My first week
In May I started a remote summer internship as a Research Assistant in the Department of Global Health at HSPH, having never met any of my colleagues in person. I took a class with Dr. Margaret Kruk this past term, and met her virtually right at the start of the COVID-19 pandemic. I admired her both as a professor and researcher and knew I wanted to get involved in her work. In class one day she described her new project on the COVID-19 pandemic and its impact on other routine health services in low-and-middle income countries and I decided to reach out to see if I could get involved. The COVID-19 pandemic seemed to not be ending any time soon and I knew that my summer internship plans had to change. Finding myself overwhelmed with new COVID-19 information daily, I wanted to find a way to use that energy to produce meaningful research in the field.
Just 3 days after my last final, I began working for Dr. Kruk from the comfort of my Jamaica Plains home. The first week started slow, familiarizing myself with the project and reading lots of literature on the topic, but I knew this was arguably the most important part of the process. I read about the Ebola epidemic and estimates of potential indirect morbidity and mortality that resulted from people fearing infection and avoiding routine health services, like immunizations our ANC services. I read commentaries that predicted similar outcomes with the COVID-19 pandemic that described people’s avoidance of healthcare services or inability to get care due to stay-at-home orders and cancellations of elective procedures. I knew understanding this literature would be important as I began the project and started looking at the data of routine health services in different countries.
Policy Data Collection
One of my main tasks for the project is collecting COVID-19 policy data for countries involved in the project. This includes school cancelations, travel bans, non-essential business closures and more. We will then look at this policy data over time and look at COVID-19 case and death data over time as well as health service utilization and see if there are any correlations in each country. These data will hopefully provide important information as to which policies are effective and necessary and which are not, and what impact they might have on the health system.
It has been fascinating researching this data and realizing how variable responses have been from country to country—many countries following China’s and South Korea’s extreme lockdowns. Many of my colleagues have varying opinions on if low-and-middle income countries should be taking on the same level of restrictions as high-income countries. Some argue that in many of these low-income countries there will be less COVID-19 burden because they have a smaller elderly population, and their economy and other services would be terribly impacted by a lockdown. Hopefully, our data collection will help answer this question. It is also important to understand policy response with health service utilization. If a lockdown were in place, or elective procedures were not allowed then it makes sense that utilization would be lower. These policy data can be tedious to collect but are extremely important to collect as the pandemic continues.
Policy Database Presentation to country leaders
This past week I presented my policy database to country teams at one of our weekly workshops. I was honored to have the opportunity to present my work to research leaders from across the world and was grateful my team here at HSPH trusted me with this large responsibility. I was quite nervous before the meeting but felt confident because I had done a significant amount of research on policy indicators to collect and their definitions and thought that my indicators were comprehensive and definitions were understandable. My team at HSPH had also reviewed all of my work and had agreed that it was sufficient and comprehensive. In the workshop I actually received a lot of feedback on how the policy indicators and definitions could be improved.
Initially after the meeting I felt discouraged by the feedback, and felt I hadn’t done a good enough job. But as I processed the feedback after the fact and began trying to incorporate it, I realized how useful this collaboration was to the Global Health field. A lot of the policy indicators I had initially listed had a Western lens. For example, when monitoring school closings, I used the term “K-12”, which I recognize now is not understandable beyond the US. I also received feedback on including more policy indicators that were more common in Asian countries’ response to COVID-19 that weren’t as common in the US, that I hadn’t known about.
I realized truly how necessary collaboration is in Global Health and how the structure of this project was built to ensure that. This project has weekly meetings with all countries involved in the project where we do training workshops, collect feedback or ask for other thoughts and ideas. It can be challenging to coordinate so many people and these meetings can get very lengthy, but they allow for this project to truly be a collaboration and bring all voices to the table, which is essential in the Global Health field.
Our project has been delayed as we wait for country teams to gain access to data sources for the health facility utilization data, but our team here at HSPH is still working diligently so that once the data is available, we can promptly move on to cleaning and analysis. Next week, we have a workshop on data cleaning for all country teams to join where we will share a sample dataset of Sierra Leone, a country not involved in the project whose health facility data is publicly available through DHIS. Our team will train all country teams on the data cleaning process so once they gain access to their own data they can lead the process themselves.
This summer I have also been working on developing a data visualization tool, so once the data is cleaned, we will create a platform where country teams can interact with the data. I have been using Google Studio to develop this data visualization and it has been quite challenging. Although Google Studio is quite easy to pick-up and learn, its functionality is limited and we’ve had to do a number of work-arounds to get the visualization to show exactly what we want. We initially chose this platform because we didn’t think it would have the same learning curve as other platforms and it is free, but we have quickly realized that its simplicity to use has not come without its shortcomings. Regardless, this past week I developed a neat and simple visualization for Sierra Leone that I will share with the country teams during the workshop next week. The country teams will then hopefully be more motivated to work on the project if they see a potential final product of their cleaned data. I’m hoping to share a video here of my process of working with Google Studio soon.
