UVA-SEWA Partnership: Understanding Occupational Health among Informal Agricultural Workers in Gujarat, India

Mary Collins, Lina Hong, Patrick Robinson, and Elise Watt

This experience has instilled in me an appreciation for the paramount importance of personal relationships to successful grassroots public health work. Simple, informal conversations undertaken in a spirit of friendliness and open exchange often yielded some of our most valuable and rewarding insights. The sevikas, or community health workers, were our models; their inexhaustible commitment to the health and well-being of their families, friends and neighbors was unrivaled. – Patrick

Hello from Ahmedabad! We just finished our last day in the field working with the Self-Employed Women’s Association (SEWA). We visited four villages surrounding Ahmedabad city over the course of many weeks, and are excited to begin analyzing more deeply the information we have learned about occupational health in relation to agricultural work. We spoke in depth with women about their commonly experienced aches, pains, cuts, bruises, and work-related mental distress. SEWA will be using this information, along with the results of a similar study conducted with home-based workers in urban areas, to develop an occupational health training program that will strengthen their existing healthwork. We have been here for two months, and as daunting as it may be to lose half our body weight in sweat during the summer just to get drenched by rain during monsoon season, we can all agree that this has all been part of the learning experience.

Not all information that helped us in our research came from an academic source. Just being in India long enough to get familiarized with the culture proved to be immensely helpful in understanding the women that we met in the villages. In our first few days of fieldwork, it was difficult to understand why health was not a top priority. Some women seemed to brush off very concerning health problems so that they could continue working in the fields. We are used to health, both physical and mental, being almost always of utmost importance in American culture, so the difference was especially striking. Most people in the villages need to be able to work every day just to earn enough to feed their families, and are willing to exchange health for income.

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Here we are with women from one village after our focus group activity, the final activity in our study. We are joined by the village’s Sevika, who coordinated and helped facilitate many of the research activities with us.

Additionally, we learned the importance of informal conversation beyond research activities. Every day, we went to the field with an agenda, in the hopes of completing at least one participatory action research activity, or at least one interview, but we realized that research is more than the activity itself. Some of our most enjoyable time with the women we worked with was before and after formal research activities, as women trickled in from their various homes after eating lunch or coming in directly from the field, with mud caked on their feet and sweaty saris. Almost all of our time in these villages was spent under a fan on the open porch or in the shady interior of a Sevika’s, or SEWA community health worker’s, home. These spaces were blessedly cool compared to the scorching fields, yet the women hardly complained about their work unless explicitly prompted, and even then with hesitation. As women arrived for our research activities, we chatted casually about their mornings and their plans for the afternoon–household work, a nap, an afternoon hour spent at the local mandir, or Hindu temple. Sometimes women or other onlookers, like the Sevika’s children or curious passerby, would venture a question to us–how old are you? Are you married? How do you like India?

My favorite part of doing field work is meeting women whom I know I would be good friends with in another setting. We only get a few hours with most of these laborers, but they are women of my own age, moms, daughters, and sisters; all people that I recognize. It’s amazing how well you can connect with people without a shared language, just through genuine curiosity, kindness, and shared senses of humor. I feel so lucky to get to know these women. – Elise

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Following our interview with this landowner, she showed us her field of jasmine, cotton, and cucumbers. Although she employs laborers, she works with them side-by-side in the field despite being ninety years old. We observed how she carefully plucks jasmine each day.

We realized we could not do formal research activities without informally speaking with our participants. We needed to engage women to understand who they were outside of the research activities. Not every interaction we had needed to have an aim – drinking chai, laughing with the women, and trying buttermilk became the best parts of our research. These moments became opportunities for the women to get to know us as well. Some of our most engaging conversations usually followed our research activities, when we had spent enough time with women for all to be comfortable with one another. This was usually when participants would ask about America and American culture–what do you usually eat? What kind of crops do you grow in America? We weren’t sure what to expect as the typical curiosities about American life, but we were surprised and intrigued to get a peak at popular conceptions of American culture in India through hearing these questions.

