Conversations of the Stars

This past weekend in New York both Passover and Easter were celebrated.  Passover being a commemoration of the passing over of the angel of death thereby sparing the lives of Jewish firstborn children.  Easter is the celebration of Jesus rising from the dead after being crucified.  Whether you participate in these religious rituals and believe in the miracles of lives saved/a life rekindled, or if you just enjoy the family and friendship of a Passover dinner or revel in the fun of an Easter egg hunt, or have no personal connection with either of these religions or these holidays, it is evident that they are both about life and death being inextricably bound together.

Those of us who work in public health frame much of what we do in terms of health problems that increase morbidity and mortality rates, interventions that yield outcomes of lowered rates of mortality and morbidity, measuring the outcomes in lives saved/lives lost, quality of life, costs/benefits, basing evaluations of determinants and distributions of health.  There are experimental studies, quasi-experimental studies, ecologic studies, observational studies, cross-sectional studies and case/control studies.  This all sounds very boring and very academic, but actually it is all about life and death.  A flip through the most recent issue of the American Journal of Public Health reveals:  Genetic Physiological, and Lifestyle Predictors of Mortality in the General Population; Effect of Intensity and Type of Physical Activity on Mortality: the Whitehall II Cohort Study; US Cultural Involvement and Its Associations With Suicidal Behavior Among Youths in The Dominican Republic; Worrying About Terrorism and Other Acute Environmental Health Hazard Events; The Role of Health Systems and Policies in Promoting Safe Delivery in Low- and Middle-Income Countries..  To those of you outside the public health world and even to some of us in the public health world, these studies may seem esoteric and abstract, but they are really about lives lost, lives that can be saved, lives that can be rekindled.

I participate in a few Linked In forums:  Global Health Public Health, Water Sustainability, my New York Medical College group.  The conversations in these groups also are about life and death and pretty much everything in between.  I have met some amazing people in these conversations as we talk about research and programs and we share our own personal thoughts, feelings and ideas.  I have met Kato and David and Mebra and Cornelia and Gordon and Mary and Keith and so many others who experience life and death on a very personal level.  There has been a long-running Global Health discussion on why maternal mortality remains so high in Sub-Saharan Africa which was started by the question raised by Jane on March 4.  A couple of weeks ago I consolidated responses into several broad categories: resources, education for girls and women, poverty, tradition and culture, funding, empowerment and the topic that keeps surfacing, political will.  I’ll add this to the end of this post.  There have been comments that cite statistics and data, programs, outcomes, but mostly there have been the comments about hurt and frustration and challenges and through the conversations incredible commitment to save lives and increase health and well-being.  And what I think often is not communicated in the research and the peer reviewed articles, is PASSION.

There has been another conversation about why public health is so often unrecognized as the powerful agent of change and life-saving interventions.  Think about the media, films, songs, TV shows.  Where are the public health professionals?  There are sexy doctors, there are romantic lawyers, there is Nurse Jackie, definitely detectives and police officers and crime lab specialists.  Public Health?

The passion of public health, the commitment to saving lives, the miracles that are perhaps sometimes lost in the data need to shine through like stars.  I invite all of my colleagues in public health to tell the stories of life and death and anyone who will listen, who must listen, to hear.  When I think about the challenges of saving lives, especially in maternal health and birthing, I think about the last verse of W.H. Auden’s poem September 1, 1939:

Defenseless under the night

Our world in stupor lies;

Yet dotted everywhere,

Ironic points of light

Flash out wherever the Just

Exchange their messages:

May I composed like them

Of Eros and of dust,

Beleaguered by the same

Negation and despair

Show and affirming flame.

To my dear colleagues around the world who continue to teach me about your work and commitment, I thank you for being the stars continuing to shine and show the way to life.

Why is maternal death still high in Sub Sahara Africa despite all the effort being made globally?  Posted by Jane on March 4, 2012

Literature referenced:

Declaration of AlmaAta

Annie Feighery

Hogan, M.C., Foreman, K. J., Naghavi, M., Ahn, S.Y., Wang, W., Makela, S.M., Lopez, A.D., Lozano, R., Murray, C. J. L.  (2010).  Maternal mortality for 181 countries, 1980-2008:  a systematic analysis of progress towards Millennium Development Goal 5.

