Sometimes it’s hard to differentiate between the scientist and the activist," says Miguel Hernán, MPH’96, an epidemiology doctoral student at the School. At least that was the case when Hernán, Sonia Hernández-Díaz, MPH’97, also an epidemiology doctoral student, and Paula Brentlinger, MPH’96, conducted a study last year on the factors associated with childhood malnutrition in the small Central American country of El Salvador, which is still recovering from a brutal 12-year civil war in which 70,000 people died. Sponsored by the Boston-based Physicians for Human Rights and two other groups, they set out to investigate the relationship between the bevy of well-intentioned but fragmented postwar relief programs in El Salvador and the health status of children. Though clearly not standard health-study fare, their research passed muster with editors at JAMA, and the results were published in the journal on January 13. Two other alumni, Lenore Azaroff, S.D.’97, and Maureen McCall, MPH’97, are co-investigators on the study.

Brentlinger, who spent several years as a volunteer physician in El Salvador, said she was drawn to epidemiology because "I was up to my eyeballs in the small picture. A combination of clinical work and epidemiology allows you to do both in a more effective way." She organized this study when Hernán, Hernández-Díaz, and other Spanish-speaking students let her know they would volunteer time to work on a Salvadoran research project. Along with other health workers in El Salvador, Brentlinger had observed that levels of poverty in regions targeted for postwar assistance seemed to remain staggeringly high despite an internationally financed reconstruction program that has poured up to $200 million into the country each year. El Salvador is an agrarian country; about 40 percent of the working population of 2.3 million still farms. The fact that a few wealthy people owned most of the arable land fueled the vicious civil war, and land reform aimed at more equitable distribution of ownership was a fundamental part of the 1992 peace settlement.

Partly because it was an area with which Brentlinger was familiar, the research team zeroed in on Cuscatlán, a "department" of El Salvador dominated by small dormant volcanoes and river valleys. Residents of Cuscatlán live in small villages and farm. With the help of local midwives and village health workers, they covered 27 villages in just ten days, surveying households with a questionnaire that asked about land ownership, farming practices, water, housing, latrines, family size and composition, maternal education, and birth dates of young children.

What they discovered was that nearly one-third of the 761 Salvadoran children in the study was stunted. Stunting is a deficiency of height in relationship to age; it is considered a better indication of the cumulative effects of poor health and nutrition than wasting (a deficit of weight with respect to height) or simply weight (for age). The prevalence of stunting among the children in the study increased steadily with age, which points to repeated infections and a chronically poor diet.

Much to their surprise, Brentlinger, Hernán, and Hernández-Díaz did not find an association between stunting and the amount of land owned by a family. When they looked more closely, however, the researchers did find that stunting was linked to certain aspects of Salvadoran agriculture and the postwar reconstruction effort, such as crop diversification. The study authors say the key finding was that stunting, though minimally associated with acreage acquired through the postwar land transfer program, was strongly associated with the amount of acreage actively farmed, and that most families were not actively working even a third of the land redistributed according to the peace settlement. As a practical matter, therefore, life had changed little for many from the prewar days of being landless peasants. Access to water was also key: over a third of the children in the study lived in households that had no access to piped water and where there was piped water, the supply was often rationed.

The Cuscatlán findings do more than link agriculture and current health status: they are a socio-economic forecast, and a rather grim one at that. Besides affecting stature, stunting is associated with diminished intellectual capacity and impaired work performance later in life. And when it affects a substantial proportion of the population it may have health and economic consequences for years to come.

The same week the study was published in JAMA, Brentlinger, Hernán and Hernández-Díaz went to El Salvador to present their findings at the national conference on nutrition sponsored by the U.S. Agency for International Development. They also met with physicians, aid workers, and village health workers from the study region. "Presenting the data to the study subjects and health workers is at least as important as presenting it to the policymakers," says Brentlinger. "They are the people who are best equipped to make the changes on the ground."

Together, Brentlinger, Hernán, and Hernández-Díaz make for an energetic and dedicated team. Brentlinger is in the process of translating the study findings into Spanish. Hernán, whose primary area of research is epidemiologic methods, is currently working on his thesis, as is Hernández-Díaz, whose area of research is pharmaco-epidemiology. "But once a year," says Hernández-Díaz, "we would like to apply epidemiology to human rights."

-- Chelsea Merz