Category Archives: APHA IH Section

Modern Day Slavery: A Public Health Concern?

Guest Blogger: Carli Richie-Zavaleta

Social Justice in Public Health

Dan Beauchamp’s professional and academic works have established a legacy of connecting public health with social justice. It was during my first year of a graduate program at Drexel University School of Public Health when I was introduced to the framework of Social Justice in Public Health. Through Beauchamp’s social justice framework, we—public health students, practitioners, and researchers—are challenged to rethink our approaches to public health practice. He challenges us to dismantle the social structures of society and examine health disparities. His framework is to analyze health disparities as consequences of a lack of an ethical approach to the protection of the health of those who have limited or no social, political and economic power in society. Recognizing these social structures that benefit those in power and create disproportionate health disparities among vulnerable subgroups of the population is the first step. Secondly, it is not enough for Beauchamp to merely illuminate the health disparities in society. For him, being a public health doer is a collective movement that struggles politically to restructure fundamental systems of justice.

As I have experienced graduate school here in Philadelphia, Pennsylvania, Beauchamp’s framework has resonated with me more and more. It has pushed me to rethink my public health doing in terms of finding approaches that continue to create collective definitions of public health that prevent health disparities. More importantly, it has challenged me to begin seeking a greater understanding of policy creation—one that would be effective at protecting those who are vulnerable due to health disparities.

Modern Day Slavery and Public Health – The Connection

It was twelve years ago when I first learned about Modern Day Slavery (MDS). It was through reading “Disposable People New Slavery in the Global Economy” by Kevin Bales (1998). MDS, commonly known as Human Trafficking or Trafficking in Persons, is a global issue that is found in most corners of the world—most likely in your own locality. Research of MDS victims’ vulnerabilities (qualities that put victims at higher risk prior to their experiences), speaks loudly of the inequalities and health disparities these people are burdened with, prior to their victimization (See Supplementary Reference List[i]). Here lies the call for concern for public health doers: to create a collective concern for MDS in our field, as a preventable social peril, especially for those who are most vulnerable. In addition, in our attempts to narrow the gap of health disparities, it raises the need to prioritize the creation of policies and accountability of said policies to protect the lives of those who are disenfranchised in our communities, including the United States of America.

No easy solutions exist to address social perils; yet, the history of mankind demonstrates that when collective forces unite their voices, talents, and resources, change happens. Examples of achieved social change in the context of the US are the African American man’s right to vote, a woman’s rights to vote, and more recently, the unconstitutionality of DOMA (Defense of Marriage Act). In the international context, the creation of the Universal Declaration of Human Rights, the Millennium Development Goals, and now the working of the Sustainable Development Goals are also great examples of collective movements that have forged new paths of justice and protection of human rights.

When I first learned about the social peril of MDS, I was hopeless and overwhelmed to say the least, but I have come to develop new perspective. I have seen through my professional and academic background that beginning with our locality, we can move forward to create change. California was the first state in the US to define MDS at a state level. This was a collective effort of local committed citizens, MDS survivors, non-for-profit organizations, and governmental agencies that came together to create a state-level definition of Human Trafficking. The goals were to be able to prosecute the Human Traffickers, but also to increase the protection of victims, to provide more financial resources to victims, and to create programs that focus on assisting and providing victims autonomy once more. The latter resulted in the creation and the passing of CASE (Californians Against Sexual Exploitation) with over 10 million votes! As I witnessed and participated in the process as part of this movement in my locality at the time, San Diego, California, I developed an approach to engage in social change:

CRZ graphic

The above model is not a simple one. It requires at the very least a commitment to the cause, time, and resources; nonetheless, that is what we are being challenged to do when we want to be doers of Public Health.

