Community and Culture Are Essential Factors in Public Health Practices

Group of Indian women sitting in a circle
Dr. Purnima Madhivanan’s global research experience has taught her that evidence-based interventions, aligning with community cultural patterns and values, are an important determinant of success when targeting diseases caused by HIV, HPV and SARS-CoV-2.
Jorey Cohen, BIO5 Ambassadors Intern

According to Dr. Purnima Madhivanan, failure is the best teacher.
Four – that’s how many hospitals Dr. Madhivanan was thrown out of during her dissertation research in India, with a variety of factors including her age and gender against her every time. In the face of defeat, she founded her own community-centered clinic to finish the dissertation, where she realized the disconnect between the formalized health care system and what people in the Indian communities actually needed. 
“I didn’t know at the time how important those early lessons would be to our eventual success,” she said. “We really didn’t need to be part of the medical system to become part of the community.”
That research was the foundation for the Prerana Women’s Health Initiative in 2006, and eventually led to the origination of the Public Health Research Institute of India (PHRII). PHRII continues to operate today with the goal of empowering women to take charge of their own health.
Dr. Madhivanan, an associate professor in the Mel and Enid Zuckerman College of Public Health and BIO5 Institute member, has gone on to build a career empowering rural women’s health while navigating many challenges. Importantly, she learned that culture and community play vital roles in addressing health outcomes, and that there’s no one “right” global approach to tackling disease. Her experience in India – where low status, lack of education and little control over one’s own life are determining factors in how and when women access care – led her to realize that we must deliver solutions that meet people where they are.
Considering Community Need to Break Barriers
For Dr. Madhivanan, it was HIV that catalyzed her efforts to change healthcare for women. More than 880,000 women had contracted the disease in India at the time, and for most, being married was their only risk factor for HIV. 
“It was a watershed moment for me,” she said. “I couldn’t change the culture, but I could find ways to prevent women from getting infected in the first place. I was tired of being a spectator.”
Accordingly, Dr. Madhivanan furthered her education about public health-oriented approaches, earning a master’s of public health and doctoral degree in epidemiology on top of previous medical training.

