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HSPH pairs with refugee public health students to create a healthier Burman

HSPH pairs with refugee public health
students to create a healthier Burman

The thatched bamboo huts sprawling up the side of a mountain near Thailand’s border with Burma could at first be mistaken for a tranquil rural village. Surrounded by a lush forest, Umpiem Mai hums with life. Roosters dodge motorbikes whizzing by on the carless streets. Laughing children play ball in front of a market where women in colorful skirts balance babies on their hips as they shop for vegetables. It is a community of more than 13,000 people, densely packed and tightly knit. A wooden pole operated by hand is raised and lowered for entering cars. The only permanent structure is the main road, and even that is just partially paved.

The people who live in Umpiem Mai and in the eight other camps along the border are Burmese refugees, mainly from Karen state, who have fled turmoil in the eastern part of their homeland and are seeking asylum from sectarian violence. Decades of civil war in Burma have created one of the most protracted refugee crises in modern history. Some people have lived in the camps for nearly 30 years and an entire generation has known no other life.

The end of military rule in Burma (also known as Myanmar) in 2011 signaled new hope that a resolution was in sight. But even if ceasefires hold between the Burmese government and ethnic minority groups, the conflict has left a legacy of devastation that will linger for years. While some predict that the Thai border camps (which are separate from the refugee camps housing another persecuted minority, the Burmese Rohingya Muslims) will close within the next three years, the future of the 130,000 people who call them home remains uncertain.

Students at Harvard School of Public Health who are training for humanitarian careers often study life in refugee camps, but few have seen these settlements in person. Fewer still have the opportunity to work with refugees as colleagues and get to know them. In January 2014, eight HSPH students traveled to Umpiem Mai for the School’s first experiment with a “twinning” class in a refugee camp. For three weeks, they studied alongside 21 refugee students at the camp’s Public Health Institute (PHI) and developed a joint research project that would be carried out remotely during the first half of the spring semester.

Shyness evolves to sharing.

The selection process for students participating in such a unique experience had to be thorough, says Parveen Parmar, MPH ’10, who designed and led the course and is associate director of the Brigham and Women’s Hospital International Emergency Medicine Fellowship and an associate faculty member at Harvard Humanitarian Initiative. Gregg Greenough, assistant professor in the Department of Global Health and Population, also served as an instructor. Parmar looked for students with the spirit and experience to deal with squat toilets and other austere realities of fieldwork.

But more important, “Understanding how to work with colleagues in a respectful and egalitarian way when they don’t speak your language and have different skill sets and backgrounds—that’s not something a lot of researchers do well, even very experienced researchers,” Parmar says. “The students appreciated that they weren’t the experts in this situation. This was intended as an equal exchange.”

While the PHI students were initially shy around the HSPH newcomers, barriers broke down during the daily meals the group shared at the camp. “They opened up about their lives from the first day,” says Corey Peak, SM ’14. “I heard about students who had left their families behind to get an education. Some had crossed over a landmined border to come here because there were no other opportunities. They wanted to share their stories and hear ours, too. And to understand that while we may be different, we’re all just people.”

Formidable needs, few training opportunities.

The HSPH students traveled to the camp each morning in the back of a truck after spending the night at a nearby home in a Hmong village. Daily lectures by faculty members from both institutions covered water and sanitation, women and children’s health, and tools used to develop and assess public health programs—skills the PHI students will need after they graduate and join the region’s public health workforce. With one of the highest rates of maternal death in the world, along with high rates of malnutrition and drug-resistant malaria, the public health needs are formidable and the opportunities for training are few.

The twinning course grew out of Parmar’s work with Community Partners International, a nongovernmental organization that has operated the camp’s Public Health Institute for the past two years in collaboration with the Karen Refugee Committee Education Entity and the Karen Department of Health and Welfare. It was offered by the Humanitarian Academy at Harvard through HSPH’s Department of Global Health and Population.

Parmar plans to develop an evaluation component for the course next year, so that its success can be demonstrated and eventually replicated elsewhere. “The ideal situation would be for refugee students to access education back home,” she says. “But in the absence of that opportunity, programs like this are a great way to ensure that a group of well-trained individuals can carry out the necessary services to rebuild when peace does return to their homeland.”

The Public Health Institute provides students with internships in the region that often lead to permanent placements. Students graduate from the program motivated to give back to their damaged communities.

Help vs. self-reliance: Striking a balance.

Today, the idea of closing the camp and repatriating the refugees is gaining political traction in Thailand. International donors are turning their attention to other hot spots, and agencies that provide camp services have seen their funding cut. Monthly rice and charcoal rations have in turn fallen. The key question—how to strike a balance between providing for refugees’ needs and fostering their self-reliance—has no easy answer.

“Understanding how to work with colleagues in a respectful and egalitarian way when they don’t speak your language and have different skill sets and backgrounds–that’s not something a lot of researchers do well, even very experienced researchers.”– Parveen Parmar, MPH ’10, associate faculty member, Harvard Humanitarian Initiative

During the course, students met with the NGOs and community-based organizations that deliver public health services to the camp and divided into teams to develop a research project to support their work. The aim was to create a snapshot of health-related practices, such as rubbish management and condom use, to help the organizations decide how to best allocate dwindling resources.