My hope is that you join me in the collective construction of MDS as a concern in the Public Health field in our localities. As we join together, we can propagate a culture of social justice that translates into the narrowing of human right violations and health disparities. As a MDS survivor put it, “…in the fight to abolish [MDS] we all stand in Unity! There is no big I’s and little U’s”.[1]

[1] Supplementary Reference List

  1. Bean, L. J. (2013, June 26). LGBTQ Youth at High Risk of Becoming Human Trafficking Victims. Retrieved June 14, 2014, from Administration for Children & Families:
  2. Greenbaum, V. J., and Crawford-Jakubiak, J. E. (2015, March). Child Sex Trafficking and Commercial Sexual Exploitation: Health Care Needs of Victims. Pediatrics , 566-574.
  3. Greenbaum, V. J. (2014). Commercial sexual exploitation and sex trafficking of children in the United States. Current problems in pediatric and adolescent health care , 44 (9), 245-269.
  4. Hodge, D. (2008). Sexual trafficking in the United States: a domestic problem with transnational dimensions. Social Work , 53 (2), 143-52.
  5. Oram S, S. ̈. (2012). Prevalence and Risk of Violence and the Physical, Mental, and Sexual Health Problems Associated with Human Trafficking: Systematic Review. PLoS Med , 9 (5), online.
  6. Polaris Project. (2014). Human Trafficking The Victims. Retrieved May 10, 2014, from Polaris Project:
  7. U.S. Department of Health & Human Services. (2013, June 26). LGBTQ Youth at High Risk of Becoming Human Trafficking Victims. Retrieved June 14, 2014, from Administration for Children and Families:
  8. Walk Free Foundation. (2015, April 17). Findings. Retrieved May 20, 2015, from Global Slavery Index:

[2] Miller, D. (2013). I have a dream. In A. C. Richie-Zavaleta (Ed.), Unheard Voices of Redemption Transforming Oppression to Hope (p 125). San Diego: Justice Press. (Original work published 2013).

carli pic

 Arduizur Carli Richie-Zavaleta, MASP, MAIPS, DrPH(c)

Carli grew up in Mexico City and immigrated to the US at age sixteen. She has worked as a professor of Sociology, medical interpreter, program director, field researcher, and mediator with diverse populations in the United States and abroad—from children to adults with a range of socioeconomic, cultural, and racially diverse backgrounds. Since 2010, Carli has focused her energy on conducting social research on human trafficking in San Diego, California, as well as volunteering for non-for-profit organizations that reach out to victims trapped in sexual exploitation. Her research and advocacy work in San Diego, California culminated in the publication Unheard Voices of Redemption Transforming Oppression to Hope (2013)—an anthology of creative writing and essays from victims and those who advocate in ending Modern Day Slavery (MDS). Carli is currently a doctoral candidate in the School of Public Health at Drexel University under the department of Community Health and Prevention. Her doctoral dissertation focuses on understanding the experiences of MDS survivors in the health care settings with the aim to create feasible and viable intervention programs to identify and assist potential victims.

Water is Life by Mary Louise Tatum


Water is the essence of life. Your body is mostly composed of water, approximately 60% (  As a result, without water you would cease to exist. Yet, 1.1 billion people lack access to safe drinking water (World Health Organization). The World Health Organization (WHO) and United Nation’s Children Fund (UNICEF) Joint Monitoring Programme (JMP) for water and sanitation defines drinking water as: water with microbial, chemical, and physical characteristics that meet WHO guidelines and are used for drinking, cooking, and personal hygiene. The collaboration further defines access to safe drinking water as a source that is less than 1 kilometer away from place of use and reliably supplies 20 liters per household member daily (

One of the natural wonders of the world, Victoria Falls, located in Zambia, has approximately 625 million liters of water flowing over its edge per minute ( During the peak flood season, the Falls create a thunderous roar and drench all that is near. Nevertheless, UNICEF reports 4.8 million—approximately one third of the population— Zambians are without access to clean water. Moreover, insufficient drinking water and poor sanitation in the country have contributed to over 800,000 deaths related to diarrhea alone (not including other illnesses related to water issues) (World Health Organization).

In another part of the world, in the mega-city of São Paulo, Brazil, residents go days at a time without water. How did this happen to a country with access to the Amazon River, industry, a bustling tourist industry and sandy beaches? The Amazon River, the world’s largest river by volume, supplies  Brazil its fresh water, yet due to urban growth, poor city planning, leaking water reservoirs, destruction of forest and wetlands, and pollution, there is a lack of safe water for drinking, cooking, and personal hygiene (Nations, 2015) . As a result, water is now being rationed and some residents may be allowed access to water only biweekly.

