Global health - the lives of women and children.

Yesterday was the final day of the NYU/WHO course.  My colleagues and I grouped ourselves into five topic areas and each group had 20 minutes to present, and then 20 minutes to discuss,  our integrated communication/marketing plan.  In broad strokes, the topics were preventing the transmission of HIV from mother to infant in Sudan; reducing sexual harassment of women by Cairo cab drivers; reducing/preventing girl-child marriage in Mozambique; increasing hospital births among Cambodian women.  My group focussed on increasing the use of modern methods of contraception among 15-19 year old rural Mozambican women.

In Mozambique, women bear an average of 5.7 children. Maternal mortality is very high at 500 deaths per 100,000 pregnancies; and 38% of these deaths are 15-19 year old women.  Mozambique is a country where marrying off girls as young as 10 years of age is common, but sexual intercourse is illegal before the age of 18  years.  Only 11% of women of child bearing age use modern contraception; 20% of women who do not want any more children have no access to contraception.  Among the 15-19 year olds, 40% are either pregnant or already mothers. Once pregnant, these girls are forced to drop out of school and most never return.  And so the cycle of illiteracy, poverty, disempowerment continues.

The factors which influence women's choices and actions about contraception are many:

• A man's wealth is judged by the number of children he produces with his multiple wives and casual affairs.
• Children are also seen as a gift from God, and interferring with this gift is considered unnatural,  sinful.
• Even in parts of the country which are matrilineal, men are the decision makers and prohibit their wives from using contraception.
• Many people believe that contraception leads to infertility and other reproductive health problems

Although contraception is dispensed for free at government run health clinics,  this is small comfort:  the supply and range of choice is inconsistent and limited, and sometimes there are no supples; the health centres are often located far from the villages so transportation costs and the lack of privacy become issues.  Even the small minority of women who want to use contraception are often unable to do so.

Our instructor has pushed us to leave our social conscience behind and adopt tunnel vision - act like Nike, segment the market, go for the low-hanging fruit.   We are encouraged to adopt the same strategies and tactics that are used to sell footwear to "sell" the behaviour of contraception use:

• Connect with the consumers' wants, needs and desires
• Know your competition
• And above all, listen to the consumer

I am reminded of a TED talk given by Melinda French Gates which also focuses on applying private sector approaches to public health issues.  At the same time I am mindful of the advertising budgets which make companies like BMW, Coke, and Prada so successful.  The $200,000 cost of a full page ad in the New York Times for one day buys a lot of HIV rapid test kits, condoms, and text books.

 http://www.ted.com/talks/lang/eng/melinda_french_gates_what_nonprofits_can_learn_from_coca_cola.html

My group focuses on 15-19 year old girls in rural Mozambique who are pregnant or have recently given birth because we think this might be a time in which using modern contraception may respond to our consumers' needs and wants.  This is also when they are more likely to see a health care provider for pre-natal, post-partum, and immunization services, visits which provide both opportunity and privacy to discuss spacing of pregnancies.  But even if this focus is strategic, the challenges seem overwhelming and far beyond what a communication strategy - even one modelled after Nike - can do.  A week's worth of work only scratches the surface.    But the point is not to come up with a quick fix to the health and social challenges faced by Mozambican young women - it is to start the process of thinking about how to make a tangible difference in the lives of some young women and build on that. One of our group members sits on the Family Planning Working Group in Mozambique and she is eager to build on the tentative, skeletal plan we developed.

The course has provided me with new information, tools and techniques which I am eager to share with my colleagues in Yukon.   But importantly, this course has provided me with a small, brief window that I would not otherwise have had into the lives of men, women and children in the developing world.  I am humbled by the commitment and big hearts of my fellow students who will be returning to their homes and work in Africa and Southeast Asian.   It propels me to think about our lives of relative privilege and the urgency of doing more than pulling out a cheque book in times of drought and other disasters....especially as I sit in my air-conditioned hotel room in Toronto which is the same price as one of the goats an uncle receives in Northern Mozambique in exchange for accepting a marriage proposal for his 10 year old niece.

Making it work

I've been delinquent on my posts; in part because I've been busy exploring, having fun, and even studying.  But mostly this post is delayed because I've been trying to organize my observations and thoughts on the many ways in which the health, safety and happiness of 1.6 million people living  on an island which is 60 sq km can be protected and promoted.  To give you some idea of the scope of the challenge, there are more people (26,891) per square kilometre in Manhattan  than live within the city of Whitehorse. 