Soap and charcoal.

Peak, an infectious disease epidemiologist, noticed right away that many toilets in public places such as schools and government offices did not provide soap, in part because money for soap had been cut. For many refugees not accustomed to having soap, its absence didn’t seem worrisome— but from a public health perspective, individual cleanliness was paramount to preventing the spread of infection. So Peak worked with his PHI colleagues to document hand-washing capabilities in every public toilet in camp. Back in Boston, he stayed in touch remotely with his team as they systematically gathered data—contending with a 12-hour time difference and spotty Internet service in the camp. Meanwhile, the students continued meeting each week for joint lectures (delivered through videoconferencing) and drew up a comprehensive map of the camp’s sanitary facilities.

At this year’s graduation, HSPH members of the twinning course received the James H. Ware Award for Achievement in the Practice of Public Health. (From left) Corey Peak, SM ’14; Kelsey Gleason, SM ’14; Jean Nepomuceno, MPH ’14; Rachel Whelan, SM ’14; Julia Hellman, MPH ’14; Courtney Cox, SM ’14; Parveen Parmar, instructor and Harvard Humanitarian Initiative associate faculty member. Not pictured: Phillip Summers, MPH ’14, and Jami King, SM ’15.

Kelsey Gleason, SM ’14, worked in a group that investigated how fuel usage could be made more efficient and less risky to health—results that will be shared with refugees during classes at the camp. But as Gleason conceded self-deprecatingly, another of her ideas did not pan out. After studying fuel usage for household cookstoves, she had determined that it would be healthier if the stoves were raised higher so that the women who did the cooking did not have to lean over the stoves. An American Refugee Committee representative pointed out, however, that this small change would pose a fire hazard. Building materials in the camp are highly flammable and have erupted in serious fires over the years. For Gleason, it was a lesson in humility. There also were lessons in another virtue that can be hard to master for high-achieving Harvard students: patience. “Every time I got frustrated by a communication issue, I realized it was my fault,” Gleason says.

“In the camp, there were weird oscillations between things that were exciting and new and things that would bring home the reality of how hard life is there,” says Peak. “You’d see beautiful kids being kids, playing games that you recognize, next to people scraping by. The emotional highs and lows were very close. It was hard—but I learned so much.”

The course was an equal exchange of passion and expertise, Peak adds. Unlike typical fieldwork, which might employ locals simply to collect data, the course made PHI students full collaborators. “They were invested in the study and plugged us into the community,” says Peak. “I saw them gain in confidence just during the three weeks we were there. I think they are well equipped to make a difference for health, both in the camps and back in Burma.”

In their own words: Stories from refugee students.

The Harvard teachers explained that in public health, “prevention is better than cure.” I really like that meaning. My ambition is to become a good health worker. When l was living in my village in Burma, I saw many pregnant women die from postpartum hemorrhage problems. I saw many children delivered by village midwives come out yellow on the whole body—and three days later, the newborn died. So I feel very sad and I want to give education about family planning, hygiene, and washing methods to control disease.
— Kyi War Khaing, 20

In 1997, the Burmese military attacked our Karen people, killed them, burned our house. At that time, my parents could not do anything for us. We didn’t have shelter or enough food to eat, so we moved to the refugee camp.… When the Harvard students arrived, I was very excited to see them. They were patient and explained the lesson when we didn’t understand. They have a good relationship with us.
— Naw Eh Tu Lo K’mwee, 23

When I was a child, I wanted to become a doctor and my parents encouraged me. My family and villagers often had to escape from the military. I had to finish my school in the jungle because of the military. When I was eleven and a grade four student, there was a day that I have never forgotten. The troops came to my village and burned all the houses in the village and killed the villagers. Since that day, I fled to Thailand and a refugee camp to continue my education. I graduated high school with high motivation and strong courage from my parents.… I decided to study public health because you can help many people at the same time. [In the HSPH course] I learned how to manage and how to be a leader. Now we are using public health training in our internship. We figure out root causes of diseases and work with different stakeholders to set up sustainable public health projects. I hope one day public health will succeed.
— Saw Tei Htoo, 22

When I was 10 years old, I told my parents, ‘I want to go to school.’ But we didn’t have the money. Almost all the children in my village could not pay the school fee, so we had only primary school. I faced many problems: no food, no umbrella, also no shoes because my parents are poor. In 2002, I moved to the refugee camp and had the opportunity to continue my studies.… I chose the public health program so I can promote health and give education to the public about prevention. — Saw Maung Pay, 28

I learned at PHI that if we spend 1,000 baht, we can cure only one person—but we can prevent many people from becoming sick and injured.— Naw Hsa K’ Pru Paw, 22
— Amy Roeder is assistant editor of Harvard Public Health

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