Mary Anne Mercer has vivid recall of the clinic in Dili, the capital of East Timor. It was early 2000, and the clinic was filled with women in peril of dying as they tried to give birth. One showed up after being in labor at home for more than two days before her family could borrow a car to bring her in. When she finally delivered the baby, it was dead, and she was close to death from exhaustion. Another woman arrived after being in labor for days with a baby in breech. The traditional midwife who had tried to help at her home had packed the pregnant woman's vagina with leaves and rice, assuming the baby would want to eat and come out for the food. Others arrived at the clinic after being in labor for so long their uteruses had ruptured. The majority of these complications, had they been treated early on, would not have become life-threatening. But in war-torn East Timor in 2000, there was only one viable health clinic, run by an expat doctor, Dan Murphy. Part of his staff was funded by a Seattle-based NGO called Health Alliance International, and Mercer, SPH '81, SPH '87 (DrPH), was HAI's deputy director. When she had climbed off the plane to Dili, she could still smell ash in the air from so many fires.
Image caption: Rural women in Timor-Leste watch a drama on maternal care
Image credit: Mary Anne Mercer
In August 1999, the East Timorese voted for independence from Indonesia, which had invaded and occupied the country in 1975. Estimates of the death toll from Indonesia's brutal occupation and the fighting after the vote vary from 90,000 to 200,000. Several hundred thousand more were forcibly displaced, and 75 percent of the country's infrastructure went up in flames at the hands of pro-Indonesia Timorese militia and the Indonesian army. When Mercer arrived in Dili, the World Health Organization listed the maternal mortality ratio for East Timor at a staggering 660 deaths for every 100,000 live births (the 2015 figure for the United States was 17), and the lifetime risk of maternal death at one in 30. "There had been this tradition that you didn't have to have a doctor or midwife for a delivery," Mercer says, "which is OK a good part of the time. But when it's not OK, it's really not OK." She quickly learned the women didn't have options. They could be in labor for days with nowhere to go for help.
The solution was obvious: adequate prenatal care, a midwife or doctor present for delivery, and postpartum checkups for mother and baby. But East Timor's Ministry of Health was starting from scratch, and Mercer knew a new system would not be established fast enough—or reach far enough into the mountainous, isolated rural country—to save all the women and babies who needed saving. The challenge would be keeping them alive long enough for the public health infrastructure to build out to them. How to do that?
Mercer is bouncing along in her 1992 Nissan Pathfinder on the 250-acre ranch she owns in eastern Montana. She is on the hunt for Canada thistle—a pernicious weed that can grow over three feet tall and is notorious for colonizing pastures. "Weeds just take over. If you don't keep 'em down, they will take you down," Mercer says.
Dozens of black cows with plastic yellow tags pierced through their ears hustle to get out of her way, mooing and looking back with indignant expressions. "Mooove, cows, moooove," Mercer croons. "All right, ladies, this isn't about you." Mercer's husband, Stephen Bezruchka, is riding shotgun. He stays quiet as Mercer remarks on the location of weeds, identifying where they need to return later that afternoon to spray with herbicide. The pair met at Johns Hopkins when Bezruchka, SPH '93, was a student, and reunited a few years later at the 1994 American Public Health Association annual meeting. After spending an evening successfully chartering a boat—they used library books to figure out how to drive, since neither had any previous boating experience—they decided that getting married was a good idea.
Mercer spies a patch of the offending plant in the pasture: "Ah, it's too late. They are seeded out. And this one too—oh my, my, my!" Her voice has a singsong quality to it—one that's picked up the affects and accents of too many people and cultures to reflect just one of them. She speaks four languages—English, Nepali, Spanish, and French—and she's currently learning Greek. When she bought the property in 2005, she asked the realtor what the relative value of the small house was compared to the land. The realtor didn't hesitate. "Zero," he said. Buying the spread was a homecoming for Mercer. She was born in 1944 in eastern Montana and grew up on her grandfather's 5,000-acre property, eight miles from Sidney, the nearest town. Her grandfather had homesteaded with a herd of cattle in 1906. Mercer was the oldest girl of seven children in a family that lived without indoor plumbing and electricity until she turned 6. In the middle of one winter, their car wouldn't start, so Mercer's father harnessed their horse, hooked a sled to the back of the saddle, and rode the kids to school.