Unfortunately, the extent of water issues is not limited to merely a few, but is increasingly becoming a global issue impacting many—including the developed nations. Case in point, the western region of the United States of America, specifically California, has been experiencing increasing drought issues for years. In fact, it has gotten to the point that policy and regulations are being considered and implemented to limit use of water with fines for noncompliance.  It will be interesting to observe how the United States, who manages numerous water programs in developing nations, resolve this issue.  This is a nation of people who, for the most part, are used to having free access to water for not only basic needs, but also luxuries. And now many Americans may have to face not only regulations restricting their use of water for swimming pools, lush green lawns, washing cars, skiing, and other recreational activities, but they may also have to deal with the more serious issue of having affordable foods as the water shortage impacts the agriculture sector. It has already been estimated that California will lose $2.7 billion this year due to the current drought issues (U.C. Davis Research Project). In addition, they may have to deal with the possible increase of disease, such as West Nile Virus, and the difficulty of dealing with wildfires due to water shortages.

Of course there is much discourse regarding who or what is to blame for the impending water shortage in the US.  Is it the pollution distributed into the air from numerous factories, vehicles, and farms or is it just a natural occurrence which would occur regardless of human action? Is it archaic water regulations that have not kept up with the diminishing supply of water, or is it our disregard and misuse of what we think is a never-ending supply? Regardless, we are no longer hypothesizing about the lack of water. At least 40 million Americans are actually experiencing the reduced availability of water.

Now that the problem is no longer afar, but at our front door, what do we do?  This issue is not just an issue out west in the US. It is a global issue that will continue to worsen as the population of the earth increases. So now is the time for everyone, whether directly affected or not, to wake up and to encourage not just policy makers, but each of us to make behavioral changes and be more conscientious on our use and waste of this precious resource.

WHO Video: Touchy-feely response to harsh international criticism?

Note: This was cross-posted to my own blog.

Yesterday, the WHO released a short YouTube video, “If you can beat Ebola, you can beat anything,” featuring the story of a Liberian doctor who contracted Ebola and recovered with the help of his family. After some dramatic music and musing from Dr. Philip Ireland, the video goes on to interview several other clinicians who provide hopeful reflections on how to better prepare African countries to respond to future outbreaks.

The video’s description reads:

When Ebola hit West Africa the healthcare systems of the region were under-financed and poorly equipped. Liberia had only 130 doctors for a country of 4.5 million people. Many of those doctors died of the disease. As Liberia, Guinea and Sierra Leone look to the future and to rebuilding their countries, recruiting and training doctors, nurses and other health professionals will be key to avoiding another devastating crisis. Dr Ireland, a Liberian doctor who has recovered from Ebola, says in the video that if
you can beat Ebola you can beat anything.

Ensuring quality healthcare and protection from disease outbreaks for the people living in Ebola affected and other poor countries is possible and our Number 1 health priority.

It’s safe to assume that the video is part of WHO’s PR response to the damning assessment of its handling of the persistent Ebola outbreak that is still (yes, still) going after over a year. While MSF began calling for outside intervention fairly early on, the WHO intentionally delayed sounding its own alarm and even contradicted MSF’s assessment of the severity of the outbreak due to political pressures:

Among the reasons the United Nations agency cited in internal deliberations: worries that declaring such an emergency — akin to an international SOS — could anger the African countries involved, hurt their economies or interfere with the Muslim pilgrimage to Mecca.

Those arguments struck critics, experts and several former WHO staff as wrong-headed.

In public comments, WHO Director-General Dr. Margaret Chan has repeatedly said the epidemic caught the world by surprise.

“The disease was unexpected and unfamiliar to everyone, from (doctors) and laboratory staff to governments and their citizens,” she said in January. Last week, she told an audience in London that the first sign that West Africa’s Ebola crisis might become a global emergency came in late July, when a consultant fatally ill with the disease flew from Liberia to a Nigerian airport.

But internal documents obtained by AP show that senior directors at the health agency’s headquarters in Geneva were informed of how dire the situation was early on and held off on declaring a global emergency.

