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Thinking Globally and Working Locally

Holly Harner and Monique Howard have ambitious plans for the Center for Global Women’s Health centered on three strategic priorities: violence and victimization, maternal morbidity and mortality, and gender equity and inclusion.

Penn nursing seniors Andrise Alzuphar and Audrey Henderson had a kernel of an idea. Inspired by a lecture in which they’d learned about the dearth of resources often available to women and children in marginalized groups, the pair—lab partners, close friends, both excited about women’s health—started talking.

“We decided we needed to do whatever we could to help,” says Alzuphar, from Haverstraw, New York. Unsure of how to actually do that or where to begin, they reached out to their professor, Holly Harner, the Afaf I. Meleis Director of the Center for Global Women’s Health, which she co-runs with Monique Howard.

“They initially wanted to do an infant formula drive,” says Harner PhD MBA MPH RN WHCNP-BC FAAN GNu’97 GR’01, Practice Professor of Women’s Health. Harner suggested they might instead focus on another important issue: period poverty. She connected
them to No More Secrets, a community-based Philadelphia nonprofit that gathers and distributes free menstrual products.

“We sat for hours discussing this,” Alzuphar recalls. “Period poverty is one of those things that we automatically as- associate with third-world countries. We rarely think it’s something happening in our own backyard, so of course, we’re not going to make resources for it.” Yet in the United States, it affects as many as one in five people—maybe more.

That initial conversation led to an outreach plan and eventually, six large bags full of products, which Alzuphar, Henderson, and Howard donated to No More Secrets in early February. Such work is exactly the kind Harner and Howard say they hope the Center for Global Women’s Health can foster. “We’re thinking globally, but working locally,” says Howard, EdD, MPH, the inaugural Senior Director of Women’s Health Initiatives in the School of Nursing.

Though the center is more than a decade old, founded by former Dean Afaf I. Meleis in 2011, the tenure of its newest leadership team began less than a year ago. The two have big ideas. They created a three-pronged strategic plan that they’ll carry out over the next three years focused on violence and victimization, maternal morbidity and mortality, and gender equity and inclusion. They want to engage students from Penn Nursing and across campus, and make the center the worldwide gold standard for research into and education around global women’s health. Given their energy and experience, along with backing from the institution and elsewhere, they’re poised to make a real impact, fast.

ROOTS OF CHANGE

Harner and Howard have known each other for years, working together first at LaSalle University. “I was leading a public health program. She taught our leadership and ethics course and was also part of our advisory board,” Harner says. “That’s how we met.” Each had previous stints at Penn, too: Howard worked as an intervention specialist while earning her Doctorate of Education in human sexuality education. She returned in September 2021, about a year after Harner, who had earned a master’s degree and PhD from Penn and had worked as a postdoc in the Center for Health Equity Research before joining the School of Nursing faculty in 2020.

“It’s absolutely critical that we have this kind of center in a school of nursing the caliber of Penn. Where we go, other people follow.”

In conversations with them both, their mutual respect and genuine warmth quickly emerge. They share a passion for women’s health, having dedicated a combined half-century or so to topics like maternal and child health, sexual violence, and women and HIV, Harner in a range of nursing and nurse leadership roles, Howard in the public health arena.

They bring that expertise to the center, where Howard is the first full-time staff member. In less than two months on the job, she secured her first grant, $30,000 from It’s On Us PA, a state-wide campaign aimed at ending sexual assault. “We’re looking at economic justice, reproductive justice,” she says, “and being a victim will always prevent that.”

Together, the duo also facilitated selection of the center’s latest Renfield Foundation Award, a $100,000 prize for global women’s health leaders; this year it went to Gabriela Meléndez-Peláez, a Guatemalan nurse-midwife and maternal health advocate. And after a months-long process that began in Fall 2020 and included identifying the priorities of students, faculty, staff, and external stakeholders, Harner and Howard finalized a strategic plan that will guide the Center for Global Women’s Health for the next three years and beyond.


