University of Minnesota Alumni Association


The Education of a Public Health Worker

U of M students studying public health in India returned home shortly before the COVID-19 pandemic exploded. What they found there underscores the importance of public health efforts, and how hard this pandemic will hit the poorest in the world.

In Kolkata, dense populations and overcrowding threaten the health of residents.
Photo Credit: Elizabeth Foy Larsen

Editor’s note: In early January, Minnesota Alumni senior editor Elizabeth Foy Larsen accompanied a group of U of M School of Public Health (SPH) students on a two-week volunteer trip to India. The students were in the country to gain international experience in health issues.

While the students assisted a local organization called Jan Seva in Kolkata, a mysterious respiratory virus roughly 1,700 miles away in China was just starting to make headlines. On January 30, less than two weeks after the students had returned to the U.S., India reported its first confirmed case of COVID-19.

Public health education such as that offered at the U of M covers a multitude of arenas, including epidemiology, or the science of disease and how it spreads. Epidemiologists have been among the most quoted public health experts in recent months as COVID-19 has marched across the globe. Public health efforts, however, cover a much wider scope than just epidemiology, and include trying to ensure people remain healthy wherever they are, and whatever challenges they face locally.

As the coronavirus crisis has made abundantly clear, public health efforts are critical to keeping people across our interconnected world safe. And we have learned, to our dismay, that public health calamities in one area of the globe can soon become everyone’s problem.

From left to right: Hannah Currie (M.P.H, '20), Zoe Kusinitz (M.P.H. '21) and Jeanne Moua (M.P.H. '21).
Photo credit: Elizabeth Foy Larsen

On a rainy morning this past January, Jeanne Moua (M.P.H. ’21), Zoe Kusinitz (M.P.H. ’21) and Hannah Currie (M.P.H. ’20), sipped tea and nibbled cookies as they listened to the community health team at the Jan Seva Centre in Kolkata, India, describe their initiatives for the upcoming year. The Jan Seva team explained that tuberculosis remained an issue for the families in their area; the center is located in a high-poverty suburb of the East Indian metropolis and provides healthcare, vocational training, support for children with special needs, and a preschool for 225 children between the ages of 2 and 6. Health team members also told the U of M students they wanted to educate their community on a range of public health issues, including dental care, menstrual hygiene, cancer awareness, early marriage, safe touch, and self-defense for women.

The roster Jan Seva’s four-person team described was ambitious, and program coordinator Indrani Dey and the school’s public health officer, Debolina Roy, told the three graduate students they welcomed any advice the trio could offer during the two-week field study.

The gesture was both gracious and heartfelt. And yet, the Jan Seva team’s deference caught the three students off guard.

“You are the experts,” Kusinitz demurred, while Moua and Currie nodded and smiled. “We want to support the work you are already doing.”

The work being done at Jan Seva is funded primarily by Pathways to Children (, a Twin Cities nonprofit founded by Minneapolis-based philanthropist Grace Strangis and her late husband, attorney Ralph Strangis (B.S.L., ’58, J.D., ’60).

The school operated by Jan Seva is an oasis of stability for its families. Painted in shades of pinks and greens and yellows, the classrooms and common areas are cheery and spotlessly clean. Jan Seva also has a bountiful vegetable garden; a kitchen staff makes nutritious, homecooked meals for the students. For many of the hundreds of children who attend the school, the only protein in their diet is what they eat while they’re there.

Since 2016, Pathways to Children has paid for SPH graduate students to spend winter break getting field experience on the ground at Jan Seva. A former corporate travel executive, Strangis believes these educational opportunities make textbook subjects come alive in a way that has a lasting impact for the common good. “We are a global society,” she says. “Especially when it comes to public health. How do you understand who these people are and how they live if you haven’t visited them?”

Faculty at SPH have also been espousing the importance of this type of world-focused insight since the school was established in 1944. Over the decades, SPH’s global initiatives have included everything from training engineers in the 1950s to build wells for fresh groundwater to launching a global trials network in 1999 that coordinates clinical trials across countries to ensure that study sites are run consistently.

Beth Virnig, the SPH professor who created the Jan Seva field experience and who now oversees its implementation, says exposing students to conditions in the real world makes them better prepared to address current and future public health crises.

“Public health professionals who have had these immersive global experiences are able to help in … global crises because they are able to put themselves in people’s shoes without judgment, and to then help them use information to make decisions that keep them and their families healthy,” Virnig says.

