Chytanya Kompala is currently completing a Hilton Prize Coalition Fellowship with PATH, a global health and innovation NGO based in Seattle, WA. Chytanya holds a Master of Science in Public Health degree in Nutrition from the Johns Hopkins Bloomberg School of Public Health.
In this blog post, Chytanya writes about her experience working with PATH’s Nutrition Innovation team to explore the effects of tobacco use during pregnancy on childhood stunting. She is also currently drafting a policy brief to highlight interventions that could help to reduce chronic undernutrition.
Stepping Out of the Silo: Advocating for Interdisciplinary Approaches to Undernutrition
By Chytanya Kompala
Global nutrition is my passion. In graduate school, I was trained to think about nutrition problems in the developing world from a certain perspective. My training came from nutritionists and did not emphasize collaboration with sectors outside of nutrition. My peers have been nutritionists. All of my previous work experiences have been completely focused on nutrition. As a global health nutritionist and researcher, I was eager to work with the Nutrition Innovation team at PATH and gain an insider’s perspective into one of the most reputable global health NGOs in the world. When I started my fellowship in February 2017, I was expecting something similar to my previous nutrition-centric experiences. I was anticipating joining a team that worked similarly to other organizations in this field. I was expecting to rely on my existing knowledge of nutrition. Instead, I had an entirely different experience. I found myself learning so much about new topics from a team with diverse backgrounds and next-generation ideas.
The issue of chronic undernutrition (technically known as stunting) has been at the center of my fellowship research. Chronic undernutrition among children under age five is one of the largest burdens of malnutrition and is an unavoidable topic in the developing world.
Chytanya Kompala at the PATH 40th anniversary celebration in Seattle, WA (courtesy of Kelsey Miller)
Early this spring, I attended a presentation at PATH’s headquarters by Roger Thurow, a senior fellow at the Chicago Council on Global Affairs and the author of The First 1,000 Days. “Stunted children have a life sentence to under-performance and under-achievement,” he said. As Thurow described, stunting during childhood impacts a child for the rest of his or her life. Long-term consequences of stunting include reduced educational attainment, impaired cognitive function and development, poor economic productivity, and even an increased likelihood of having stunted children. Stunting is an intergenerational condition that hinders the growth and development of individuals, families, communities, and even countries.
The Lancet 2013 Series on Maternal and Child Nutrition was a seminal set of papers that acted to coalesce the nutrition and development communities around a set of proven, “nutrition-specific” interventions to address stunting. They estimated that scaling up 10 nutrition interventions to 90 percent coverage would reduce stunting by about 20 percent. While this finding gave the community renewed focus, it also highlighted how much we still do not know about the complex determinants of stunting. What about the remaining 80 percent?
One of the aims of PATH’s Nutrition Innovation team is to help answer that question. During my six months at PATH, I worked on two projects: an ongoing systematic review and meta-analysis on the effects of tobacco use during pregnancy and its association with stunting, and drafting a corresponding policy brief on “nutrition-sensitive” risk factors that may be contributing to stunting—those that were not highlighted in The Lancet 2013 Series.
I never thought that my research would be focused on tobacco use. At first, I was skeptical about researching this topic. I have no background or experience working on tobacco, and I was unsure about how relevant tobacco would be to stunting. But through our meta-analysis, my eyes have been opened to the idea that much more cross-sectoral research still needs to be done to explore the intersection and overlap between different health and development issues and nutrition outcomes.
"Meet the Future" panelists discuss innovation and diversity at the PATH 40th anniversary celebration in Seattle, WA (courtesy of the author)
Working on the Nutrition Innovation team at PATH has taught me an invaluable lesson about the interdisciplinary nature of global health and nutrition. Too often, people try to do great work in silos. Echoing this message at PATH’s 40th anniversary celebration in May, a diverse panel of innovators and young leaders discussed the importance of making connections across sectors to solve the world’s problems. By working collaboratively and moving away from the “business as usual” mindset, we can achieve greater impact. Thinking about stunting outside of the “nutrition-specific” lens enables us to better understand the complex and broad, sweeping determinants of the problem. Our research on tobacco is just one example of this.
