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Health Challenge Past Interns: 2008

Social Sciences

Alex Gertner, 2010, Anthropology

Internship:
The Future of Global AIDS Treatment

Organization:
Princeton University

Adviser:
J. Biehl

"I accompanied Professor Biehl on a research trip to Brazil, where in the wake of universal access to AIDS medications, other patients and groups are demanding increased access to a variety of basic and high-cost medications. Following the precedent set by AIDS activists, tens of thousands of patients are suing the government to force it to pay for their medications. They base their claim on the Brazilian constitutional right to health, which they understand as a right to access to pharmaceutical products. The court cases are straining state budgets, disrupting established drug distribution schemes, and raising challenging questions about the right to health, the role of markets and the nature of pharmaceutical access. We are setting up a database to collect information on these cases in southern Brazil, while we engage in a long-term ethnographic project carrying out interviews with members of the judiciary, NGOs and healthcare providers. We aim to understand the meaning and consequences of a right-based administration of health through the judiciary."


Ali Kelley, 2009, Politics


Internship:
Project Microbe

Organization:
Princeton University

Adviser:
Evan Lieberman

"This summer I went to South Africa with three other Princeton students to study local government responses to infectious disease.  In today’s globalized world, effective authority is needed to contain the risk of infectious disease, yet the perceptions of and efforts to contain these threats vary across time, space, and infection.  Significant variation exists at the national and sub-national levels, and it was our goal as members of “Team Microbe,” to determine potential causes for and implications of these discrepancies across municipalities in South Africa.  In order to do this, we designed and conducted a survey of local councilors across two of the country’s nine provinces.  By focusing on these two adjacent provinces – the Eastern and Western Capes – we were able to control for “provincial effects,” given the highly similar demographics and socio-economic conditions at their border.  We selected our municipalities based on two factors: the degree of racial heterogeneity and the relative strength of political parties.  Then, we created categories based on these factors and aimed to include an equal number of municipalities from each group. "

"Over the course of two months, we administered our survey to over 120 officials across fifteen local councils and one “metro” council.  Each interview lasted for about an hour and included both open and closed questions that related to each councilor’s policy beliefs, priorities, and personal background.  In determining the root causes of these responses, we considered several potential factors of influence, including ethnic/racial identity; international organizations; levels of civil society; strength of institutions (political parties, courts, etc.); as well as cultural attitudes toward the problems themselves. Our project was based out of a rented apartment in Cape Town, though much of our time was spend traveling to outlying municipalities.  The logistics of our research were often more complicated than we had anticipated, but we came up with creative solutions and achieved our goals nonetheless. We were especially proud of the information we gathered during our two-week road trip to the Eastern Cape, during which we drove hundreds of miles, interviewed dozens of councilors, and even got to visit a few wildlife preserves."

"Now that the survey is complete and the results have been compiled into a large database, our goal is to find and explicate patterns within it.  Each of us is currently working on a thesis or dissertation on a specific component of the survey, and our Professor, Evan Lieberman, will eventually incorporate our study into his own research.  As I begin to focus on my own project – a study of policy diffusion among the local governments we surveyed – I realize how much I learned during my summer in South Africa – not just about politics and public health, but about myself and my values, talents, and ambitions.  Joining “Team Microbe” was one of the best decisions I’ve made at Princeton, and I have no doubt that I will continue to reflect on and benefit from this experience for a long time to come."


David Laslett, 2009, Operations Research and Financial Engineering

Internship: Social Welfare and HIV

Organization: Princeton Univeristy

Adviser: Joao Biehl

"I had no idea what to expect as I strolled into the Rixile HIV clinic at Tintswalo Hospital in the rural town of Bushbuckridge, South Africa. I certainly didn’t expect an African clinic with 6,000 patients to be run by a scrawny, Scottish doctor in his late twenties. On my first day, I saw more infectious disease than many will see in a lifetime. But just as ubiquitous as the patient’s suffering was the doctor’s constant struggle to provide adequate care. When a doctor had to redo a blood test after the lab lost the previous sample, I was shocked to learn that this was a common occurrence. One mother died in childbirth when a simple blood transfusion would have saved her. The hospital wasn’t out of blood; the nurses simply couldn’t find it. A year after the government purchased the antiretroviral Tenofovir for its treatment regimen, it summarily pulled the plug and failed to issue a plausible explanation. The Scottish doctor told me once that most of his job was spent trying to diagnose TB. The PPD test is useless in immuno-suppressed HIV patients, growing a TB culture takes 40-50 days, the one x-ray machine is constantly broken, and it is nearly impossible to get patients to produce adequate sputum samples."