Public health bylaws are part of the story.  Although on-line blogs complain about dog droppings and noise levels, New York is much cleaner and quieter than I remember it to have been.   "Curb your dog" (which means to both keep your dog under control and clean up after him/her) and "Don't Honk - $350 fine" signs go some ways towards reminding people that the streets of New York should be enjoyed by all, even if these bylaws are not actively enforced.  

Most recently New York, under the leadership of Mayor Bloomberg,  has upheld its history as a leader in progressive public health legislation.    Controversial or cutting edge, depending on your perspective, is the 2006 bylaw which banned the use of transfats in foods served in NYC restaurants.  And effective May 23th of this year smoking is banned in all public parks.

If Bloomberg continues his reign, I would not be surprised if he tackles the thorny issue of smoking in rental accommodation to reduce non-smokers exposure to the second hand smoke created by smokers in their building.   Given that most of the 1.6M Manhattanites live in multi-family dwellings, such a move could have a significant impact on public health. 

Of course, there are many other ways to protect and promote public health which are not regulatory.  Similar to Stanley Park's seawall, the Manhattan Waterfront Greenway, a walking, running and cycling path that winds its way around the island, is a great example.   Most of the greenway is separated from motorists, and much of the path separates walkers, runners and cyclists.  Along some parts of the path, banners are hung to identify adjacent tennis courts, skateboard parks, and quiet spots for reading.      http://www.youtube.com/watch?v=bjCBseeRII4  

The City has also designated cycling lanes on many of its avenues.  The design, though not without controversy, divides one of the outer lanes in two.  The outermost section is for the cyclist - the concrete is tinted green; the adjacent section provides a good buffer from cars and trucks.  New parking spots have been created in the adjacent lane to support neighbourhood businesses.  While the design of the lanes is a peaceful compromise for motorists, cyclists, and businesses, the next battleground is between the competing interests of pedestrians and cyclists at the intersections.  It is ironic that cyclists are now doing to pedestrians what motorists once did to cyclists --- an example of the law of the (urban) jungle?

Another great example of promoting health is the city's 30-odd year old Green Thumb program to support community gardens.  It began in the 1970s in the East Village when "green guerillas" threw seed bombs onto city lots abandoned by their owners in an effort to beautify their neighbourhood.   Today the City is home to over 500 gardens, most of which are less than 1/6th of an acre in size. Pretty impressive when you consisder that this adds up to well over 80 acres of the most valuable real estate in the world.   The City supports neighborhood volunteers by providing gardening tools, seeds and plants, information and training.


                                           

You'll be pleased to know that rebellion continues to be alive and well, but relatively harmless, in NY.
 



With most city residents living in postage stamp apartments or condos, the importance of protecting public spaces cannot be over-emphasized; in fact,  this may be the urban issue of the 21st millenium. Union Square, once a seedy, dangerous part of the City now hosts a broad range of activities from street performing b-boys to green markets, chess tournaments and tango nights. It is a wonderful example of city living.  Jane Jacobs would be proud.

                                         

Exploring my neighbourhood

This week  I ventured into Alphabet City.  Alphabet City is an area in the Lower East Side that is bounded by Avenues A through D to the east of First Avenue, 14th Street on the North and Houston Street on the South.  In the 70s this area was notorious for violence, drug use and poverty.   Fear and avoidance of this area was so great that when I exited the cross-town "L" train on the southeast corner of First and 14th Street, I would race across First Avenue, a superstitious behaviour to protect me from some some unspecified ever-present,  imminent danger.  I recall going to Alphabet City only once when I lived in NY - four of us (two men, two women) took a cab to a jazz bar, and arranged for the cabbie to pick us up some time later so that we would not be have to risk wandering the streets to hail a cab.

Today Alphabet City is a reclaimed part of the city.  It is not as upscale as the East Village, its neighbour to the west, but is walkable and liveable.  The streets and cafes are alive with the sights and sounds of young adults, Latinos and Latinas, and gay men.  Many of the buildings have been cleaned up or renovated, Tompkins Square Park offers safe passage from Avenue A to B,  and the community gardens  found along the side streets are sources of pride.

In the 70s Tompkins Square Park was a not so safe injection site. Today it is a park for all ages and at least two species. The gardens are beautiful and thick with a large variety of plants and trees, including towering elms which provide relief from the heat. Although it is very hot and very humid, the many basketball courts  are filled with young men shooting hoops and playing one-on-one, or two on two, half-court games.  Ping pong and chess are played on specially designed concrete tables.  There are  playgrounds for children and the biggest dog run in the city.