We are currently in the process of drafting our policy brief with the aim of broadening the conversation about stunting to address issues beyond the nutrition interventions highlighted in The Lancet. We are exploring sound evidence on additional determinants of stunting, such as household air pollution, tobacco use, hygiene and sanitation, education, and delaying the first birth and birth spacing.
Part of our message is to advocate for more interdisciplinary approaches among people working in different sectors—to encourage researchers, program implementers and policymakers to expand their approach to include cross-sector indicators in their research and programs. Many health and development studies and programs do not include stunting as an outcome of interest, even when evidence indicates that there may well be an effect. We hope our work can help guide the conversation out of the box and lead to new, creative, and interdisciplinary approaches to end undernutrition around the world.
I am grateful for this fellowship and exposure to the great work of the Nutrition Innovation team at PATH. My time here has greatly expanded and shaped my perceptions and approach to thinking about global nutrition.
Samantha Acosta is currently a Hilton Prize Coalition Fellow with HelpAge USA, an organization which advocates and empowers older persons to secure, active and healthy lifestyles. In this capacity, she focuses on the organization’s Healthy Aging Programs, conducting research related to fundraising, partnership building and grant management.
Samantha recently graduated with her Master’s degree in Social Work from Dominican University in River Forest, Illinois, where she explored gerontology infused courses with both a national and international focus. She has also conducted field research in Uganda, where she collected data on older persons’ quality of life, along with perceived needs and barriers. She received her Bachelor’s degree in Sociology, Cultural Anthropology and Politics in 2014.
In the blog post below, she writes about her experiences in Uganda and the implementation of the Healthy Outcomes Tool.
Oli otya, Greetings from Uganda
In May 2016, I embarked upon my first trip to Uganda, where 12 Dominican University students and I had the opportunity to work closely with Health Nest Uganda, addressing the health needs and concerns of older persons by utilizing the Healthy Outcomes Tool (HOT). HOT is used as an assessment tool to evaluate an older person’s health status, functionality, access to health services, safety, and self-care. During this process, we traveled to four rural communities, where we followed up with older persons for the second round of data collection. By promoting the Healthy Outcomes Tool, the team was able to clearly identify barriers and obstacles that the older persons’ were facing in everyday life. Some of the obstacles addressed were mobility, distance to the health centers, whether medications were readily available, cost of medications, fear of being abandoned by family members, and property being taken. As we were able to gather and evaluate the given data, we addressed these issues and concerns with the leaders of each community. We gathered qualitative data on simple programs that could be implemented in order to create possible solutions for the barriers that were addressed. During our final meeting, a leader from each community joined to discuss what their personal community had decided to implement. The ideas were magnificent and suited each community in their own special way. I said my goodbyes to Uganda and the communities I worked with in May 2016, not knowing when I would return.
(Key older person leaders and Dominican University students, May 2016)
Thankfully, my story and work with Uganda and with Health Nest Uganda continued. Following graduation and after receiving my Master’s degree in Social Work, I decided to focus my studies on Uganda and how older persons are affected throughout the world. I collaborated with Kristin Bodiford, Health Advisor at HelpAge USA, learning about the issues of older persons and HelpAge’s mission to tackle those barriers. Through my work as a Hilton Prize Coalition Fellow, I was able to return to Uganda in February 2017. During the second phase of my fieldwork, I was able to see the incredible progress that was made. Some communities incorporated singing, dancing and exercise programs in their regimen (photo below), while others focused on sanitation surrounding the latrines and handwashing, enhancing nutrition by building their very own catering business, and setting up regular check-ups within the community to test and treat non-communicable diseases. Witnessing this first hand was absolutely fascinating.
