Tuesday, July 28, 2009
After my first one-hundred hours with the Institute for Global Health, I began focusing more on preparing for the diabetes research in India. Beyond working in the IGH office with Dr. Wipfli and Ivette, I worked with Dr. Jaimie Davis and Dr. Mustaq Qureshi of Pardi Hospital on building the questionnaire for the study. After thorough advisement from Dr. Wipfli, Dr. Qureshi, Dr. Davis, and Ivette, the final questionnaire primarily will assess various known risk factors for diabetes (including age, sex, body characteristics, physical activity, diet, and health beliefs/attitudes). Extrapolating from previous questionnaires, the final questionnaire had seven components (including: General Information, Diabetes/Family History, Body Characteristics, Physical Activity, Diet, Health Beliefs/Attitudes, and Additional Comments). In the process of building the questionnaire, I visited Dr. Davis’ office, where I was trained on how to measure waist circumference, calculate waist to hip ratio, and to calculate body mass index, all of which I used for assessing body characteristics. I was also trained on how to take a detailed Food Intake Record, which asked for all food and liquid intake throughout the day. I felt that this detailed record would be too time-consuming and not appropriate for the sample population, which is why I decided not to use it. Instead, diet was assessed by asking simple questions including an open-ended question on a typical meal at home. Overall, the final questionnaire consisted of 37 questions. I had not realized that building a sufficient questionnaire would require numerous drafts and an extensive amount of time. I actually ended up working on it on the plane ride to India and had a final copy of the questionnaire on the first day of the study.
The first part of study was conducted at Pardi Hospital (a privately owned clinic) in the small rural town of Pardi in Valsad, Gujarat. The hospital is owned and operated by Dr. Qureshi, who is also the Chief of Medicine and Surgery. Dr. Quresha Qureshi is the OB-GYN Doctor and Surgeon and lent her expertise during my research at the hospital. Dr. Qureshi and Dr. Quresha have provided their expertise in medicine and clinical research over the course of planning the research study and in-country logistics. With their guidance, I met leading physicians in the field of diabetes, which made my experience in India was amazing.
Since I have visited and worked at Pardi Hospital a few times in the past two years, it was easy for me to assimilate in the daily routine of shadowing Dr. Qureshi during rounds, meeting patients, and conducting one-on-one interviews. After going over my questionnaire in detail with Dr. Qureshi, it was finally time to do what I had been preparing for, conduct an interview with a diabetic patient. Coming from Indian descent and knowing how to fluently communicate in Gujarati and Hindi made it easy for me to talk to the patient and beyond that, build a relationship in the 20-30 minutes it took to fill out a questionnaire. One of my concerns before conducting interviews was any pre-conceptions that patients may have of an Indian American and the possible lack of trust in sharing personal information. However, I was very surprised on how much patients were willing to share about their history with diabetes, their health beliefs and attitudes, and their curiosity in my background and what type of work I was doing. Many people in India think that once people leave their home-country and are raised in a place like America, they forget their language and culture. But because I spoke the language and was willing to learn about the daily lives of patients, I was able to gain trust quickly. Beyond just filling out a questionnaire, I learned so much from the patients that I talked to (as well as their family members) and I had a chance to impart the knowledge that I have gained throughout my undergraduate and graduate careers.
In addition to interviewing diabetic patients, I interviewed respective family members, since they would have similar health behaviors, eating habits, and share a family history. Because it took about a 1-1 ½ hour to interview a diabetic patient and family member, it was difficult to obtain a great number of interviews. However, the interviews that I did conduct proved very informational and extremely qualitative because most of the participants were willing to share their personal information.
Monday, July 27, 2009
The practicum offered by IGH is a 400-hour commitment, in which 150 hours are dedicated to “in-office” work and 250 hours are dedicated to conducting a research study on the topic of our choice. To date, I have completed about 65 hours of in-office work and about 35 hours have been spent on planning my research study.
Specifically, the in-office work includes anything that the Director, Dr. Jonathen Samet; the Associate Director, Dr. Heather Wipfli; and Project Manager, Ivette Flores needs. Since Dr. Samet and Dr. Wipfli are new to the USC community (they were recruited from Johns Hopkins in August 2008) and IGH is in the process of finding the right niche, the first several weeks of my practicum were spent creating databases on relevant schools within USC, departments, and faculty to Global Health. These databases were a crucial part of organizing and finding an effective way to have all relevant individuals meets and find the role of The Institute for Global Health in the USC community, both on a local and global scale. Furthermore, getting a concrete idea of what everyone in the USC community is doing in global health will give IGH a direction, mission, and the means of implementing an interactive, user-friendly website (set to be up and running by summer 2009).
