GHJG Blog

Dr. Micaela Martinez is an Adjunct Assistant Professor in the Heilbrunn Department of Population and Family Health at the Columbia Mailman School of Public Health. An infectious disease ecologist, she earned her Ph.D in Ecology & Evolution in 2015 at the University of Michigan, followed by two years at Princeton and four years as an Assitant Professor at Columbia. She is now a member of the faculty at Emory University in the Department of Biology. Dr. Martinez's research aims to understand how ecology, structural determinants of health, immunology, climate change, and demography intersect to shape health and disease. Her expertise includes vaccination and transmission of epidemic-prone diseases, climate change and human health, structural racism and health. During the pandemic, Dr. Martinez has been working on how environmental racism and social inequities manifest COVID-19 health disparities, with particular emphasis on Black and Latinx communities in NYC. 

Tell us about your interests and the work being done at the Martinez Lab. Are there any discoveries (or lack thereof), that have influenced your current research?

Over the last nine months or so my lab has been focused on structural racism, particularly in New York City, and trying to come up with holistic approaches and policies for dealing with structural racism across aspects of society, particularly think about climate justics, maternal and infant health, health disparities, environmental issues such as chemical pollution, air pollution and defects within homes. What we've been doing is large data collection and data integration where we can think of new analytical tools for trying to quantify structural racism and how it impacts communities with the goal of then being able to use New York City's data as a template to look at structural racism more broadly across the country. 

In addition to my work on structural racism, I have two ongoing reproductive health collaborations. The first project is using data from menstrual cycle tacking appls to look at sexual activity and fertility and how that is structured seasonally. We have been studying 500,000 women from around the world from which we have data where they record daily their sexual activity, their menstrual symptoms, birth control use etc. Second, I have a collaboration with colleagues at MIT and Dartmouth focused on the composition of breast milk. My lab's contribution is thinking about the parts of the maternal immune system that moms pass to their infants via breast feeding.

What is your current research on birth seasonality?

Birth seasonality is this phenomenon that—even though humans can give birth all year around, we are fertile all year around, and can conceive year ‘round—when we look at data from anywhere in the world, whether contemporary or historical data, you can see that births are not equally distributed throughout the calendar year. It has been argued about for 200 years, why is this happening? Is birth seasonality due to differences in sexual activity or is fertility actually changing throughout the seasons? Fertility is notoriously hard to measure, especially when it comes to female fertility, and it is hard to measure the frequency of sexual activity at a population level throughout the seasons because that is very intimate data. 

With the health tracking revolution and digital apps we decided to take a stab at addressing this more than 200-year-old question. We took the simple approach; we know that conception is a combination of fertility and sexual intercourse, in particular, unprotected sexual intercourse. If we can nail down how much sex is being had day-to-day in a country, we can account for that part of the equation and mathematically back out the fertility rate since we know how many babies are being born. We found it was very clear that there was seasonal fertility. Based on our study of US, France, Brazil and the UK, fertility is elevated around the time of winter solstice in each country. 
 

How does this compare with quantifying structural racism? How do you think about measuring and data?

One of the things that set my lab aside from other labs in public health is that myself and the people that come into my lab are trained as ecologists and my PhD is in Ecology and Evolutionary Biology. Specifically, I worked on population ecology. Other people with my kind of background would typically study things like interactions between species or how populations change over time and wildlife. Largely when it comes to studying wild organisms we rely on thinking about the population as a unit and even though you might not be able to get data on every individual you can look at patterns at the population level, either across time or across geographic locations. That’s what we do with seasonal fertility but the same holds true when we think about structural racism. We have discrimination that individuals can and do experience and we can look at how individual experiences can manifest as population-level features, such as population health disparities, that differ among populations due to their unique composition of individuals. We can see that those population differences are manifestations of what is happening to the individual in that population. 

"We have discrimination that individuals can and do experience and we can look at how individual experiences can manifest as population-level features, such as population health disparities, that differ among populations due to their unique composition of individuals. We can see that those population differences are manifestations of what is happening to the individual in that population."

What are the tools and data sets that are most interesting?

There has been quite a call in the health disparities literature to come up with mathematical tools and statistical tools for quantifying structural racism as a system. The best working definition of structural racism is that it is the way in which society fosters discrimination through a set of mutually-reinforcing systems of inequity; these systems include inequity in education, housing, healthcare, economics, etc.  The important thing is that these systems of marginalization and discrimination reinforce one another. For example, communities of color or communities in poverty being underserved by the education system, if you do not have an educational foundation for viable employment then you have more poverty, which can lead to the ratcheting-in of poverty-driven health disparities. This whole system self-perpetuates. These health disparities can then feedback on the system. 

Recently, I have been proposing the idea that we can mathematically quantify structural racism as an ecosystem. If we can get data on health disparities whether this be food security, infant mortality, air pollution, defects in the home, we can see how tightly correlated they are to each other, then construct a quantitative picture of how things are interconnected. 

You joined Mayor Eric Adams’ Social Justice Commission last fall. Tell us how your recommendations will impact the lives of Black and Latinx New Yorkers.

Before I begin, one important point about the commission is that it is independent of the mayor and has no political affiliation, but we are making recommendations to the mayor. Our hope is if every single one of our recommendations is taken up by the mayor, and tackled by the city, that we can see a just city, where we have fairness, equity, and equal opportunities for all New Yorkers regardless of the color of their skin, disability status and socio-economic status.

"Our hope is if every single one of our recommendations is taken up by the mayor, and tackled by the city, that we can see a just city, where we have fairness, equity, and equal opportunities for all New Yorkers regardless of the color of their skin, disability status and socio-economic status."

Our policy recommendations range from ensuring that we have proper maternal care across the city, buffers from climate change, green space access, protections for freedom of speech and we address the criminal legal system. It is a tragedy that NYC has really strong health disparities in communities of color. We have really strong disparities in the infant mortality rate. We have some neighborhoods with 20 times more childhood asthma hospitalizations. This is unacceptable.  

