On Public Health, Perception, and the Interconnectedness of Things

A Side Conversation With Masters of Public Health Candidate Hestia Rojas

By Editor Joyce Chen

When the White House failed to pass a new health care bill hell bent on eradicating former President Barack Obama’s policies back in March, the reactions were swift. For those like Hestia Rojas, who study and work in the field of public health, Paul Ryan’s decision to pull the bill before a vote was a very big, very visible win. The passage of the bill would have signified many changes to the American health care system, and for those working in the realm of public health, it could have meant not only a major cut in funding, but also a damaging message: that the government does not prioritize the health and well-being of America’s citizens.

To understand public health is to understand that everything is public health. The quality of our air and water is directly linked to a community’s overall physical health; proper education about gender equality and sexuality can help to ensure more informed decisions about sex; and understanding the cultural forces that necessitate transactional economies or reinforce stigmas allows health care providers to tackle issues more effectively. There are few industries and complexes that are unaffected by the public health industry, and so, much like a tower of precarious Jenga blocks, the shifting of one thing will inevitably affect another.   

 The Seventh Wave recently sat down with Hestia, who worked in Guatemala for two years through the Peace Corps, helping to bring sexual and reproductive health education to middle schoolers, prior to pursuing her Masters in Public Health at Columbia University. The field is changing swiftly, and the current administration’s attempts to reverse many of Obama’s policies signals a turbulent time ahead for those who are directly involved in the public health industry. In her words, facing the uncertainty of all these changes doesn’t mean giving up the fight for more equitable, accessible health care for all, however. Instead, it just involves “being optimistic and being hopeful and finding creative ways to deal with realities.” Read on to see what else Hestia had to say about public health, what’s at stake, and the intricate ways that it all ties together.

THE SEVENTH WAVE: Tell me a bit about your background. How did you get interested in public health, what interests you about it, and what is your specific focus within the field now?

HESTIA ROJAS: So I initially got interested in public health through my experience in the Peace Corps, and before Peace Corps, I really didn’t know anything about public health. Through the program, I ended up living in Guatemala for two years, and I took on a position as a youth specialist, working with adolescents at a middle school in a community and teaching sexual and reproductive health. I was really interested in education before, but hadn’t really worked on health at all. But while I was there, I just had some really personal experiences with adolescents struggling with different health-related issues; the teen pregnancy rate is really high in Guatemala, so I got a very firsthand look at what it’s like to live in a place where you’re not so certain if you’re going to make it out of your teens without having a baby.

I mean, I think that everyone should have control over their reproductive health choices, but I think the problem in Guatemala specifically is that there isn’t comprehensive reproductive health education in schools, and I think that’s something that all adolescents should be entitled to. And so I got really passionate about that, and that’s how I decided to pursue public health. A lot of my friends who were in the Peace Corps had studied public health, so they had either gotten their masters already in public health or knew that they wanted to pursue that afterwards. And so I applied to Columbia while I was living in Guatemala and just started once I got back and made that transition. It’s a new field, and it’s something that’s involved with a lot of different facets of what’s happening currently politically. But also, it’s something that people are not so aware of. And I think it’s very broad, so it’s difficult to explain sometimes, so I hope I do it justice.

TSW: I think that’s what I was going to ask about, how you define public health. Because if you say “health care,” most people associate that with going to a doctor. What’s my insurance like? That sort of thing. But if you say “public health,” people might think you’re talking about public services, though that’s clearly just one part of it. So what’s the best way to describe it?

HR: When people ask me about public health, my short way of defining it is that it’s really acting as the mediator between medical care and people. I think people automatically assume that because doctors are around and health care providers exist, that people are going to have access to the health care that they need and health care education and preventative services and all of that, but the reality is a lot of people can’t afford that care. And even for those who can afford that care, the providers do not always have the social skills that they need to be able to explain certain situations or conditions. Or people might not have the education and the background that they need to really bridge the gap between science and reality.

TSW: Ah, that makes sense. So medical providers know the medical terms and they know how to diagnose, they know how to prescribe things, but they’re sometimes lacking in the people department?

HR: A lot of public health is thinking about preventative health care services, and the thing is that I think we often focus on what you do once you’re sick and how you can get healthy after you’re sick, but the thing is, you really need to care before people become sick. For instance, if you think about the major diseases that are killing people, in this country, at least, they’re chronic diseases and mostly heart-related illnesses and stroke, etc. — and that’s a lot related to food and diet and exercise, and so those are things we have to think about before it becomes too late.

