The New York Times, October 2015
"What if there were a remedy that could save more children...
For the purpose of our DefeatDD Initiative – which is, of course, to defeat diarrheal disease – we focus interventions that support child health through the age of five. As such, we don’t talk about menstrual hygiene a lot, but that doesn’t mean we’re not huge supporters! Given our shared emphasis on sanitation, integrated efforts, and making a stink about taboo topics, we find ourselves in friendly and familiar territory.
We sat down with Nancy Muller, Senior Program Officer for the Devices & Tools program at PATH, to learn more about PATH’s work in menstrual hygiene and how these investments can improve child health, too.
How did you first become involved with the issue of menstrual hygiene?
In 2006, I was en route to Seattle from Uganda. I was traveling with our very own Sara Tifft, director of Sayana Press Pilot Introduction and Research project at PATH, who asked me what I thought low-income girls in Africa did when they had their periods. I felt like the bottom of the plane had dropped out! I had never thought about it. I became a bit obsessed with understanding how girls and women manage their periods, especially if they live in rural areas. My first passion was medical waste management, which was great preparation for my work in menstrual hygiene management.
We are currently conducting a review and landscape of menstrual cups to identify design and user challenges; develop design concepts to address barriers around cost, use, and cleaning; and contribute to the dialogue on improved menstrual hygiene (MH) products by publishing our work.
Nancy Muller gives an overview about menstrual hygiene and possible solutions that can make an impact in low-resource settings.
Why menstrual cups, as opposed to pads or tampons or reusable cloths?
We think there is a need for many improved product choices. Menstrual cups sidestep many challenges associated with other menstrual hygiene products in low resource settings. For example, pads, which have to be purchased every month, may not be either available or affordable. And in poor areas, where women may not have underwear, it is tricky to keep a disposable or reusable cloth pad in place.
Menstrual cups hold up to 12 hours of menstrual fluid and also help eliminate waste by lasting up to 10 years. Disposal bins are not available in the majority of bathrooms or latrines in low resource areas, and discarded MH products may end up clogging toilet pipes, filling pit latrines, or collecting along roadsides and in rivers. They become added environmental hazards where children live and play and eat and drink.
Importantly, menstrual cups are discreet, can prevent leaking, and eliminate odor: features that are important to women.
Photo credit: Wendy Stone.
Have you encountered any resistance from women about using menstrual cups?
I have to say that I was not a proponent of menstrual cups originally. I didn’t think there would be a high level of acceptability in traditional, rural areas, but a study done among low-income women in rural Bihar, India, completely opened my mind. Half of the 480 women who had been using rags and who were then given a cup, used it; many kept using it beyond the study. That’s pretty telling! It speaks volumes to the headaches that women go through just to manage their periods. Considering what women are doing currently, it’s easy to see why a menstrual cup would be appealing.
And it sounds like these investments in menstrual hygiene stand to benefit many other issues, too, including child health.
I think WASH in schools programs are one of the most practical examples of this. From what I have experienced in traveling and living abroad, girls have potentially a 10 (or more) hour school day. How do you manage a period during that time? It’s hard to begin to even imagine what you would do with a used cloth. Latrines along with a private space to wash hands and cloths (or other MH products) are essential for girls managing their periods, and also providing an opportunity to encourage good personal hygiene and handwashing behaviors.
We’ve also learned how important it is to consider MH if sanitation systems are going to be properly utilized. In India, even women with access to sanitation facilities washed their cloths in the river – because they weren’t allowed to use the facilities due to the taboo of menstrual blood! Innovative “dry” toilets, which use little or no water, also pose a challenge in the Indian cultural context, which puts a high priority on cleansing with water. Programs seeking to tackle the health and environmental impacts of poor sanitation must incorporate culturally-appropriate MH solutions as well, or their full potential won’t be realized. India currently has a great opportunity to consider the potential for MH solutions within the context of its national Swachh Bharat (Clean India) sanitation campaign.
What will PATH be doing to commemorate Menstrual Hygiene Day?
Our country staff will be joining celebrations that are being organized in India and Kenya. These countries, along with South Africa, have committed to providing free or subsidized pads for poor women and girls – which is worth celebrating!