The  dog run has three sections, one for small, medium and large dogs and 3 swimming pools.  I can't help but compare the freedom of Mattie and Thea (and their many walkers) in Yukon, with the dogs and people of Alphabet City who frequent the Tompkins Park dog run.   But these runs do work for dogs, and for dog owners because the rules of the game - of which are many - are practical and clear: 

• No dogs without people. No people without dogs.     
• Neuter your dog (Puppies under 6 months are allowed to keep 'em.) 
• but just in case...No dogs in heat.  
• Clean up after your dog, shovels provided to assist with the dirty deed.

I saw only one man urinating in a bush. There are no signs asking people to relieve themselves in the public toilets.  Maybe there should be.

Elementary schools in NYC resemble what I imagine the style of Communist-era, Soviet architecture to be: large, square, squat buildings devoid of character.  Adjacent concrete playgrounds surrounded by cold, high metal fences.  The names of schools are purely functional:  PS (public school) followed by a number. Even when the yards are filled with children laughing and playing, the look and feel is more like a correctional centre than a school.

Not so for PS 63, located on East 3rd Street; the front doors are painted bright red with ABCs and 1-2-3, the walls of the basket ball courts are canvases for student murals; the front steps and porch are lined with large and carefully tended planters and trellises.  A banner draped along the front fence introduces us to the school's values:  Diversity - Community - Leadership - Excellence.   The school proudly proclaims, "small classes...big difference."  The spirit of the students, teachers and parents is clear - PS63 is a community school, a school without walls.

Not everyone is happy with the changes that have taken place in this part of the city.  The Mars Bar which operated from 1984 to 2011 has closed, the property having been sold for condo development.   Notwithstanding the legendary filth (and the approximately 850 fruit flies recently found on inspection by the Department of Health), it was a place for local artists of all descriptions and talents to showcase their work on every surface in the bar and on the outside walls.  Every month or so the outside wall facing 1st Street has featured a new mural; the current and final mural is named The Last Summer.

While I can empathize with the patrons of the Mars Bar, it is the loss of Tannenbaum's Bakery on Houston Street that I grieve.  Tannenbaum's was a Jewish bakery where I used to buy rye bread, bagels, and biales (a flattened bagel flavoured with fried onions and extra salt.   I guess Tannenbaum's couldn't compete, or maybe it is no longer welcomed, in a neighbourhood taken over by Crate and Barrel, American Eagle Outfitters, and Adidas.

Thank you to those who have commented on the blog in personal emails to me - I hope you are vicariously enjoying your trip to New York.  A special thanks to Emily who sent me the link to the YouTube video, "Empire State of Mind" by Jay-Z and Alicia Keys - it will inspire you - http://www.youtube.com/watch?v=0UjsXo9l6I8  and Wynne for flagging the TED talk on the High Line,
http://www.ted.com/talks/lang/eng/robert_hammond_building_a_park_in_the_sky.html.

Enjoy the day!  

Settling in

It is very easy to settle into life in NYC.  Michele Landsberg, while husband Stephen Lewis was Canada's Ambassador to the UN, wrote in her Toronto Star column, that no matter where you come from, you immediately feel at home. No one is a foreigner.  The rhythm and flow of the city are seductive, and there is a place for everyone.

I have already made good progress in becoming a student - I am one third of the way towards the 15-lb weight gain of freshman year, in just one week!   New Yorkers don't cook; they don't need to.  On any given street, every second door is a restaurant.  On East 6th between 1st and 2nd Avenue, the ground floor of every brownstone is an East Indian restaurant, offering 3 course dinners for $9.95.   It used to be that "dirty water dogs" were sold on every other corner; today street vendors sell exotic, organic, gourmet meals.  Some vendors are so popular that fans follow them about the city on Twitter. 

Every night outside my dorm you will find Korilla -  a Korean grill serving hormone- and antibiotic-free pork,chicken and beef, and home-made tofu coupled with kimchi, delicately seasoned julienned carrots, daikon and Napa cabbage with a choice of 4 sauces served on rice, or in burritos or tacos for $7-8.  The workers are charming; because they work quickly, the line-up of customers also moves quickly.  It takes no more than two minutes from order to payment. If you don't know what to order, no problem - returning customers freely dispense recommendations.  The fact that the food is great is a bonus.