TSW: It’s such a cycle. It’s like, if you don’t know what foods to be eating or how to take care of your body, then you’ll get sick. And then if you get sick, and you don’t have the money to get treatment, then …

HR: Yeah, exactly. And I think a major part of public health is that recognition that a lot of what’s been done previously has focused on the individual. So if we talk about diet and exercise, in the past, it’s been: “Oh, what should you be doing. You should be eating healthier. You should be getting exercise.” But public health really aims to address things like, what are the structural factors that can enable people to engage in healthy lifestyles, or disable them from participating in those lifestyles? So for example, in certain communities, do they have access to healthy foods? Do they have safe spaces where they can work out and exercise? Are they being cued to exercise, and can they afford the foods that they should be eating? And that’s just one aspect of public health.

TSW: OK, I have a better understanding now because before, I was kind of like, OK, I know you’re dealing with public services, but how exactly? I didn’t realize that public health is the bridge between the medical community and the public.

HR: Yeah, there’s a lot involved with public health.One aspect is epidemiology, which is more like the spread of diseases and analyzing them from a more scientific perspective. Say with a certain disease like ebola, for example, how much can we expect it to spread in a given community given how the infrastructure of the health care system is in a given country? But another aspect of it is really addressing the health care systems and looking at how we can strengthen systems before diseases hit. And a third aspect — I’m in the population and family health department at my school — that’s more the social work-y side of it, in the sense that it is a lot of health care communication, and also, understanding promotion and communities. And figuring out how to best work in communities to empower people who have not necessarily had comprehensive education. Some may have had education and are still unable to afford access to health services.

In general, I think public health is just looking at how to empower organizations and how to bridge gaps, and a lot of public health focuses on the holistic health of people. Oftentimes, we’re like, “OK, we want to address, let’s say, unwanted pregnancies.” And so one solution is to provide condoms. But there are so many aspects that are feeding into people’s behaviors that it’s not just having access to condoms, it’s also having access to a quality education and it’s about having access to strong family relationships, and so all of these different things play a role; I think public health is trying to figure out all these determinants, and addressing those things to make sure people are healthy. So everything is public health, ultimately, and that’s what we learn in our classes.

TSW: I didn’t realize it’s a new field, also.

HR: Public health really started with the cholera epidemic, and people were initially given instructions like “Don’t be in the cold” and “Don’t eat these foods,” etc. so it was very individual-level approaches to solving health. But then they realized that cholera was being spread through the water system, and so they realized that they were only going to achieve population-levels of changes in health if they addressed the water system. So they created sanitation, and that’s the start of public health. But it’s interesting to think about where it’s going to go next now, because a lot of public health is debating what the role of the government is in monitoring determinants of health.

TSW: And everything is a determinant of health.

HR: Yes, everything from the ACA, and determining if the government should be involved in moderating the system so that everyone has access to health, to the EPA, is all a part of public health. So making sure that we are examining water sources in different communities and making sure that it’s safe, that’s all public health, because if people don’t have access to clean water, then that’s going to make them sick.

TSW: Right. Take Flint, for instance.

HR: Yeah, so we talk about all of that.

TSW: So when you say there’s different segments or different paths and concentrations, is that in terms of studying public health and the environment or public health and the infrastructure or …

HR: At my school, there’s the epidemiology department, there’s the health, policy and management department — they deal more with things like insurance and more domestic issues in terms of access to insurance and things like that — and then there’s sociomedical sciences, which focuses more on the determinants of health, so like, race and socioeconomic status, and how do those affect access to health care and lifestyles. And then there is environmental health sciences, which focuses on how the environment affects people’s health. And even though this isn’t a class within that department, I recently took an environmental justice advocacy class, and so now I sort of see everything’s related to the environment. And with public health being very affected by the communities in which people live and their access to safe water, I mean, even things like DAPL and the impact it has is indicative. There’s a lot of protests and movements around oil pipelines and things like that because it affects so many other aspects of health, so it’s not just like, land, but it’s also how it’s going to affect women who live in the communities and sexual violence and things like that. So there’s a lot of interconnectedness.

TSW: So tell me a bit more about your time in Guatemala. Tell me more about the specific issues that you were interested in, and what you were working on.

HR: What I’m most interested in is sexual and reproductive health. And so that looks at a lot of different things, like maternal and child health, making sure that moms are equipped to have babies, that systems are prepared for when things go wrong during deliveries. Making sure that babies are healthy when they’re born. That’s the maternal and child health component. But it’s also looking at pregnancy, and if people have access over their reproductive health choices and if they want to have children, are they able to do so? If they don’t want to have children, do they have the means to prevent pregnancy, and are they able to choose what they do? So not just providing condoms, but also looking at whether IUDs are available, or different kinds of birth control.

