You must get the buy-in of the village chief before the villagers will listen to you, according to Sherzel Smith, '13. Smith, who has studied public health on three continents, believes knowing how to operate within a society's cultural context is the key to successful health care promotion.

The Bonner Center for Civic Engagement (CCE) awarded Smith a competitive Burhans Civic Fellowship to intern this past summer with two Ghanaian nongovernmental organizations (NGOs): Health Protection and Environmental Sanitation and the Planned Parenthood Association of Ghana.

Smith conducted health care outreach to rural communities, schools, churches, and prisons on topics including diabetes, malaria, food-borne diseases, HIV/AIDS and other sexually transmitted diseases, and contraception and family planning.

"City-based NGOs are mindful that you can't enter rural communities expecting to change everything," Smith said. "NGOs are trying to push their agenda but realize that it's important to talk to the village chief first. It's a formal process—you sit in his house and talk. If you can get his blessing, you can take your agenda to the people.

"This internship exposed me to the distinct cultural nature of public health and how culture plays a large part in the decisions people make that directly affect their health.

"For example, the Ghanaian culture promotes large families. Some villages still stage a big celebration when a woman has her 10th child. But it is difficult to feed and educate this many children."

Dr. Rick Mayes of the political science department served as Smith's Civic Fellows faculty advisor and had a profound effect on her understanding of her Ghanaian experience, Smith said.

Smith first encountered Mayes when she enrolled in his U.S. Healthcare Policy and Politics course. This course inspired Smith to major in interdisciplinary studies with a focus on health care policy and public health.

Smith subsequently pursued cocurricular opportunities to deepen her knowledge of health care in different societies, including her native Bahamas.

In Richmond, she volunteered at a free medical clinic and taught health-and-nutrition lessons to children in an after-school program affiliated with Build It, the CCE's neighborhood-based civic-engagement initiative. She researched the ethics of mandatory vaccinations in the United States as a 2011 summer intern at the Yale Interdisciplinary Center for Bioethics. In fall 2012, she studied public health in Northern Europe at the Danish Institute for Study Abroad in Copenhagen.

All these experiences informed Smith's understanding of the connection between culture and health care.

For example, Smith found it challenging to reconcile her lessons on health and nutrition with the realities facing the low-income children she taught in the after-school program in Richmond.

"How do we teach them about healthy eating when they can't access healthy food because their neighborhood is a food desert?" she asked.

"Denmark has a community-focused ideal of health care," Smith continued. "People don't mind paying higher taxes to support community health care. But people in America are more individualistic and want a different kind of health care system.

"What works in Denmark may not work in the United States or Ghana or the Bahamas. You have to consider complex cultural and sociological factors when designing a health care system.

Smith described her Civic Fellowship as a public health intern in Ghana as one of her "top learning experiences in college."

"My work in Ghana has formed the foundation of the development of my senior thesis," Smith said. "I desire to study health systems and policy and global health development in my postgraduate career as a result of this internship."

Photo: Sherzel Smith balances a water basin on her head during a visit to a Ghanaian village.