Mercer left Montana for the first time in 1962 to attend the College of Saint Teresa, a small women's college in Winona, Minnesota. She hadn't dated much in high school and often caught herself staring at her male classmates, thinking, "Imagine spending the rest of your life with him. It would be so boring." Her senior year of college, she studied for one quarter at Montana State University, where she met a college dropout with a motorcycle and a disdain for most people, though not for her, apparently, as he became her first husband. He had grown up in the military and called the shots, relocating them to San Francisco, Boston, Denver, Spokane, and, in 1971, back to San Francisco, all based on his whims. Mercer was happy to lead what she then perceived to be an unconventional life, a life that pushed the boundaries, until her husband pushed the boundaries of monogamy. She asked for a divorce in 1974.
The next year, she enrolled in the nurse practitioner program at UC San Francisco and soon after graduation began working at a small community clinic in Chinatown–North Beach, treating Chinese and Italian immigrants and patients who lived in a nearby African-American housing project. She was in the clinic one day when a friend who had recently been traveling in Nepal stopped by. "Oh my God, if there is any place you can work in the whole world, Nepal is it," her friend insisted, giddy as she recalled the beauty of the landscape and the culture. Mercer knew nothing about Nepal, but she had always wanted to go abroad. A few days after that conversation, while reading the newspaper in her kitchen, she came across an ad that read, "Nurses wanted in Nepal." She didn't hesitate. Three weeks later, after a crash language course in Nepali, she found herself beginning the first of 18 months in the country.
The Cherry Ames novels, created by author Helen Wells, detail the adventures of a rosy-cheeked, red-lipped young nurse who bravely sprints to far-flung places on missions to help those who would die if she were not there to save them. Mercer laughs now, embarrassed, when she recalls the books, which she devoured as a teenager and credits for her decision to become a nurse. Now, in Nepal, she had become her own iteration of the untethered, continent-hopping Cherry Ames, all pluck and caution-to-the-wind. "I don't think I was really smart enough to be scared," she says. "I saw it as an adventure and an adventure I'd always wanted to have. I had no idea what an important thing it would be. Once I was there, it became clear that it would be life-changing."
From 1978 to 1979, Mercer's base camp was in Nepal's north-central Gorkha district. For weeks at a time, she trekked with Nepalese vaccinators to remote villages to immunize children and educate communities about basic health issues such as diarrhea and worms. Villagers sought Mercer out, day and night, with questions about their health. Their ailments ranged from stomachaches to a thyroid gland so swollen it visibly protruded through the skin of a woman's neck. Mercer learned to measure distance to a village in terms of how many days' walk it was from the one highway.
One of Mercer's assignments took her on a three-day trek north to Gumda on trails lined with rhododendrons. When she arrived in the village, she could see Ganesh Himal, a tall mountain peak that is part of the Himalayas. A young Nepali medical assistant named Sailendra asked Mercer to accompany him on a visit to a 2-year-old boy who he believed had pneumonia as a complication of measles. As they approached the house, they began to hear eerie howling sounds ahead on the trail. "Oh no. We are too late," Sailendra told her quietly. As he explained, women make a distinctive wail after someone dies. This someone happened to be a child who might have been saved by a few doses of penicillin. Mercer had the drug in her bag. "That old saw—'People die, it happens to them all the time, they get used to it.'—that's a ridiculous idea," Mercer says. Since arriving in Nepal, she'd seen person after person die whose deaths could easily have been prevented by basic medicines.
Those 18 months in Nepal taught Mercer that she wanted to do something beyond treating individual patients, something that would get at the systemic public health problems in places like Gumda. The newspaper ad that drew her to Nepal had been placed by the Dooley Foundation (now called Dooley Intermed International), founded by Verne Chaney, Med '48, SPH '72. From Chaney, she now learned more about public health and heard from him that she needed to go to Johns Hopkins.
Mercer applied to the Bloomberg School of Public Health right before leaving Nepal in 1979, not long after Vietnam invaded Cambodia and drove the Khmer Rouge from power. Shortly after returning to San Francisco, Mercer got back on a plane and spent six months in Thailand with the International Rescue Committee, working as a clinician with thousands of refugees who had been pushed over the border by the Vietnamese. Her mother sent her a telegram from Montana while she was there with the news that she'd been accepted to Johns Hopkins.