TSW: There’s so much to consider.

HR: Yeah. So it’s a lot. Then there’s sexuality and sexual identity and gender all included in that as well. Because all those things are interrelated, and if you don’t protect one, if you don’t advocate for one of those areas, then you’re going to end up impacting another.

TSW: Do you think there is a big misconception about how all of these things tie together?

HR: I definitely think so. I think especially if we think about funding and organizations that provide reproductive health services, people often think about abortion as a primary thing that they do, but there’s so much more. And a lot of it is related. Again, even looking at abortion is considering someone after she has become pregnant and doesn’t want to be pregnant, and how we address that before. And so I think such an important part of what we do with sexual and reproductive health is we try to address that as well, but also the pre part of it, which is looking at how we make sure that people have access to contraception so they don’t end up in that situation.

TSW: It’s cause and effect. If you aren’t properly educated, or have access to the education, then you won’t know what your options are. Or, you won’t know not to do X, Y, or Z, or …

HR: Yes, and it’s about education, but it’s also about access and stigma and discrimination. I think even though people are aware that different contraceptive methods exist, there’s so much that goes into it. So even looking at HIV, for example, it’s not really just a measure of how effective condoms are or condom distribution, it’s also about economic means, so a lot of the spread of HIV in Africa has happened, for example, because people have transactional relationships, and in order to sustain themselves economically, they have to take those health risks. So a lot of women know that HIV exists, and a large part of it is education, but at the same time, a lot of it is addressing these root problems that will lead to the spread of disease, which is often about economics and inequality.

TSW: Yeah, I was going to say that economics and culture play such a big role, but sometimes I feel like when we’ve got such an American-centric view, it’s hard to recognize that.

HR: I think even within the United States there is such a big issue in terms of access to health care and I mean, with the ACA still here, I hope that people will still have that access, but I think it’s something that we always have to think about, even within the U.S. — who is able to afford quality care? What is the type of care that we’re providing?

TSW: So tell me and this might be a big, big topic but with this administration, in terms of funding for so many important programs like Planned Parenthood etc., what are the bigger infrastructures or organizations that you think will be impacted?

HR: Phew! That’s a big question. I don’t even know where to start. I will just say that a lot of us were very concerned after the administration was sworn in on January 20. I think public health is very affected by the new administration, so I don’t even know where to start, to be honest. There are changes in funding, so with regard to Planned Parenthood, for example, we can expect that they’re not going to receive as much money, but on the other hand, other people are donating so much more, so they’ve actually received a ton that way. What I hear from my professors and from my peers in school is that the way that we fund public health is just going to be a bit more creative, and how we advocate has to change. And I think we do have to address these different fundamental opinions about health in the country, and so in some sense, it is encouraging us to address the way that we talk about health and the way that we explain how health is impacted.

I think America in general has this really strong sense of individualism as part of its culture, and this idea that the success you have in your life is directly related with what you put into it. It’s the same thing with health care. I think in a lot of ways there is still stigma and discrimination against people who are in poor health because the assumption is that they’ve done something to be unhealthy. And if they don’t have access to care, that it’s their own fault. But I think public health is really looking at the structural determinants to see how we can provide a system that cares for everyone.

TSW: Right, and it’s the same as anything else related to race and ethnicity and socioeconomic disparities. It’s not like everyone started out in the same spot.

HR: Exactly, exactly. I think from a personal perspective, what I’m most worried about is that the narrative of health is going to change. I’m worried that we’re not going to understand the underlying forces of health.

TSW: Is that because so many issues will be glossed over?

HR: Yeah, I think that things will be glossed over and stories will be told with dangerous perspectives. Just as an example, in funding for sexual reproductive health services — the majority of funding does not go to abortions. And there’s this myth that it does. What you’re really taking away by defunding these organizations is things like cervical screenings and things like that. Things that are what I consider to be basic care.

TSW: Right, because whoever’s in charge can create whatever narrative they want to tell the public, and it’ll be hard to change the public’s minds unless they see something different.

HR: I mean, I guess that’s always the concern. I think it has more to do with the culture than with who’s in charge and who’s in political power, but at the same time, I think it even comes down to what we’re teaching in schools. And at a very basic level, if the president is the leader of our country, then the administration does set the tone for our country, so by arguing that spending money on health care is something that is not necessary, we are influencing how people think about health care. So I think that’s my concern.