More recently, an expert assessment commissioned by the WHO to review the organization’s response released its own findings. While somewhat critical, the report was much more muted and also fairly optimistic (as self-assessments are bound to be). In addition to internal reforms, the report calls for a revision of the International Health Regulations; there was a commentary piece calling for the same thing in the most recent issue of Lancet Global Health (I am not sure if the authors of the article were also on the panel). For its own part, MSF responded in its typical straight-shooting fashion:

“MSF has repeatedly raised the alarm on the WHO and global response to Ebola and was also interviewed by the panel. On paper, there are a lot of strong points in the report that reflect many issues MSF is concerned about, but the question how will this translate into real action on the ground in future outbreaks and epidemics and what will Member States do to make sure this really happens?

We have seen so many reports calling for change, with everyone focused on how to improve future response and meanwhile, with 20-25 new Ebola cases per week in the region, we still don`t have the current epidemic under control. On Ebola, we went from global indifference, to global fear, to global response and now to global fatigue. We must finish the job.”

Cultural Challenge of Female Genital Circumcision by M.L. Tatum


A very basic definition of culture is the cumulative deposit of knowledge, experience, beliefs, values, attitudes, meanings, hierarchies, religion, notions of time, roles, spatial relations, concepts of the universe, and material objects and possessions acquired by a group of people in the course of generations through individual and group striving (Hofstede, 1997).

Undoubtedly, most humanitarians, community workers, and public health specialists would be able to supply a sufficient definition for culture. The words may vary somewhat, but the basic concept would be the same. However, how many of them truly grasp the vitality of this definition? Moreover, truly value why various practices or beliefs came to be and have continued for generations even in today’s fast-paced and shrinking world with advances in technology, increased availability of education, increases in family income, et cetera.

One cultural practice common in parts Africa and a part of the Middle East is the practice of female genital circumcision (FGC). FGC is believed to have been initiated in the fifth century B.C and continues today, affecting an estimated 2 million girls annually (Shah, Luay, & Furcroy, 2009).

FGC is a coming-of-age tradition for females which takes a variety of forms. It includes the partial or total removal of the external female genital, near complete sewing-up the vagina with only a small opening for urination and menstruation, introduction of corrosive substances into the vagina, and other injury for non-therapeutic reasons (WHO, 1997). Some of the biomedical consequences include infection or hemorrhaging which can lead to loss of life, bowel and bladder incontinence, painful intercourse, and complications with childbirth.

Many persons would consider this to be an atrocity and defilement of girls; as a result, there has been a great deal of global support to implement programs and various interventions to support the cessation of this act. However, termination of FGC continues to be an uphill battle.

I believe us, as professionals, sometimes, do not grasp how deeply ingrained FGC is believed to be necessary in the preparation of a young girl for womanhood. The roots of this practice are so deeply psychologically and emotionally based that families have risked breaking judicial law to continue preparing their child for womanhood. For example, Kenya’s Children’s Act of 2001 made it illegal to subject girls to any form of FGC; consequently, it is believed that practicing tribes are now performing the act secretly, to decrease the risk of being imprisoned. This theory has been supported by people being caught in the act or dealing with girls who are infected or bleeding after going through the procedure (Library of Congress, 2011). What’s more, families who have migrated to Europe and the United States bring their daughters back to their country of origin when they come of age to have this procedure performed.

The complexity of cultural beliefs and their unseen components are sometimes difficult to conceptualize, thus, making it challenging to influence health behavior change. FGC is not just a physical alteration to the body; it is a celebration among friends, mothers, grandmothers, aunts, cousins, and neighbors. It means the individual has now graduated to the next level. She is now of age and ready to progress to the next stage in life. Yes, female genital mutilation is a procedure with unfortunate consequences and it should be addressed by community workers, public health professionals, and humanitarians. Nevertheless, we have to proceed respectfully and view cultural practice in a holistic manner to be effective in implementing sustainable behavioral changes.

What is sustainability?

By Abbhirami Rajagopal, PhD MPH
This was cross-posted to my own bog

Sustainability is the ability of a system or a process to endure. And for a process to endure, we have to build it in such that it remains flexible and adaptable in many contexts.