(An older person from Bugonga Village showing a Dominican University student the way they use dance and singing to promote healthier living and lifestyles)
I’m so thankful I was able to explore these issues in-depth and better understand the barriers that older persons experience daily through HelpAge and my Hilton Prize Coalition Fellowship. This opportunity not only provided me with the opportunity to return to Uganda and continue my direct field experience, but I gained deeper insights on how HelpAge is working to address and assist older persons to be recognized more readily around the world and within local and national regulations.
Weeraba, Farewell, until next time.
Steve Davis, President and CEO of PATH. "What's Your Story?"
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Ms. Anna Russell is currently completing a Hilton Prize Coalition Fellowship through HelpAge USA, the U.S. headquarters of an international network of NGOs focused on including older people in international development and ensuring that they have access to emergency relief, income security, health services and basic human rights. Anna is also pursuing her MPH in Global Health Program Design, Monitoring, and Evaluation at George Washington University. In this blog post, she writes about her experiences as a Hilton Prize Coalition Fellow with HelpAge, supporting the organization’s Health Outcomes Tool.
The Health Outcomes Tool: Making Older People Count
by Anna Russell
“How would you rate your health?”
“To what extent do you require support from other people?”
“During the past three months, how affordable was healthcare?”
These are all questions asked in the Health Outcomes Tool, a mixed-methods survey focused on older people’s quality of life in developing countries. The tool focuses on six main areas of concern for older people: qualitative experiences of health, functionality, dependence, self-care, health care, and a quantitative measurement of certain physical and mental functionalities. These are all areas that older people tend to experience differently than younger people. The tool not only provides validated quantitative data on the abilities of older people, but also includes context for the way older people experience their day-to-day lives.
HelpAge is an international NGO focused on assisting older people in humanitarian and development settings. The organization and its partners created the Health Outcomes Tool to shine a light on the perceived needs and barriers that are faced by this group. HelpAge has published an annual Global Age Watch Index since 2012, which uses publicly available data and information to rank countries based on the quality of life for older people. However, it was noticed that data for these rankings were usually incomplete or even nonexistent. Older people are often not counted in traditional monitoring systems, which typically stop data collection at age 49. They tend to have more health problems and less functionality than younger people but are invisible in most monitoring systems. The lack of data means that they are often not considered during the creation of global health programs. This group would benefit tremendously from health interventions, and collecting qualitative and quantitative data is a step in that direction. The Health Outcomes Tool has been implemented in four pilot countries: Bolivia, Colombia, India and Tanzania. The organization hopes to expand it to the Philippines.
(HelpAge staff and partners implement Health Outcomes Tool training in Ethiopia)
The good news is that the need for data on older people has just become part of a plan passed by the World Health Organization (WHO) at last week’s World Health Assembly. The Global Strategy and Action Plan on Ageing and Health – a follow up to the WHO’s report in 2015 on aging and health – includes 5 steps, one of which is to increase the data collection of older people’s health metrics. International commitment through the global strategy and resources like HelpAge’s Health Outcomes Tool will bring attention to the needs of older people. With this awareness, it will hopefully increase programmatic and technical support to those most vulnerable in the developing world.
I first learned about HelpAge at a global health policy event, and was intrigued by their work and the Health Outcomes Tool. I have always been fascinated by monitoring and evaluation systems and quickly learned that the tool fills a niche that otherwise had been ignored. Through my work as a Hilton Prize Coalition Fellow, it has been truly valuable to see this work up close, and to work with HelpAge’s international partners on the effort. While currently small in scope, the Health Outcomes Tool is already assisting the organization to understand and better address the unique experiences of older people in developing countries. Through HelpAge’s tireless efforts in implementing this tool, older people are starting to be counted.