I have also conducted literature searches and reviews on the topics of global obesity, cervical cancer policy issues, and the effects of international shipping regulations on environmental health. Conducting various literature searches for IGH has contributed to my skills of criticizing and choosing credible articles, taking advantage and effectively using surrounding resources, and broadening my knowledge base on a variety of global health issues. Findings from these literature searches were used in various grants and papers that Dr. Wipfli and Dr. Samet are working on. In addition, I also aided in IGH in Global Health Awareness Week events. IGH’s two events: “The Global Double Burden of Obesity and Malnutrition” and “The Interdependence of Global Health and the Environment” were a success and provided a solid introduction of the institute to the USC community. Other duties include assisting Dr. Wipfli and Ivette in future projects. Currently, I am assisting Dr. Wipfli create a database of various soft-drinks sold around the world for a “Global Soda Study.”
In conjunction with my work in the office, I have been spending a lot of time planning my research study that will take place in India this coming May. Over the course of the past couple months, I have narrowed down on the topic of choice, which is Type II Diabetes in the Asian Indian Population. My research question is: “Is there a difference in body type, obesity, genetic factors, and diet among the rural, urban, and cosmopolitan populations of India with Type II Diabetes?” At the beginning of the semester, I was not sure what topic to do my research on. As I progressed through the semester, my PM 599 (Global Implications of the Obesity Epidemic) enhanced my interest in the subject. Coming from an Asian Indian background and culture, I have had personal experience with Type II Diabetes (both sets of grandparents have the disease in addition to my aunt and uncle), which encouraged me to focus on this population. In February, I traveled to India to conduct the pre-assessment phase of the study, which consisted of making contacts with relevant doctors and planning out my actual research study. Dr. Mustaq Qureshi has really helped me thus far in planning the study. The current plan is to visit three different populations (rural, urban, and cosmopolitan) and research the differences in body structure/lifestyle on their incidence of Type II Diabetes.
Thus far in my practicum experience, I have really enhanced my skills in cultivating professional relationships, not just locally, but also on a global scale. Under the guidance of Dr. Wipfli and Ivette Flores, I am using my classroom knowledge and applying it to the real world. Furthermore, I have seen the striking difference in learning in a classroom setting versus a real-world situation. My practicum at IGH has really taught me how to conduct effective research, how professional relationships are formed, how much effort goes into starting an institution and trying to figure out the role of it in a larger community (IGH is the new institution). Being one of first student practicum interns, I stand in the frontlines of the making of this institution. Seeing the efforts of Dr. Samet, Dr. Wipfli, Ivette Flores, and others working toward a common goal is truly a once in a lifetime learning experience. I believe that my involvement with IGH has opened up interest among the undergraduate and graduate students to pursue practicums and experiences of this magnitude. So far, it is one of greatest experiences of my professional career. ☺
Sunday, July 26, 2009
With only a few days of our Korea trip remaining, John and I have experienced first-hand barriers to public health fieldwork in a global setting. As I have pointed out in a previous blog post, culture has an immense effect on the health of individuals and the communities they inhabit. To begin to understand a culture, one must dive directly into it: eating their food, learning their language, participating in their customs and establishing meaningful relationships with locals. My graduate training at USC has instilled a sense that we, as both practitioners and students, must take a bottom-up approach to global health activities. As Westerners, we must continually avoid portraying prefaces of being too privileged, too “right.” I highlight this point because there is a widespread misnomer among Westerners that the “West is the Best” while the rest of the world is trying to catch up. Indeed, in many nations across the world the US and Europe are viewed as Mecca’s for opportunity. While we do have our strong points, we cannot allow this to cloud our judgment. We cannot look at vital issues, such as health care, from an ivory tower. Look at any comparative health system report: the US is far from the top. We are not the best.