A city is only able to do so much in terms of changing overall legislation. A mayoral office does not have full, complete power, but it does have some power and a budget. As a commission, we asked ourselves, how do you go in with limited resources and limited power to attack a big problem? Last semester when we were working on those policy pieces, myself, Terry McGovern and others in the commission were thinking about big picture interventions. We needed to be able to measure the existing disparities, have a target for addressing it and a metric for measuring how well we are doing at addressing it and the downstream effects. 

In addition to New York, environmental exposures disproportionately affect Black and Brown people in states like Mississippi and Louisiana. Describe your experience as the moderator of the Scientific Evidence panel at the December RJ/EJ panel, where those states were the focus. What do you think is the most effective way for scientists and advocates to work together to address the poor reproductive outcomes for Black and Brown women?

For me it was a life changing experience, especially as a scientist because it really highlighted how so much of science is done backwards. My first long-term research project was on seals in the arctic. We had to work carefully with Indigenous populations, anything we did we had to get permission. We relied heavily on Indigenous knowledge. So being someone who had experience having research tied into community, this was very visceral. There have been so many years of activists led work. There has been too much siloing between the research community and the research agenda versus what really needs to be done on the ground and what has already been pushed forward by activists. I think that scientists need to start learning to follow the lead of the activists, have them set the agenda.

"There has been too much siloing between the research community and the research agenda versus what really needs to be done on the ground and what has already been pushed forward by activists. I think that scientists need to start learning to follow the lead of the activists, have them set the agenda."  

Following the meeting, I have now been a part of a working paper to structure science to study chemical pollutants and removing pollutants from the market. In this country the process of things is no regulation or little regulations for these chemical companies. All of the chemical manufacturing gets rolled out. It is not until there is sufficient harm that we evaluate if there was enough harm done to remove a chemical. 

What do you have planned next that has you excited?

Ongoing research that I’ve had has been looking at seasonal changes and circadian rhythms in the human body, so how our bodies not only change throughout the seasons but how they change during the day and night cycle. Right now, I am in the process, at Emory, of building a clinical facility. It is going to be what is called a Chronobiology facility. Chronobiology is the study of biological clocks. The facility is going to be equipped to do mother-infant dyad studies and adult studies where we can look at all kinds of aspects of the body thought the seasons and day and night. Individuals can stay for multiple days or a week at a time, where during that time we can take biological samples and keep them in constant conditions. 

One thing that ties into the justice work that I have been interested in doing for a number of years is trying to understand why childhood asthma exacerbations can happen in the early morning hours, in that transition period from nighttime to wake-up time. There have been proposals that it has to do with circadian rhythms. We know that childhood asthma is shaped by many environmental conditions, whether there is a gas stove burning, whether there is air pollution, whether there is mold in the home. There are all these environmental and structural racism components, and potentially there is this body clock component to it too− I want to use my new clinical facility to do this work. My new facility will allow me to design studies to understand how our environment and biology interact to shape our health. Unfortunately, our environment has a lot of negative components to it, especially for marginalized people, but if we can understand how our environment gets under our skin and impacts our health, then we may be able to policy forward that protects people. 

This interview was conducted by Ashley Williams, a Communications Officer in the Heilbrunn Department of the Population and Family Health and Clarisa Bencomo, Associate Director, Global Health Justice and Governance Program. It has been edited for length and clarity. 

On October 18, 2021, the Heilbrunn Department of Population and Family Health (PopFam) hosted a webinar on global vaccine equity featuring Yoke Ling Chee, Executive Director of Third World Network, Achal Prabhala, Coordinator of AccessIBSA Project and Dr. A. Kayum Ahmed, Assistant Professor in the PopFam Department. The discussion, moderated by Department Chair and Global Health Justice and Governance Program Director Terry McGovern, highlighted elements of the global health architecture that drive vaccine inequity and health inequity more broadly. Panelists challenged audience members in the US to advocate for change in US policies and to rethink their assumptions about the role of the university in the global health architecture.

Currently, 2 billion people lack access to essential medicines and 15% of the world’s population consume over 90% of the world’s pharmaceuticals. This huge imbalance, which Chee brings to our attention, has created a serious human rights issue. In the U.S alone 15 million vaccines were discarded in a five-month time span, from March to September of this year. And the issue doesn’t end with vaccines: addressing the pandemic requires diagnostics, therapeutics, medical devices, and protective supplies, all of which may be subject to intellectual property agreements that limit who can produce them and at what cost.

What are the TRIPS Agreement and Waiver?

The WTO Trade-Related Aspects of Intellectual Property Rights (TRIPS) Agreement, effective on January 1, 1995 is “the most comprehensive multilateral agreement on intellectual property.” This agreement allows members of the WTO to place extensive protection on intellectual property (IP), including copyrights, trademarks, and patents. TRIPS “flexibilities” allow for member countries to negotiate compulsory licenses, but they must be negotiated on a patent-by-patent basis, creating huge obstacles for governments that attempt to do so.

Yoke Ling Chee cited Malaysia’s experience with HIV and Hepatitis treatments to show the limitations of such flexibilities. “Each flexibility is product by product, and we had so much pressure. We had visits from the US Ambassador, the Trade Representative flying over, the pharmaceutical trade industry putting so much pressure on the Malaysian government….Every time you use a flexibility in the TRIPS agreement you get so much pressure.”

In October 2020, in response to the COVID-19 Pandemic, the Indian and South African governments proposed a waiver that would allow countries to manufacture locally, COVID-19 diagnostics, treatments, and vaccines by temporarily removing IP rights protection. On April 30, 2021, PopFam’s Global Health Justice and Governance Program (GHJG) and partners signed a letter urging President Biden and his administration to support the temporary the waiver proposed by India and South Africa. The following week, on May 5, 2021, the Biden administration announced its support for a waiver that only removes IP protection from vaccines. European countries, led by Germany are opposed to the waiver. Yoke Ling Chee called on Americans to keep pressure on the US to expand its support for adoption of a full waiver and bring pressure on the EU. “The US is rather silent after that big [May 2021] announcement and we know there is continuing to be opposition from Pharma in the United States and therefore the campaign and the activism in the US is absolutely crucial,” she said.