“It is absolutely critical that we have this kind of center in a school of nursing, particularly in a school of nursing the caliber of Penn. Where we go other people follow,” Harner says. “Being a lead- er in this role will hopefully help other universities take up this same mantle.” The mission is ambitious: to promote the health and empowerment of women, girls, and people of diverse genders and sex characteristics from birth through death.

VIOLENCE AND VICTIMIZATION

One way they plan to do that is by addressing the social determinants that perpetuate violence against women. Statistics here are staggering. According to the Centers for Disease Control and Prevention (CDC), more than 52 million women in the U.S., or 43.6%, experience some form of sexual violence in their lifetime. For about 44 million, that equates to groping or other unwanted sexual contact, and about one in three goes through this with an intimate partner.

Harner has extensively studied in- incarcerated women and sexual violence.
“About 90% of them have past histories of violence and victimization,” she says. “Just being incarcerated is traumatic, too.” Howard has worked on human trafficking, the nature of which makes it tricky to quantify accurately, though she describes it as more significant in the U.S. than most might suspect.

“Women are always second-class citizens someplace,” she adds. “Part of that is oppression and victimization. We’re trying to figure out, how do we solve for that. How do we solve issues of domestic violence here and elsewhere? How do we activate young people to become active bystanders and help reduce the incidence of sexual violence?”

The money from It’s On Us PA will go toward that latter effort, through a new program that trains Penn Nursing undergraduates and high school students on how to identify risk factors of such violence and safely intervene. The initiative, called “The Successful Bystander Program,” aims to tear down societal norms that might stop young people from standing up to these unwanted interactions, for themselves and others.

“Violence against women is really hard to deal with,” says second year Jessey Yang, from Knoxville, Tennessee.“It’s not always easy to get out of a situation. To make it easier for these women to seek help, it’s so important to become more knowledgeable, so that we can identify danger signs and know how to navigate those situations well.”


The center is working on this type of education. This past January, for example, during Human Trafficking Prevention Month, Howard moderated a webinar on the subject, in partnership with the Penn Women’s Center, the Ortner Center on Violence & Abuse, and several other university and public partners. “I’m excited about our efforts thus far,” Howard says, “yet I know there is so much more work that needs to be done to reduce the incidence of human trafficking.”

Supplies to combat period poverty.Supplies to combat period poverty.

MATERNAL MORBIDITY AND MORTALITY

A second broad focus for the center is maternal morbidity and mortality. “All over the country, we know that we’re in a maternal mortality crisis,” Harner says, “and we know that Black and brown women are disproportionately affected by this due to a host of factors, including past history of discrimination and racism.”

In the U.S., some 700 people die annually from pregnancy- and child-birth-related complications, with Black people who give birth three times more likely than whites to face this risk, ac- cording to CDC data. “If there’s a deep sense of distrust in the provider, why would anyone go? If there are biases around pain, around substance use, why would anyone go?” Harner adds. “What can and should we be doing to improve outcomes?”

A virtual conference the center hosted in April 2021 touched on some of this, with a keynote on racism in maternity care and with speakers from Penn Nursing, the Philadelphia Department of Public Health, the Institute for Medicaid Innovation, and Irth, an organization founded by activist Kimberly Seals Allers dedicated to “equalizing the experience of giving birth in this country for every person.”

The center is also engaging with students like Stephanie Acquaye, a Penn Nursing Hillman Scholar, on community-based programs, most still early on in their planning phases. One area of interest is access to doula care.

“We focus a lot on the medical aspect of birth, but I think it’s really interesting to see what happens when you pay attention to the physiological aspect of birth, too,” says Acquaye, a trained doula herself. “Doula care is the flip side of the coin from the medical side. It’s statistically shown that doula care, even though it’s not inherently medical, still improves medical birth outcomes.”

That’s not true just in the U.S., Acquaye adds. “I feel like I’m always talking about doulas but it’s amazing that doulas can be such a resource. Globally they have the potential to provide a lot of support and could decrease maternal mortality rates.”

“I’m challenging myself and future clinicians to think about how not everyone who gives birth identifies as a woman and a mother.”