PATH’s aim is to be a resource for governments and partners as they implement MH programs. Our colleagues in Kenya are working with the Ministry of Health to pull together a landscape of available MH products, which we’re hoping will be used to inform the conversation with the government and other partners about product choice, access, acceptability, cost, systems impact, and sustainability.
What is the one message you’d like to share with other advocates as they commemorate Menstrual Hygiene Day?
It’s so hard to say just one thing, but the bottom line is that the shame around menstruation just has to go. There wouldn’t be life without menstruation! So why should a period hold girls and women back? If we’re serious about equity and girls’ and women’s empowerment, we need to be serious about their right to manage menstruation safely, effectively, affordably, and with dignity.
For more information:
- Learn more about PATH’s work in menstrual hygiene management.
- Find social media resources on the Menstrual Hygiene Day website.Read more
This post was originally featured on the PATH blog.
Worldwide more than 700 million people lack access to good-quality sources of drinking water. This health inequity has deadly consequences: safe water is critical for preventing diarrheal disease, one of the leading killers of children in developing countries.
For people in many parts of the world, a typical day includes collecting water in containers and carrying it home for cooking, washing, and drinking. Fetching water may take over an hour, and too often the water contains pathogens that cause disease.
Responding to this challenge, MSR (Mountain Safety Research Global Health) and PATH have spent several years developing a small, easy-to-use chlorine maker appropriate for resource-limited settings. It’s called the MSR SE200™ Community Chlorine Maker.
The device, which is being launched today, is manufactured in Seattle. It requires just water, salt, and electricity from an outlet or a vehicle battery. In a few minutes it produces enough chlorine to treat up to 200 liters (55 gallons) of water.
The SE200 Community Chlorine Maker is a portable device that uses salt, water, and electricity to rapidly produce enough chlorine to treat 200 liters of water. Photo: PATH.
For entrepreneurs like Nairobi’s Patrick Mailu, a PATH pilot project to test and refine the device created an opportunity to build a small business selling treated water. He’s earning a living while improving the health of his community.
“I am proud of this business,” Patrick says, “because it supports my family, and also I am able to provide affordable, safe drinking water.”
Patrick Mailu is an entrepreneur in Nairobi, Kenya, whose kiosk sells treated water that he makes using the SE200 Community Chlorine Maker.
It’s definitely not the most popular meal-time topic, but guests of PATH’s annual Breakfast for Global Health graciously heard me out last week as I discussed diarrhea—the burden, gaps, interventions, and PATH’s part in defeating it. Some nodded knowingly, others raised their eyebrows. But across the board, everyone shared the vision of a world where all children have opportunities for healthy lives, and the determination to be a part of the solution.
A lifelike diorama of a typical rural Cambodian home served as my backdrop, much like the homes that welcomed PATH in 2011 for a project to assess an integrated, community-based approach to childhood diarrhea and pneumonia. If we want to improve child health, I told guests, we have to defeat diarrhea and pneumonia. In and around the home, common risks were apparent: uncovered food, contaminated water, an indoor wood-burning stove, livestock roaming where children played just outside the window.
Alongside the risks, a colorful photo collage displayed the simple solutions available today to prevent and treat diarrhea and pneumonia—tools that are proven, affordable, and saving lives. We shared PATH’s broad work on child health, like user-centered design for latrines, improved access to zinc and ORS in rural villages, new vaccines against pneumonia and diarrhea.
‘PATH’s Devices and Tools team joined me to share their innovative technologies that are simplifying access to filtered water in poor communities and breaking down financial barriers to a family’s opportunity to buy clean cookstoves and latrines.
Creative, thoughtful, and inclusive strategies are essential to bring these tools farther than ever before and keep kids safe. PATH has put a spotlight on child health as one of four pillars in our aim to reach higher, bringing the hope of a healthy future into the world’s poorest places. If I can do my part by broaching an uncomfortable topic as a prelude to an inspiring breakfast, I’ll be there!Read more
In 2014, PATH welcomed Dr. Cyril Engmann, a world renowned expert in newborn health and our new director of Maternal, Newborn, and Child Health and Nutrition (MNCHN). That sounds like a lot of disciplines to take on, but Dr. Engmann is used to playing many roles in global health--as a teacher, clinician, advocate, and leader. Between advocacy to US congressional staff and visits to witness PATH's MNCHN projects throughout Africa, Dr. Engmann took a few moments to chat with DefeatDD about his team's work, his vision for integration, and reflections on his newest role.