The health program that comes to mind when you think about sustainability is the eradication of smallpox. The smallpox eradication effort was continually adapted to fit the changing needs and goals of the disease eradication program. Over time, with decreasing number of smallpox cases, the emphasis shifted from routine vaccination to surveillance.

Far too often, public health policies and programs are implemented on small scales and with limited funds and risks being discontinued when funding runs out – even if it was successful. There is a mismatch between the expectation of long-lasting effects of large-scale interventions and reality. Trying to scale up health innovations or even continuing a program when the funding runs out or political landscape changes is challenging.

In the last decade, there has been a big push toward creating programs and interventions that are sustainable. More and more donors are recognizing the importance of the sustainability of evidence-based health interventions and favor programmatic approaches that include long-term maintenance. All of this recognition has culminated in the adoption of Sustainable Development Goals (SDGs) by the United Nations earlier this year.

The SDGs differ from the Millennium Development Goals (MDGs) by virtue of being much more comprehensive with 12 goals and 17 focus areas. The SDGs set zero-oriented goals: getting to zero cases of hunger, child and maternal deaths and poverty. This lofty goal cannot be achieved by relying solely on the ever-shrinking development assistance from rich donors, as was the case with the MDGs. This is why the SDGs put sustainable, economic development right at the core of the strategy. The goals have been developed through consultation with nearly 100 member states and millions of citizens—probably the largest and most inclusive and participatory process we have ever seen. This allows for adaptable goal setting by countries that would then allow them to assess their own strengths and leverage their assets to meet the targets. To me, some of the most significant changes that we see in the SDGs are the emphasis on accountability, the separation of the issues of poverty from issues of food and nutrition security and the stronger goals with respect to women’s empowerment.

To strategically include sustainability in health programs and policies requires a “clear understanding of the concepts of sustainability and operational indicators to monitor sustainability” (1). The first step in designing sustainable health programs is to define the program elements that need to be sustained. It is also essential to build and effectively leverage partnerships for a program to be sustainable. This would imply that if you are planning a large scale program or intervention, you need to start early by planning, engaging the partners, using appropriate frameworks that conceptualize sustainability and incorporating outcome/success measures for your sustainability approach.

To go from theoretical frameworks to successful sustainability, there has to be more research with regards to how sustainable existing programs are, especially the ones that have incorporated “sustainability” into their programmatic approach. We need to know what works and what does not. We need to know what are the stumbling blocks that prevent programs from becoming sustainable. In doing so, in the future, we can design better plans for sustainable health programs, especially in settings where resources are becoming more and more limited.

Sustainability has been a huge challenge in programs designed to address micronutrient (vitamin and mineral) deficiencies. Micronutrient deficiencies impact a large number of children under-5 years of age worldwide. Many of these deficiencies co-occur with infections can exacerbate other infections that may be present (2-4).

One such micronutrient is Vitamin A; globally, nearly one-third of children under the age of 5 are deficient. We know vitamin A supplementation (VAS) works; a meta-analysis of 43 studies published in 2011 showed that VAS in children at risk for deficiency reduces mortality by about 24% (5). Despite large-scale efforts for VAS in children since the 1990s, as of 2013, the coverage rate is anywhere between 10-90% (6).

Nutrition interventions often rely on aid dollars and fortified foods or supplements from wealthy countries or private donors (for e.g. Vitamin A products for supplementation are obtained from the Micronutrient Initiative which is supported by Canadian International Development Agency). Both lack of support from the local Ministries of Health (since these programs may not align with their top priorities) and lack of policy initiatives to address micronutrient deficiencies contribute to the problems that dietary interventions encounter. The issues mentioned above point to one major theme— SUSTAINABILITY—that we as public health practitioners have to take into account when planning programs both at local and global levels.


1) Shediac-Rizkallah MC, Bone LR. Planning for the sustainability of community-based health programs: conceptual frameworks and future directions for research, practice and policy. Health Educ Res. 1998 Mar;13(1):87-108. Review.

2) de Gier B, Campos Ponce M, van de Bor M, Doak CM, Polman K. Helminth infections and micronutrients in school-age children: a systematic review and meta-analysis. Am J Clin Nutr. 2014 Jun;99(6):1499-509. doi: 10.3945/ajcn.113.069955.