Gabriela Meléndez-Peláez is working toward that same goal in Guatemala, through an organization she founded in 2014. Asociación Corazón del Agua advocates for maternal health on a na- tional stage there and trains midwives to incorporate traditional Mayan prac- tices into the work they do. The idea is to increase both the maternity care workforce in Guatemala and the likelihood that those in the indigenous Mayan community will utilize such a resource.


For that work, Meléndez-Peláez became the fifth recipient of the center’s Renfield Award, established in 2012 by the Beatrice Renfield Foundation and aimed at honoring leaders in global women’s health. In March, Harner and Howard presented her with the prize during a virtual ceremony.

GENDER EQUITY AND INCLUSIVITY

The final prong of the center’s strategic plan centers around gender equity and inclusivity. On its face, that might seem at odds with a group that has the word “women’s” in its title, but Harner doesn’t see it that way.

“This is really a catchall looking at gender roles, norms, identities, and how that influences human health,” she explains. “I’ve been talking about ‘pregnant women’ my whole life. But that’s not an inclusive viewpoint. I’m challenging myself and future clinicians to think about how not everyone who gives birth identifies as a woman and a mother.”

Some such future clinicians belong to the Penn chapter of Nurses for Sexual and Reproductive Health, a student-run group for which Harner is an advisor. Junior Tara Teipel, from Pittstown, New Jersey, is its founder and president.

Taking a broader approach, specifically to facets like the language providers use to describe their patients, brings into the health care fold many groups often left outside of it, Teipel says. “I’m thinking especially of LGBTQ health and addressing transgendered men and women. I feel like not doing that contributes to the current mistrust in the health care system, especially gynecology and the exclusivity that patients might perceive.”

Really, gender equity and inclusivity overlaps with the other strategic initiatives, and Howard and Harner say it’s hard to parse each one in isolation. At their intersection lies the mission of the CGWH. Harner says, “If you think about this conceptually, the social determinants of health wrap around them.”

‘HALF PAST THE RIGHT TIME’

Since the conversation about period poverty, Andrise Alzuphar has been all in with the center. “They’re stuck with me for good,” she says. “I want to be at- attached to everything they do.”
Students like Alzuphar—and Yang, Acquaye, Teipel—motivate Harner and Howard to keep rethinking and reshaping the center, responding to the moment rather than standing still.
“They are demanding change,” Harner says. “They are demanding to be part of the process.” For that reason, since she began, Howard often reaches out to students to understand where their passions and the center’s goals transect; they’ve helped shape the blueprint for the center, she says.

By their own admission, Howard and Harner have set the bar for success remarkably high. “I want to hear a student say they wanted to come to Penn Nursing because of the Center for Global Women’s Health. To me, that means we made it,” Howard says.
“That’s what I’m working on. That means we’ve done some really significant work to heal and help people here and in other places.” Adds Harner: “It’s half past the right time for this work. The right time was 100 years ago.”

They’re not starting from scratch, of course, but rather building on the strong foundation laid by Meleis and the center’s previous directors Marilyn Sommers and Wendy Grube. If they continue their current trajectory, many more people will live safer and healthier lives, and many more partners like No More Secrets will receive bags of donated good collected by enthusiastic and passionate future nurses.

Mission Strategies

Holly Harner, the Afaf I. Meleis Director of the Center for Global Women’s Health, and Monique Howard, inaugural Senior Director of Women’s Health Initiatives in the School of Nursing, recently released a strategic plan for the Center.

“Rather than focus on particular geographic areas, we really wanted to focus
on issues of global concern,” Harner says. “No matter where you go on a map, you’re going to face violence and victimization, maternal morbidity and mortality, and gender-based health issues. Whether in our backyard or across the globe, these issues affect everyone.


To meet the goals of this new plan, Harner and Howard will use five diverse strategies:
  1. Promoting and delivering quality, timely educational opportunities and training.
  2. Championing rigorous, interdisciplinary work that addresses issues affecting the Center’s target population.
  3. Growing and strengthening a diverse population of health care providers dedicated to the struggles of the people who the Center serves.
  4. Leveraging the strength of Penn Nursing and colleagues to champion changes in service to women, girls, and people of diverse gender or sex characteristics.
  5. Building relationships that engage partners dedicated to improving the lives of individuals, families, and communities around the world.