You’ve already traveled quite a bit to visit PATH programs. Where have you visited, and what did you see in action?
In Ghana, we have a large project called the Making Every Baby Count Initiative, or MEBCI, addressing the main causes of newborn death: prematurity, birth asphyxia, and sepsis. We’re working in health facilities and hospitals with this project, and in community settings with a complementary USAID project called Systems for Health. We partner very closely with the Ghana Health Service throughout whether at strategic policy, program, training, or research level. I think MEBCI and our work in Ghana has the potential to make a major impact in the newborn space.
Ghana was one of the first countries to adopt the Essential Care for Every Baby (ECEB) module. These are fundamental interventions: ensuring warmth for newborns, clean cord care, breastfeeding in the first hour, recognizing breathing problems, and infection risks, among others. The answer is not always the high-tech solution: The simple practices and solutions often present the greatest opportunities for improving newborn health.
How does PATH’s MNCHN Program integrate a focus on those first critical newborn weeks with further healthy development?
I saw this in action when I traveled to South Africa and Mozambique to visit our Windows of Opportunity project, a comprehensive focus on a child’s first 1000 days. This is a critical time period that shapes long-term physical, cognitive, and emotional health. Early childhood development is the next frontier in MNCH. We’ve had a survival lens for the last 10-15 years, and necessarily so. But now we need to broaden to not just ensuring a child is surviving, but also thriving. PATH is carving a niche role leveraging the health system to mediate early childhood development, including focusing on the mother before, during, and after pregnancy; and integrating education and surveillance on developmental milestones and assessments of risk factors with routine clinic visits, etc.
It was terrific to see how excited the healthcare workers were to implement and then witness the benefits of early childhood development and the commitment of families, especially mothers, to this. We are helping clinicians and families anticipate a child’s health needs and proactively recognize when early development milestones aren’t being met. An ounce of prevention is always better than a pound of cure. Now they can intervene early, during the most critical period of time, to make a long-term impact.
This video highlights PATH's work in South Africa, where we are strengthening care in the first 1,000 days of life—from a mother's pregnancy to her child's second birthday—to ensure a healthy start and lifetime of possibility.
Teaching and empowering communities must be particularly resonant for you. In addition to a researcher, program leader, and clinician, you are also a teacher.
I am passionate about teaching and come from a long line of teachers. From probably the last 10 generations, back to the 1600s, I come from a family of people who have taught in one way, shape, or another. My father described himself as a teacher first and foremost. He was also a physician who worked with the group at Cambridge (the original Cambridge that is in the UK!) in the 1950-60’s who helped characterize Trisomy 21, what we now know as Downs syndrome. He was a professor of cytogenetics and anatomy, helped found three medical schools in Ghana, subsequently becoming Dean of one of them, had a television program, and wrote books on public health. Yet, he always thought of himself first and foremost as a teacher. And because I think particularly highly of him, I don’t know that I’d necessarily call myself a teacher in that same league. But I love teaching and it’s something that is in my DNA, and which I really enjoy. I have had the privilege of working with many rural remote communities in Africa, Central and South East Asia, and South America. Without a doubt, fully understanding the milieu in which one is working aids tremendously in developing programs and studies with a strong element of teaching. By contrast, in high-income hospital settings such as in the UK or US, whether it is teaching medical students, physicians training to be pediatricians, pediatricians training to be neonatologists, or teaching MPH and PhD students from the Schools of Public Health, teaching and mentoring are two things I really love doing.
What are some of your favorite things to teach?
Fundamentally I love to teach where there is some action to follow. I also love to teach people to think broadly. I’m not as interested in what the “right” answer is, because often there are many right answers. But has the logic been followed through? Have all the factors been considered? The process can influence the end result so much more.
