Journal: Summer in at the WHO by Rachel Folz

Planning the summer in Geneva

I was accepted to the Duke program in for Global Governance, and specifically to the global health track in December. While I thought that it would be smooth sailing from there to Geneva, in reality there was a marathon of hoops to jump through before landing in Geneva. First of all I had to secure an internship. This entailed several drafts of resumés and cover letters and meetings with our program director to strategize where I would fit well within the vast network of global health organizations in Geneva. After rewriting a draft to emphasize my interest in women’s health, I landed an interview, and the next day a position within the department of Reproductive Health and Research at the World Health Organization.

I was elated at securing the job, but again I realized that there were many more obstacles to overcome before reaching Geneva- namely getting a visa, securing funding, and finding housing for the summer. For the visa process, it is necessary to obtain a Schengen region working visa if the stay will be less than 90 days- for me it was about 70. To do so, I had to first secure a letter of recommendation from my sponsors at the WHO. This had to be processed through multiple levels of WHO bureaucracy, which took several weeks. In the meantime I scheduled an in-person meeting at the embassy in New York. This type of visa requires a brief interview, during which all the (many!) required documents are transferred. I got my letter of sponsorship just in time, and compiled it with my other documents before leaving for New York. At this point, I had only 3 short weeks before my flight, and the embassy needed to process and mail back my passport with my visa inside, which I was told would take about two weeks. I was nervous that it wouldn’t arrive in time, but the next morning my buzzer rang with a delivery to sign for, and one more obstacle was out of the way.

Apart from interviewing subletters to stay in my apartment in Philly for the summer, and my impending finals, I was most distressed about finding housing in the ridiculously expensive, summer-booming city of Geneva. I was very lucky in that my boyfriend was also moving to Geneva a few weeks before me for his work. He arrived in late May and stayed with friends for a week while he looked for, and successfully found a place for us to live- in the spare bedroom of a family who would be taking vacation for much of the summer. Though I didn’t go through this process myself- I would recommend that those looking for summer housing in Geneva rent a room in a hostel for a week, and find housing during that time. While stressful, I think that this is the best way to find a good situation for a reasonable price. Through connections at work, or just people that I met in my first few days in Geneva, I would have been able to easily find housing for the summer.

Working at the World Health Organization and meeting with donors for global health

After a couple of weeks settling into my new job at the World Health Organization, our department- Reproductive Health and Research - was having it’s annual budget meeting with donors. I was asked to attend the meeting, and to be the official note taker for one of the sessions. This conference was like nothing I have ever witnessed before, and gave me an interesting insight into the world of global health financing.

The meeting was scheduled to start at 9 am sharp in the executive board room- the largest and fanciest space at the WHO. I arrived promptly, and twenty minutes later the chair was calling for order and wrangling people to their seats. In the inner circular table sat the chair, representatives from two WHO committees, representatives from the top country donors (which included US, Norway, Belgium, the UK, Sweden and Switzerland), representatives from 2 countries chosen from each of the world regions to sit on the board this year, a couple countries who have special situations (including Russia, who has said for the first time this year pledged to fund Reproductive Health and Research, and Brazil, who has special interest in RHR in face of the Zika virus epidemic), and some large donor organizations such as International Planned Parenthood Foundation and the World Bank. Outside this main circle were about 60 other representatives from countries or organizations that are interested in reproductive health- Bill and Melinda Gates Foundation, the CDC, Marie Stopes International, Pathfinder and many more. In the very back sat all of the researchers (and interns) for the department.

The proceedings of the meeting were dry, but I found the most interesting parts to be the dance of diplomacy that I had never witnessed before, and the extreme networking that went on in the coffee breaks. The chair would introduce a speaker, the speaker (usually a researcher from the department) would give a presentation on some aspect of reproductive health, and then it was time for comments. Representatives would turn their name cards vertically and the chair would invite them to speak. They would turn on their microphones and say something along the lines of “Afghanistan would like to congratulate the department on its most excellent and impressive research, but would like to raise the concern of ….” Among the most contentious points was what most donors felt was not enough attention given to safe-abortion. Many representatives criticized the department on their lack of commitment to promoting safe abortion through official WHO recommendations. However, the department’s hands were tied by conservative donors who threaten to pull funds if money is spent on anything related to abortion. Watching the attacks and delicate responses surrounding this issue was very interesting. Also interesting was the predictably delayed proceedings, mostly due to the prolonged coffee breaks, during which researchers chatted with representatives to talk about funding upcoming research and bounced ideas around.