"But amazingly, the doctors persevered. They would all meet for tea in the morning and discuss difficult cases. X-rays and blood vials made frequent guest appearances. Each day, the HIV clinic doctor squeezed in extra time between his patients to consult on patients in other wards. But most importantly, he treated all of his patients with complete respect, even a traditional healer who was convinced that a rival clan had poisoned her food with HIV. If patients were doing well on treatment, he would down-refer them to local community clinics, for he rightly conceived HIV as a manageable, chronic illness that can be treated on the primary care level. He even helped people secure their disability grants, which was often the biggest concern of many of his patients. Successful treatment regimes were ensured be a variety of social and psychological requirements that complimented the science of treatment. Before starting treatment, each patient had to demonstrate psycho-social preparedness. This included having a “treatment supporter” that could pick up the ARV mediation if the patient were incapacitated and disclosing to one’s partner or family. Each patient also had to attend classes about the ARV drugs and the importance of 100% adherence and meet with a dietician and social worker. This model where laypeople are supporting the scientific community in delivering treatment is the emerging model for successful treatment programs in Africa, and it should undoubtedly be extended elsewhere."


"After my time in the clinic, I spent a month at an economic policy research institute, where I looked into the nature of South Africa’s social welfare system and its effect on HIV patients. I discovered the integral role of the disability grant in the health care system, where patients relied on the grant to finance food and transportation expenses. Unfortunately, HIV patients who begin the ARV treatment regime are losing their grants as their health gets restored by the drugs. Stripping patients of their grant after several months of successful treatment, however, is a paradox of the worst kind. It ignores that patients will still need the same food and transportation security to continue their treatment, which for HIV and other chronic illnesses, is a life-long commitment. With regards to HIV treatment, nutrition is especially essential because malnutrition exacerbates the immunosuppression triggered by HIV. Nutritional deprivation also worsens treatment side effects, which are a main cause of poor adherence. Transportation is equally important for adherence since most patients must travel considerable distances to collect their medication from the hospital.  Without drug adherence, drug resistance is inevitable, a phenomenon that will only magnify the HIV epidemic. Since disability grants are not permanent by nature, and since relaxing the eligibility requirements would encourage fraud and distort the labor market, I found that many experts considered it most prudent to address these issues with a basic social grant. A social grant targeted only for those people with HIV would obviously be a stigmatizing nightmare, so the most appropriate solution is a universal, basic income grant."


 


Karen Lillie, 2009, Anthropology

Internship:
The Future of Global AIDS Treatment

Organization:
Princeton University

Adviser: Prof. Joao Biehl

"I conducted a study in Puebla Mexico on how the therapeutic itineraries of HIV/AIDS patients affect their lives. I found that even in the presence of a national plan to distribute medications, stigma remains a huge impediment to treatment and prevention efforts. Doctors assigned by the government to AIDS clinics saw the responsibility as an unwanted burden. Though patients communicated complex fabrics of self-perception, their medical choices were frequently informed by a desire to hide their disease. My research allows for a consideration of how medical and local cultures affect patient and disease conceptions, access to information and the success of treatments."