One of the women that we worked with in the village told us that we made her feel like someone cared about her well-being. I’m excited to see where this project will go in coming years and hope we can help them with interventions, but if making them feel cared for is the only way that we can impact the women for now, I still consider that a huge success. – Lina

These simple exchanges proved extremely important. They allowed us to establish bonds of trust and goodwill that created opportunities for genuine relationships. This not only improved participants’ experience as well as our own, but markedly augmented the quality of our findings. These conversations always seemed to inform our understanding of village life in new and unexpected ways–something that bolstered the precision and nuance of later inquiries. We found our inspiration in the village sevikas. These women know their communities inside and out–from the fluid dynamics of the local economy to the difficulties women laborers face in harvesting jowar, or grass, to feed their buffalo. And their knowledge is entirely based on relationships–with the people, with the place, and now with us.

The women we talk to daily are inspiring in conversation when we learn that their rheumatism, feet infections, or headaches do not stop them from working in the paddy field and making an income. They are also inspiring beyond research activities. Research is so much more than conducting the activity itself; it is informally asking a participant how their day went and how they are feeling – this is so important to understanding their experience as a self-employed agricultural worker. – Mary

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Thohoyandou, South Africa

Cameron Haddad

After a lengthy cross-Atlantic flight and a slow drive through dense patches of fog, we arrived in the beautiful town of Thohoyandou.

We are a team of two researching the socio-economic status and health care utilization of the traditionally religious in Limpopo, South Africa. We have been here for a little over a week and have been adjusting to life in Thohoyandou – driving on the left side of the road, the abundance of chicken eateries, but namely, the slower pace of life and work. In the first week, disorganization and mismatched schedules have proven challenging to our research project’s progress; however, we have still done some work and were able to get a better idea of the healthcare system and traditional healing culture in South Africa through individual conversations.

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Photo of us and Vhutshilo at his birthday party.

One issue we found in America while researching traditional healing was the immense variability of statistics on the prevalence and usage of traditional healing. Studies claimed that anywhere from 2% to 80% of South Africans utilize the services of traditional healers. Interestingly, we have found a similar discrepancy in some of our discussions with local people and new friends, with some claiming that the 2% metric is more accurate, and others the 80%. While our research project is admittedly not large enough to provide a robust answer, we hope that our project can provide more insight to this puzzling question.

We have also been learning a lot about Venda culture, and just a few days ago we were invited to our new friend Vhutshilo’s birthday party. He was incredibly kind and welcoming to us, like most everyone else here in Thohoyandou. While this was a lot of fun, we expect and also look forward to our research project picking up soon!

Cape Town, South Africa

Lauren Greenwood

I was doubtful that my time in Cape Town this summer could surpass the time I spent there last year, but I was completely wrong. This summer, I grew so much as a person, as a researcher, and as a global citizen.

My time in Cape Town this summer was truly incredible. The Town Two community welcomed me with open arms, and I learned so much about township life, the research process, and myself in my time there. Through my research, I was able to see the world from another point of view and learned to talk across layers of difference. I am so thankful to have had this experience.

My research allowed me to deepen the relationships I had developed there last year, while also forming new ones. I interacted mainly with people aged 20 to 25 years old, and most of the time, I was only the only researcher present at my focus groups. As I am also in my early twenties, the conversations were very casual and there was a sense of relatability. Both my research participants and myself were in a period of transitioning to some form of “adulthood,” filled with all sorts of life decisions and uncertainties. Because of that, I felt they were open and honest with me. While the exact manifestation of this differed, I found that many of their desires and hopes for the future were similar to my own – they wanted independence, stability, adventure, education, and to be seen as an adult.

Similar to many young adults, I found that my research participants employed specific strategies, consciously and unconsciously, to make their hopes a reality. My conversations also revealed that many of the strategies utilized by this population are often seen as public health and community development issues. A few examples of this include: young women purposely going off birth control to conceive a child to prove their adulthood and the seriousness of their relationship, young men engaging in multiple concurrent sexual partnerships to avoid a serious relationship that could lead to a pregnancy causing them to drop out off school to provide for the child, and young men involving themselves in crime to get the money they need to open a business. I think these findings and examples prove the value of my research and the importance of understanding how people view the world in order to tackle public health issues effectively.