"For us around the world, this is probably historically one of the most unprecedented social mobilizations around health…we cannot pass up the chance to not just solve the problem with suspending temporarily but to rethink the intellectual property regime that is unsustainable, violates the human rights of everyone, not just for me in the South, which is pretty inevitable, but also for those in the North."

The Global Health Architecture

Professor A. Kayum Ahmed challenged us to reframe the vaccine discussion to one of power in the global health architecture. “The vaccine has evolved in some ways from being a health technology that should be equitably distributed to becoming an instrument of power to decide who will live and who must die,” he argues. Citing a Chatham House study that found that  90% global health actors are headquartered within Euro-America, contributing to a hierarchy of power where profit-driven Pharma has in many ways displaced the World Health Organization (WHO) to become the center of the global health system during the pandemic. Asserting that civil society has failed to apply the lessons of earlier movements, he asked us to think about the world without Pharma, reconsider the role of the university to ensure its R&D is not sold off to the highest bidder, and challenged us to find ways to support manufacturing in the Global South that don’t simply replicate the existing Pharma model.

Achal Prabhala brought us back to the urgency of the moment, the challenge of producing at least 10 Billion vaccines, which can only be achieved if the US and German governments “dismantle a fierce web of monopolies” so that every vaccine manufacturer in the world can contribute. He highlighted the divergence between American activists, who often focus on mRNA vaccines, and activism in many poor countries like India, where mRNA vaccines are completely unavailable, that is focused on any vaccine that works. Sinovax, Sinofarm, and Cuban vaccines have less efficacy than mRNA vaccines, but there is hard data that all these vaccines have done their job and are easy to make, so the choice is not mRNA vaccines or nothing. He also challenged claims in the US that mRNA vaccines are hard to make, saying they are easier to make than any other vaccine in the history of the world, and there are dozens of companies in India that could make them if only the multiple, multiple layers of monopolies were broken.

How do we achieve Global Vaccine Equity?
According to Dr. Ahmed we need to decolonize the global health architecture to delink it from the Euro-American geography, white supremacy, patriarchy, and capitalism.

• Intellectual property rules need to be revised and reinvented. As Achal Prabhala mentions mRNA vaccines are easier to make but largely unavailable where he lives (India) and most countries in the world.

• We need to move away from the increasingly dominant Pharma models, which may be difficult as the industry is enabled by the most powerful governments in the world.

• We need to realize that this work will take time. Yoke Ling Chee reminds us that as these policies have been in place for over 20 years. PopFam Department Chair and GHJG Director, Terry McGovern suggests that foundations spend more time on issues that are long term. Foundations frequently change the issues they work on, often proving to be extremely destructive.

• “History has shown us the power of civil disobedience”. McGovern reminds us that there are plenty tools and tactics available, civil disobedience being one of the most effective.

To watch the Global Vaccine Equity Recording, click here.

Dr. Kelli Stidham Hall is an Associate Professor in the Heilbrunn Department of Population & Family Health at Columbia University's Mailman School of Public Health. She also holds the roles of adjunct Associate Professor with tenure and former Founding Director of the Center for Reproductive Health Research in the SouthEast (RISE) at Emory University, and serves on the Board of Directors of the Society for Family Planning, Editorial Boards of the Maternal Child Health Journal and Contraception, and the Executive Committee of the National Medical Committee of Planned Parenthood Federation of America. Previously having received a PhD from Columbia, a postdoctoral fellowship at Princeton University, and a NIH "BIRCWH" K12 Faculty Career Development Award at the University of Michigan, Dr. Hall's research program uses social justice and health equity perspectives, multi-level and biopsychosocial frameworks, and interdisciplinary methods to study the social determinants of maternal health and health disparities in the U.S. and Africa.

You started your career in clinical practice and now are entirely research focused. How and why did you make that transition?

My nursing background is the lens through which I see the world, and that has stuck with me and guided how I approach science, including a very interdisciplinary focus. I became interested in women’s health and reproductive health while training as a family nurse practitioner. During my clinical rotations, I became very interested in the role of evidence-based practice in addressing health and health inequities for socially disadvantaged populations in my native state, Kentucky. In my opinion, traditional medical models have often failed to account for the intersectional dimensions of women’s health, wellbeing and lives. For instance, I noted in my early work that a young woman’s mental health, substance use history, or social context are typically ignored in conversations about her sexual and reproductive health issues and needs. I became very interested in a more holistic approach to research in women’s health. I pursued a PhD to address what I saw as a salient gap for women in communities like that in which I grew up. I completed my PhD at Columbia, and was fortunate to have a diverse set of multidisciplinary mentors in the School of Nursing, the School of Public Health, including PopFam [Population and Family Health], and the Department of Obstetrics and Gynecology in the Medical School. So my training and experience was highly interdisciplinary. During my PhD, I maintained a clinical practice; first at an intensive family planning clinic in New York City, then later at Barnard College Student Health Services, and a private OB/GYN practice. In my practice, I noticed the ways in which contraceptive behaviors were influenced by young women’s mental health symptoms and thus my dissertation study took shape. I wrote and was awarded a NIH F-31 predoctoral training grant to support my dissertation, which was excellent career development opportunity at the time and from a grantsmanship perspective, served as an early and solid foundational experience.

You describe your research as intersectional and interdisciplinary. What has that looked like in practice?

