n a rural area of Kenya, not far from Lake Victoria and the town of Kisumu, a network of unpaved roads leads to houses scattered over the hillsides. Members of Kenya's Luo ethnic group live here in dispersed communities and trading centers spread along the lakeshore and inland plains. Luo farmers grow maize and beans as their staples and supplement their diets with fish from the lake. Safe drinking water is hard to come by, and diarrhea in Luo children is a b ig problem. But an even greater health threat is malaria. In western Kenya, two annual rainy seasons create ideal environmental conditions for year-round malaria transmission. The long rains begin in late February and last through June, and the short rains occur throughout November. As a result, the rates of malaria in this area are some of the highest in all of Africa. Pregnant women and young children are particularly susceptible to repeated infection. Karen Shelley, a postdoctoral fellow at the Rollins School of Public Health and the Centers for Disease Control and Prevention (CDC), has worked with Luo mothers who have experienced repeated episodes of malaria. Bringing an expertise in medical anthro pology and public health to the area, she hopes to bolster the community's resources to better educate mothers about malaria prevention. Shelley collaborates with a local Kenyan woman who is a community health worker trained in the social sciences. As a team, they canvass homes in the rural community on foot in the dry season or by four-wheel-drive vehicles in the rainy season. Shelley interviews the women at home and holds discussions with women's groups at a nearby community center. She brings a behavioral and social sciences perspective to community health workers at a CDC unit based there. Shelley is not new to Kenya, having conducted research there since 1971. She speaks several African languages. In the mid-1980s, she was awarded a Fulbright Fellowship to further her African studies, and in 1985 she completed a PhD from the University of North Carolina in medical anthropology. Her dissertation was an ethnomedical study of how western biomedicine can be integrated with the lay traditions and folk medicines of Turkana, an area in northern Kenya. Shelley's recent fieldwork in Kenya has been sponsored in part by the Center for the Study of Health, Culture, & Society (CSHCS) at Emory. Established in 1993, CSHCS encourages interdisciplinary and comparative approaches to problems of public health i mportance. The center promotes workshops and conferences as well as supports the development of interdisciplinary research programs and courses. CSHCS also is lending its efforts to a collaborative research project between the CDC and the Kenya Medical Research Institute based near Kisumu. The goal of the project is to determine the effectiveness of bed nets to reduce child mortality in some 60 ,000 households in the region. CSHCS's particular contribution is a household and social economic survey linked to the larger study. "We're providing expertise in the social sciences and public health," says Randall Packard, director of CSHCS, a professor in the Rollins School of Public Health and chairman of the history department at Emory University. "In turn, this project is offe ring an opportunity for our students to get field experience."

Speaking several African languages, postdoc Karen Shelley brings her expertise in anthropology and public health to Kenya. Keeping a toddler under a bed net is a challenge for these Luo women but essential to a public health study being carried out in rural western Kenya to determine if bed nets, which have been effective deterrents to malaria rates elsewhere , will work here, where the transmission rate of malaria is among the highest in the world.

he World Health Organization has found that netting significantly lowers the incidence of malaria in other parts of Africa, according to Packard. "However, the places where they have tried bed nets have much lower levels of malaria transmission," he says. "The question is, will they work here where the transmission rate of malaria is among the highest in the world." To help answer that question, researchers need the perspectives of social scientists and public health educators. The household survey, prepared by Packard and Shelley, delves into sleeping patterns and economic conditions to see if bed nets are a reas onable intervention for the Luo and if they are culturally appropriate. "Bed nets are somewhat of a challenge for mothers," Shelley says. "Keeping a 3-year-old under a bed net, for example, can be an ordeal." Also, if the population uses the nets improperly, without tucking them in well at night, the effectiveness will be diminished. "These sound like simple things," Shelley says, but in real life, when mothers remove a child from a net to breastfeed or when toddlers escape, the bed net may not work." Besides participating in discussion groups with the Luo women to gather information, Shelley has been surveying the research literature in other parts of Africa to see what has proven successful elsewhere. One method that seems to work is to enlist old er siblings, who often sleep with their younger brothers and sisters on floor mats, to train the youngsters to stay under the netting. This summer, Kendra Hatfield, a doctoral student in Emory's anthropology department, spent eight weeks in western Kenya, completing the pilot of the household survey. Like Shelley, Hatfield is a seasoned student of Kenya. As an undergraduate, she worke d in the Machakos district with a traditional herbalist. Her return to Kenya this summer allowed her to add Luo - a tonal language - to the Swahili that she already speaks. And her experience, she believes, has enhanced her dissertation plans to study the experiences of infertile women in this high fertility country. In their work in Africa, both Shelley and Hatfield are carrying out two of the goals set by CSHCS, says Packard. "We want to achieve a closer integration of academic scholarship and health intervention activities," he says, "and to provide advanced int erdisciplinary training for our students."