TSW: And people only know to seek certain services if they know it’s available or if they feel like they need it. For instance, if people hear that climate change doesn’t exist people who readily believe what they’re hearing will say, “Well, I guess it’s really not a problem then.” Then they won’t care about carbon emissions or how much they’re driving because they’ll just say, “Well, the government said it’s not a problem, so…”

HR: Exactly. I think even for the people who don’t necessarily believe that narrative, it’s still a problem, because we need to know that information. We need to have that information. If we can’t rely on government organizations to provide that to us, to do the science that’s necessary for these things, then it affects even those who don’t necessarily believe the narrative being told.

For instance, with birth control, I saw something recently on Facebook, which said something like 50 percent of men believe that they don’t need birth control, or that they’re not impacted by a lack of birth control.

TSW: So that to me is a giant hole in logic. This is where someone needs to step in and say, “Well, actually … y’all would have a bunch of babies running around.”

HR: Definitely. I think a lot of public health is talking about equity, and part of that is gender equity in sexual and reproductive health. I think that a lot of the narrative around sexual and reproductive health is often focusing on women, and that is why we have been so unsuccessful in a lot of ways, because we do need to include men in the dialogue of sexual and reproductive health to protect both the health of men and women.

TSW: And to make them recognize that there are repercussions when you take away birth control.

HR: Yeah, exactly, and everyone’s lives are impacted by this. I mean, unwanted pregnancies are not a great thing for a lot of reasons. For the economic strain on families and all that.

TSW: And then you’ll have kids who are getting cycled into a school system and it’s just a snowball effect from there. There’s so much to think about!

HR: There definitely is.

TSW: So you said that your biggest concern personally is the narrative of public health and how it’s going to change. Could you expand on that a bit?

HR: I do think that if we think about the budget and resources that are being allocated to organizations that work on health issues, it’s not much. And that’s a concern in a lot of ways. I think there’s also this assumption that individual health does not affect other individuals, but that’s such a lie — I mean, we’re all affected. Like, if my health is affected, it’s going to affect your health as well. Zika is a global issue. There’s a reason that this is spreading around the world. It’s not just in one area. The idea is that we focus on health systems everywhere because only then would we be able to protect all individuals. No one’s immune to an unstable health system.

TSW: So tell me a little bit about your experience in Guatemala. What kinds of issues did you deal with there that might demonstrate this interconnectedness?

HR: Sure. So I’ll give you one example. Suppose there was an adolescent Guatemalan girl who told me, “I’m pregnant, and I want to know how I can get rid of the baby. “ And suppose this girl was going to a really prestigious high school in Guatemala and was doing really well and had these great opportunities, and the reason she became pregnant was because her boyfriend told her that the second time they had sex, he didn’t need to wear a condom. There’s a lot of things playing into that scenario.

First, this boy probably knew very well what he was saying — if he knew he had to wear a condom the first time, he probably knew you had to wear it every time. So that speaks to education. It also speaks to communication. Like, who is talking to kids in these families about sex and about their health? And I think it also speaks to access to services. In that case, I would tell her that it would be best for her to have the baby, just because in Guatemala, abortion is illegal, so she would not have been able to abort the fetus, and so because of that, I would know that it would be dangerous for her to have the abortion.

And teenage girls’ bodies are not prepared to have babies. A lot of maternal mortality is related to girls’ physical ability to have babies, and if they’re getting pregnant at younger ages, that’s a concern, because their bodies are not physically able to have children. So I think there is accessibility of service included in that scenario, and then also, just thinking about access to economic means, that girl would probably have to quit school. So it’s a lot about the economy and all these different factors I’m bringing in, that’s what public health is. It’s focusing on all the different aspects that affect health and all the different ways that health affects other aspects of life.

TSW: There are so many different pieces. And I’m seeing more that literally, we need to look at what the actual outline of the different pieces of the puzzle look like, and then based on the community and their needs, decide how they all fit together.

HR: Exactly. And something that I do want to clarify is this is not something that happens in just Guatemala, this is everywhere. This is in the U.S. This happens all the times in the United States. And I met somebody else that I knew who said that she didn’t know anything about condoms, she was from the south, and she became a pregnant teenager and had the baby, and I mean, that’s in the United States. I think that’s a common misconception, that this only happens to ‘uneducated poor people’ living in the rest of the world, but no, this is happening in the United States, and it’s something we should be concerned about

TSW: With all these budgetary cuts, is there one segment that people who are studying public health now are saying, “This is what we need to bolster most?”