When I was at Princeton University for my postdoctoral research fellowship, I started thinking more about the social determinants of health (SDOH), considering access to health care and service utilization, population health disparities, and the ways in which structural and social factors like health policy, sexual education, religion and others impact maternal health, especially for adolescent and young women in the U.S. Later, as a faculty member at the University of Michigan School of Medicine, I began to draw connections between the SDOH and mental health dimensions of my research program.  Psychological stress, the ways that stress gets under the skin, and the impact of stressful life experiences and the adverse social context of stress shape biological and psychological functioning emerged as an increasingly important focus of my maternal child health research. I was largely focused on reproductive outcomes during adolescence and young adulthood, including pregnancy and fertility. One of my Society of Family Planning-funded studies in partnership with my in-country collaborators in Ghana examined how adverse social exposures and adverse life events, including stigma and discrimination, influences adolescents’ sexual and reproductive health experiences in Sub-Saharan Africa. Later, with my transition to a faculty role in the Rollins School of Public Health at Emory University, I was awarded a NIH K01 grant to advance my stress research, focusing on novel applications of biodemography to family planning. As part of this grant, I conducted a series of secondary analyses of National Longitudinal Study of Adolescent to Adult Health (Add Health) data focused on the influence of social stress, adverse life events and depression on unintended pregnancy rates and disparities. As part of the K01, I also led an original community-based longitudinal pilot study of a cohort of 200 young women in Atlanta Georgia, in which we collected and analyzed a range of biological markers of stress and fertility and psychosocial measures of health and wellbeing.

In my early tenure at Emory, I was among a few researchers across the nation invited to envision, develop and implement new regional-based research programs for engaging local community partners to build a scientific evidence base on the structural and social determinants of reproductive health care access, service delivery, outcomes and disparities in understudied areas in the U.S. Along with a stellar team across the university, I launched the Center for Reproductive Health Research in the South East (RISE). Building RISE and working with that team was among the most rewarding moments of my career to date and was so much fun and also brought so many important lessons learned in partnering with communities and translating evidence for social and policy change. We initiated the center with six large projects, and all of them tackled, to some extent, the ways in which policies in the Southeast drove systems-level responses to reproductive health service delivery, and community- and patient-level experiences with access to care for people in our neighborhoods and surrounding states.

How has your experience creating RISE impacted your work today?

I learned a tremendous amount through building and leading RISE, most importantly about policy-relevant research and engaging with community partners, letting the research be driven by the needs and priorities of the communities and organizations who serve them. Evidence is urgently needed to inform more supportive, positive, proactive and equitable laws and programs, particularly in the US. We’ve seen how powerful scientific evidence can be, for instance since the Supreme Court’s decision on Whole Women’s Health and TRAP Laws [restrictions targeting abortion clinics and healthcare facilities that offer abortion services, including stringent guidelines for facilities and reporting]. In working in Georgia, Alabama and Mississippi, which have experienced a multitude of legal threats to abortion rights and access, and engaging with clinical and community partners there, I began to understand the notion that research can and should be credible, insightful, and useful for the people we care about. This is why we (academic-based researchers) should be pursing this work – and it might benefit from a paradigm shift of “how” we do the work, which is perhaps different way than our traditional models.

In working in Georgia, Alabama and Mississippi, which have experienced a multitude of legal threats to abortion rights and access, and engaging with clinical and community partners there, I began to understand the notion that research can and should be credible, insightful, and useful for the people we care about.

I was initially trained to believe in medicine and science as truth. Then, when one has the experience of serving as expert public health testimony in legislative hearings for restrictive abortion laws in Georgia, for example, and other testimony is debunking hundred years of medical and scientific knowledge, one gains new perspective on how policy making works. For some people and decision-makers, evidence is not simply defined by science, but rather is equally or even more informed by values and norms. This more nuanced understanding of what it takes to change hearts and minds has only strengthened my commitment to advancing interdisciplinary approaches for policy evaluation, evidence production and translation. That’s how we can move the needle on some of these really complex, controversial and cross-cutting, issues of our times, not just reproductive health or maternal mortality, but public health crises like climate change, the opioid epidemic, or COVID-19. My community partners often stress the need to better harness mixed methods approaches, the power of coupling scientific facts with testimonies of lived experiences of real people, and the importance of representing data collected from within, and even by, organizations and stakeholders centered in their own contexts. It’s our job as researchers to figure out how to more effectively partner in order to help shift the paradigm so that our work has greater real-world impact. The Global Health Justice and Governance Program has been applying such innovative models successfully for some time, as have many Pop Fam faculty.

My community partners often stress the need to better harness mixed methods approaches, the power of coupling scientific facts with testimonies of lived experiences of real people, and the importance of representing data collected from within, and even by, organizations and stakeholders centered in their own contexts. It’s our job as researchers to figure out how to more effectively partner in order to help shift the paradigm so that our work has greater real-world impact.

What research projects are you currently working on?

At this stage in my career, I am working to align and synergize two major research paths: 1) the social and structural determinants of maternal health inequities, and 2) the intersections of women’s reproductive, mental, behavioral and social health.  Since even my doctoral program, I saw Pop Fam as being an ideal fit for my work and interests and so I was beyond thrilled to return to Columbia in 2020. My works nicely complements our Global Health Justice and Governance and Averting Maternal Death and Disability programs and I have been eager to build collaborations with faculty working in those programs.

Since joining CU, I have submitted several relevant NIH, foundation and internal grant proposals to advance my program in these areas. One focuses on state-level economic support laws, including those addressing TANF [Temporary Assistance for Needy Families], EITC [Earned Income Tax Credit], minimum wage, childcare and development funds, and free community college and variations in those state laws across the entire U.S. over the last two decades and the impact of those laws on maternal mental health outcomes and inequities. I’m also focused on state-level laws that govern access to reproductive health care, particularly insurance-related policies including Medicaid Expansion, and how those policies may alleviate or perpetuate disparities in maternal morbidity and mortality. In conversations with my local and national advocacy and policy partners, for example Center for Reproductive Rights, ACLU, Sister Love, Black Mamas Matter Alliance, and others, I have heard clear priorities in regards to economic justice, access to care and maternal morbidity and mortality. I hope to partner and help contribute research to these gaps.