Perhaps most of all, conveying complex concepts to non-clinical people, whether to families in low-income country community settings or in high-income country hospital settings, this is particularly rewarding especially where it leads to a desired improved health or other outcome. At PATH I have also had the opportunity to spend some time on Capitol Hill sharing evidence-based practices with Congressional folks. The questions and interchanges that occur are fascinating, usually starting gently about MNCHN –related issues and then rapidly moving onto broader things. One recent question was about the intersection of global health and world peace!
My orientation is very multi-sectoral and multidisciplinary in nature. I see the value in and love being able to share, to hear people’s ideas, see people look at things with a different lens—and then put it all together and move on it. That’s very special. I’m always learning that way. That’s one of the things I’m excited about in this role, working with a talented MNCHN team to do a multiplicity of things across the research, policy, implementation science, and priming-to-scale continuum. And much of it is interdisciplinary, which really appeals to me. As a frontline health worker, I don’t take care of a critically ill baby and not talk with his/her mother and father about contraception, nutrition, diarrhea, vaccinations, early childhood development. It’s a very comprehensive package. I think of a neonatalogist as a family practitioner for these little babies, our little citizens. It’s a wonderful subspecialty to have, a real privilege. One of the things that drew me to the position with PATH was this idea of integration.
The Every Newborn Action Plan is a great example of integration. Can you tell me about your work as an architect of that effort?
About three years ago when I led the newborn program at the Gates Foundation, I was struck by how many different people were digging neonatal wells in different parts of the world, so to speak.
I remember thinking we needed a grand vision, a concerted movement which could affect policy, programs, and research globally. And one had to think strategically about how to shape it such that countries would ultimately have ownership, there would be strong demand generation from civil society, great buy-in and ownership multisectorally, and accountability. I invited a small team to work with me and we pulled out all the stops! Now we have all 193 countries signatory to the UN who have ratified the Plan and committed to make themselves accountable at the WHA. We also really worked hard at making the Plan a multisectoral one, broader than solely on the newborn focus. We worked with various other communities – utrition, maternal health, child health, civil society, the private and public sector, academic institutions, NGO’s and governments, among others. In fact, it was originally called the Every Newborn Action Plan, but now it’s called Every Mother, Every Newborn.
Frankly I had seen so many glossy global action plans gathering dust in Geneva and I was terrorized by the idea of pushing for this global movement which would end up in similar fashion. I think our final ENAP product has a lot of tangible promise and the effort has momentum. I’m very passionate about trying to see it through.
In talking about the Every Mother, Every Newborn Plan as a very practical resource for countries, it reminds me of the Global Action Plan for Pneumonia and Diarrhea (GAPP-D). Now that we have both of these plans in hand and in practice, do you see an opportunity for further integration?
I’m a firm believer in the power of thinking big “with the lid off” so to speak. I believe that if one does not have a vision, a sense of how one can make things work, and then a means to measure that effort, it definitely won’t happen. I think we should integrate further; it’s almost irresponsible of us not to.
A lot of people might say that is blue-sky thinking. But how much would the sum of the parts be, how audaciously huge, if we could harness more efforts? To paraphrase Nelson Mandela: “Everything seems impossible until you do it.” With the Every Newborn Plan, some people thought that was too blue-sky, and now it’s come to pass. There have been mothers who have looked at their children who are critically ill, even with doctors saying they are going to die, and some of them have kept that blue-sky approach and their children have lived.
Is broader integration blue-sky? Maybe. Is it impossible? I’d say not.
While keeping this comprehensive perspective, what’s next for PATH’s work in MNCHN?
It is an exciting time for the fields of maternal, newborn, child health and nutrition. Within each of these areas, there are a multitude of programs, policy work and, research that MNCHN is involved in. Externally I’d like us to deepen our relationships with donors such as DfID, CIFF, UNICEF, USAID, WHO, BMGF among others. Internally, within PATH, we are broadening our involvement to include issues such as vaccines, maternal immunizations, family planning, WASH, among others, deficiencies of which are significantly associated with adverse survival outcomes for mothers and their children, the very populations that PATH focuses on.
