Centers for Disease Control and Prevention, United States

Final Report:

This summer I spent nine weeks interning at the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia. I worked for the Division of Violence Prevention’s Special Surveys Initiative which is contained under the CDC’s National Center for Injury Prevention and Control.

The summer prior, I spent two months in rural Uganda working at maternal and outpatient health clinics. I loved this opportunity to be immersed in Ugandan culture, and I spent my days on outreach and in the clinics engaging in direct interpersonal care. I lived firsthand the successes and struggles of a small under-resourced clinic striving to provide quality care to their patients. As rich as this experience was for me, I felt this knowledge was myopic without insight into the overarching policy and governmental sphere of this field. My time in Uganda reaffirmed my interest in public and global health and sparked a desire to learn about the macroscopic policy decisions that inform and frame the direct patient care I experienced. My time at the CDC proved to be a wonderful continuation and expansion upon the experiences I had in Uganda.

As I delved into the work of the Division of Violence Prevention, the data jumped off the page at me. For nearly every statistic and infographic I read on violence, I had an experience with a young woman, mother, or schoolchild in Uganda who was grappling with their victimization and looking for support. Some of the young girls I worked with had become pregnant and were forced to halt their education to stay home and care for themselves and their children. Having witnessed situations like these and heard personal stories from patients, my work at the CDC assumed a face and particular urgency.

Childhood violence victimization is well acknowledged to have a cascade of lifelong negative effects on health, and many studies have found that children who were subjected to violence have significantly higher odds of perpetrating violence against others as adults. Knowing this, though, there is very little country-specific data on violence. At the CDC, I worked on the Violence Against Children Surveys (VACS) conducted everywhere from Sub-Saharan Africa and Southeast Asia to Eastern Europe and Central America. Accurate identification of country-specific patterns and drivers of violence is an essential precursor in effectively targeting upstream solutions like prevention programs. This is the root motivation for the CDC’s VACS project: to assess the prevalence and burden of violence within a country to guide action and hopefully interrupt the cycle of violence perpetration. VACS is the first study to use nationally representative methodology to measure violence against children across the world.

At the CDC, I listened to an interview with the CDC Director, Robert Redfield, as he discussed the current and future objectives of the CDC as a science based and data driven organization. He stressed the importance of “not leaving science on the shelf,” but instead disseminating findings so that they are acted upon and become part of public knowledge. I was drawn to the CDC because of their involvement in both the novel research and development phases of science and also because communication with the public and outreach is a massive part of what they do. I find this type of longitudinal work particularly gratifying and was very excited to be involved in the VACS project for this reason. My work on VACS provided the incredible opportunity to be actively involved in all phases from orientation and piloting to implementation and policy change within the countries surveyed. Using results from previously conducted VACS, I became familiar with overarching trends in data and compiled a living document of the recommendations to various sectors of government that could be used to inform future PEPFAR funding. I worked on determining an estimate for how much funding has gone into the research and development phases of the 42 antiviolence and antipoverty programs included in the INSPIRE technical package which is backed by the CDC, WHO, and UNICEF among others. I also worked on preparing article briefs for the CDC website on recently published papers that use VACS data, and helped prepare a presentation on the response plan during VACS implementation to synchronize the team on country-specific learnings. The response plan is enacted to connect children surveyed who are in imminent danger or dealing with the effects of violence with a social worker if they agree or ask the interviewer for help. The response plan looks different in each country because of varying country capacity and tracking, government relationship and trust of NGOs, and laws about mandated reporting.  Prior to this internship and response plan meeting, I had little knowledge of the logistics of policies that inform global health campaigns and funding, and thought that standardizing operations would be the best way to ensure consistent delivery of quality response across countries. This was a real-life crash-course for me in the vast logistical challenges of conducting research in foreign countries and how nuanced implementation can be. I learned that standardization is oftentimes an ineffective route given how different employment of the plan can look on the ground. The CDC firmly believes that “No single agency can confront all global health challenges alone” and that conquering complex health issues requires the cooperation of many sectors. I loved that my work at the CDC allowed me to engage with many sectors and domestic and foreign agencies to make strides toward reaching goals.

About halfway through my internship, I listened to a congressional hearing held by the House Committee for Oversight and Reform on “Identifying, Preventing, and Treating Childhood Trauma: A Pervasive Public Health Issue that Needs Greater Federal Attention.” Deb Houry, the director of the CDC’s Injury Center, spoke on a panel of experts who detailed the prevalence of childhood trauma and the limit of current federal initiatives. This discussion was opened by several panel witnesses sharing their personal journeys of trauma, healing, and advocacy. Listening to this hearing brought together all of the things I had been learning throughout my internship and elucidated the importance of awareness of violence. Some witnesses were more than thirty years removed from their victimization, but the gravity of the trauma and the role that it played in molding their future never wavered. Americans like myself who were fortunate enough to escape a childhood of abuse and victimization are lacking exposure to and knowledge of the crisis of violence. One of the panel speakers testified to this point, stating that no elected official on his statewide cabinet had an ACE (Adverse Childhood Experience) score above a 2. The ACE score scale goes from 0 to 10 with 10 being the most severe. For the most part, the unaffected general population and our decision-making officials lack background and understanding of the effects of violence. A privileged and peaceful upbringing is not an excuse for passivity, and this internship has armed me with empathy and understanding moving forward. I have seen ACEs as a root cause issue that have immense neurological, physical, social, and other risks on future life.

I thought that a more overtly medical experience studying something like tuberculosis or immunizations was what would be good for me this summer. However, as I learned that half of the children worldwide, an estimated 1 billion, are victims of abuse each year, and that more people die of injury and violence in the first 3 decades of life than any other cause, I realized my CDC internship was precisely what I needed. I began my time at the CDC rather ignorantly believing that violence had very little to do with medicine. What I failed to realize is that violence, particularly against women and children, is one of the most damaging and under-funded public health crises facing the world today. I am now attuned to the stresses and cascade of health risks that violence poses to the victimized, and I feel like a much more deeply informed and holistic future provider of healthcare.