In line with my clinical background and interests in integrated care, I’m also developing substance use-related implementation science projects in partnership with several national healthcare organizations, including Kaiser Permanente and Planned Parenthood Federation of America, in collaboration with researchers at Columbia, Emory, Stanford, Harvard, and Research Triangle Institute. In the former project, we are investigating structural and social barriers to integrating substance use care cascade services in obstetric clinics for pregnant and postpartum women who use drugs. We are particularly interested in the ways in which socioenvironmental influences shape the ability of systems to produce more equitable, accessible substance use disorder (SUD) services and impact maternal morbidity outcomes and disparities for SUD patients. In the latter project, we are investigating a novel telemedicine-based alcohol and other substance use SBIRT [screening, brief intervention, referral to treatment] implementation model. This work builds upon some of my early efforts to integrate mental health care into family planning clinics with Planned Parenthood.

Much of your work focuses on social and economic factors that are markedly worse for young people, people of color and socioeconomic disadvantage, and women since the pandemic. How has your thinking shifted compared to a decade ago?

We’ve learned a lot about socioeconomic drivers of health inequities, particularly during the transition from adolescence to young adulthood and social mobility. While some work in this area isn’t new, the ways in which the gap between the rich and the poor continue to divide us, especially in this country, and the ways in which racism contributes to , have only become more clear in the face of the pandemic. I see our job as academic-based researchers as being in a position to advance “rigorous,” innovative, paradigm-shifting ways to study the SDOH. Multidisciplinary fields of scholarship, for instance implementation science or community driven research, have advanced (in some dimensions) rapidly and lend themselves well to some of these refractive public health issues. Yet in many cases, they have not been formally or comprehensively applied. I see these as prime time opportunities. As academic researchers and institutions engage in these conversations, so are funding agencies now trying to evolve and accommodate new collaborative approaches for improving population health, grounded in the lives and communities of those we serve. Thus, I see now as an ideal moment, or perhaps better late than never, to be unafraid to ask bold questions and pursue methods and answers that may be historically uncomfortable for academic-based researchers.

Thus, I see now as an ideal moment, or perhaps better late than never, to be unafraid to ask bold questions and pursue methods and answers that may be historically uncomfortable for academic-based researchers.

This interview was conducted by Sofia Herron Geller, an undergraduate intern in the Global Health Justice and Governance Program. It has been edited for length and clarity. 

Emily Maistrellis is a Senior Program Officer for the Global Health Justice and Governance Program, where she conducts mixed-methods, policy-oriented research on barriers to and facilitators of sexual and reproductive health and rights and justice in marginalized communities. Emily has an interdisciplinary background in anthropology, public health, and human rights; and has worked in Sub-Saharan Africa, Asia, and the Middle East. Since 2017, she has managed a multi-country study on the impact of the expanded Global Gag Rule on access to and provision of sexual and reproductive health services in Kenya, Madagascar, and Nepal. Prior to joining Columbia, she held positions at the FXB Center for Health & Human Rights at Harvard University, Boston Children’s Hospital, and Jhpiego; and earned a Master of Science in Public Health from the Harvard T.H. Chan School of Public Health.

How did you become involved with the Global Health Justice and Governance (GHJG) program?

I entered the department about a year before Global Health Justice and Governance (GHJG) was formed, and was hired to implement the research on the Global Gag Rule (GGR), which turned into the inaugural research project of GHJG. It represented something a little different in that it included a blend of people from across the department who hadn’t explicitly worked together before. This is similarly emulated in GHJG, which is bringing together experts from across the school, along with viewpoints from different regions of the world, relationships with civil society partners, and different lenses through which we might look at policy and governance.

What draws me to the GGR project is that it’s “research plus”: the data is immediately relevant for advocates and policy makers here [in the US] and abroad. In addition to my work as a researcher, I’ve been involved in sexual and reproductive health advocacy at the state level, worked as a birth doula for several years, and was a case manager for the New York Abortion Access Fund.  In the months before joining Columbia, I was really feeling the weight of political changes in the US that threatened women’s health and rights, and felt called to work that would give me a space to do something about that. For a lot of us working in sexual and reproductive rights, there was a huge amount of uncertainty in 2017. It was a tough time.

What is the global gag rule?

President Ronald Reagan first put the Global Gag Rule into practice in 1984 and it has since been reinstated by every Republican president and rescinded by every Democratic president since. Under earlier versions of the Gag Rule (before the Trump presidency), if a foreign nonprofit organization received money from the US government to do family planning work, they were prohibited from providing abortion as a method of family planning, counseling to women on all pregnancy options including abortion, referring women seeking abortion care, or advocating for the liberalization of an abortion law. In 2017 the Trump administration expanded the policy to encompass a broader pool of funds—US global health assistance rather than only family planning assistance—so that in the last couple of years, the policy really branched out to affect new organizations, new kinds of healthcare services, new countries, and even non-US government donor funds.  

What is GHJG doing about the global gag rule?

Our project works with three research institutions in Kenya, Madagascar, and Nepal to tease out how the GGR policy impacts the delivery of sexual and reproductive health services as well as the make-up of a health system in those countries. We looked at the impacts on providers, nonprofits, and clients that sought sexual and reproductive health services. We chose those countries because they all receive large sums of US government global health assistance, but they have varying abortion laws and contexts for public health infrastructure and advocacy. 

Our partners—the African Population and Health Research Center (APHRC) in Kenya, the Center for Research on Environment, Health and Population Activities (CREHPA) in Nepal, and L’Institut National de Santé Publique et Communautaire (INSPC) in Madagascar—were really key to our strategy in each country, and we looked to them to guide our methodological approach. We started by working with trusted stakeholders to host meetings in capital cities, where someone from our team was there, our research partner was there, and we held discussions with service delivery organizations, women's groups, human rights groups...we really tried to bring as many people together as we could to share our goals and to ask specifically, “given what you know, what do you think are the most important questions we should be trying to answer?”

In each of the three countries, our findings surface pathways through which the GGR fractured health care systems. For example, in Nepal and Madagascar, the GGR led to decreased access to contraception and the termination of rural outreach services in some areas. And in Kenya, NGOs reported having to choose between implementing HIV projects and providing comprehensive sexual and reproductive health services. In all three countries, public sector providers and clients were hindered by the GGR. This is important to recognize, as the policy ostensibly affects foreign (meaning non-US-based) NGOs, not governments.