As I sit here writing this in a local cafe, my mind wanders back to my previous field experiences in countries where I have spent extended time researching health issues. My stays in Denmark, Bangladesh, Thailand and now South Korea have been particularly insightful. They have allowed me to discern general trends that influence the ways people access and, more importantly, utilize health services. The way one situates their identity within their community and nation has profound influence on their health. On a rudimentary level, homogeneous nations like South Korea more readily accept collective efforts by stewards (e.g. the government or other influential entities). These collectivist cultures are more likely to “jump on the bandwagon” if convinced that a new action or belief will benefit their lives, their families and greater community. Talking to Koreans, many exude a sense of pride about their nation and the way they do things. The Korean flag steadily waves on both major thoroughfares and small alleys alike. Brand names like Samsung, Hyundai, Kia and LG are sources of national pride. Adding collective ownership to a product, company or thought promotes widespread use and acceptance – this same model also applies to health care systems. Possessing the ability to say one’s own country has a national health system is rewarding; it slides off the tongue. It provides a sense of security when tumultuous life events seem to derail even the best laid out plans.
In Korea, citizens have ownership over their health care system. Many understand that supporting and maintaining such a system benefits both their immediate family and their nation. Of course this is a broad, if not simplistic, analysis of a nation’s approach to health care. However, this sort of scrutiny is exactly what we need – when tackling health reform, policy makers must understand that culture has a direct relationship with the health of a nation. In the US, few disagree that health reform is needed – yet how do we do it? This is truly one of the most pressing issues of our time.
I cannot fathom meaningful change unless we look outside our borders to understand how our sister nations have approached this persistent problem. We cannot simply replicate a system, however – the intricacies of each national culture are too different. One can even argue that in the US we do not even have a collective identity. Can Americans, who value individualism and the power of free trade, readily accept a national health system? Our burden lies deeper than simply changing policy; it lies in changing cultural norms.
Friday, July 17, 2009
Take a look at the food. Though PETA would have a heyday with dog soup and many people would cringe at eating a live octopus delicately wrapped around two chopsticks and dipped in red bean paste, Koreans find both dishes to be not only delicacies but food that empowers them, especially among men. Dog meat is supposed to provide virility and increase a man’s libido. A live octopus is said to soften the skin and better one’s complexion. (I’ll put up pictures of Juleon and me eating them later.) What is inedible in one country becomes a fanta-bulous dish in another.
Even our housing situation is a bit odd as Juleon and I have been given two rooms that are akin to prison cells. Yet, despite the small size, students rent out these “goshiwons” to study for exams months at a time. We obviously had the penthouse version as we have our own bathroom/shower stall. We even have our own window! The amenities are endless, but limited, without a doubt, by the size of each room.
Now, I’d like to share with you a sad truth that I learned today about bears in Korea. During my visit to China in 2007, I learned that the bile from bear gall bladders were expensive medications used as remedies for various ailments in Asia. In Korea, a teaspoon of the stuff is mixed in with a shot of soju and taken in the morning or the evening. Because of its coveted nature, many Koreans have farmed bears and have been killing them as cubs to extract the gall bladder. They don’t wait for them to mature as cubs have the same amount of bile as adult bears. Currently, there is a movement to put a stop to this heinous crime. Maybe if there was bear soup on someone’s menu, it would be an acceptable act of violence. Maybe not.
Rain, rain, go away. Come again some other day…..or never.
Tuesday, July 14, 2009
Upon returning to the nightclub we first visited (picture to the left), I pointed to a light fixture where we had affixed a nicotine monitor. “It’s not there!” I shouted to John, trying to project my voice over the booming hip-hop music in the background. We both looked around aimlessly. One down.
That’s fine, I thought, knowing that we had put up two other monitors in a different location. Arriving there, however, they were also missing! We found one of the study participants and John explained what had happened – he quickly disappeared to investigate.
Once he returned, they had a brief exchange while I politely sat there, my usual practice whenever Korean is spoken around me. As a blaring foreigner here, I pay extra attention to my actions in an effort to avoid looking bored or uncomfortable when being left out of a conversation. I figure this is something I will have to get used to if I want to work in the global arena. Respect, it turns out, is paramount in Korea.
Described as one of most Confucian states in modern times, the country is built on traditions and unspoken regimens of respect. While many Koreans will attribute my ignorance of protocol to my foreignness, they still greatly appreciate any effort I make to adapt to their environment. They are particularly keen on my appreciation of their food and are overjoyed when I add spoonfuls of spicy red chili paste to my favorite Korean dish, bibimbap. Some are even surprised that I would know the name of one of their staple dishes.
