This is in Ejido Hidalgo after a meeting with the women of the community. I facilitated small group discussions in which the participants could share their honest opinions and questions about SIT.

Coffee beans drying/fermenting in Ejido Hidalgo. The region of Soconusco is world-renouned for its coffee production, as there is a nearly perfect climate for coffee tree production, with tropical heat and humidity in full force.

Dogs and a pig walking in Ejido Hidalgo.

Coconuts on the side of the road can be an unintentional source of standing water, especially during the rainy season. Turning them over so the holes are facing down can eliminate this potential mosquito breeding ground.

Going house-by-house to examine the water storage and sanitation in Ejido Hidalgo. It was roughly 46°C/115°F that day.

After checking in with each house on our list in Ejido Hidalgo, our team celebrated with some iguana mole. Very tasty.

During one of our community meetings, there was considerably confusion surrounding what to do if suspecting that one's child or family member or friend has Dengue Fever. When is it necessary to go to the hospital? This is an important question because Dengue Fever can be hemorrhagic and deadly. Though there is no specific treatment for this viral infection, delayed fluid resuscitation can result in preventable deaths. Therefore I thought it was important to address this apparent community need: clarity over when to go to the hospital. Dra. Ariane and Dra. Romero helped me design this table that we presented at the subsequent community meetings:

Presenting this table resulted in interesting discussion, much of which was centered on the reality that for a family to take someone in one of these rural communities to the hospital represents a significant burden, taking multiple days off work and traveling far distances. And that is all the more reason why it is important to be clear about when going to the hospital is an urgent concern and when it is not. However, such a distinction is difficult, and I could see distributing such information in the United States generating a number of lawsuits for instance, yet it is information that the people want to know and I am glad we were able to provide it. After these presentations I found a few other examples of clearly communicating this type of information in a more visual format.

Ultimately, a clinical differentiation of Dengue no Grave verses Dengue con Signos de Alarma verses Dengue Grave requires an experienced clinician's assessment. But the decision of going to the hospital or not will hardly ever be available to the experienced clinician. Therefore making this information accessible to the community was important.

Public Health Competencies

• Biostatistics
• Apply basic statistical techniques to describe, analyze and interpret public health data and research
• Epidemiology
• Identify key sources of data for epidemiologic purposes, draw appropriate inferences from epidemiologic studies and understand the limitations of a specific data source
• Environmental Health
• Describe major environmental risk factors, evaluate their impact on the health of populations, describe and critique the risk assessment process, and review strategies for prevention and remediation within the context of environmental justice
• Health Policy and Management
• Describe medical care delivery and policy processes with an emphasis on systems thinking, basic management concepts and quality of care implications
• Social and Behavioral Sciences
• Understand and critique the application of theories, concepts and models used to interpret relationships between social determinants and health outcomes in research, interventions, policy and practice
• Cross-Cutting Public Health
• Identify valid sources of public health information including peer-reviewed literature, government records, and publically available datasets
• Global Health
• Demonstrate an understanding of community’s awareness of their own health problems and their solutions.

Relevant Public Health Coursework

Summer 2015:
Biostatistics
Environmental Health
Health Policy & Management
Social Behavioral Aspects of Public Health
Research Methods

Fall 2015:
Social Justice in Public Health

Summer 2016:
Emerging Health Threats
Epidemiology
Essentials of Global Health
Program Evaluation

Results

During my field study, the Community Engagement team met several times with the communities of Ejido Hidalgo and Rio Florido, reinforcing their understanding of SIT while listening, documenting, and responding to their questions, comments, and concerns about the experiment. We met with the Promotores de Salud in the Biofabrica, the facility that will eventually breed the millions of sterile male mosquitos to be released in these communities. After each meeting we documented our findings and discussed next steps. At my suggestion, after noticing that mostly men were participating in dialogue with our team during our meetings, we scheduled a meeting with the women of Ejido Hidalgo, which included a small group discussion activity that I designed.

I did not specifically achieve each goals set forth in my Scope of Work agreement between Dra. Ariane Dor and myself. Rather than conducting the puppet show for educational outreach to the children of Ejido Hidalgo and Rio Florido, I facilitated discussions with the Promotores de Salud of Soconusco and the women of Ejido Hidalgo. The puppet shows had already taken place before I arrived, and then the school year was over and there was no dependable way to gather all the children together. However, in replacing my goal for performing in a puppet show with the discussion facilitation of these two groups, including developing an interactive activity for the women of Ejido Hidalgo, overall, my field study was a success. The other goals of my Scope of Work, including data analysis, communicating findings in both English and Spanish, and conducting epidemiology research, were all achieved.

Theoretical Grounding

Though the Sterile Insect Technique (Alphey et al., 2010) is the main technical intervention taking place, our team's focus was based upon the theory of Community Engagement (Stuart, 2017). In the context of an interventional research project, this theory borrows from the idea of community based participatory research (Holkup et al., 2004). Fundamentally, horizontally engaging community members (i.e., including the communities as equals with the experts on the research team) in developing relationships, building capacity, and making decisions should generate synergy in the results of our combined efforts to achieve, in this case, fewer cases of mosquito-borne illnesses.

Another public health theory that offers theoretical justification for the project design is the Theory of Planned Behavior (Montaño & Kaspryzk, 2008). There are also a number of simple habitual changes that families in the communities can do to help reduce the population of mosquitos. For example, cleaning up trash, ensuring there is minimal standing water in the yard, or changing the sink water frequently, can all help to interrupt the mosquito life cycle and reduce the mosquito population. Therefore by engaging in dialogue with community members throughout our planned events, sharing information and emphasizing possibilities (e.g. sharing the story of how a nearby community has organized a collective, regular, house-by-house trash collection service), a gradual shift in knowledge attitudes and beliefs may result in these desired behaviors, thereby reducing the number of mosquitos independent of SIT.