At the end of three days of meeting came the official drafting of meeting proceedings and the pledges. The draft included notes (some that I had taken) that the entire board needed to agree on. It was basically like a team writing assignment, where a notetaker projected a word document onto the screen and everyone made edits… “I feel that we should change ‘congratulate to thanked, as it more accurately represents the tone of the esteemed delegate from Norway’s comment’”. Then came the time when some countries told the department how much money they would be giving, while others gave their support and said a number would be provided later and still others kept silent, preferring their deals to be made more privately.

The PCC meeting in the executive boardroom at the WHO. You can see the inner circle where the board members of the meeting are sitting

My project: a systematic review of characteristics of users of long acting reversible contraception (LARC)

One of the largest projects I worked on this summer was a systematic review of the women that choose to use two different types of long acting reversible contraception or LARC: intrauterine devices (IUDs) or subdermal contraceptive implants. Many have called for this review to be done, so family planning projects can focus marketing efforts on certain populations in order to increase the uptake of LARC. I took a class at the WHO library to learn about systematic reviews and how to do them, and then I dove in.

I developed a complicated search strategy to search medical and public health literature. I waded through more than 1,500 published studies about implant and IUD users from all over the world, and picked 83 most relevant papers to include in my study. I gathered quantitative data from all of them, and spent a lot of time reading and recording qualitative data as well. I analyzed my data and came up with results in the following areas:

1. what influences women to decide to use one type of LARC over another 2. the demographics (age, education level, number of children, marriage status, income level etc.) of women who chose IUDs or implants 3. how many women discontinue the use of these contraceptive methods and why

In general, I found that women most commonly hear about LARC through their healthcare provider, though they can be swayed by women who are current or former users of the method, or mass media campaigns. Implant users tend to be younger, less educated, less commonly married and with less children than IUD users, but there is a lot of variation depending on where in the world they live. My favorite part of my analysis was the rates and reasons for discontinuation of LARC use. While data from all of the different studies varied greatly, when all the numbers were averaged the rates of discontinuation for implants and IUDs was about the same. However, the reasons for discontinuation were very different between the two methods. Menstrual issues was the most common for both methods, and wanting to have the device removed because they were planning pregnancy was also very common.

Malaria vaccine project and Duke course week

As part of the Duke program in global health, I was required to take a one week break from my internship at the WHO to attend a class run by an amazing expert in the field of global health- Dr. Gavin Yamey. The course consisted of several sessions every day, given by experts from different fields. In the afternoons we traveled to different global health organizations and took tours and learned about the work that they do. Among the most interesting site visits were Doctors without Borders, the Global Fund, Gavi the Vaccine Alliance, and the World Trade Organization.

Another interesting component of the course week was a group project that we were assigned in mid-May. The gist of the project was that in light of a new Malaria vaccine that is undergoing clinical trials at the moment, what would a global roll-out of the vaccine look like and how would it be funded. It gets more complicated though- the vaccine is only about 30% effective, and though it could save a significant number of lives, it is also much less cost effective than other programs in place such as insecticide sprayed bednets. Another layer of complexity comes in the fact that the Global Fund is the worlds largest funder for malaria prevention and treatment, but almost all vaccines programs in the developing world- where this rollout will happen- are funded by Gavi. On top of this the World Health Organization has made statements about what to do and not do in the roll out of this vaccine. For our project, three groups were assigned to represent each of these three organizations. The project was also a competition- in that the final presentation would be given to the members of the three organizations who are currently in charge of planning the roll out, and they would judge us to decide who has the best and most comprehensive plan.

I was assigned to the Global Fund team, and we were lucky to be able to visit their organization and meet with the point person for this new and exciting Malaria vaccine project. Our group of 6 met several times leading up to the course week to prepare our project and presentation. My contribution to the project, apart from being the graphic design coordinator, was developing a case study. We chose a country that we thought would be ideal for the vaccine roll-out and walked through which districts we would target first based on their infrastructure, malaria burden, and current bednet coverage. All three groups had amazing projects with very innovative ideas, and it was humbling to see how much our groups had critically thought about this project. In the end though, the judges awarded my team with the first place prize for the competition :)

The members of the Global Fund Malaria Vaccine team after winning our case competition. All students were part of the Duke Global Health program, but we each came from a different medical school or MPH program across the US.

Living in Geneva

Geneva is a great place for a graduate student to be in the summer. Easily the best part of my experience living in Geneva was the vast body of interesting people who were around my age and shared many of my interests. Most people are there for a short time, and making friends is easy because everyone wants to hang out and travel together. In the short span of the summer, I made some amazing lifelong friends, all who will go on to have amazing careers.