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Bonga Maqogi outside the community center in Town Two, Khayelitsha, Cape Town
Bonga was one of the young men with whom I hung out with the most during my ethnographic work. He is the son of a local pastor, Monwa, who was my primary field contact. Bonga participated in my focus groups, helping translate portions that were in Xhosa, and also participated in the youth group that I observed. In his early twenties, Bonga is the typical age of the people with whom I spoke. Bonga loves rap and hip-hop, and this photo was taken while hanging outside the community center.
Photo Courtesy of Natasha Kannemeyer

Spending a second summer in Khayelitsha, I felt I saw the challenges people faced more intimately and that people were more vulnerable in sharing the struggles of their lives with me. My field guides had become my close friends, and I care deeply about them. I went to church one weekend in the township with them, and while this was a very joyful experience, there was a lot of underlying sorrow. I heard stories of what it was like to live in a shack during the winter, and I would look outside the church to see lines of people collecting muddy water with buckets. This was one of the times when I felt defeated; like structural violence was a boulder I was trying to chip away at but would never really move. While this was very difficult for me to handle emotionally, I also saw the resiliency and spirit that existed in these communities – they would not let these challenges overcome or define them.

As I continue in my journey to make an impact in the field of global health, I will take these stories, moments, and memories with me, letting them guide, shape, and motivate me. I am incredibly thankful to have had this experience and have collected these memories, and am extremely grateful to CGH for providing me with the opportunity to do so.

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Bonga, Siyabonga, Lauren Greenwood, Siphosihle, and Sonwapile in Monwa’s church in Town Two, Khayelitsha, Cape Town
This was taken following my final focus group and thank you event. For my final focus group, we discussed my four remaining questions about the future, support, uncertainty, and relationships and wrote out their comments and thoughts on a whiteboard. Everyone was very proud of their work and the whiteboard – several asked for a picture with it, as is the case here. Siyabonga and Siphosihle were my two primary field guides for my time in Town Two. Bonga and Sonwapile also participated in multiple focus groups.
Photo by Monwa Maqogi

 

Tanzania

“Do what you can, with what you have, where you are.” – Theodore Roosevelt

Jack Hensien

I learned an incredible amount during my time in Tanzania—from the research project itself, working with locals, living in a completely new cultural and physical environment, and talking to people of very different backgrounds. To summarize, I joined the research group at the Haydom Lutheran Hospital and primarily worked with the field team for follow-up of the MAL-ED (Etiology, Risk Factors, and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development) study. We either walked or drove to the houses of participants in villages surrounding Haydom to perform cognitive tests and take anthropometry measurements of children enrolled in the study. Along with the fieldwork, I also gained exposure to other ongoing studies in the research laboratory during the afternoons and evenings.

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Most afternoons and evenings, I spent my time working in the laboratory at the Haydom research center. This is Rosemary, a member of the lab team. In this picture, she’s working on processing samples that have been collected by other field workers.

Although data collection will continue into September, I was happy with the amount of progress we made during my six weeks, along with everything I learned through my participation in the study. By the time I left, my field team had collected data from over 90 children, with approximately 100 more to visit in the future. Along with gaining experience taking anthropometry measurements and observing the process of cognitive testing, I learned a lot about cross-cultural collaboration and local customs. In spending time with the field team and experiencing village life around Haydom, I learned the importance of being friendly and open-minded, expressing non-judgmental curiosity regarding local culture, and demonstrating effort in learning and practicing local languages.

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My field team is heading to visit a house in the hills surrounding Haydom. This was a typical morning, as we left the research center early to reach our scheduled houses before the children left for school.

Though I felt like our work in the field was largely successful, I experienced some of the difficulties of conducting fieldwork in a resource-limited setting. For example, we were limited in where we could drive by lacking road infrastructure and occasionally had communication issues with parents regarding when their children would be home from school or herding cattle. However, I was impressed with how the field team adapted to these frustrations—texting or calling parents that had cell phones to verify appointments, splitting up home visits among team members, and scheduling appointments in clusters within walking distance.

Outside of working in the field and lab, I was able to see more of Tanzania. With some friends I met at the hospital guesthouse, we took weekend trips to see local craftsmen, go on a short safari, visit a nearby hunter-gatherer tribe, and hike a couple mountains. On one of my favorite trips, we went with local friends on a small boat to visit a missionary site that is now on an island in Lake Basotu. I was surprised to see that in major contrast with other local buildings, the church on the island was nicer than the one I go to at home (and to find a hippo in the lake). Along with enjoying the trips, it was nice to experience Tanzania with other foreigners from different parts of the world. I learned a lot and found it helpful having conversations about our own cultures and how we’ve perceived our time and experiences in Haydom.