Lastly, a focus on enriching the "social fabric of the community" (Syme & Ritterman, 2009) by offering inclusion in participation and share of control in this research project, and by dropping the "expert" role of researcher, it is hoped that the people of Ejido Hidalgo and Rio Florido will work within their communities to decide what steps are best for themselves, including the behaviors just mentioned and the potential release of sterile mosquitos.

Recommendations

For similar projects:

Going into another completely foreign community for the purpose of joining a team and contributing to an ongoing public health project entails a steep learning curve. From the basics of safe transportation between home and work, to navigating the intricate differences in social norms and customs, it helps to have additional time to adjust and integrate. If I could, I would prefer to take more time than 6 weeks for this type of field study. I would also take time earlier to discuss the specifics of my anticipated work with the team prior to arrival, but that is difficult without awareness of the institutional relationships involved. And of course, I would have studied Spanish intensely for at least 3 extra years prior to pursuing this, however I am very pleased with the development of my Spanish language skills during these 6 weeks.

For myself: 

Stay in touch with the people you met during this amazing experience. Continue to follow the development of this project. Stay humble in understanding where you stand in the context of an ever-changing global health landscape. Continue to work toward health for all people in research, advocacy, and building relationships.

Professionalism

Other than the differences in social norms and customs, professionalism wasn't really an issue for me during this research project (that I know of). Coming from a year of clinical rotations, I am used to punctuality, professional attire, and staying engaged for long periods of time. There was more flexibility than I was used to during this field study, and that was a welcome change for me. Being engaged in the community setting can mean dropping the role of "professional" and coming across more as an equal. In that regard, it was cool to observe folks like Dra. Ariane or Sra. Ana Laura in their professional roles of leading a community meeting or facilitating discussion among concerned community members, while being on-the-job mothers with their children playing or being kids at the same time.

References

Alphey, L, Benedict, M, Bellini, R, Clark, GG, Dame, DA, Service, MW & Dobson, SL. (2010). Sterile-insect methods for control of mosquito-borne diseases: an analysis. Vector-Borne and Zoonotic Diseases, 10(3), pp 295 - 311.

Holkup, PA, Tripp-Reimer, T, Salois, EM & Weinert, C. (2004). Community-based participatory research: an approach to intervention research with a Native American community. Advances in Nursing Science, 27(3), pp 162-175.

Montaño, D. E., & Kasprzyk, D. (2008). Theory of Reasoned Action, Theory of Planned Behavior, and the Integrated Behavior Model. In Health Behavior and Health Education (4th ed., pp. 67-96). San Francisco, CA: Jossey-Bass.

Nava-Frías, M, Searcy-Pavía, RE, Juárez-Contreras, CA & Valencia-Bautista, A. (2016). Chikungunya fever: current status in Mexico. Boletín Médico del Hospital Infantil de México, 73(2), pp 67-74. Retrieved 6 Aug 2018 from <https://www.sciencedirect.com/science/article/pii/S1665114616300168>.

Secretaría de Salud. (2018). Panorama Epidemiológico de Dengue 2018. Retrieved 10 Aug 2018 from <https://www.gob.mx/salud/acciones-y-programas/panorama-epidemiologico-de-dengue-2018>.

Stuart, G. (2017, December 5). An introduction to community engagement. Retrieved August 7, 2018, from <https://sustainingcommunity.wordpress.com/2016/02/25/introduction-community-engagement/>.

Syme, L & Ritterman, M. (2009). The importance of community development for health and well-being. Community Development Investment Review, 5(3), pp 1-13.

Acknowledgments

This public health field study would not have been possible without help from so many orgs/people.

• http://moonflowerdragon.blogspot.com/2010/06/html-code-for-hanging-indents-for-apa.html for helping me fix the indentations in the references list above
• The ECOSUR Mosquito Team: Ariane Dor, Ana Laura Pacheco, Roberta Causa, Martha, René, Hugo, César, Daenna Romero, 
• My Public Health mentors at Touro University California’s Public Health Program: Carinne Brody, Miranda Weintraub, Sarah Sullivan, Nemesia Kelly, Elena Lingas, Assefaw Ghebrekidan, Gail Cummings, Deirdre Wilson, Trina Mackie
• Eduardo Velasco & Yvette Carrillo from Touro University California’s College of Osteopathic Medicine.
• Rogelio Danis, Iliana Rosalía Malo-García,  from INSP/CRISP.
• Dra. Daenna Romero from Hospital General de Tapachula.
• My friends from Compañeros en Salud in Jaltenango de la Paz including Argel, Rodrigo, Faátima, and many others!
• My mentors and peers from Natividad Medical Center, including: Chris Carpenter, Chris Irvine, Bret Namihas, Alison Clark, Nathaniel Uchtmann, Lorna Echipare, Jeff Lin, Forrest Hamlin, Alejandra Espinoza… and everyone who taught me so much during my year there.
• My landlord in Tapachula, Sra. Martha from Apartamentos Ejecutivos Los Anturios.
• My support network who kept me socially connected during these 6-weeks (and beyond): Diana De Vore, Miriam Menzel, Jim Musselman, Adam Whitlatch, Charlie Clements.
• And anyone who bothered to read this blog!