“We really tried to bring as many people together as we could to share our goals and to ask specifically, 'given what you know, what do you think are the most important questions we should be trying to answer?''

The Biden Administration recently rescinded the global gag rule. What does this mean for you and your partners' work going forward?

We are hopeful that our research findings will help advocates in the US push to finally permanently repeal the GGR so that it doesn’t creep back in a new form under a later administration. Policy advocates in Washington have already made the Global Her Act, which would permanently repeal the GGR, a priority this year.

We are also seeing greater demand from civil society organizations for evidence to help them in their advocacy to improve sexual and reproductive health in all the countries where we’ve done research. We co-chair an interdisciplinary, international working group of researchers working in academic, advocacy, and service delivery institutions, who came together in solidarity at the outset of the expanded GGR, saying “we want to ask complementary questions and build an evidence base for change, we want to do this together.” Going forward we will be working to track how the GGR recission is being implemented, and build the evidence base for what new policies need to be in place to address the harms the GGR created and to ensure access to safe abortion globally.

“It’s well established that counseling on all reproductive health options is essential to decision-making, bodily autonomy, and for future life chances; and this gag rule prevents providers from delivering evidence-based care"

In addition to the GGR, GHJG is starting research on what’s become known as the “Domestic Gag Rule.” This Trump era policy changed Title X, the federal program that subsidizes family planning and reproductive health services for low-income individuals. The Trump administration change says that Title X providers cannot provide counseling on or refer clients for abortion care, and must create and maintain physical separation of abortion care from Title X service delivery.

Unlike with the GGR, the Biden administration initially requested a review of the Title X changes rather than a repeal, and in April published new proposed regulations to replace the Trump era regulations (which remain in place to date). It is crucial for these policy making processes to be based on strong evidence of the real-world impacts of the Domestic Gag Rule. It’s well established that counseling on all reproductive health options is essential to decision-making, bodily autonomy, and for future life chances; and this gag rule prevents providers from delivering evidence-based care. However, there is limited research documenting the harms of the Domestic Gag Rule over the past 3 years.

We are currently working with sexual and reproductive health service providers and community-based partners in three states—Maine, Wisconsin, and North Carolina—to help capture what is going on in their states and how the Title X changes interact with other policies to advance or undermine sexual and reproductive health and rights. We chose these states in particular because they represent a range of policy contexts for health equity and abortion. We’ve been fortunate to find really strong partners in each state—like Maine Family Planning, Health Equity Alliance, and the Foundation for Black Women’s Wellness--and we are working together with them to hone in on research questions that are meaningful for their programming and advocacy, and that also shed light on bigger questions that will be helpful for advancing sexual and reproductive rights in other states too. It is really exciting and timely research.

This interview was conducted by Sofia Herron Geller, an undergraduate intern in the Global Health Justice and Governance Program. It has been edited for length and clarity. 

Jennifer Britton, MPH is a 2019 graduate of the Heilbrun Department of Population and Family Health. From 2017 to 2019, she worked as a research assistant on the department's multi-country, mixed methods study of the Global Gag Rule's impact on access to and provision of sexual and reproductive health services. 

In Homabay, Kenya, an increasing number of young, vulnerable women are turning to unsafe and clandestine abortions. This is following the recent closure of the local Family Health Options Kenya (FHOK) clinic, a branch of Kenya’s oldest provider of sexual and reproductive health (SRH) services. The impact is being felt throughout the community.

“With the closure of FHOK clinic, unsafe termination of pregnancies by the teens in Homabay slums is now getting out of hand. We are worried this practice could lead to more deaths if nothing is done,” says John Ogweno, a nurse at the Homabay Omega Foundation, a community health and development NGO.

Like many communities around the world, Homabay has been impacted by the Global Gag Rule (GGR; sometimes referred to as the Mexico City Policy), a US foreign assistance policy that restricts the family planning activities of foreign non-governmental organizations (NGOs) that accept U.S. government (USG) global health assistance.

Foreign NGOs subjected to the GGR are given a choice: sign a pledge to refrain from counseling, providing, or advocating for abortion as a method of family planning, even with the support of non-USG funds, or forgo all USG global health assistance.

THE GLOBAL GAG RULE, EXPLAINED

Earlier iterations of the policy, implemented by Presidents Ronald Regan, George H.W. Bush, and George W. Bush, applied solely to U.S. foreign assistance for family planning—approximately $400 million in 2001. President Trump expanded the scope of funding and activities subject to the policy; the majority of global health assistance going to foreign NGOs – not just family planning – now faces the GGR. Approximately 9 billion dollars in funding may be affected.

Research has demonstrated that past iterations of the GGR had significant impacts on sexual and reproductive health by reducing access to family planning services, weakening HIV/AIDS prevention, and even increasing abortion rates in impacted areas – and there is no reason to think that the impact of this expanded policy will be any less harmful. These and other findings from the George W. Bush era GGR define a clear causal pathway from the GGR to poorer health outcomes for women: as the policy forces SRH programs to shut down or silo themselves from each other, access to family planning decreases, particularly for the most vulnerable populations – leading to more unintended pregnancies and fewer accessible resources to address them.

So why would any organization certify this policy? For many foreign NGOs, they are left with little choice. While refusing to sign the GGR means maintaining organizational autonomy, it also means forgoing financial support from a significant global health donor. For some, this means losing over 50% of their family planning budget.

As the largest provider of global health assistance, the U.S. government has the power to cause immense damage to health programs worldwide by withholding and dictating the use of these funds.

DIFFERENT ABORTION LAWS, PERSISTENT IMPACT

National context is particularly relevant to gauging the impact the GGR will have in a particular country. Abortion laws vary widely around the world, from highly liberalized to extremely restricted. Nepal, Kenya, and Madagascar provide an example of this variation. While Nepal’s law is the most liberal of the three, with abortion available on demand up to 12 weeks’ gestation, Kenya allows abortion in a broadly interpreted law that only makes exceptions for the life or health of the mother, and in Madagascar, abortion is illegal.