In the great metropolitan area of Kolkata—with a population of over 14 million—density and poverty are both factors that play heavily into the potential for disease spread. This became grimly evident on March 24, when Indian President Narendra Modi mandated a lockdown that prohibited any movement in the entire country for three weeks. Despite his efforts, at press time the spread of COVID-19 in India, including in the region visited by the SPH students, was reported to be growing dramatically.

“To see a city that is so enormous made a huge impact,” says Currie, who had previously spent a semester as an undergraduate studying in Ghana, where she worked at a tuberculosis clinic. “It was more the population density and scope of what happens and the fact that Kolkata is one city and India is an enormous country. This is life for so many people.”

The realities of Kolkata—the city transitioned from its colonial name, Calcutta, in 2001—became all the more real on the second day the students spent at Jan Seva in January. The local community health team took Currie, Kusinitz, and Moua to visit a student’s home. The school’s neighborhood combines all the paradoxes of modern India: A nearby shopping mall was selling saris, blue jeans, and fast food. But just steps away, behind narrow alleys, thousands of families were living in slums, in one-room homes with no windows and dirt floors. The student’s mother, a domestic worker, smiled as she proudly pointed out a single-burner propane stove to her visitors, noting she opened her door for ventilation when she cooked. Blankets for sleeping were stored on an overhead shelf, and a single fluorescent light—with electricity jury-rigged off the main power line—provided the only light source. In addition, the entire neighborhood shared a single tap, shut off for portions of each day, for both drinking water and for bathing. All local residents also shared a latrine down the alley.

With hindsight, those two bleak details showcase how vulnerable the residents the students met are to COVID-19. The key, often-repeated command by health experts to wash hands regularly with soap and water is defeated by the sobering reality that so many lack the facilities to do even this simple task. UNICEF estimates that 91 million urban Indians lack handwashing facilities at home. 

Children wash their hands with soap at a UNICEF-supported learning center at a Rohingya refugee camp in Cox’s Bazar, Bangladesh.

Clean hands are out of reach for much of the world

According to UNICEF, in many parts of the world, children, parents, teachers, healthcare workers, and others do not have access to basic handwashing facilities at home, in healthcare facilities, schools, or elsewhere. The group provided these latest estimates:

40 percent of the world’s population, or 3 billion people, do not have a handwashing facility with water and soap at home. Nearly three-quarters of the people in the world’s least-developed countries lack basic handwashing facilities at home.

47 percent of schools lack a handwashing facility with water and soap, which affects 900 million school-age children. Over a third of schools worldwide and half of schools in the least developed countries have no place for children to wash their hands at all.

16 percent of healthcare facilities, or around 1 in 6, have no hygiene service, meaning they lack hand hygiene facilities where patients receive care, as well as soap and water at toilets.

UNICEF also notes that urban populations are particularly at risk of viral respiratory infections due to population density and more frequent public gatherings in crowded spaces like markets, public transport, or places of worship. People living in urban poor slums are particularly at risk. As a result, handwashing becomes even more important. Yet:

In sub-Saharan Africa, 63 percent of people in urban areas, or 258 million people, lack access to handwashing. Some 47 percent of urban South Africans, for example, or 18 million people, lack basic handwashing facilities at home with the richest urban dwellers nearly 12 times more likely to have access to handwashing facility.

In Central and South Asia, 22 percent of people in urban areas, or 153 million people, lack access to handwashing. Nearly 50 percent of urban Bangladeshis, for example, or 29 million people, and 20 percent of urban Indians, or 91 million, lack basic handwashing facilities at home.

In East Asia, 28 percent of urban Indonesians, or 41 million people, and 15 per cent of urban Filipinos, or 7 million people, lack basic handwashing facilities at home.
Photo Credit: Elizabeth Foy Larsen

As they settled into their routines in Kolkata and at Jan Seva, the SPH graduate students each volunteered to work on different initiatives that aligned with their experiences and interest.

Moua, who is studying epidemiology at the U of M and has done field work in Thailand and Laos, offered to run spreadsheets and research initiatives aimed at raising cancer awareness. In that research, she learned that residents who agreed to even one cancer screening— which the school had previously provided—were more likely to agree to additional screenings in the future.

That showed the work the community health team was doing was benefitting the community. Moua also created flyers with graphics to explain warning signs of cervical and breast cancers, provided extensive resources for the community health team, and offered suggestions for follow up strategies with families.