Geneva is also a beautiful city in the summer, and there is a lot of fun to be had. Some of my favorite things I did in Geneva this summer include:

*Fete de la musique (in late June). The whole city turns into a huge concert with tons of various kinds of music in every park or street available. Without planning anything, we wandered downtown and heard a classical quartet, a Peruvian flute group, an American rock and roll cover band, the most awesome Jazz clarinet + guitar duo, an organ concert in Geneva’s famous cathedral, a full symphony, a mixing battle between two DJs in a park (they provided free headphones with which to tune into both tracks), a tango demonstration, and a punk band that was singing in English with the most hilarious french accents. There is really something for everyone

*Jumping off the bridge at Jonction into the river. Hanging out and barbecuing along the river in Geneva is what everyone in the city seems to do after work. To make the post-work hang out a little more interesting, my friends and I would set up camp, then walk up the road a little ways in our swimsuits, walk out onto a bridge, and then jump off the bridge and float back in the river until we reached our camp. The river water comes straight from the lake and is crystal clear. After the first couple bridge jumps, the nervous butterflies about jumping from a 15 feet up start to disappear.

*Gelato. While many people touted the superiority of the swiss ice cream brand, Movenpick, I personally staked out a delicious Italian gelateria that I think was miles better. Geneva is quite close to Italy, and this place, Manu, was run by Italians. My favorite flavor was mascarpone aux figues- it may have been the best ice cream I’ve ever tasted.

* Farmer’s Markets. Every weekend there is a farmers market on Saturday and Sunday in two different parts of Geneva. They are spectacular. Not only are there stands selling fresh fruit and vegetables, but there are also places selling freshly baked bread, freshly made pasta, cured meats, and wonderful cheeses. Geneva is a very international city with immigrants from all over the world, so there are also middle eastern stands selling olives, nuts and dried fruit, African stands selling freshly squeezed ginger juices and traditional snacks, and south American stands selling empanadas.

Top: SKMC students in Geneva (Christina Lewis, Rachel Folz, Jarett Beaudoin) Middle: Jumping off the Jonction bridge with my friends Bottom: Geneva from Saint Pierre’s Cathedral My homestay and perplexing things about Geneva

During my time in Geneva I stayed (with my boy friend) in the guest bedroom of a host family. The family consisted of the Mom- Benedicte- who had grown up and lived her whole life in Geneva, the Dad- Zorrino- who had grown up in Chad and moved to Geneva when they married, the daughter- Mallika- who was 15 and liked hanging out with her friends and sassing her parents, and the son Izzane- the most adorable 12 year old who loved eating any sweets in the house (usually bags of meringue cookies) before his parents came home from work. Only Benedicte spoke any English, so most of my communication with the family was through her, as my French is subpar.

We shared a kitchen and one bathroom for 6 of us, and though the apartment was crowded, the atmosphere was surprisingly harmonious. All of the family members took various vacations - to girl scout camp, to Germany for a class trip, to visit an aunt in , to visit family in Chad - so there was a lot of coming and going throughout the summer. The apartment was laden in beautiful artwork from Africa, and when it was Zorrino’s night to cook the house was stunningly fragrant with the smell of African food.

Our apartment was in a quiet neighborhood outside the city center, with a soccer field right outside where Izzane and his friends played after school. There was a grocery store within 3 minutes walking where I did most of my shopping. The most frustrating thing about living in Geneva is that everything closes ridiculously early, and nothing is open on Sundays. Our grocery store closed at 6:30, so once a week I would leave work early and rush in before closing to gather everything that I needed for the next couple days.

The other unfortunate thing about living in Geneva is the cost. Everything is expensive, from bus tickets, to food, to sunscreen (20$ for a few measly ounces!). Eating out was prohibitively expensive, so I almost never bought food out (with the exception of ice cream of course). Groceries were certainly cheaper than eating out, but it took some time to adjust to the fact that fruits and vegetables contain a lot less preservatives in Switzerland and go bad astonishingly quickly. You have to eat your produce within a day or two maximum of purchasing, lest you end up having paid an unreasonable amount of money for produce in vain.

The last perplexing thing about Geneva is their washing machines. While the city is French speaking, the washing machines are in German. Not only was it confusing to operate, but it also destroyed some of my clothes by washing out the dye somehow or totally ripping apart one of my shirts. This experience was strangely common among my friends living in different places. Fun fact: it is also technically illegal in most buildings in Geneva to do laundry before 7 am or after 10 pm, and it is illegal to do your recycling on Sunday. Hiking in Switzerland

While other interns and friends took many city hopping trips across Europe, I chose to spend most of my free time hiking, and being in Switzerland was the perfect place to be based. Within the Geneva region, I did two hikes. One was called Mont Salève, and is accessible by the city bus system- specifically the 8 but to Verneir Duoane. It was about a 2 hour hike up and because it is so close to the city it gives you a great view of Geneva, the Jet d’eau and the lake. The other hike in Geneva was on a mountain called Le Reculet, which is part of the Jura mountain range on the border of Switzerland and France to the north of Geneva. This hike was great as well, and involved wooded areas, big open fields with lazy cows, and cliffs and caves towards the top. It was also easily accessible by public transportation. I took the 18 tram to CERN, and then the Y bus to Thoiry (France) and hiked from there.