The GGR includes exemptions in the cases of rape, incest, or to save the life of the pregnant woman.  Post-abortion care is also allowed, as are counseling and referrals in certain limited situations. One might assume that a country with highly restrictive abortion laws – one that does not even allow for these exemptions under its own statutes – would not feel an impact from the GGR. In other words, if abortion is illegal in a particular country, shouldn’t that country be immune to a policy that is meant to restrict funding for organizations that provide abortion-related services?

Madagascar is particularly dependent on US government funds, which account for 88% of their Official Development Assistance in reproductive health. Marie Stopes International (MSI) is the leading NGO provider of women’s SRH services, including family planning counseling and methods and STI services. MSI abides by the laws and policies of Madagascar and does not provide abortion. However, MSI—which operates in 37 countries – has chosen not to certify the GGR, given its organizational mission to support SRH, including safe abortion where it is legal.

As a result, the organization as a whole faces a funding gap of $50 million, the effects of which ripple throughout all the countries they serve. In Madagascar, this has already resulted in the discontinuation of a voucher program that provided contraceptive counseling and services to women and girls living in poverty, the termination of 20 outreach teams, and the closure of 66 private sector clinics.

Although Nepal and Kenya have more liberalized abortion laws compared to Madagascar, women still face many barriers to accessing the procedure – issues that are compounded by the GGR. In Nepal, there is an extreme lack of awareness surrounding abortion, with 59% of women of reproductive age remaining unaware that abortion is even a legal option for them. In Kenya, requirements such as securing physician and court approval for abortion prevent many women from accessing safe services. This includes a teenage rape victim who died from complications after being unable to access post-abortion care (PAC) for a clandestine abortion. The GGR exacerbates these issues by reducing the reach of services to women who already have the most difficulty accessing them.

GLOBAL GAG RESEARCH

In trying to fully understand the nuanced impacts of this policy, national context really matters. The Heilbrunn Department of Population and Family Health is conducting mixed-methods research to demonstrate the repercussions of the GGR on health outcomes in Kenya, Nepal, and Madagascar. These countries were selected for the varying legal, socio-political, and geographic contexts they represent.

Leading the study implementation are local research and service-delivery partners who provide the most nuanced insight into the dynamics and needs of each country. Quantitative data on service provision by public and private women’s health clinics in both rural and urban areas are being triangulated with interviews with key stakeholders including government, NGO, and donor staff, urban and rural health providers, clinic managers, and individual clients. By collecting these data at multiple time points, including prior to implementation of the GGR, researchers hope to create a rich picture of an extremely complex situation, demonstrating how the GGR impacts different actors and health sectors over time.

FROM RESEARCH TO IMPACT

For people living in the shadow of the GGR, its effects are real and imminent, as Wilfred Owuor, the CEO of the Omega Foundation in Kenya describes:

“Reinstatement of Global Gag Rule by US administration has impacted negatively on diversified funding streams Omega Foundation enjoyed in the past seven years. The long term effect of this is that hundreds of thousands of these women and girls have not been able to make informed decisions about their health care options when pregnant, thus putting their lives at risk and rolling back the gains Omega Foundation has made at county and community levels towards improving the general health of women and girls.”

With no end to the GGR in sight, it is important to focus on how to mitigate the impacts that real people are facing, here and now. Strong advocacy movements in the United States have mobilized against the GGR, but in-country advocacy is also key for change to take place. National and other local efforts involve supporting the liberalization of abortion laws, strengthening health systems, and increasing access to sexual and reproductive health services.

Women and families need providers like the Omega Foundation for SRH services that are essential to their life, health, and wellbeing. The key to combatting the detrimental effects of the GGR and keeping these services alive is supporting the efforts of local healthcare providers and public health advocates. As researchers, it is our job to find and amplify the voices of those who are most deeply affected by this policy, and to bolster those who can defend against it.

Goleen Samari is an assistant professor in the Heilbrunn Department of Population and Family Health at the Columbia Mailman School of Public Health. She completed an MA in Islamic Studies, MPH in Community Health Sciences, and a PhD in public health and demography at UCLA. Her research focuses on social inequities and health, examining how racism, gender inequities, and migration-based inequities and xenophobia shape population health both domestically and globally. She primarily focuses on issues related to immigrant health, women's health, and sexual and reproductive health and justice, among communities in or from the Middle East and North Africa. Building on the legacy of structural racism and health scholars, she was the first to draw attention to racialization of religious minorities and Islamophobia as a public health issue and is one of a handful of public health researchers examining gender inequities, women's empowerment, and reproductive health in the Middle East and North Africa. In April 2021, she was named a William T. Grant Scholar, a five-year award that supports promising early-career researchers with interests in reducing inequalities. In 2020, she was also named a Changemaker in Family Planning by the Society of Family Planning Research Fund for her work at the intersection of immigration and sexual and reproductive health. Her work has been widely published in academic journals and books, and her editorials and op-eds have been published in local and national media outlets.  

How does your background in demography shape your research methods, and how did you arrive at your main areas of focus?

I have three main buckets of work, all related to social inequities in population health. I look at migration-based inequities and xenophobia; at gender-based inequities; and at racism and racialization of religious minorities and how these factors affect health and health outcomes. These three separate bodies of research are interrelated, and are distinct aspects of demographic research. At Columbia, I’m faculty in the Program on Global Health Justice and Governance (GHJG) and the Program on Forced Migration and Health (PFMH) in the Heilbrunn Department of Population and Family Health (PopFam). What I do is very much in line with GHJG because I focus on structural drivers of health, including looking at governance and policy. My early work, on women’s empowerment and fertility in the Middle East and North Africa (MENA) region, concluded that community-based gender norms and structures were driving women’s empowerment at the individual and household level, so I’ve had that focus in my work since my doctoral years.

“What I do is very much in line with GHJG because I focus on structural drivers of health, including looking at governance and policy."