Raaj Mehta, 2010, Ecology and Evolutionary Biology


Internship:
Health Intern at the Center for the Study of the Presidency

Location:
Center for the Study of the Presidency, Washington, DC

Adviser:
Prof. Joao Biehl

"Over the summer, I worked at the Center for the Study of the Presidency, an advocacy organization in the lobbying K St corridor of Washington.  With the conclusions from our discussions in April and May in mind, I set out to better understand the politics behind HIV/AIDS.  It was much sooner than I'd expected that I found myself knee-deep in data about the epidemic, shockingly not from abroad, but rather, from right under our nations' lawyers' noses in the District of Columbia. " 

"I was riding the Washington Metro on my way home to Virginia when I noticed that I was staring at a public service announcement poster calling for more DC youths to get tested for HIV.  The next morning, I was back in the office google-ing the project, and as soon as I discovered that 1 in 20 people live with the disease in the city, I told my boss, Dr. Susan Blumenthal, that I had come up with a research project for myself.  She was more enthusiastic than I could have ever imagined, giving the amazing opportunity to publish my thoughts (under her name, with my name listed as the second author).  


I could go into a lot of detail about what happened between then and the publication date because I gained a tremendous amount of very practical knowledge like developing better policy writing skills, how to communicate with no-nonsense government officials, how to communicate with nonsense government officials, etc. But, I'll stop there, and list my four big epiphanies from working on this project: 1) statistics and ethnography must be in equilibrium; 2) politics almost always make things messier and more confusing than needed; 3) community health programs are vital regardless of where you are, including the US; and 4) HIV/AIDS scientists are remarkably sanguine. " 


"This op-ed only was about 25% of my summer, however.  Another 25% was dedicated to investigating the Presidential hopefuls' health care plans, and particularly to how well they will deal with people with AIDS.  In case you were wondering, it's indisputable that Barack Obama has a better plan than John McCain for HIV/AIDS patients (and if you ask me, for everything else except choice).  Also, during this part of the summer, I spent some time helping a colleague write a policy brief on the status of AIDS in Asia. "


"I spent the third quarter working on the Palestinian Israeli Health Initiative, the health project that the Center was commissioned to investigate.  This essentially was a large social experiment testing the validity of health diplomacy, or using health to bring people closer together.  Not only did we have to do research for a report, but I spent a lot of time trying to create a WebMD/CDC.gov type site with health information for both Arabic and Hebrew speaking populations." 


"The last 25% of the summer was spent researching tobacco, specifically concerning the possible FDA regulation of the substance.  Dr. Blumenthal asked me to write another op-ed, but it hasn't been published yet.  Look out for it in October or November. "


Amy Moran-Thomas, Graduate Student, Anthropology


Internship:
Trajectories of Medical Technology Distribution: A Comparative Ethnographic Study of Deworming Campaigns in Ghana and Belize

Organization:
Princeton University

Adviser:
João Biehl
 

"I am interested in the cultural dimensions of infectious disease, and my project combines ethnographic and archival research on the newly created category of "neglected tropical diseases."  This new emphasis in health policy began to affect both Ghana and Belize very directly in 2006, when they each began to widely distribute pharmaceuticals as part of new National Deworming Campaigns. The comparative nature of this study is intended to emphasize the distinct social factors that come into play in the local reception of health policy, by tracking essentially parallel programs in the contexts of two former British colonies."

"While several anti-parasitic drugs (now donated by pharmaceutical corporations Merck and Glaxo-Smith Kline, respectively) are temporarily effective in combating intestinal parasites, local adults often hold their own beliefs regarding what causes such visible intestinal worm infections and how they are best cured.  I am interested in exploring how pharmaceutical treatments are being received in such areas, and what lessons any conflicting beliefs or cultural tensions that emerge might hold for tropical health policy more broadly.  How do international funding and global media attention play a role in shaping programs and the treatment resources available to community doctors and local families, or inflect their experiences of disease?  My project explores the way that local perceptions of technology and medical need can dramatically affect the ways health programs are received-with the ultimate aim of illuminating both the intricacies of intercultural relations, and the life -shaping ways this knowledge might one day inform more culturally nuanced health policies."

(See presentation for Josephine Yolisa Nalule, Alex Gertner, Raaj Mehta, David Laslett, and Karen Lillie.)