Overall, I’m really grateful that I had the opportunity to participate in this international research experience—it’s confirmed and reinforced my desire to pursue future global health opportunities, hopefully both in research and clinical settings. Many, many thanks to Dr. Houpt and the UVA Center for Global Health for allowing me this opportunity.

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My field team shares a meal outside a villager’s house. It was unusual for us to stop and eat at a villager’s house, but we often had a meal or tea at a local restaurant if our work went later into the afternoon.

Who Shows Up When You Arrive?

Trina Kumodzi

Literature review? Check. Research proposal? Check. Center for Global Health Scholars application submitted? Check. Award granted? Check. UVa IRB approval? Check. IRB approval in the relevant country? Check. Congratulations! You are ready to change the world with your research project! Purchase your ticket because your research career is launched!

This is how you think it is going to be when you envision an international research project. Our focus is often on securing finances and permission, because these seem like the biggest hurdles we must overcome in our academic lives at UVa, so our confidence is high when money and permission are no longer issues.

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Me sitting on a rock at Timothy Hill, St. Kitts. The left of the picture is the Atlantic Ocean. The right is the Caribbean Sea.

I have traveled to the Federation of St. Kitts and Nevis in either a research or teaching capacity every year over the past three years of my PhD studies. My mentor, Dr. Jeanita Richardson, has been the principal investigator or professor each time. I learned so much about the do’s and don’ts of global research and this year I was ready to develop and conduct a research study on my own on homicide in Nevis.

I arrived on Friday, June 22nd fully expecting to start the project on Monday the 25th. By the 29th I was still waiting to start my project. I was nervous this delay might cause me to miss my objectives. An unexpected phone call that came on July 3rd stating I was granted a meeting with the Police Commissioner and the respective Island Superintendents the next day was a godsend. I prepared a short Power Point presentation, printed it out in case there was no available computer, and ironed my clothes for the next day’s meeting.

Once at the Basseterre Police Headquarters, I waited for the Police Commissioner to summon me to his office for the meeting. To say I was nervous was an understatement. The Nevis Permanent Secretary of Health and I are the only women in this room full of high-ranking law enforcement officers. How am I going to convey to them how my health-care related research involves them? This was a hurdle I didn’t expect to jump!

I present my information and they listen. They then ask me questions about the logistics of the project and I answer them. The meeting is moving along smoothly. They ask me about my studies and my clinical background. I answer the questions and they are slightly more engaged. They then speak of current issues in the Federation and I reply with what I know of these topics, how the same issues manifest in the U.S. in both the health care and penal system, the positives and limitations of the systems, and potential solutions. They are now completely engaged. The meeting concluded with immediate access to the necessary information, and the assurance of future help should I need it. I collected the data and did a preliminary analysis before I left the country.

I learned that while access is critical to research, who you are still matters to the people who your research will affect. Bureaucratic entrée is only the beginning: you must show up as a person who can handle and respect the access you are given. My research proposal demonstrated that I had the intellectual skills, but the meeting confirmed my intentions. I have developed a personal stamina that is unique to conducting global research. Human interaction is still important.

 

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Native plants.

 

 

 

 

 

 

Kigali, Rwanda

Sam Powers 

“We’re driven by the belief that all people, no matter who they are or where they live, deserve the chance to reach their full potential.” I saw this quote written on the wall every morning when I walked into the University of Global Health Equity (UGHE) in Kigali, Rwanda this summer. It is the mantra of UGHE and quickly came to color my entire experience in East Africa. Founded by former Rwandan Minister of Health Dr. Agnes Binagwaho and Partners in Health co-founder, Dr. Paul Farmer, the University of Global Health Equity seeks to research innovative ways to provide equitable and quality healthcare in resource-poor settings while training the next generation of African medical leaders. My role at UGHE was as a research intern under Dr. Binagwaho, conducting a few projects to investigate several aspects of health system strengthening and health disparities. Having the opportunity to learn from a global leader like Dr. Binagwaho made me consider so many new angles to my work with each discussion.