The other night  the whole class, instructor, support staff, and associate dean went out to dinner to Jane on Houston.  There is nothing quite like breaking bread and clinking wine glasses to loosen inhibitions and get to what is really important.  We debate ideas, question the wisdom and trade-offs of applying a private sector marketing approach to public health and social justice, and compare tastes in music and beer. I discover that the poetry of  Leonard Cohen transcends age and culture; Blue Moon ale not so much.   iPhones, blackberries, and digital cameras give us instant entry into each others' worlds, and we are quick to introduce our new friends to our children at home.  And when conversation turns to physical activity, we discover that five of the six women at my table - from Canada, Phillipines, Zimbabwe, Jamaica and Mongolia - share a love of Zumba.

This week we had to prepare a 3-minute presentation on something important to us, and which we believe would be of interest to our classmates.  The presentations range from the importance of vaccinating for HPV, to enjoying the sights and sounds of NY, to how to attract a Swedish woman if you are a visiting Italian single man.  I learn that Brazillians celebrate New Year's by wearing white to signify peace, but through their choice of underwear make a wish for the new year - red for passion, yellow for prosperity, green for health.  Apart from the accent, Melissa from Jamaica could have been talking about sexual health education in the Yukon.  It seems that the problem of ensuring that the curriculum is consistently taught in schools is universal. 

I used my 3 minutes to "sell" - for that is what this course is all about - the idea that social relationships should be at the core of a wellness strategy.  I was more anxious than I anticipated, but the presentation was nevertheless well received.    The core messages of healthy living:  move more; drink water not sugar sweetened drinks; don't smoke; eat real food, but not too much; get a good night's sleep most nights make sense but do not inspire.  It is only when I talk about the importance of our social relations which connect head to heart that the ideas come alive, gain traction, resonate.  Heads nod - first in recognition and then in agreement.  The approach is intuitive, and appealing.

Yesterday we had a special presentation by Asiya Oduglen-Kolev with the Global Alert and Response Department of the WHO on  using COMBI (Communication for Behavioural Impact - the course I am taking) to guide communications in an outbreak of Ebola in South Sudan in 2004.  After we complete the course, we will be invited to join a Global Technical Network and if we are interested, we will  be placed on a roster of health professionals that WHO can call upon to assist in emergencies throughout the world. 

We also went to the Advertising Council of America - a non-profit organization that leverages millions of dollars of free creative work from leading advertising firms and free media to address public health and social justice issues of national significance.  The Ad Council began during WW II with Rosie the Riveter, war bonds, and victory gardens, created Smokey the Bear, and continue tackling issues such as autism, drunk driving, father involvement with children, high school dropouts, and many many more.  The photo below was taken in the subway en route to the Ad Council.  From left to right are Dorcas from Nigeria, Sengsay from Laos, Vania from Cote D'Ivoire, and Lurdes from Mozambique.

I learned many valuable tips this week, one of which I will pass on to you now.  When you write on a dry erase board with permanent marker (as we all inevitably do), write over it with a dry erase marker and then erase as usual.  Saying abracadabra is strictly optional.

I'll leave you today with a photo of what I believe is the most beautiful building in NYC: The Chrysler building.  I took this as I was walking home after meeting my sister for an Italian seafood dinner at the Eataly - a raucous Italian food retail and food service bazaar.

Coming full circle

In 1970  I began my undergraduate studies at New York University and  a few years later I moved into a one-floor walk-up on 14th Street between 1st and 2nd Avenue.  Today I am a visiting student for 3 weeks living in a dorm on 14th Street between 3rd and 4th.  I have come full circle.  In my introduction to my classmates I mentioned the 41 year gap which resulted in the only applause of the morning - it is a safe bet that I am the most senior student in the class! A couple of my fellow students in private conversation with me made reference to the 21 year gap - did I make a Freudian slip and knock 20 years off?

My return to student life fulfills a gap in my education  - living in a dorm. My room is single, small, sparse and the walls are scarred from the many students that have come before me.  It seems as though the other rooms in my suite are vacant, so I have avoided sharing the bathrooms.   The accommodation is fine...for 3 weeks - it is functional, near to just about everything, and importantly air conditioned.  My sister and her family brought me to my dorm, and the mock tearful parting for the benefit of my adolescent nephews masked the anxiety on all our parts at being dropped off in a strange place before dorm culture and norms are clear. 

