The sun rises high over the flat, dusty ground of rural Ethiopia. A young woman walks toward the distant horizon.
Her trek takes hours before she boards a crowded bus for a ride that will take another 17 hours. Her destination is the Addis Ababa Fistula Hospital. Several years earlier, prolonged labor during childbirth tore a hole or fistula in her body. It caused urine to leak continually.
On the bus, she tries to hide her shame. She has endured social ostracism due to the condition, affecting 2-3 million young women worldwide. But hope awaits at the hospital. There, surgeons change lives.
“It’s sad,” says Ellen Eggers, a U-M sophomore from Grand Rapids. “These women lived for a long time with serious medical issues and they were never treated. Whether this is out of their own ignorance or fear, it still upsets me to see them suffering for so long before finally receiving help.”
Eggers and fellow students have just viewed the women’s plight in the documentary film “A Walk to Beautiful.” It details just one of the gritty, real-world global health issues students take on in Dr. Sofia Merajver’s class “Global Health Equity for the 21st Century: Thought, Consciousness and Action.” It is among seven presented through the Michigan International Seminars for Undergraduates (MISU) program, through LSA.
MISU is one of several U-M initiatives to promote global learning and engagement, in keeping with President Mary Sue Coleman’s conviction that international education and engagement is vital to the future. Coleman has stressed that students must be prepared to live and work in a global economy, and MISU seminars are designed to help students get a jump on preparing for that global engagement.
“It’s important to do this early in a student’s college career to broaden worldviews and to permit better planning and more informed choices when selecting future courses and considering the possibility of an education-abroad experience,” says Ken Kollman. He is director of the International Institute, which administers and helps fund the program.
Now in its second year, the program brings together students from different disciplines, and with different interests. The students read, hear about and discuss issues of global importance, often outside their own disciplines. The seminars also bring together faculty members and senior scholars from different departments, schools and colleges to work together.
Seminar topics have ranged from “The History of Human Rights in Latin America” and “War, Rape and Trauma in Human History: Three Moments,” both offered in winter 2012, to “Cultural and Social Aspects of Global Health: A Social Determinants and Social Justice Perspective,” offered this semester.
While students sign up for a three-credit seminar or course, they also join with MISU students in other courses for monthly joint sessions to support program goals.
“The goal of the common sessions is to have students from different groups mixing to address broader international issues than their normal seminar topic,” Kollman says. “Inside the smaller seminar the goal is to go into depth on specific topics and disciplines, and then the goal in the common sessions is to connect their specific field of study to larger questions of significance.”
Readings focus on prominent international themes, questions and concepts, justification for international intervention, colonialism, empire, human rights, transnational culture influences, and global health problems.
In one recent session, students from varied disciplines weighed the rights of people who live in slums and shantytowns outside major cities in the Third World. Kollman says students are challenged to address questions and to evaluate a problem from different angles.
“We also try to encourage them to study abroad, and to think about studying languages,” he says.
Global health focus
“There is a lot of inequity in health, so what is important is to learn how to think like a global health leader and figure out what to do next,” says Merajver, professor of internal medicine, Medical School; professor of epidemiology, School of Public Health; and director of the Breast and Ovarian Cancer Risk and Evaluation Program.
A recent winner of the Michigan Institute for Clinical & Health Research Distinguished Translational Mentor Award, she says the interests of students taking her global health equity seminar range from premed to women’s studies, from anthropology to business. “Many of them, I think, aspire to pursuing graduate school but they are undecided which field. But they are fascinated by the international aspects of health and inquiry,” she says.
At a recent class session, Merajver discusses the ethics researchers must consider when organizing subjects for clinical studies. She talks of the evolution of research ethics, as demonstrated through the Nuremberg Code of 1946 and the Helsinki Declaration of 1964. Generally, they advance the view that the well-being of the individual research subject must take precedence over all other interests, including the study.
Continuing the ethics-based discussion, Merajver tells students that researchers must not take advantage of patients who may not be as well informed as others.
“They are taking the blood, so they say, ‘I might as well study also the genes. These are people in the bush, they won’t know from their culture what exactly you are doing.’ The cultural tendency of the highly trained scientist from a high-resource environment is to undervalue the lives of those in a natural environment. This is scientific misconduct,” she tells the class.
Tracey Fu, a Canton sophomore interested in public health as a career, joins a group of students analyzing a case study presented in class. It involves an isolated, indigenous community in South America and a health assessment research initiative that overstepped ethical boundaries.
“We didn’t see the necessity of blood sampling, or the photographic demographic profiling,” Fu says. The students also found researchers had exhibited cultural insensitivity for failing to predict how their presence and practices would affect the community psychologically and physically.
“There is a cultural sensitivity that is crucial to these campaigns, and it’s something I think is important in any initiative which hopes to involve a community of people. This global perspective has pushed me to think about how cultures and countries affect one another, positively and negatively,” Fu says.
Overcoming stigma to aid populations
In one class section, Merajver addresses a key problem faced by those seeking to promote better health practices around the globe – removing stigma assigned to some practices by native populations.
“What is the path to eliminating stigma? It starts with an L – literacy,” Merajver says. She presents to students study data that show more literate mothers are better educated about nutrition and other resources to care for their offspring. That results in healthier babies. She challenges students to think about how education can be promoted in such cultures without destroying tradition.
After showing students “A Walk to Beautiful,” Merajver class assistant Connie Shi tells students it is important to think about the stigma about disease in various cultures – and how that stigma may be overcome to improve health outcomes.
“Think about the importance of building a community of people that have been treated. They can start to educate friends with the same problem,” Shi says. This is an effective way to educate the public about possibilities for treatment, better than notification via public banners or fliers, she adds.
Michael Jacobson, a senior and public policy major from Grand Haven, says he learned that along with several other health issues discussed in class, fistulas can be the result of malnutrition and lack of contraceptive or family-planning options. “Young brides, who are already malnourished, have to deliver a baby out of their small body,” he says.
Jacobson says the class encourages multidimensional and complex examination of a problem, and how to break it down by looking at inputs, process and possible outputs of interventions. “Professor Merajver has taught us that bad data is worse than no data. I’m learning how to find evidence, dismiss poor evidence, learn from mistakes, and learn from history, the good and the bad,” he says.
Merajver says she expects from students perfect reasoning, flawless logic, creativity, and ultimately the ability to lead and create the right projects to truly help populations in a sustainable way. “There are challenges and I think they like it. I expect a lot because I believe in them,” she says.
Eggers, who is considering a nursing career, says the global health ethics class has stirred a desire to travel or be part of a bigger reform in global health. Merajver says students have told her the class changed their lives, that they see the world differently and have changed their career outlook as a result. “I love to hear the passion in their voice and attitudes,” she says.
While Kollman says the program is drawing upbeat reviews from students, the true measure of its value will come later.
“Program success would be if students taking these courses get turned on to become more likely to learn new languages, study abroad, take more internationally-oriented courses, and perhaps undertake international careers,” he says. In the meantime, he says the MISU program, now offered in winter, could expand to both semesters.
The program is supported and administered by the Office of the Vice Provost for International Affairs and the International Institute.
