Tell us about your early training and how you found your way to public health.
I was a history and anthropology major but I got interested in public health through a women’s health class I took my senior year of college. It was life changing. I knew I was interested in women’s issues but I didn’t know there was a field like public health that I could go into.
After I graduated, I was in Pakistan for a year volunteering in an urban community health program. That was my first experience doing public health in a community—seeing how people live in a community and what that’s like, what it’s like to be in a clinic. That experience had a big influence on how I thought about public health, and about communities and global health in particular.
And then you got an MPH.
When I finished my MPH in 1993 I worked in D.C. for John Snow, Inc., a big public health consulting group. I worked on a maternal mortality reduction project with a focus on delivering health services to women in remote places. I travelled and did training workshops in India, Pakistan, and Egypt. This was when I first became interested in adolescent health. It was relatively new at the time, but people were starting focus more on poor reproductive health outcomes among younger women and adolescents.
You didn’t start your Ph.D. right away. You went to South Africa.
I first went to South Africa in 1996 to work with the South African Medical Research Council. I worked with Mark Lurie on a team of HIV researchers. (Professor Harrison is married to Mark Lurie, a native South African and associate professor in the Department of Epidemiology) It was a very interesting time to be there, in both the immediate post-Apartheid period and at the start of the AIDS epidemic. We worked at a rural hospital and research site where some of the early work was being conducted to understand the patterns and causes of the HIV epidemic. This was a good five years before drugs [antiretroviral therapy] were available anywhere. The epidemic was exploding and there was a lot of denial and a lot of stigma, for women in particular. HIV was wreaking havoc in people’s lives and in communities, but treatment was not available until 2001. Even when drugs for HIV did become available in South Africa they were contested and fought and argued about. It took several years for policy to catch up with science the needs of the country.
Why was it especially difficult for women?
It’s so hard for younger women to advocate for themselves. They can’t stand up and say, ‘Give me those drugs’ or ‘Give me access to those resources’ or ‘Make my community safer’ or ‘Help me reduce gender-based violence.’
HIV works like any other infectious disease. The fact that people are disadvantaged in terms of access to resources, that they are living in communities without good access to health care, that gender inequalities are so profound, all of those pieces are so important, and yet people tend to point the finger and say actually, it’s about behaviors. It’s about how people are behaving and who they’re having sex with and how many partners they’re having. All of those things matter, but what really matters is the bigger picture of social determinants.
Of all those factors, you focused your work on gender inequality.
I was interested in writing about and working on the gender inequality piece, and then the flip side of that, which is empowerment. We worked to put frameworks in place for what is now standard practice in global HIV research—positive things like resilience and access to care. There is a USAID/PEPFAR initiative called D.R.E.A.M.S., Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe. That’s the paradigm now for working with adolescent women and girls, but it’s taken a long time to turn around the focus on risk to being more positively focused on helping women help themselves, on helping them to be safe and protected.
You have worked in South Africa from the very beginning of the HIV disaster all the way through today. You’ve witnessed huge changes.
There have been huge changes in South Africa. The most important part of that has been bringing in drugs for treatment. There’s no question about that. That’s affected women in two ways. First, like anyone else, if they’re living with HIV they have access to treatment for free, which is an amazing thing. But women also have access to treatment to prevent mother to child transmission. That was where we first really saw improvement in the epidemic, in the reduction in the rates of mother to child transmission.
Despite these advances, South Africa still has the world’s worst HIV epidemic, with 19% of the adult population living with HIV and 40% prevalence among women in some areas.