(Dr. Prakash Tyagi, Executive Director of HelpAge partner GRAVIS, performs a functionality test of an older man in Colombia)
Ms. Nikhila (Nikki) Kalra is currently completing a Hilton Prize Coalition Fellowship through PATH, a Seattle-based global health innovation NGO and Hilton Prize Laureate. Nikki holds degrees from the University of Cambridge and the London School of Economics, and most recently received her PhD from Oxford University in International Development. In this blog post, Nikki writes about her field work experiences as a Spring 2016 Fellow in Ghana and Senegal through PATH’s Nutrition Innovation Program.
Innovation through Insects: Tackling Malnutrition with the Palm Weevil Larva
by Nikhila Kalra
At the start of my fieldwork in Ghana, I visited a rural community in the country’s Ashanti region to meet with some smallholder farmers who have been involved in an exciting new micro-farming initiative. Soon after I arrived, one of the project participants led me around to the back of her house and showed me the operation that has been helping her to feed her children and make some valuable extra income: six large buckets filled with wriggling white larvae.
They are palm weevil larvae (pictured above), known as akokono in the local Twi language. These edible insects could have big potential when it comes to addressing the issue of undernutrition in Ghana, a country that faces significant rates of childhood stunting and anemia. As an intern at PATH, I was working with the Nutrition Innovation team to explore the ways in which the palm weevil larva can be developed as an accessible, sustainable food source that will improve nutritional outcomes for mothers and children.
Considered something of a delicacy in many parts of Ghana, palm weevil larvae are packed with protein, essential fatty acids and many important minerals including iron, zinc and potassium. They’re also a great candidate for micro-farming. PATH’s partner in this project, Aspire, a Canadian social enterprise company with a focus on edible insects, has developed a low-cost set up that allows smallholders to produce the larvae in or near their homes for both consumption and sale. The low start-up costs and proximity to the household make akokono farming particularly viable as an economic activity for women. But there’s another important benefit: insects have a much smaller environmental footprint than traditional livestock, requiring significantly less land, feed and water to generate the same amount of protein. This is just the kind of triple impact that we’re looking for at PATH: positive effects on people’s health, their income, and the environment.
If the palm weevil larva are going to be a successful tool for tackling malnutrition and advancing women’s empowerment in Ghana, it’s important that we understand it as part of a complete food system, all the way from production to consumption. This is what my work as a Hilton Prize Coalition Fellow has been focused on. Thanks to this fellowship I’ve had the opportunity to travel to Ghana to conduct a value chain analysis for palm weevil larvae, which will allow us to answer some key questions: who are the actors in the value chain and what activities are they engaged in? What are the issues and challenges that they face? And, most importantly, which opportunities exist to add economic and nutritional value along this chain, and how can they be harnessed most effectively?
As well as helping us to gain these important insights, this fellowship has been a great practical training ground for me. When I first started on this project at PATH’s office in Seattle, I had no idea I’d get to contribute my own piece of fieldwork to it. The fellowship has been an invaluable learning opportunity, allowing me to take ownership of the research process from start to finish. This experience has given me a clearer understanding of the process of generating evidence for public health interventions, the skills to manage it, and a greater capacity to translate research into useful strategic insights.
This is Agnes, a project participant, and she’s holding up a bowl full of powder that she makes by drying and grinding up the larvae from her farm. She adds a pinch of this powder to the soups and stews she cooks for her family, giving them an extra nutritional boost. I think that this is illustrative of one of the most important things I’ve been afforded by the Hilton Prize Coalition Fellowship: the chance to learn first-hand from the knowledge and experience of the people involved in this initiative, and, as a result, to gain fresh ideas and explore innovative avenues for implementation that I would probably never have thought of sitting at my desk in Seattle.
Click here to learn more about the Hilton Prize Coalition Fellows Program
By Bob Kelty, Executive Director, Amref Health Africa in the USA
Ma Soumah, mother of six in Forécariah, a district in Guinea at the epicenter of the Ebola outbreak where it all started over a year ago, lost her husband to the virus. He was taken away from his family and never seen again. Soumah became infected while looking after him, but was turned away from the health facility, due to poor health worker training, even though she was clearly exhibiting Ebola symptoms. Even now Forécariah doesn't have a place to test blood samples.