My main project was a detailed analysis of the faith-based healthcare system in Rwanda. For the past twenty-years, the Rwandan government has cultivated community ownership of its healthcare system by partnering with local organizations to put health centers in each district. Currently, faith based organizations comprise 30% of the healthcare infrastructure. But due to close coordination, the government funds 50% of those facilities’ operations. The faith-based institutions commit to providing the same care as public institutions, acting simply to extend the network of health throughout the country. My job was to interview key faith-based and health sector leaders to evaluate perceptions of the program’s effectiveness and to document its role in the Rwandan healthcare system. From speaking to these individuals, my key finding was that religious organizations provide a vital service in delivering healthcare to poorer and more remote Rwandan communities. Fueled by a religious desire to serve the poor, over 90% of faith-based healthcare facilities operate in hard to reach rural areas. This conclusion wove perfectly with the equity agenda developed at UGHE, showing that in resource-poor areas key partnerships with religious organizations can be a vehicle for providing a preferential healthcare option for the poor.

While I learned a great deal from my work, I grew so much more from living daily in Kigali and travelling through East Africa. Rwanda is an incredible country. I witnessed firsthand the impressive, equitable development achieved over the past decade through the government’s dedication to its people. Driving in to the city, I was struck first by its order and cleanliness. I felt significantly safer and cleaner in much of Kigali than I do in a majority of cities in the US. They have monthly car-free days where everyone takes to the streets to play sports and meet their neighbors. Even the local markets are organized and tidy. I found this all incredibly inspiring. I feel as though growing up in the states, we are presented with a limited view of Africa. The stories are typified by villages, safaris, and jungle animals, not stately clean cities and universal healthcare. Simply being there shattered stereotypes and exposed single narratives that I had ingrained since my childhood. Coming home, it made me question what other people, places, and ideas I have reduced into one-dimensional, archetypal visions. Simply put, my time in Rwanda, made possible by the Center for Global Health Grant, instilled in me a passion for crafting equitable systems of healthcare access and challenged some of my basic assumptions about living in a developing country.

My time in Rwanda at the University of Global Health Equity helped me codify my belief that health care is a universal right. Regardless of social status, access to quality care is a nonnegotiable. Witnessing this play out in Rwanda was inspiring, challenging some of my assumption about how we think of healthcare back home in the United States.

la República Dominicana

Jesse Duska

Most people when they think of the Dominican Republic think of this:

duska 1 - CopyWith the help of an internet search and maybe a raving friend, this is the Dominican Republic many people get to see, a DR of cheap all-inclusive resorts and incredible service. After almost 10 weeks in the Dominican Republic I was incredibly fortunate to see so many other sides of this diverse island. 

My journey began as a class: two weeks with six other students and two professors studying public health and learning about research practice. We had the sweetest Dominican driver, Henry, a van that accommodated all nine of us, and the luxury of an organized trip with a steady stream of direction and food.

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I was blown away by our “classroom” experience on this trip because of how much I learned. While I normally don’t like to go into any situation with expectations and I definitely am not a cynical person by nature, I had heard that many programs were much more casual work and vacation than a rigorous learning experience. I cannot attest enough to the professors’ balancing act in this regard, it was truly incredible. We had classroom sessions with active discussions, tours all over the island, intimate conversations with medical students, locals, and professionals… and yet we were learning while on island time!

duska 3“That your dreams are much bigger than your fears.” A mural from a neighborhood that we explored while conducting interviews for our classroom research. I thought it was particularly inspiring and colorful!

While I could talk about these two weeks for forever, the real journey began the day everyone left Jack and I on the side of the road in front of our new apartment. Two months… eight weeks… Jack and me and a research study that was up in the air. (You truly learn patience and understanding when you are in a different country or even a different culture than you are used to). And just like that we were off… 

Since our initial two weeks of class were jam packed with adventures and learning, we didn’t have much time to explore the touristy parts of the city. I find that often times when I travel I cannot get deep into the culture of the place; it is hard to meet local people sometimes and have in depth conversations, it can be hard to work or be fully integrated. We began with the opposite problem. My partner, Jack, and I were incredibly fortunate to have established connections with a local diabetes clinic and a local university both of which had gracious people willing to assist our research whenever we needed the help. But we hadn’t been tourists yet. We went straight for the deep connections and missed some of the quintessential Dominican experiences. 