I thought I would need to re-acquaint myself with my former neighbourhood but  it is really more like re-learning.  The neighbourhood has been transformed from seedy 70's to trendy teens; the Puerto Rican groceria which was on the ground level of my former apartment building is now a high end bicycle shop; the panhandlers at Union Square have been replaced by street performers;  Gristede's is gone, and Trader Joe's competes with Whole Foods  for customers.  But the neighbourhood is still anchored by its institutions - the synagogue next to my former apartment, New York Eye and Ear  on the corner of 3rd, and Beth Israel one block over, and thankfully Vaneiro's on 11th and First, an Italian bakery which has made  the finest not too sweet but oh so rich canoli, a Sicilian pastry,  for over 100 years.

Last night I walked the High Line - the  elevated subway which ran along the West Side through the meat packing district that was saved from the brink of demolition and transformed into an elevated park which runs from about 10th Street to 30th Street.  All along the park some sign of the original subway remains - the tracks, the railroad ties, the decorative iron railings to allow us to keep one foot in the past.  Between and among these reminders  is an oasis of decorative grasses, trees, Shasta daisies, and the occasional strip of lawn; family sized wooden chaise lounges, benches of all shapes, sizes and in every orientation; the ever-present view of the Hudson River and Jersey skyline.

A delightful feature which makes a child of all ages is an adaption of the  waterfall walls -   a shallow sheet of running water shimmers in a 6 x 30 foot area with benches where people can take off their shoes and cool their hot, tired feet.  Another delight is a beautiful modernistic wood and steel sculpture - it is only when the birds arrive that I realize it is a feeding and watering stop for NYs resident birds.  

As I walk the city streets, I find myself mindful of the care and attention  given to creating green spaces wherever there is just enough room for roots to take hold - in window boxes, rooftops, planters,  2x3 plots of land that surround side street trees, and buckets tied to fire escapes!  People create and seek out nature perhaps because of the seemingly universal positive effect it has on physical and mental well-being.   New Yorkers are known to be fast walkers - but I noticed that this was not so on the High Line.  People stroll, take in the sights and sounds, talk in pairs and groups, lounge... it is as if being surrounded by nature gives permission even to driven and uptight New Yorkers to relax, restore, re-connect.

The program which brought me to New York is truly a global classroom - there are students from Uganda, Zimbabwe, Cote D'Ivoire, Nigeria, DRC, Botswana,  the new North Sudan, Ghana, Nigeria, Egypt and a good sized contingent from Mozambique.  There are also students from Tajikistan, Kazakhstan, Mongolia, Laos, Cambodia, Myanmar and Timor-Leste.   There are also students from Spain, Russia, Sweden, Scotland, Finland, USA, Italy, and Denmark working in the developing world, and many others - 38 in total.  Their interest span the range of public health - from maternal and reproductive health and violence against women and children to HIV and TB.  It is as if the interests of my classmates span by professional history.   Standing out from the crowd of health professionals and community development specialists is a student from Brazil who is interested in mitigating the negative social impact of oil and gas development in Southern Brazil (? relevance to mining in Yukon), and a journalist from Scotland who is with a UN Peace Keeping mission in East Timor.  Most work for UN agencies (I am struggling to keep up with the acronyms) or NGOs (e.g., Project Hope). 

The breadth and depth of experience, and the circumstances in which fellow students live and work is humbling.  Today in a small group discussion, I learned about  preventing significant disease and injury associated with leprosy from Sunday, a student from Nigeria, if those who are newly diagnosed would inspect, soak and lubricate their feet once a day, and wear soft insoles. This is easier said than done as only 20% of persons with leprosy engage in self-care now.  And this is but one of example of the reason for our course: to figure out all the factors which influence behaviours like foot self-care, determine the potential role of a communication plan, and then create plan which results in the desired behavioural impact.


Our instructor's unique education and experience in communications, psychology, marketing and business administration, and his talent for story telling makes the class lively and provocative. I would have described him as charasmatic, but his self-description is equally apt: "charming and arrogant."

Yesterday I was reminded that the average American couple spends only 7 minutes per day in conversation, mostly in short 3-5 second sound bites (e.g., Good morning, dear; can you pick up the kids today?; it's been a long day; dinner is great).   How can we possibly think that we promote family planning, negotiations on condom use, healthy child rearing practices which require intimate and lengthy discussion on a base of 7 minutes per day? 

Cheers from NYC!