Susan Bartels (center) during her first trip to Ethiopia
MPH student Susan Bartels knows about the situation firsthand. She traveled to Ethiopia in fall 2006 to conduct an assessment with the Oromia Regional Health Bureau, under the auspices of the Harvard Humanitarian Initiative and Oxfam America. A report partially based on her findings was published recently, and Bartels is currently using the experience as the basis for her HSPH thesis.
"Learning in the classroom is rewarding and necessary, but I jump at every opportunity to do fieldwork," said Bartels, a physician who works as a fellow at Brigham and Women's Hospital in the Emergency Department. Her fall trip to Ethiopia was the second time she traveled there in 2006. Last spring, she helped set up a drought warning system in Moyale, Ethiopia. She has also done relief work in the Gambia, Kenya, and Tanzania. Next month, she will travel to the Democratic Republic of the Congo with the International Rescue Committee.
The first signs of trouble in Oromia - which is divided into county-like "zones" - emerged in June 2006 with an outbreak of acute watery diarrhea. By the time that Bartels arrived in September, five out of 14 zones in Oromia had been affected. Illness rates in two of the zones were tapering off, but the other three remained hotbeds of illness. That's where Bartels headed.
With a driver and an interpreter, Bartels traveled to special treatment centers, many of which had been set up by international aid agencies working with local health boards. In the span of two weeks, Bartels visited 10 centers that were miles apart and accessible only by often dilapidated roads. One center took a four-hour drive to get to.
Treatment centers were usually erected adjacent to regular health clinics, said Bartels. Some consisted of tents, but others were little more than tarps roped to tree branches that tended to collapse in heavy rainfalls. Staffing the treatment centers were the same nurses and health workers who manned the adjacent health clinics.
A well-functioning treatment center
The treatment centers were strategically separated from the health clinics because cholera is easily spread through contaminated water and food, explained Bartels. The bacterium can incubate in feces or vomit anywhere from 18 hours to five days. Often, the illness is mild, but the severe form can kill through rapidly dehydrating the body. The treatment typically consists of a simple solution of oral rehydration salts or IVs to replenish lost fluids. Sometimes, antibiotics are prescribed, not so much to cure the disease, but to shorten its duration.
During her visits, Bartels interviewed patients, some of whom had literally been carried for miles by their friends or family members. She recorded demographic information such as gender and age. She inquired about the patients' knowledge of acute watery diarrhea and its prevention. She examined the centers' sanitation capabilities: did they have latrines, showers, and clean linens? She reviewed medical management approaches with the staff. And she assessed supplies, which she said were a "huge problem."
"Some of the centers didn't have water or disinfectant, and then you become concerned that the centers meant to treat the illness may become yet another source for it," said Bartels.
This tarp, used as a cover for a treatment center, collapsed in the rain.
She reported her findings to the local health boards and to the Oromia Regional Health Board. The data also helped form the basis for the December 2006 report "Acute Watery Diarrhea Epidemic Public Health Response," a collaboration of the Harvard Humanitarian Initiative, Oxfam America, Oxfam Horn of Africa Regional Office, and the Oromia Regional Health Bureau.
Among the report's findings were that men between the ages of 15 and 45 seemed disproportionately affected, perhaps because they tend to travel more than other groups. Women over the age of 45 also appeared to be disproportionately affected, perhaps because they are the primary caretakers of sick family members. In both cases, pointed out Bartels, the observations could not be proven statistically because the baseline data was unavailable.
The locations of cases were mapped, and most of them aligned with the Ganelle River.
And the critical role of village leaders, called kebele chairmen, in educating their fellow villagers about acute watery diarrhea was described. These leaders were first taught by local health bureaus about the detection and prevention of the illness. The leaders then were asked to spread the word among villagers and to report any cases to the local health bureau.
"I was struck by the ability of the community members and local health boards to come together and respond to the outbreaks," said Bartels.
This June, Bartels will graduate from HSPH and will start clinical work at Beth Israel Deaconess Medical Center. She plans to continue to do fieldwork in developing countries whenever she can.
"I have practiced medicine in the U.S. and in Canada and have had many rewarding experiences with my patients," said Bartels. "But the needs in resource-poor settings are so great that I am drawn to the people there, and those experiences seem all the more rewarding."
Copyright, 2007, President and Fellows of Harvard College