While John can more accurately describe the intricacies of respect here, I am interested in how this behavior affects their health. That is, can the Korean way of interacting with others hinder or promote healthy living? I have already witnessed their healthy eating habits (John and I have had to tighten our belts!), their active lifestyles (walking and using public transportation) and their heightened awareness of healthy living, especially compared to Americans.
Yet last night at one of our study sites, a young man gave us insight on the smoking and drinking habits of Koreans, particularly among men. While times have changed, smoking has traditionally been viewed as masculine and men opting out of the practice are essentially isolating themselves from their own gender. Drinking alcohol, as he explained further, is another behavior associated with social standing. Even the way one pours and receives their drink (as John and I are showing in the picture below) requires attention to detail. He pointed out that in the past, business partnerships were always solidified over alcohol because “if [the potential partners] cannot drink together then they cannot work together.” This behavior, as one can surmise, essentially forces an individual into an unhealthy practice. Now, though, times are adapting to the influx of individualism brought in by the West. Breaking tradition is not as dire as it once was.
There are many unanswered questions here. As John and I delve deeper into Korean culture, we will try to understand how cultural norms affect the healthy (or unhealthy) practices of the Korean population. Because practices directly contribute to outcomes, this is a vital area to understand.
Sunday, July 12, 2009
At the Graduate School of Public Health, Juleon and I worked on data we collected at the nightclub the other night. (For privacy reasons, I will refrain from being too specific with the location.) I was relieved to have put up our first set of monitors, the filter badges that will be used to analyze the nicotine in the air. It’s not easy to suggest to a manager that I'd like to place plastic objects in areas that might disturb the aesthetic setting. But, by far, the hardest part was obtaining hair samples from the employees. With nervous hands, it’s difficult to cut only 30 to 50 strands of hair. I was afraid I would accidentally make a bald spot on their heads. And, if you’ve already read Juleon’s previous entry, these aren’t the type of people you want to infuriate.
Despite the weather, though,
Now, here are three tidbits I’d like to share about
Thursday, July 9, 2009
Amid the ongoing, dramatic, and critical problems in the Middle East, the issue of health care in the region is often largely ignored. However, we are seeking to shine a spotlight on this vital, yet woefully underrepresented and poorly understood area.
We recently spent a month in Istanbul intensely researching the Turkish health care system and focusing on the current transition from mainly public, community-based, socialized medicine to a more private scheme, reminiscent of the United States. Throughout our stay, we conducted 12 official interviews with health practitioners across a range of occupations (e.g. health officers, medical directors, pharmacists, clinical psychologists, and herbal practitioners) that were working in each of the major sectors of health care (private, public, or both). Understandably, the experience has left us with an even greater respect for the immense complexity of balancing all the different aspects of health care development and provision, especially in such an intricate society.
The primary struggle for Turkey is to simultaneously “Westernize” without losing the old Ottoman values of community and cooperation that directly relate to the sharing of health risks. This illustrates the unique complexities that exist in a society with such an ancient culture, central geographic location, and distinctively secular political structure. Preliminary data shows that this current transition marks an intense period of change for the government, business, and the people of Turkey, with strong, informed, and conflicting opinions dominating all sides of the evolution of the health care system.
We look forward to continuing our research in Istanbul and the other major regions of Turkey in the near future, as it has become apparent that modern Turkey provides limitless opportunity. Nowhere is this truer than in the realm of health care. Currently we are in the process of analyzing and organizing our data into a number of different presentations, with the intent of publishing a paper on the subject later in the year.
For more information, please contact the authors: Sonny Patel (firstname.lastname@example.org) and Luke Manley (email@example.com).
First Picture is of Luke (Left) and Sonny (Right) outside an Istanbul Hospital. Second Picture is of Sonny (Left) and Luke (Right) inside an Istanbul Hospital.
Wednesday, July 8, 2009
Fortunately, we had an in. One of the researchers actually plays golf with one of their leaders, ominously called “Boss.” He is the head of his family and I couldn’t help but think of The Godfather movies. We were dealing with the Korean mafia.
On Tuesday we arranged a meeting with him - he is a tall, encroaching man with dark piercing eyes. He wore a suit and had a charismatic, yet shaded, air about him. It was strikingly obvious that this man did not mess around.