Apart from hiking in Geneva, I also took several day trips. I took a trip to Gruyere, which is a big draw for tourists due to its castle, chocolate factory, and cheese factory. I stopped by these attractions, but the best part of the weekend trip was a long hike called Gorges de Jogne, which went through a gorge, around a big lake, and through the countryside (with lots of cows). Another weekend I took a day trip to Zermatt where the Matterhorn is. I took a cable car up a ways then did about a 5 hour hike. The trails were beautifully marked and easy to navigate. I hiked around on the mountain across the way from the Matterhorn, which was great because I had a fantastic view all day. This hike was different than my others, however, because it had little tree cover, and was mostly rocky surrounding a glacier.

My favorite hike of the summer was the hike to Lac Blanc in Argentiere, France. Only about an hour car ride from Geneva, it was the perfect distance and location for a day hike. Argentiere is just 15 minutes up the road from Chamonix, which is where , the tallest mountain in Europe is located. I chose to hike across the valley from Mont Blanc to maximize my stunning views of the big . The mountain I chose though, was also nothing to scoff at, and the last hour of my hike was done in the snow and ice. I was expecting a beautiful lake at the top where I could go for a swim, but in reality lake Blanc was covered in 2 feet of ice. The terrain and the views were some of the most beautiful I have every seen though, and I would highly recommend the hike. I took an airport shuttle from Geneva, which dropped me off at the trailhead, and picked me up at the same place in the evening. After the hike we had 45 minutes to kill before my pick up, so we got beer from the Mont Blanc brewery and sipped it in the shadow of it’s namesake.

Top Left: Part way up the hike at Lac Blanc. Mont Blanc in the background Top Right: Hiking in Zermatt. The Matterhorn in the background Middle Left: Hiking in the Jura. Lac Leman (Geneva) in the distance Bottom Left: on top of Mont Saleve looking out on Geneva Bottom Right: Cows during the hike in Gruyere Contraceptive Supply Chain Management Protocol

One project I worked on this summer was designing and writing a protocol to strengthen contraceptive supply chains in low income countries. Below is the rationale for this project.

While there have been significant improvements in reducing maternal and child deaths in past decades, a significant proportion could still be averted with improved access to family planning. When working towards improving maternal health and achieving the Sustainable Development Goals (SDGs), expanding access to contraception will be one of the most cost- effective investments for preventing deaths in the coming decades. As of May 2015 there are an estimated 225 million women in developing countries who would like to delay or stop childbearing but are not using any method of contraception. The unmet need for contraception is due to many factors, which vary between different countries and communities. One of the most commonly cited barriers to increasing the rates of contraception use in low and middle income countries (LMICs) is a lack of access and supply chain failures.

A supply chain is the path that commodities take from the manufacturer, to the country of intended use, to the service delivery point, to the user. For a supply chain to successfully transport goods from manufacturer to user, a complex flow of information, finance and transportation is required. In a traditional “three-tier network”, an order must be placed from the service delivery point to a regional store, which procures goods from a central store. Alternatively, in a “two-tier network”, facilities can procure goods directly from a central store. This type of network has been shown to be more effective in LMICs where unnecessary steps complicate and impede supply chains. One of the challenges of supply chain management is accurately predicting the amount and type of goods to order at each tier of the network. This can be done with either a “push” or “pull” system. In a “push” system, the central or regional store determines how much of a commodity to send to facilities. In a “pull” system, local information about demand from facilities is used to determine the amount of commodity to be procured from a higher-level warehouse. A combination of these two systems is often used, as both have their advantages. Various studies show that contraceptive supply chains in LMICs benefit from a push system when there is a lack of dedicated and well trained staff to manage supply chain issues, but from a pull system when the system is well managed, supported by the government, and has a strong logistics management information system (LMIS).

A stock-out is the result of a supply chain failure. When a health facility does not have an adequate stock of a sought commodity that should be routinely available, clients are turned away without the care that they need. Contraceptive stock-outs are especially unfortunate because in rural and remote areas women face many challenges to reaching clinics or other SDPs, especially in non-emergency situations such as seeking family planning. If a woman comes to a health facility seeking contraception and is turned away due to a stock-out, it may be unlikely that she will return to receive the care that she seeks. This results in a restriction of contraceptive choice and diminished confidence in the healthcare facility. The lack of access resulting from stock-outs is a significant factor contributing to the unmet need for contraception. Therefore, contraceptive stock-outs have been identified as a major barrier to achieving global family planning goals by UNFPA, and the WHO.