Moua also researched first aid for burns. The standard advice—to place the burned area under cold running water—doesn’t work for the majority of Jan Seva families since they don’t have plumbing. What’s more, any useful advice was written in Hindi, not Bengali, the local language. Moua knew from conversations with the community health workers that a common traditional remedy was to cover a burn with flour. That led her to create literature for the folk remedies and traditional medicine approaches identified by the community health team. (For the record, flour absorbs moisture and protects the skin from irritants.)

Currie capitalized on her past experience working at a tuberculosis clinic to create a low-literacy screening tool that the community health workers could use when they were meeting with families. (India has a comprehensive plan to eliminate tuberculosis by 2025.) She says she was careful to present her findings as questions, not solutions. “I’m a student, not a professional,” she says. “But often our opinions as Westerners are taken as fact. That’s an ethical issue that comes up when it comes to global volunteer and mission work.”

Kusinitz, who spent an undergraduate semester in Copenhagen studying gender and sexuality, focused her work on menstrual health and hygiene. She learned that tampons are not widely used in the area because of a cultural belief that they compromise virginity, and that while the community health team wanted to encourage mothers to use menstrual pads, most Jan Seva mothers use rags, which they clean at the community taps and then dry inside their home.

Kusinitz also discovered that douching is common among the residents and the practice was supported by the health team at Jan Seva. That was challenging information from a public health standpoint, because douching has been linked to problems such as bacterial vagninosis and pelvic inflammatory disease. But, instead of correcting the team, Kusinitz instead offered to make sure the science was backing up her reservations and presented them with studies they could use to make their own conclusions.

Despite the tangible assistance the students offered during those two weeks, they were also humbled and saddened about the limits of what was possible. After a self-defense workshop was offered at Jan Seva, a mother reported that her husband was so angry she had attended that he beat her. At another home visit, the mother tearfully explained that her husband was such a violent alcoholic that she dreamed of making enough money to send her 13-year-old daughter to a boarding school for her safety.

“It was incredibly painful to know that there was absolutely nothing we could do to help her,” says Kusinitz. “We were in her home, listening to her story, but we would leave soon, and she would continue to exist in her reality.”

Virnig believes that all of these experiences—even the painful ones—will ultimately help Currie, Kusinitz, and Moua become more qualified public health professionals, even if they choose to work in the United States. “Ultimately public health is local and is about coming up with programs, policies, and guidelines to help people reach their maximum health,” she says. “And we can’t do that unless we understand how to listen and learn who people are, where they are coming from, what their values are, and what they are facing.”

That the students left India with more questions than answers is, in Virnig’s opinion, proof that the program is a success. Questions make a person pause and continue the search to find answers. In that way, the graduate students’ time in India will stay with them. “The growth they experienced in two weeks is equal to years of classroom work,” Virnig says, adding that she and her students remain deeply concerned about what will happen to the Jan Seva community because of COVID-19.

“I think it was a practice in empathy and discomfort,” says Kusinitz about her stay. “It was an opportunity to be uncomfortable and out of your element and to find connections and commonality, to learn from people whose experiences are so different from your own. I got to experience what it was like to feel like there was nothing I could do to help. And to then figure out what to do anyway.”

Reasonable expectations

At the time the graduate students from the U of M School of Public Health visited Kolkata, the Jan Seva Centre also hosted a two-day, free dental screening for all its students, which was staffed by two Kolkata dentists, as well as Elise Sarvas and Teresa Fong, faculty from the U of M School of Dentistry. The two traveled independently to India to volunteer their services.

Studies show that tooth pain can be a profound detriment to success in school. Although the dentists found several local cases that required immediate treatment, a follow-up analysis showed the Jan Seva students had a rate of tooth decay comparable to that in the United States, even though the students brush less and don’t have access to sealants. That’s likely because there is very little sugar in the students’ diets.

The dental clinics were followed by afternoon education sessions about dental care, which the SPH graduate students attended. They listened as both mothers and fathers asked the dentists questions and heard that persuading reluctant children to brush and floss is a parenting challenge that transcends borders and economic circumstances.

The sessions were supportive, informative, and enthusiastically received by the parents. But the site visits had given the graduate students new insight into what’s essential versus what’s optimal. After all, Jan Seva parents work long hours only to return to homes without any modern conveniences, save for cell phones. Having the time and patience necessary to enforce flossing seemed to be just one more challenge they might not be able to meet.

It was yet another awareness that will guide the SPH graduate students in their work.

“It takes empathy to realize that just because we care about dentistry, that doesn’t mean it’s these families’ most important need,” says Virnig. “We need to reach families where they are.”

Elizabeth Foy Larsen is the senior editor of Minnesota Alumni.

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