Data Access Challenges
As mentioned in my last blog post, we have had some challenges getting data from many of the countries involved in the project. The delay is quite understandable considering we are in the middle of a global pandemic. A lot of the country team leaders have to work closely with their Ministry of Health which can lead to some bureaucratic challenges. Some countries have access to health service utilization data as recent as June 2020, while others can’t even gain access to the 2019 data. It is important to have the 2019 data as a comparison to the 2020 data to see if there really was a change in utilization and that change may not just be seasonal. Another concern is that some facilities might be so overburdened they may just stop reporting, but we are coming up with some analytical strategies to address this.
I feel though that this delay has allowed us to focus on the details and planning of the project in advance and consider very thoughtfully what the procedures will be once we gain access to all of the data. It has been the reason I have been able to create a demo data visualization and practice working with the Google studio software. It has also allowed us to use our meetings with country leaders as training sessions where we look at sample data together over Zoom. Although it feels like the project has been slow to progress, once the data are available we will move quickly and strategically thanks to this planning stage.
I am grateful that all of my colleagues throughout my internship have been incredibly kind and supported me in my work. I was worried that I would feel disconnected from my co-workers in a completely remote internship. I had taken remote classes the past semester and knew how easy it could be to feel disconnected and removed from your classmates, and I was worried the same might happen with my colleagues. I wanted to make sure my internship was productive and that I was making connections with these researchers, so when I started, I reached out to many of them individually to meet. They gladly took time out of their days to have one-on-ones with me where I got to know them and their backgrounds before diving into work. They also gave me wonderful advice as a student and researcher, and how to be successful on their research team.
We also have bi-weekly meetings with all members of all teams working under Dr. Kruk where we give updates on each other’s lives and share highs and lows of the past two weeks. It has been so nice to have that space to share and to get to know one-another. We have shared countless baking recipes, books to read, shows to watch and more. We have also shared frustrations with the current climate in the United States. Beyond COVID-19, it has become incredibly clear the racial disparities that exist across almost all institutions in the United States this summer, and there have been some terrible rulings surrounding reproductive health, international students in the US and more. This summer has not been easy by any means. It was important to me though that these were recognized by my supervisors and co-workers as terrible things, and also validated as real distractions that made it hard to do work and made us all feel very down at times. I am grateful to work among people who recognize this and also shared different ways that we could take action.
Building Stata skills
An important aspect of my degree at HSPH is gaining statistical analysis skills. I took many classes my first year that required use of Stata or R but I never gained full comfort with either programming software. I had used Stata much more than R and had expressed to my supervisor at the start of my internship that one of the main outcomes I’d hoped was to build my skills in Stata and to use the software outside of the classroom. She said that was absolutely possible and a necessary part of my degree and this internship. The delay in access to data though meant that this opportunity may not come. Fortunately, my supervisor recognized and allowed me to set-aside work time to take online Stata courses.
Although working through online modules can feel quite tedious, I am incredibly grateful to have this devoted time to truly learn this software. My mastery of Stata will be necessary for my thesis this upcoming year as well as my future career in research. Furthermore, I plan to continue working on this project in the Fall semester with Dr. Kruk. The opportunity to become fluent in Stata now will allow me to more quickly and efficiently work during the school year once we start receiving more data, which will likely also be when studies my studies begin to pick up. My colleagues have also been gracious with their knowledge. They have shared code with me to review and set-aside time to ask questions about code as well. I am grateful that this internship has allowed me to gain many skills and that my supervisors and colleagues have been transparent to my needs.
Final weeks of my internship
As my internship comes to a close this month, I find myself feeling incredibly grateful for this opportunity. I have had the privilege to work with an esteemed professor in my department and build important relationships and significant skills. This year has brought many challenges but I am grateful that the knowledge and skills I gained this past year in my Master’s program allowed me to still contribute to the field. Furthermore, it allowed me to make a difference in the current crisis affecting our World, and soon we will publish on the indirect health effects of the COVID-19 pandemic in many low-and-middle income countries and share these results. We will be able to share the results on the changes in vaccination rates, Antenatal Care visits, contraceptive uptake and more with important stakeholders. Although this is not the work I had planned to work on this summer, it has been meaningful and important and allowed me to accomplish every goal I had hoped I would achieve out of a summer internship.
Furthermore, I am grateful I get to continue working with Dr. Kruk and her team this Fall semester. Although my time will be much more limited because of my classes, I am hoping to contribute as much time as available. I also am planning on making this work a part of my Master’s thesis. My supervisors and I are not sure exactly how that will work, but we are hoping that I will lead the analysis in one country. I am eternally grateful to my supervisor, Dr. Kruk and the WAPPP Cultural Bridge Fellowship for making this possible.