Josephine Yolisa Nalule, 2010, Molecular Biology


Internship:
The Future of Global AIDS Treatment

Organization:
Princeton University

Adviser:
Prof. Joao Biehl

“Increasing access to antiretroviral drugs (ARVs) has been a hard-fought battle made possible by unprecedented alliances among AIDS activists, governments, philanthropic and international agencies, and the pharmaceutical industry. Many public- and private-sector treatment initiatives are being launched worldwide, raising a whole new set of national and global healthcare policy challenges regarding adequate drug delivery, sustainable treatment access, and the integration of treatment with prevention. Broader questions arise as well: How can international institutions hold donors and partners accountable in the long term? In what ways can national governments stay involved (or increase their involvement) in ARV rollout?  How does the variability of care infrastructure and treatment adherence affect drug resistance? And what effects do all of these issues have on the experience of living with HIV/AIDS and poverty on the ground?" (Joao Biehl)


"I specifically picked the topic of drug resistance to first line treatments and the access (or lack thereof) to patent protected treatment in Uganda. I had originally planned on looking into initiatives being taken to deal with drug resistance and also the distributions of ARVs in Uganda. However, on reaching  Kampala, Uganda, with reading literature and talking to various health professionals, I changed my topic and started to focus on the issues surrounding treatment failure and decision making process of when to switch a patient from 1st to 2nd and line treatment. Faced with varying thresholds of measurement, definitions of treatment failure, limited switching options and issues of cost effectiveness, it was enlightening to learn how different treatment centers are dealing with this in an effort to provide the most efficient health care to those who need it.  So I went around Kampala, the capital city, talking to different organizations including church organized AIDS programs, some government owned treatment centers, hospitals, NGOs etc talking to varying health professionals ranging from nurses, treatment dispensers to some administrators, trying to get understand what was happening with this issue of drug switching."


"From the different answers from different centers, the question of effectiveness/success of the Ugandan ART in absence of efficient monitoring strategies is raised. How best can this success be monitored? If patients are switched too late how will this affect the clinical success of 2nd line? Is a set of national guidelines and thresholds needed for health professionals to follow in order to have early detections? If so, how will the thresholds be determined, given the limited switching options available in resource limited settings? Given that a lot of these issues come up as a result of lack of switching options, the question lingers about whether it should be acceptable that resource limited settings should settle for just 2 regimens yet there exist 3rd and 4th line regimens in the Western world that have just been made available/accessible to this side of the world. It was a very amazing project that i would like to continue to do even this upcoming year."


Brittany Stanley, 2009, Woodrow Wilson School


Internship:
Who Governs the Microbe

Organization:
Princeton University

Adviser:
Evan Lieberman

"To my extreme delight, I was chosen by the Grand Challenges Program of Princeton to be a research intern this summer in South Africa. The aim of the project was to study the connection between infectious disease priorities at the local government level and public health policies. The internship was sponsored by the Grand Challenges Global Health Initiative of Princeton University. As an intern, I (along with a team of three other students) was responsible for setting up and dialoging over 100 total interviews with elected officials of the Western and Eastern Capes to gauge how they prioritize challenges (especially those relating to health) that are faced by their constituency. I learned to remain focused and alert during our sometimes 12 hour work days. I learned to coordinate schedules with my research mates so that we could always travel in small teams for greater safety. I also learned how to upload data into online web portals and make analyses using excel programs. Although my Mondays-Fridays were normally devoted to interviewing and data entry, I also set up my own interviews with clinic administrators, doctors, and activists to create a body of knowledge for my own Honor's Thesis. My thesis will focus on the causes of stigma variance and its importance in a cross-regional context--an interest that was strengthened as an intern. I am so grateful for this amazing opportunity and have told so many people to connect with this Initiative to help uncover some of the most pressing challenges this world is facing."


Alex Vuckovic, 2009, Politics

Internship:
Local Government in South Africa

Adviser:
Professor Evan Lieberman

Organization:
Princeton University

" Me and a group of three other students traveled to the Eastern and Western Capes of South Africa administering a standard survey derived by Professor Lieberman to various local government officials including municipal councilors, mayors, and municipal managers. The survey contained a series of questions that provided insight into how local officials prioritize issues facing their citizenry. Over the course of two months we were able to conduct a total of 117 interviews. All of the interviews were conducted in person."

(See presentation for Ali Kelley, Brittany Stanley, and Alex Vuckovic.)