The three Yonsei researchers that accompanied us explained the study to him while John and I quietly looked on, meekly sipping coffee. Once they were finished he paused and slightly tilted his head – we all waited for his decision in anticipation.
Finally, he agreed.
I sighed and realized that my body had been tense during the entire exchange. I quickly glanced over at John and saw him deep in thought. Success! One down, nine more to go!
The next day John, myself and one of the Korean researchers took the subway to his nightclub. Stone horses more than 15 feet tall adorned the main room, which featured a sizable dance floor and multiple booths. One of Boss’ underlings ushered us into a back room where we met with five employees. One of them refused to participate in the study once we told him that we needed hair samples but the others jovially accepted. They were all quite nice, actually. Very accommodating, very receptive to our cause. We snipped their hair, placed three nicotine monitors throughout the club, thanked them and were off.
Once outside we all let out a nervous laugh. We had finished the first step – will the remaining establishments be this involved? Time will have to tell…
Tuesday, July 7, 2009
Sunday, July 5, 2009
This brings me to a point on conservatism. As a Korean-American brought up in a traditional household, I was taught that public displays of affection were forbidden and doing so would be the downfall of the family name. That is why I was surprised to encounter so many young couples hugging and kissing throughout the malls and streets. Some were confident enough to even don couple t-shirts, or “couple T’s” as the locals call them. These shirts are meant to signify the existence of a strong—and cheesy—relationship. This show of affection also seems to transforms them, almost giving them an identity that frees them from the strict attitudes that confine men and women behind bars of Korean propriety. Whatever the case might be, I am happy to see more smiles from the younger couples compared to the stoic faces of my father’s generation.
As a researcher looking to influence smoking policies in Seoul, Korea and in Los Angeles, California, I have attempted to displace myself from the hordes of Korean men and women by observing them from a metaphorical ‘afar’. I say metaphorical because Seoul is extremely congested and reminds me of Koreatown in Los Angeles. There is no denying that I feel an attachment to this place, and I sometimes find myself trying to justify many of the Korean behaviors, no matter how detrimental they may be.
Take smoking for example. There are bars and restaurants at every block with men smoking at every corner. (I don’t include women in this picture, because there remains a certain taboo for women smoking in public places.) Smoking has become a cultural norm, and at the age of 19, every teenager has the opportunity of buying a pack for less than $3.00. In addition, there is no limit to where one can smoke. Be it in a restaurant, café, bar, or nightclub, everyone can smoke everywhere. The lack of policy enforcement promotes heavy smoking. As Juleon and I try to make time to observe the nightlife during the weekends, I hope to uncover more of the reasons why smoking has integrated itself so deeply in Korean culture.
Saturday, July 4, 2009
Friday, July 3, 2009
Let me backtrack a bit, however. I’m here to intern at Yonsei University (see picture below) for one month in order to carry out a research project that studies the secondhand smoke exposure of bar and nightclub employees in Seoul.
John, my roommate in LA and the principal investigator of this project, serves as my translator and window into Korean culture. While I am here to carry out specific tasks, I also see this as an opportunity to view the first-hand barriers and opportunities to healthy living within this largely homogeneous culture.
Since being here, we have scoped out two regions with a high density of bars and clubs. One is near our current residence, south of the winding river that cuts Seoul into two halves. The other surrounds Yonsei University where bright, flashy signs seem to outnumber the bustling crowds of college-aged youths. While my cultural observations are limited at this time, I have also noticed that many Koreans thoroughly embrace the party scene by drinking one of their Korean staples, such as soju or Hite beer, with their friends.
English is spoken sparingly among the people I have encountered thus far, which has prompted me to rely on John to order food and ask questions. I have seen other foreigners here and there but we are greatly outnumbered in a sea of dark, silky hair. The fashion here is eccentric, to say the least. Many men are what you would call “metrosexual” in the US and the women never cease to amaze me with their outlandish attire and uncomfortable looking high heels. It seems that a current fad involves them wearing what looks like doll dresses. Multiple Koreans have told me that Hangook (the informal Korean pronunciation of their own country) is a land of fads. They come and go as fast as the torrential monsoon downpours that plague the city during the humid summer months.
I look forward to meeting the researchers at Yonsei on Monday and hope they can make good use of my skills and abilities. I’m grateful that I have been given this opportunity to be completely immersed in yet another culture.
Stay tuned - more to come!