Unger, J.P., Ven Dessel, P., Sen, K., & De Paepe, P. (2009).  International health policy and stagnating maternal mortality: is there a causal link? Reproductive Health Matters. 17(33), 91-104.

Karel Amaranth, MPH, MA.  MPH Thesis: Safe Motherhood By Design:  A Public Health Program Planning and Evaluation Project:  Empowering Women to Prevent Maternal Mortality 

Cornelia Osim Ndifon:  Determinants of Maternal Mortality Amongst Unbooked Patients in Calabar Teaching Hospital Nigeria:  A Four Year Study.  Contact:

Riders for Health

Holistic care, Inter-relationship of resources, workforce, education, poverty reduction, nutrition

Trends in responses:

EMPOWERMENT:  Social injustice/human rights issue/gender equity

Women’s empowerment as a determinant of higher education, reduction of poverty, social status and ability to make informed health choices including spacing of pregnancies, contraception, healthy birthing practices, prevention of HIV

Women’s health as holistic including empowerment:  Inter-relationship of MDGs: maternal/child health, water, nutrition, sanitation, transport, education, agriculture

Community empowerment: Programs that Ask women what they want and need


Early marriage and child bearing

Religions that do not allow contraception

Women believe it is their fate or Allah’s/God’s will for them to suffer and die.

Cultural implications of having many children, i.e., virility of the father

Male dominated society (suggestions to engage men, rather than condemn them)

Female circumcision, violence against women

Very high fertility rates and multiple births (related to cultural and socio economic pressures)


Specific to health/child bearing/reproductive health

General education of women and girls; reducing illiteracy

Developing women’s leadership


Association of poverty with low social status, poor nutrition*, no or limited access to healthcare,

Impact particularly on pregnant teenaged girls and unmarried women

Impact on low birth weight and infant mortality

*Nutrition:  Importance of reducing anemia, building strong bones and resistance to infections.



clean birthing kits, misoprostol, oxitocin, equipment in hospitals (often inadequate)

Healthcare facilities/interventions:

Inadequately staffed and equipped.

Not accessible by rural women

Services like EmOC not available to all women

Distance from healthcare facilities/transportation

Effectiveness of focus on home deliveries to reduce MMR/home birthing as a positive choice with clean supplies and birth attendant

Skilled attendance at births:

Traditional birth attendants

Negative: interfere with safe birthing

Positive:  need to be recognized, trained and engaged since many women continue to use them


Community Health Workers: part of a decentralized health delivery system; performance based financing

Physicians (very little mention of physicians)

Limited resources for training  any of the above health providers.

Lack of healthcare infrastructure to deliver services to women


Leadership not committed to healthcare infrastructure

Government policies that do not favor women

Inefficiencies in government, corrupt use of funding and cumbersome bureaucracies

Governmental should encourage economic development to support healthcare delivery infrastructure that supports community in a decentralized health system; grass roots empowerment rather than out of touch corrupt government programs

Improvement in MMR even in low income countries if there is political will is focused on health

FUNDING (Government and Private Sector)

Funding channeled to women’s health, education and empowerment

Informed donor base to ally funding for poverty reduction with funding to reduce maternal mortality

Performance based financing


Evidence based practices:  what evidence is used to support programs and interventions?

Quality assurance in programs.

Research and successful interventions:  sharing the knowledge and replicating successes

1 Comment (+add yours?)

  1. Chi Primus
    Apr 15, 2012 @ 11:10:36

    Elaborate and thorough Karel! Because of this social injustice I find myself exclaiming at times like ‘If I had the means I will stir the people to mutiny’ against the shameless and hypocritical regimes we’ve been accustomed to in Africa.Avoidable maternal deaths remains the sad reality in the sub-region and at the top level who even cares? At times, I even get a bit scenical about the issue: perhaps since the developed world perceives overpopulation as a big problem in Africa, so having people dying help resolves the problem! Because if we can send people to outer space in a couple of years, develop technologies that have completely revolutionized our way of life, why can’t we fix the ‘avoidable’ issue of maternal deaths in SSA? Where have we kept our basic sense of humanity? As I mentioned in the beginning, perhaps (just perhaps) no one truly cares!


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