HR: I think we definitely talk about funding. Everyone is concerned about funding no matter what their field. So a lot of the conversations are about how can we use limited funding to accomplish some of the things we’ve been doing all along? We have to be creative about it. Also, changing the way that we talk about some of these issues. Making it understandable to the general public. And also, addressing opinions that are different than ours. It’s also about making those links.

So, for example, no matter what your view is about abortion, if you understand that the rate of abortion doesn’t change regardless of the laws, that might change how you view funding for certain organizations. People are going to get the same number of abortions as they do when there is a law allowing abortion. The difference is that the abortions are going to be unsafe. And so we’re going to see a lot more maternal mortality. And again, and I keep bringing it back to sexual and reproductive health, because that’s what I know, but I think if you’re talking to someone who is pro-life, you can explain this in a way where you talk about the impact on women. And I think abortion is a tricky one because people have really strong religious views, which is understandable.

A lot of people think, for example, that if we discuss sexual and reproductive health in schools that kids are going to have more sex, but that’s also been proven to be incorrect. So it’s a lot about  —  and hopefully, statistics mean something still — but it’s a lot about presenting statistics about these things so that people really understand that access to education doesn’t necessarily result in more sex.

I think there are certain things that we can agree on, no matter our political views or our religious beliefs, and I think that the way that we discuss public health needs to take into consideration the variety of opinions that are out there. And I think a lot of the discussions in class are how do we advocate for these issues that are important to us by addressing alternative perspectives? And by finding common ground? Yeah, it’s definitely tough.

TSW: I’m also curious about your personal reaction to the recent health care bill not passing,.

HR: I’m excited. I went on Facebook and saw that they were not successful in getting the votes they needed, so that was great — but at the same time, I just don’t know what to expect right now with this administration. This is one victory and I just wonder how long it will last. There’s a lot of ways to get around things and to affect people’s health and it’s not just this, but I am very excited and it’s a win and I think we should celebrate it.

TSW: It’s a very public win but it’s not like, “OK, we’re done. Moving on.”

HR: Right. But I think it’s good that it’s a public win and it gives people hope and I think this is one of the first circumstances of positivity that we’ve had in a while.

TSW: That’s true. So much within each industry that’s a win isn’t necessarily out there, and people might not understand why something’s such a big deal, but when this is something that’s so palpable, that makes a difference.

HR: And I think that’s one of the tricky things, and even I can’t explain it very well, because I’m not studying health systems, so I don’t know the intricacies of it. So it’s a win, but I think we need to talk about why this was even up for discussion. Why weren’t people assured that this is a thing that we should preserve? Why? And while it is heartening to see that people on both sides opposed this reform, and I don’t want to discredit that, at the same time, I think there’s still a lot to be done. I think it’s hard because I have a tendency to be a bit cynical about these things, and I don’t want to be, because I think part of being in public health is being optimistic and being hopeful and finding creative ways to deal with realities. So I think that we should celebrate this and be happy about it, but I think we should also discuss how we can better communicate what the ACA does, how it works, why it’s so important.

TSW: Right, and not just coast with each win.

HR: Yeah, and even in public health schools, I think that can be improved. Because I’m in public health and while I can sort of discuss some of the issues, I also don’t feel fully confident in explaining the intricacies of it. As a student right now, I never previously realized how important public health is, and obviously, that’s what I study, but at the same time, public health really is in so many aspects of our lives. It’s in our politics and the ways our society is set up, and as an example, I’ve gotten really into environmental justice recently, and that was something that I didn’t necessarily see as a determinant of health and equality. And now I definitely do. I see it as a centerpiece. And so for me, it’s so important to get that information out there.

So for example, with the Women’s March, which I attended back in January, there were signs about climate change, but there was no link between that and how it affects women’s reproductive health, among other things, and how environmental injustice does disproportionately affect women. And so that’s just one example, but I think that that’s something that the public health community needs to work on: showing links between things and finding a way to break down science and explain it in an understandable way.

Editor’s Note: The contents of this article do not reflect any position of the U.S. government or Peace Corps.

Hestia Rojas is a second-year Master’s student at the Columbia University Mailman School of Public Health. She is specifically interested in sexual and reproductive health, and currently works with the School of Nursing on several studies on symptom management of people living with HIV. Prior to grad school, Hestia served as a Peace Corps volunteer in an indigenous Guatemalan community, working as a youth advocate. Hestia is a graduate of the University of Southern California with a bachelor’s degree in communication. In her free time, she enjoys playing guitar, making art, running, and knitting.