She arrived in Baltimore in 1980 and earned her master's degree in international health. Feeling she'd only scratched the surface, she joined the doctoral program with a focus on maternal and child health. After Mercer completed her doctorate in 1987, she spent the next two years consulting for nonprofit groups in Asia and Africa. Then Hopkins hired her as director of HAPA—HIV/AIDS Prevention in Africa, a Hopkins public health grants program that sent her traveling throughout Africa. She worked with the field staffs of nine NGOs in seven different countries, educating them about AIDS and helping them learn how the communities they served understood the disease. AIDS was still a new affliction, but there were already many competing explanations within each country for how the infection was transmitted, prevented, and according to some, even cured. The explanations often relied on the individual community's belief systems about a topic that was largely considered off the table—sex. If anything was going to change with AIDS, it had to involve community participation and altering deeply entrenched behavior and beliefs.
That fit with what one of Mercer's mentors at the Bloomberg School, the late Carl Taylor, had always told her: "You have to learn from people who are living this life. You can't go in and assume you understand it." The NGOs Mercer worked with in Africa were willing to ask questions in focus groups about what local people thought and believed, and to tailor their approach to various communities based on what they'd learned from them. But she found that other organizations in the field—organizations with more money and clout—were not so willing. Mercer recalls a public presentation by a prominent U.S.-based organization, whose name she declines to reveal, about the results of their work on AIDS in Africa. "There was not a word about the social and cultural influences of people's behavior, or any mention of economic factors—and that was the whole problem," Mercer says. "That blew my mind." Too often, she says, "'we' go 'there' trying to tell them how they can improve their health. And we do it with this incredible hubris of not understanding their reality and what their real problems are."
When HAPA's grants ended in 1993, Mercer left the program and spent a year working for a child survival support program at Johns Hopkins. By that time, she had an adopted daughter, Maia, and her second husband, Bezruchka. They settled into a new life in Seattle, where Mercer met Stephen Gloyd, a friend of Bezruchka's who taught at the University of Washington's School of Public Health and was the founder of Health Alliance International, which is affiliated with the university. Gloyd invited her to join him at HAI, which is how she ended up going to East Timor.
Mercer and HAI's work was with the Timorese government to build up its health system. (The country renamed itself Timor-Leste in 2002.) In 2004, with a large grant from U.S. Agency for International Development, they took on a two-pronged effort to improve maternal and newborn health: educate communities, through films and visits to clinics, about the importance of health care for expectant and new mothers, and train midwives in up-to-date maternity care.
By the time their USAID grant ended in 2009, HAI's work had reached almost half the country's population. More women than ever were getting to prenatal care, and more women had a midwife present for delivery. But all their effort still hadn't produced the improvement they wanted. In 2009, WHO's maternal mortality ratio for Timor-Leste remained stubbornly high at 557 deaths for every 100,000 live births. For the women who were still giving birth at home unassisted, any complication could be lethal. Mercer and a colleague, Susan Thompson, were at HAI's headquarters in Seattle when they started brainstorming what to do next. Timorese women still weren't accessing midwives enough, often because they didn't feel a connection to them. "We were thinking, 'What can we do? What can we do?'" Mercer says. "By that point, we were seeing mobile phones all around [Timor-Leste]. We did not know how many mobile phones there were, but we knew there were a lot." Mercer and Thompson started digging and discovered that the rate of mobile phone usage had gone from only 2 percent in 2003 to between 54 and 61 percent in 2010. Phones were everywhere, even in the mountainous, remote parts of the country.
"What that does is give women a chance to be in contact with the outside world," Mercer says, and that contact might give them a chance to survive. She and Thompson sketched out Mobile Moms, an intervention to connect mothers and midwives through mobile phone texting. They applied for a second USAID grant, which they landed to their surprise. "We didn't have a great sense of how well it would work or whether it would work," Mercer says. It took them the first year and a half of the four-year grant to do a baseline survey and collect information from midwives and other health staff in the Manufahi municipality, work that revealed that almost 70 percent of women of childbearing age there had a cellphone in their household they used regularly. "It was mind-blowing that overnight, this technology could have reached these rural areas."
One of HAI's in-country staff was friends with the two founders of a Timorese-based technology startup called Catalpa International, who pitched in to help. Mobile Moms was born. "It was very vague in the beginning," Mercer says. "All we knew was that we wanted the midwife and the pregnant woman to have a connection. Then we wanted some information to be going out at the same time."