For her dissertation research, Dr. Madhivanan explored whether treating common genital tract infections could reduce risk for contracting herpes simplex virus-2 (HSV) infection, a risk factor for HIV infection in Indian women.
In India’s culture, the woman prioritizes the home and family – not herself. Thus, this higher prevalence of genital tract infections stemmed from these women failing to receive proper education on STDs and on the importance of pelvic exams. As a physician-scientist, Dr. Madhivanan realized these women needed to be empowered and enabled with the tools to take responsibility for their own health. 
Dr. Madhivanan was conducting her dissertation study in the hospital setting - but when she was thrown out of her fourth hospital for reasons including her age and gender, Dr. Madhivanan decided to open her own clinic, based on a community-centered recruitment approach.
“At that point, I was still naïve. I thought that hospitals wouldn’t mind that we were giving out free treatment. They came to see us as a competitor—a strange idea to me since most of the women we were treating couldn’t afford healthcare,” she reflected.
This reinforced the choice to run her own clinic where she could immediately address the disconnect between the formalized health care system and what the communities truly needed.
However, building a positive relationship with the community and gaining access to the Indian women also proved to be a challenge. Unease rippled through the villages when Dr. Madhivanan’s team first arrived to engage participants in the study. Due to deceitful past public health interventions, the community was apprehensive in trusting the team’s purpose. Further, Dr. Madhivanan’s all-female team created a gender barrier between them and the male healthcare leaders, who were essential in providing access to the village-residing Indian women.
Because of these obstacles, Dr. Madhivanan’s husband, Dr. Karl Krupp, a research associate in the Mel and Enid Zuckerman College of Public Health, took the lead in being the liaison for the community-recruitment aspect.
“India is a very patriarchal society, so Dr. Madhivanan decided a man would be best at negotiating with village leaders,” shared Krupp, who has been the Program Director for PHRII since 2007. “I didn’t know what I was getting into at the time. Sometimes I had to spend an entire afternoon on a headman’s porch chatting before they trusted us enough to allow our staff into a village.”
“It took a lot of persistence before the communities came to trust us,” Dr. Madhivanan further explained.
When the study was finished, the small staff had screened more than 3,000 women and recruited 900 of them to receive pelvic exams and get further treatment for common genital tract infections, if needed.
“These women were willing to have a pelvic exam, which is very uncommon, when we were offering them at our clinic. We were doing it in a respectful manner,” Dr. Madhivanan said. “That trust continues today.”
Because of the clinic’s success and the love she and her team ultimately received from the community, Dr. Madhivanan and Krupp sold all their belongings to keep the clinic open. In turn, it continues to operate today as the Prerana Women’s clinic, where poor women in the city of Mysore are offered free healthcare. The word “prerana” roughly translates to “motivation”, a fitting name for a clinic that aims to encourage women to take an active role in their own health.
Since making the decision to keep the clinic open, it has evolved to align more with India’s culture and community.
One way is through the implementation of group health seeking, where women are educated in their communities, then come to the clinic in groups with their children. With group health seeking, the women feel comfortable taking charge of their health and can still fulfill their domestic responsibilities, with their children never being left unattended in this group setting. 
“When they come, it is more of a social outing,” Dr. Madhivanan stated. “We changed the whole environment around health; you are not just a patient, you’re a participant. You’re making your own future.”
Real-World Experience Shapes Application of a Screening Technique
While considering the community made group health seeking a success, Dr. Madhivanan has since faced additional obstacles implementing public health interventions – one of which concerns cervical cancer, one of the top two killers of women in India. While preventable, prevalence of cervical cancer remains high because many women cannot afford screening by pap smear.
To address this economic barrier, in 2007, Dr. Madhivanan originally implemented an inexpensive technique called Visual Inspection with Acetic Acid (VIA) to identify precancerous lesions. Because published literature evinced that VIA worked in clinical trials, the physician-scientist assumed it could be applied to the real world setting in India.
However, it became clear that one downside to this technique was the high risk of false positives. When an Indian woman was told she might have precancerous lesions, the only word that registered was “cancer.” This, in addition to the fact that physicians were suggesting expensive and unnecessary surgeries, such as radical hysterectomies, caused these women needless anxiety and their husbands to suggest they do not return to the Prerana Women’s clinic.  
Even though Dr. Madhivanan began with good intentions based on the success of acetic acid screening in the literature, this method did not have the same success in the context of India’s community.
“Never believe what the publications tell you until you have some kind of real-world experience yourself,” Dr. Madhivanan shared. “It’s always a learning experience.”
Applying Lessons Learned in the Context of COVID-19
Later, Dr. Madhivanan chose to split her time between India and Tucson, where she is applying lessons learned from India into her work in Arizona. 

Based on what she’s discovered about considering culture when devising public health measures for HIV, HSV and cervical cancer, the physician-scientist strongly rejects the one-size-fits-all mentality for global healthcare practices.
This notion has become exceedingly clear in the context of the COVID-19 pandemic. While the guidelines recommend social distancing and frequent handwashing to prevent the spread of disease, they cannot be easily implemented in India and other similar cultures. 
“When you are living in an 800-square-foot room with eight other people in the house where you get water once a week from a communal tap, you tell me how you will follow all the COVID rules we have put out so beautifully and preach so well to everyone,” Dr. Madhivanan explicated.
She advises approaching COVID-19 in a more culture- and community-driven manner, where living conditions and available resources are taken into account.
“You have to approach people where they are—not where you’d like them to be. We have to always remember that people live in a world that’s not our world. We’re there on sufferance and have to make every effort to understand the pressures they face and the truths that they embrace,” Dr. Madhivanan said.
Because cultures disagree on what constitutes health, both from an individual and community perspective, Dr. Madhivanan and Krupp are currently working with the Pima County Health Department to investigate acceptance of a future COVID-19 vaccine amongst different ethnic groups in Tucson.
While the study’s findings will be released soon, Dr. Madhivanan is applying her lessons learned in India to this pandemic. As such, she thinks it will be imperative to tailor vaccine advertisements to each target community to achieve widespread acceptance.

This story was written by Jorey Cohen, a 2020-21 BIO5 Ambassadors Intern. To learn more about the Ambassadors program, please visit: