Stomach Bugs, Diarrhea, and Other Paths to Global Health Work

As a child, I could never understand why in Pakistan I had to be so careful to eat only hot food and drink only bottled water. Back home in London, everything was safe to eat.

Disease Matters

Growing up, my family made frequent visits to Pakistan to visit my grandparents. Without fail, on each trip, I would eat or drink something I’d been warned not to and would get a stomach bug. (We’ll come back to the possible outcomes of stomach bugs later.)

This confusion—and later frustration—with the inequity stuck with me, and it still bothers me today.

Research can be used to inform public health, which in turn can improve people’s lives. Research can also have a dark side.

As an undergraduate at Case Western Reserve University, I majored in economics and became very interested in development economics. I also wanted to attend medical school to become an emergency room physician—the fast pace and broad knowledge required resonated with me like nothing else.

While at Case Western, I shadowed Justin Yax, an emergency medicine physician who was also director of the Emergency Medicine department’s fellowship in humanitarian aid. Yax was an experienced responder to humanitarian emergencies, and we found ourselves discussing the field of humanitarian aid more often than emergency medicine. He recommended I consider studying public health, and I fell in love with the field while earning an MPH.

Research Matters

Public health combines nearly any discipline—for me, medicine and economics—in such effective, problem-solving ways that I set aside the path of becoming a physician for a career as an epidemiologist.

MPH in hand, I moved to Johannesburg, South Africa, to work for Population Services International, a large global health NGO with a focus on reproductive health. I would learn a lot about international health research.

Research can be used to inform public health programs directly, which in turn can improve people’s lives.

Research can also have a dark side, if we're not careful. When researchers from high-income countries conduct studies without true local engagement—using my colleagues in South Africa as little more than a mailbox for IRB applications and HR for field workers, despite these colleagues being internationally esteemed and respected researchers—it is little more than a mechanism through which colonial legacies of power and exploitation continue to play out.

In South Africa, I saw papers get published where local experts had conducted most or all of the work while foreign researchers took the desired positions of principal investigator, lead author, and so on.

Coming to the end of my contract in South Africa, I desperately wanted to work in the humanitarian aid space but had difficulty finding jobs. I decided that further schooling would be an effective way to contribute to the field and moved back to the UK to pursue a PhD in epidemiology.

On my first day as a doctoral student, my supervisor let me know he was most interested in either pre-hospital care or diarrheal disease. Thinking back to my childhood experiences visiting Pakistan, the choice was obvious: diarrhea.

Diarrheal Matters

As I began my PhD in 2018, the world of water, sanitation, and hygiene (WASH) was rocked by the results of two large-scale, multi-million dollar trials claiming that the provision of safe water and proper hygiene facilities—such as pit latrines—did not impact the rate of diarrhea among children under five.¹

I sought a path that would ensure my research could continue having a positive impact on human communities and also on how we do research.

The main critiques of these studies focused on the quality of the interventions. We thought that something else was at play, namely, how the outcome itself—diarrhea—was defined and measured.

As was the norm, these study teams had asked parents, very simply, if their child had had diarrhea at any time in the past three weeks.

But parents might

1. not understand what diarrhea is
2. forget whether their child had diarrhea
3. not want to answer honestly.

All three were indeed the case, as my colleagues and I were able to show.²

But another, more important, factor was at play in assessing the two 2018 studies: the interventions used in the trials were not directly related to diarrhea but instead to enteric infections generally. That is, these studies had used diarrhea as a proxy for enteric infection and from there to evaluate the interventions.

But is diarrhea a good proxy of enteric infection?

As we see with COVID, the relationship between a disease and its symptoms is complex.

• Having a cough does not mean somebody definitely has COVID
• Feeling 100% in good health does not mean someone is COVID free

We demonstrated the same for diarrhea—it does not make a good proxy of enteric infections because evaluating symptoms and interventions is too complicated.

The impact of our work on how other research teams might approach future studies of diarrheal diseases—which affect millions of families every year and kill around 1.5M children each year—helped see the importance of research that accounted for human experience, including how study participants experience an intervention and might report information about their family’s health.

As my PhD work came to an end, I sought a path that would ensure my research could continue having a positive impact on human communities and also—whenever possible—on how we do research.

I was delighted to discover the Center for Global Health Equity’s Impact Scholars program, which is not interested in how many publications we postdocs can produce in a year nor in how much work we can do on various topics regardless of our level of interest.

Instead, we are asked to conduct high-quality research that has a clear line of sight to impact—to clearly defined outcomes that can improve lives. Anyone doing a postdoc in the health sciences knows what an incredible opportunity this is. I have the privilege in this program of working among and alongside displaced populations in low- and middle-income countries, with excellent support and mentorship from University of Michigan faculty and staff and, most importantly, from faculty and staff in the countries where we are privileged to co-design and co-lead research.

Above. Ryan Rego at the Diarrhoea Treatment Center in the Leda refugee camp in the Cox’s Bazar camp complex, Bangladesh.

Notes

1. Luby SP, Null C, et al. "Effects of Water Quality, Sanitation, Handwashing, and Nutritional Interventions on Diarrhoea and Child Growth in Rural Bangladesh: A Cluster Randomised Controlled Trial.” Lancet 6/3 (March 2018):E302-315; Humphrey JH, Mbuya MN, et al. “Independent and Combined Effects of Improved Water, Sanitation, and Hygiene, and Improved Complementary Feeding, on Child Stunting and Anaemia in Rural Zimbabwe: A Cluster-Randomised Trial.” Lancet 7/1 (Jan 2019):E132-E147.
2. Rego R, Watson S, Ishengoma P, Langat P, Otieno HP, Lilford R. “Effectiveness of SMS Messaging for Diarrhoea Measurement: A Factorial Cross-Over Randomised Controlled Trial.” BMC Medical Research Methodology 20, art 174 (Jun 2020); Rego R, Watson S, Ul Alam MA, Abdullah SA, Yunus M, Alam IT, et al. “A Comparison of Traditional Diarrhoea Measurement Methods with Microbiological and Biochemical Indicators: A Cross-Sectional Observational Study in the Cox’s Bazar Displaced Persons Camp.” eClinicalMedicine 42/101205 (Nov 2021); Watson S, Rego R, Hofer T, Lilford R. “Evaluations of Water, Sanitation and Hygiene Interventions Should Not Use Diarrhoea as (Primary) Outcome.” BMJ Global Health 7/5 (2022): e008521; Rego R, Watson S, Gill P, Lilford R. “The Impact of Diarrhoea Measurement Methods for Under 5s in Low- and Middle-Income Countries on Estimated Diarrhoea Rates at the Population Level: A Systematic Review and Meta-analysis of Methodological and Primary Empirical Studies.” Tropical Medicine and International Health 27/4 (Apr 2022):347-368.