Back in Seattle, Mercer began writing SMS messages that could be sent to pregnant women, dispensing advice and reminders about how best to stay healthy. These were translated into Tetum, the most commonly spoken language in the country. HAI purchased smartphones to distribute to midwives, and Mercer flew out in January 2012 to oversee the first midwife training. The program was simple. When a woman came in for her first prenatal care visit, the midwife asked if she had a phone, and if she did, the midwife took her picture and some basic information: her name, her estimated due date, her phone number, the village in which she lived, and other pieces of identifying information. Then, twice a week, the woman began receiving messages appropriate for her stage of pregnancy. The first message read: "Congratulations on your pregnancy! You should be checked by the midwife at least 4 times at a health center to ensure a healthy pregnancy and healthy baby." A first trimester message read, "During the [antenatal] visit the midwife will measure your blood pressure and feel your belly to see how your baby is growing and moving." A message as the woman's due date approached was, "The baby is getting bigger and may cause your back to hurt. You should stay active but try not to lift heavy things like water or other children." The messages were meant in part to get women to think about having a midwife, now trained by HAI, present for the delivery. After birth, the messages continued for six weeks, with advice on postpartum and newborn care.
The program's early results were so impressive that HAI and Catalpa International were asked to scale up the program into three new districts, with a tentative plan to expand to all of the country's 13 districts in the next five years. In Manufahi, the number of deliveries in clinics rose by 70 percent, and total births assisted by a skilled attendant, whether at home or in a facility, increased by 32 percent. But Mercer is the first to take those numbers with a grain of salt. "There are a lot of complicated factors involved in evaluating whether the program works," she says. The ultimate outcome they hope for, of course, is decreased maternal mortality. But those numbers are hard for HAI or the Timorese Ministry of Health to measure, given how expensive and difficult it is to gather them. So the key outcome measure remains whether the women use a midwife or doctor. In the most densely populated area with the largest number of midwifery staff—the places "close to the road," as Mercer would have said in Nepal—the results were swift and impressive: more women came in for prenatal care visits, more women had their births attended by a skilled attendant, and more births occurred in a health facility. But in submunicipalities that are more remote, less densely populated, and have fewer health care staff, the increases were not as quick or as dramatic.
The Ministry of Health is currently conducting the biggest evaluation of Mobile Moms to date, surveying hundreds of women who had a child in the last two years and all the participating midwives. The results will be available in early 2016. Among other things, the survey will compare intervention districts alongside control districts, where Mobile Moms has not yet been implemented, to see whether maternal health is improving on its own, or because of the Mobile Moms program. If the survey shows that the program has been useful, Timor-Leste's Ministry of Health is interested in taking on responsibility for it over the next couple of years.
Mercer and Bezruchka sit on their back porch to eat toast and drink coffee. There are a few trees surrounding the house, and they creak in response to the light breeze. A few white clouds drift across Montana's big blue sky. Mercer is 71 years old now. She's able to visit the ranch a few times each year, to work on her memoir about her time in Nepal or to "just listen to the silence." She doesn't have a smartphone, but she keeps her flip phone close by in case Maia—now 26 and working for a nonprofit in San Diego—needs to get hold of her.
Mercer isn't sure what her involvement in Timor-Leste will be after their current USAID grant runs out in the summer of 2016. In 2011, she and Thompson switched positions at HAI, with Thompson becoming the director and Mercer becoming a technical adviser—the beginning of edging into retirement. Nonetheless, Mercer still makes the trip to Timor-Leste each year to train their staff of 43 people, or to help out with the various programs, even though it takes 44 hours to get there and exhausts her. She's mentioned a few times now that she's at retirement age, that she should be retiring now, almost as if she needs to convince herself. So why does she keep going? Her answer is that she is moved by friends in Seattle who are committed activists. "If there weren't people like that in my environment, I think I would find it much easier to step back and say, 'Oh, I've done my thing, I've done it, I'm tired.'" She interrupts herself to point out a bird behind us. "Oh, look at the clothesline. Isn't it pretty?" The bird is small with bright yellow coloring on its chest and back. A goldfinch.
Mercer picks up her point again. Her friends are part of it, yes, but the other part is what the women of Timor-Leste experience. That stays on her mind. "You can't forget it," she says. "You just can't forget what women go through when they're in labor for days and die."
Posted in Health
Tagged public health, mhealth, nursing, maternal health, infant health