As we reflect on our past successes, it is important we document how we were successful and what we learned from each experience or project – the implementation science of what we do. Doing this well will allow PATH to lead the field in how to get things done well, including shaping policies and programs that can advance and bring greater impact. PATH’s role in building these partnerships is an important one: We are not just a stakeholder, but a leader in coordinating and harmonizing efforts in maternal and newborn health.
Mother’s Day is right around the corner. We’ve talked a lot about babies, but tell me why a focus on mothers is also pivotal for global health and development.
We all appreciate the incredible role that mothers play. Without them, the data suggest mortality rates increase significantly in their children. Mothers are children’s best advocates, and being able to empower, educate, and equip mothers, (and fathers) to be able to advocate confidently for their children is very powerful.
Photo credit: PATH/Evelyn Hockstein.Read more
This post is part of the #ProtectingKids blog series. Read the whole series here.
Dhaka was people. Everywhere I looked: people. Crowded streets, makeshift markets, farmers, businessmen, families, and animals. More than 15 million people live in the 315 square milesthat comprise the Greater Dhaka area, capital of Bangladesh. With so many in such close quarters, imagine if an outbreak hit.
An outbreak hit.
When I visited in 2009, Dhaka was in the grips of a terrible diarrheal disease outbreak: not only cholera striking all ages, but also rotavirus stalking the city’s children. For weeks, the hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) admitted upwards of 600 inpatients daily Since the hospital had just 350 standard beds, massive tents handled patient overflow just outside its front steps.
We arrived in Bangladesh to witness a pivotal moment that demonstrated just how important a vaccine against rotavirus could be. Dhaka was our first stop, but soon we travelled farther in-country to learn more.
Our driver snaked through the city streets, and pavement turned to a short dirt path. Suddenly—the city at our backs—lush greenery and a calm waterway lay before us. Crowds again gathered, this time to help shove off as our speedboats started down the Dhonagoda River. The destination: Matlab Health Research Centre, to document PATH’s clinical trial on rotavirus vaccine effectiveness.
Though we found ourselves far removed from Dhaka’s outbreak, diarrheal disease and rotavirus still threatened. At ICDDR,B’s Matlab Hospital, I ment Samsunahar and her daughter Rehana. Rehana was 6 months old when she fell ill, suffering persistent diarrhea and vomiting at home for two days. The local doctor advised saline, but Rehana’s condition did not improve. Samsunahar traveled three hours by auto rickshaw to the Matlab Hospital. When we met her, Rehana’s health was finally improving, but she had her own long journey ahead. Her attending doctor was fairly sure she had rotavirus, but due to the volume of cases, not every diagnosis can be confirmed in the laboratory. After a treatment protocol of zinc, breastmilk, and ORS, Rehana and Samsunar could return home.
Further afield, in Kaladi village near Matlab, I met Shobarani, her 2-month old daughter Priti, and Priti’s proud big brother, 10-year-old, Shawon. A shy but cheerful and healthy boy when I met him, Shawon was very sick with rotavirus as a baby, Shobarani told me. Like Rehana, he spent several days in the hospital for treatment and recovery. The memory of fear for her son’s life never left Shobarani. When she learned about a clinical trial for a new vaccine against rotavirus at her local clinic, Shobarani promptly enrolled her newborn daughter Priti. As she asserted to me, “It is very important to protect this child.” With a promising vaccine available through the clinical trial, she was able to keep her daughter safe in a profound way that she couldn’t offer Shawon a decade before.
Remembering these moms reminds me that, when we look inside the crowds, across the river, even into verdant fields and rural villages—people are much the same. We all want to protect our children, and we all value our health: Samsunahar, Shobarani, even me, and you too. At this fundamental level, superficial differences fade away.
Our opportunities for healthy lives, however, can be drastically varied. But they shouldn’t be. In the case of immunization, worldwide we know that vaccines work, they protect kids from Birmingham to Bangladesh, in cities and villages, and all points in between. Every parent should have the chance to offer such protection, and every child should have the chance to realize vaccines’ lifesaving potential.
Photo credits: PATH.Read more