She eventually went back to the facility over the objections of her family, who thought she would be safer with them, and was transferred to the treatment center where husband died. Soumah believed it was unlikely she would be cured, but at least she would die in the same place where her husband passed. Miraculously, she survived.
Bordering Sierra Leone, Forécariah is 60 miles and over four hours of bumpy, dusty, traffic-laden routes out of the country's coastal capital of Conakry. With only a small portion of Guinea's 12 million people, Forécariah's population of 136,000 represents 80 percent of all new Ebola cases since January.
Dr. Sakoba Keita, Guinea National Coordinator for the fight against Ebola, describes Forécariah as "the snake's head" of the Ebola crisis. "If we can address the issues preventing the control of Ebola in Forécariah, then we can go a long way toward eliminating Ebola in Guinea."
Shortly after arriving in Forécariah, I asked the manager of The Ebola Platform, the group coordinating non-governmental organizations like ours, what the principle challenge is to reaching zero cases. The answer-- community resistance.
Much of this resistance was a backlash against the "hard approach" (here he smacked his hands together to enforce his point) taken in the initial stages of the intervention. Messages about prevention and management of Ebola were delivered by outsiders - without any involvement of community leaders. No trust was fostered. No one knew what was going on. Rumors started that thermometers and the chlorine mix used for disinfecting public spaces and hand-washing were actually tools to spread Ebola.
Because of these and other early missteps, it took months for health workers to gain the trust of the community. In November 2014, Amref Health Africa came to Forécariah and began speaking with community leaders to learn how they could put health protocols in place while still respecting traditions and culture. After a month of consultation, we decided that the best route would be to avoid direct intervention and instead, work though Community-Based Organizations (CBOs), trusted and known members of the community. Over the next few months, Amref Health Africa trained a number of people from local religious, youth and women's groups to go door-to-door with educational materials and sanitation kits, and to identify individuals with Ebola symptoms.
While it took months of work to overcome those early mistakes, residents of Forécariah have since grown accustomed to the basic protocols of hand washing and temperature taking. But when it comes to adopting safe burial practices, there is still significant community resistance. During my recent trip there, a taxi carrying a fully dressed corpse, complete with hat and sunglasses, was stopped at a checkpoint. The six passengers were arrested and put in isolation. According to a survey by The Ebola Platform, 59 percent of the population still doesn't believe that Ebola can be transmitted through a corpse. Health worker after health worker in Forécariah, told me that resistance to safe burial practices is the single, greatest barrier to reaching zero cases.
Clearly the way to eliminate Ebola is through continued education and engagement with the local community. Leading UK expert and past head of the Ebola campaign in Sierra Leone, Donal Brown, puts it this way, "You can't just press a button and change behavior. You can't just sign a cheque and change behavior. It's about person-to-person engagement. It's about verbal communication."
And that's exactly the route Amref Health Africa is taking.
At a 'community testimonial meeting' we organized with Unicef, I met citizens, district government officials and members of CBOs. The CBOs spoke about the need to increase the capacity of their organizations. Government leaders expressed concern that the international NGOs would leave or discontinue funding before the work in Forécariah was completed. Individual citizens expressed their frustrations and shared ideas on how to better educate their communities.
Challenges persist and will continue for many, many months, but at least everyone is talking and slowly wrestling that snake's head to the ground.
And Ma Soumah? She was paralyzed for 12 days after Ebola, but has since made a full recovery and is now selling pineapples to support her six children. She's also become an advocate for prevention and improved, quality services - speaking out at community meetings to help ensure fewer people experience what she endured.
Follow Bob Kelty on Twitter: www.twitter.com/bkelty