We spent our first weekend alone catching up. I did an aggressive amount of research on the island and its most renowned gems and we did some exploration of our most immediate areas. I decided I wasn’t leaving before getting to know this country from all angles.

duska 4Jack and I exploring the oldest hospital in the New World. Being in this space is crazy because as you can see in the image it is totally overgrown and juxtaposed to the newer Zona Colonial that is present today.

Jack and my 8 weeks on our own passed by like a blur. I felt like each week I learned something new about the Dominican Republic, the work we were doing on pediatric diabetes, and myself. The DR is culturally and historically rich as the first place that Columbus landed in the New World. The entire Zona Colonial (tourist-centered colonial zone) is being redone to accommodate the country’s main source of income: tourism.

 While Jack and I both were proficient in Spanish going into our trip, it took us few days to realize that locals of the DR speak their own version of Spanish, they joke that it is “Dominican” not “Spanish.” Dominican Spanish spells phonetically, leaves certain syllables off of words. 

After the first month, I took the leap to travel by myself and boy was I glad. Santo Domingo, the country’s capital is diverse in its own way, however the rest of the island has so much to offer as far as people, lifestyles, scenery, and atmosphere. One weekend I made it up to Las Terrenas in Samaná. Online it is portrayed as a more serene beach town, however, as with the rest of the DR the place had so much more to tell. There were incredible waterfalls, chickens in trees, and a large expat population among many other things!

duska 6 - CopyThis cow and the palm tree were spotted on my way to another beautiful waterfall. The island is rich in environmental gems and diverse landscapes.

Las Terrenas was vastly different from Santo Domingo because of its smaller-town, laid-back nature and the beautiful environment all around. The people I stayed with knew everyone around their community, they all bought and sold products from each other as a means of building bonds. Many expats in this particular area also built businesses around healthy lifestyle coaching, providing guidance for Dominicans suffering from Type 2 diabetes to turn around their diagnosis through lifestyle habits. (This was especially cool because it was directly related to our study!)

My next trip was to Jarabacoa, a mountain town in the middle of the Cordillera (mountain range). My favorite take away from this particular trip was about the community in the DR. While the sentiment is definitely less present in the city where Jack and I spent most of our time, people live for each other on this island. Community and family is very important. Santo Domingo itself accounts for almost a third of the Dominican population so it makes sense that the community-centered atmosphere is not as intimate, however, one local in Jarabacoa explained how safe I was to travel even as a single female, “This town is just full of good people,” he told me in slow Spanish so that I could understand 🙂

duska 8 - CopyThree medical students from the local university took pity on us and showed us their typical Saturday – a trip to the beach and then their favorite ice cream joint, Sweet Frog! 😛 After the trip, the generosity and graciousness of everyone makes so much sense as a huge part of their ingrained culture.

Upon coming home, everyone asked me “How was your summer in the DR?” I truly did not know how to respond. It was nothing like I expected, but I could not recall what my expectations were before going. After copious amounts of online searching, the depths of the internet do not do this island justice, and Jack and I were lucky enough to get to know the DR on a whole new level.

 Diabetes is a growing problem globally and especially in the DR, for individuals and health systems. By studying diabetes in the DR this summer Jack and I were really able to get to know the country on a deeper level. We conducted focus groups, did chart reviews in a local clinic, and had many informal chats with people around in the area. One of my favorite conversations was with a librarian I met in Santo Domingo, “People practically have a prescription for rice and beans around here,” she mentioned. Everyone had their own ideas about the country and the causes of burdens like diabetes on the population.

Our access and the graciousness of everyone we encountered allowed us access to a fuller image of the DR that we wouldn’t have been exposed to on any other trip. When people inquire about my summer I am still unsure what to say, it is hard to put such a large, inexpressible summer into a couple of words. If I had to summarize it I would say this: an experience like I had this summer cannot be explained succinctly, not for a lack of substance or emotion, but because it has to be lived in order to be fully understood. I learned so much from so many people because of the intimate connections I was fortunate to make and the constant self-reflection within a culture so different and yet with many similarities to my own. Having the experience to travel as a CGH scholar really gave Jack and I a deeper capacity to study and learn from everyone we encountered and I would not have learned so much or had such an incredible experience without all the guidance and generosity of everyone involved!