I’ve always been interested in the Middle East region and its cultural, religious, political, social context, partially because of my own origins from the region, but also because I was really struck during undergraduate studies and then going into my graduate work, that we often talked about the political and rights landscape of the MENA region, but we rarely talked about how that affects health and health inequities in the region and among immigrants from the region. There is more robust work on public health and demography in the MENA region now, but at the time, even ten years ago, it was novel to be interested in social determinants of health and demographic work in that region. My interests were ultimately driven by this research gap.

I started in post-disaster public health, quickly realizing that most vulnerable populations in humanitarian contexts were often women and girls. That brought me to the reproductive health space, where started looking at sexual and reproductive health in humanitarian settings. It was an evolution from my early interests that led me to realize that larger inequities on the basis of gender were driving a lot of other outcomes.  

Another aspect of my research portfolio considers demographic phenomena in the Middle East and North Africa like migration and fertility. I’m investigating how conflict has shaped some of those demographic factors, how it varies from country to country, and what data we have available to answer those questions. Part of demographic work is using existing data to show population composition and what that composition means for society. For those projects in particular, I’ve been able to leverage existing data sources to look at things like regional fertility rates. These data have to be situated in the lived realities of these communities. An example of this is how there’s a lot of talk about high Syrian fertility rates in other countries including Jordan, Turkey, and Lebanon, but in reality, if you look at the existing data and numbers, the refugee populations in those countries were from high-fertility regions of Syria. Forcibly displaced Syrian populations were from areas with high fertility to begin with, so it’s not necessarily an increased fertility rate. 

“The numbers are a starting point, but the narratives you build and tell is the powerful piece of it, as well as learning how to interpret those numbers within the context of what’s going on in the world."

In my opinion, a more interesting story comes through looking at the age distribution, where a lot of men between the ages of 24-29 and 30-34 are missing from the population because of loss during war and separation of families. The numbers are a starting point, but the narratives you build and tell is the powerful piece of it, as well as learning how to interpret those numbers within the context of what’s going on in the world. There’s an incredible way to situate the quantitative within these narrative, qualitative stories, as well as within these social and structural settings that we try to convey here at GHJG.

What immigration policy-centered projects are you currently working on?

My five-year funded research focuses on immigration policy contexts and how these structural contexts shape women’s health, including pregnancy and fertility outcomes. As a William T. Grant Scholar, I am excited to look deeply into how US immigration contexts ultimately shape immigrant reproductive health outcomes. As we know with the last administration’s restrictions on immigration at the federal level, some states responded by being more open and progressive in their policies and some states doubled down, but interestingly, a lot of times in response to federal restrictions, there are more open state environments and sanctuary cities. Immigrants’ lives are ultimately a blend of federal, state, and local policy, and I think it’s really important to focus on this multilevel perspective. Our lives are embedded in city and county policies, state policies, and federal policies, so how do these actually interplay to affect health and health behaviors? 

As part of this study, I am also directly asking organizations in the US who work in the immigration advocacy and immigration sexual and reproductive health spaces how a immigration policy climate index can serve them. Making the effort to ensure that your work has relevance for the community and community-based organizations is really important and is often where a lot of researchers stop in the process, but it’s something that’s highly valued in PopFam and part of the GHJG partnership model. 

I also have a qualitative study in New York City right now, looking at immigrants’ experiences in response to four years of the Trump Administration and the COVID-19 pandemic, and how that has shaped their experiences of discrimination and access to healthcare, and sexual and reproductive healthcare in particular. This study includes immigrant groups from many different countries of origin. Too often, people who do immigration research focus on one subgroup, so it’s a nice opportunity to look at the many different experiences of discrimination; we saw with the pandemic a rise in anti-Asian sentiment as well as a refocus on the Black Lives Matter (BLM) movement, and the last administration was notoriously anti-Muslim so these are all important factors to look at in this work.

What has your experience been doing research in MENA communities both globally and domestically? Where do you see your domestic and global work intersecting in the future?

I recently published a study that considered the impact of the Muslim ban on birth outcomes of women from the banned countries, and my ongoing US immigration policy project is quite related to my work on Islamophobia, as it’s really exploring the xenophobia and exclusionary aspects of state and federal policies for heterogenous immigrant groups. I wrote the original conceptual piece on how to think about anti-Muslim racism and health, presenting the theory and mechanisms explaining how racism plays out in people’s health and population health. Going forward, my Islamophobia and health work is probably going to go more into a comparative space, particularly looking at experiences of immigrant groups from the MENA regions in the US and other places, like Europe. We also need more differential work between the experiences of Muslims based on physical appearance, like a woman who wears a hijab versus a man who’s profiled at the airport, since anti-Muslim racism is ultimately intersectional. We still ultimately have no survey and representative information at the national level about Muslim or MENA communities in the US so any question I can answer to continue to fill these gaps are important contributions to research on these communities in and outside of the United States.

"When you start looking at structural barriers to health, for instance comparing things like abortion policies in the American South and a lot of countries in the Middle East, there are a lot of similarities in the types of restrictions to access. You see that the US is just another country in which those mechanisms are operating."

A lot of people do not engage in domestic and global research simultaneously, and while it’s challenging, I think it’s also important for research moving forward. I don’t believe in this notion of US exceptionalism, and I found that there’s a lot more similarity than difference in the theoretical factors at play. When you start looking at structural barriers to health, for instance comparing things like abortion policies in the American South and a lot of countries in the Middle East, there are a lot of similarities in the types of restrictions to access. You see that the US is just another country in which those mechanisms are operating. In GHJG, we really try to include the US in this global picture; for instance, our current GHJG studies, such as the Title X study [looking at the impact of a Trump-era domestic gag rule that restricts Title X recipient family planning providers’ freedom to discuss abortion with their patients], as well as a NoVo-funded project that focuses on gender-based violence and sexual and reproductive health in Lebanon and Tunisia. These projects show that structural drivers of health at play in the US are also at play in other countries around the world.

This interview was conducted by Sofia Herron Geller, an undergraduate intern in the Global Health Justice and Governance Program. It has been edited for length and clarity.