3) Amare B, Moges B, Mulu A, Yifru S, Kassu A. Quadruple burden of HIV/AIDS, tuberculosis, chronic intestinal parasitoses, and multiple micronutrient deficiency in ethiopia: a summary of available findings. Biomed Res Int. 2015;2015:598605. doi: 10.1155/2015/598605. Epub 2015 Feb 12.

4) Bhutta ZA. Effect of infections and environmental factors on growth and nutritional status in developing countries. J Pediatr Gastroenterol Nutr. 2006 Dec;43 Suppl 3:S13-21.

5) Imdad A, Herzer K, Mayo-Wilson E, Yakoob MY, Bhutta ZA. Vitamin A supplementation for preventing morbidity and mortality in children from 6 months to 5 years of age. Cochrane Database of Systematic Reviews 2010, Issue 12. Art. No.: CD008524. DOI: 10.1002/14651858.CD008524.pub2.

6) Vitamin A supplementation coverage rate (% of children ages 6-59 months). Available at

Abbhirami Rajagopal, PhD MPH: I am currently a postdoc at Baylor College of Medicine transitioning to a career public health. My graduate work involved identifying genes involved in heme homeostasis and for my postdoctoral work, I have worked on phosphate homeostasis and understanding pathogenesis skeletal dysplasias. During my postdoc, my drive for large-scale sustainable impact led me to an MPH degree from Johns Hopkins School of Public Health. I am interested in health equity, environmental issues, sustainable food, nutrition security and social justice. I love to write and I love to volunteer! Find me on Twitter @abbhi_515 LinkedIn and Facebook

White House Takes a Stand on Climate Change and Public Health

“Climate change is making an impact on our public health.”
-President Obama

We know that climate change threatens our air, food, water, and homes but earlier this month at a round table discussion, President Obama spoke about the effects of climate change on public health. In this video he says the temperature of the planet is rising and that not only comes with adverse weather and environmental consequences, but also a “whole host of public health impacts.”

Accompanied by Surgeon General Dr. Vivek Murthy, President Obama put a spotlight on increased heat-related deaths, severe asthma, extended allergy seasons, and the spread of tropical or insect-borne diseases as some possible consequences of climate change. He also spoke about the need to focus on prevention and action and the costs associated with inaction.

This is the beginning of a big push from the White House to better understand and deal with the health effects of climate change and this statement outlines their plan to do so. This is such a great step in the right direction and a big win for the public health field. Here’s to hoping it all leads to a long-term commitment with the necessary funding and policies to make significant changes!


“Girls must be told at an early age that they have the potential to become influential leaders before they fall victim to their own self-doubt”. These are the insightful words of Malala Yousafzaia, a Pakistani activist for female education and the youngest Nobel Prize laureate.

These words continue to ring true regardless of one’s geographical location. Girls and women from around the world continue to be marginalized.  For example, more high-income countries face challenges, such as, equal pay, maternity leave policies that allow women enough time to nurture their infants, and job security to continue in their careers.

It is reprehensible that females around the world are forced into marriage at ages as young as nine,  punished for “immodest behavior or dress”, not allowed to drive, denied an education,  excluded from politics, gang raped with no retribution, coerced into female genital mutilation (look out for  my June blog), and the list goes on.

Females are approximately half of the world’s population (  Thus, women have to be allowed equal rights for human survival. Not to mention, we all have the basic human right to choose our own destiny.

However, supporters of female rights must be empathetic and meet those who desire or need support where they are. As public health professionals, we cannot force values and beliefs because we think they are superior or imagine a clear path to their implementation. We have to be empathetic, willing to learn, and understand the values of the community we are involved. We can provide education on evidence-based health practices and provide availability to health care, education, financial training, etc. These changes will come from within the community, so we have to develop partnerships within the community and provide the necessary tools that will build capacity and self-reliance. Let’s encourage the enhancement of inherent positive cultural attributes, increase self-esteem and self-awareness with financial resources and training to optimize the quality of life.

All persons have the right for their basic needs to be met and to feel confident and empowered. All persons deserve the opportunity to realize their potential.  Education and opportunity is the key for making the world better. The survival of humanity depends on the synergy of women and men.