Historian Randall Packard believes interdisciplinary studies are critical to students who pursue health-related topics. The Emory center he directs encourages collaborative research projects.

nterdisciplinary efforts are common fodder for Packard, who works in the school of public health and the department of history. He began his academic career as a historian, completing a dissertation on 19th- century precolonial history in eastern Zaire that was published as Chiefship and Cosmology. In researching that work, he found that aspects of health and disease had shaped the history of the region. That realization led him back to school to gain the skills of a public health researcher. During a postdoctoral fellowship at the Harvard School of Public Health, he began to clearly see the links between health and social and economic history. Packard has subsequently written a history of tuberculosis in South Africa, White Plague, Black Labor. Currently he is at work on a history of malaria eradication. WHO launched its effort to eradicate malaria in 1955. The global eradicatio n campaign, according to Packard, was recognized as a failure long before its official end in 1969. Despite the failure, it remains "an important chapter in the history of international health," Packard says. He is trying to understand why WHO's first maj or global campaign was attempted and why it failed. Packard believes cross-disciplinary training is essential for writing social histories of health and disease. His training as a public health researcher helps him better analyze and interpret data, a point he emphasizes to his students. "If arts and sc iences students are interested in working on health-related topics," Packard says, "then they need to be exposed to the issues, concerns, and methods of the health sciences. It's comparable to learning to speak an African language when you plan to work in an African country. If you're going to work in health, you need to learn the language of health." Likewise, public health students working in an international setting need to understand the larger historical context, Packard says. "By looking at past experiences and programs, how and why they developed, and the issues and assumptions that led to th eir development, students can better understand the workings of international health," he says. "Students need to appreciate that policies don't simply emerge solely out of some cost-benefit analysis but also from a much larger set of political and econom ic agendas." Packard's founding of CSHCS - with the support of the Carter Center of Emory University, the office of the provost at Emory, and the deans of public health, arts and sciences, medicine, and nursing - encourages these links between public health and oth er disciplines. This year, with public health Professor Claudia Fishman and faculty members from the anthropology department, Packard has developed a course on health communication that combines the perspectives of international health and anthropology. H e is also supporting a new fellowship program that will permit the exchange of students in public health and the arts and sciences. Packard believes that his interdisciplinary studies have been critical in helping him understand contemporary problems such as malaria in Africa. "History helps you see the social and economic determinants of health and health care," he says, "because it shows you how things connect over time. My interests in public health help me understand the importance of linking history to the present." Forging interdisciplinary links between history and public health helps prepare Packard and his students to better tackle Africa's public health problems.

Community health consultants, such as these Luo women, assist researchers from the school in gathering information and educating the public about malaria prevention. Cities in western Kenya are studies in contrast, with modern architecture and transportation juxtaposed against ancient rural practices. Here, a cattle herder takes advantage of paved streets.

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n a hillside in rural western Kenya, a group of Luo men, women, and children gather in a clearing surrounded by trees. Some have walked for more than a half hour to reach this place, where soon 12 African ac tors will present a drama. Karen Shelley, a postdoctoral fellow at the Rollins School of Public Health, is among the crowd. With the rest of the audience, she finds a place on the grounds and waits. A leader, known as the animator, starts the production. "What would you like to see?" he polls the audience in the Luo language. Their choice is between a drama on bed nets or another on malaria awareness and prevention. Tonight the majority choose to see the bed net play. According to Shelley, these dramas, presented by community theater groups, are known as participatory educational theater (PET). They are fast becoming a common and effective form of public health education in Kenya, she says. Because some adults in th e society do not read, the oral presentations reach a wider audience than more traditional educational approaches. The dramas began, in part, in response to the AIDS epidemic. During these plays, actors present a theme that explores the effect of HIV on the family and the larger society. After the drama, the animator enlists audience members to change the story lin e or scenario. In addressing sensitive issues, the animator attempts to destigmatize a topic such as AIDS and follows with a discussion of the ways to reduce risky behavior, Shelley says. Recently, researchers working in malaria prevention have borrowed from the AIDS PET to create two dramatic scenarios that teach audience members to recognize the signs of malaria infection as well as prevention strategies. As an outgrowth of her involv ement with the collaborative research project on malaria in Kisumu, Shelley wants to document and evaluate these dramas. Like the bed nets, they too may make a difference in lowering the highest rates of malaria transmission in the world.

In rural Kenya, participatory educational theater is becoming a popular and effective way to educate the public about health issues. This audience has gathered to learn about malaria prevention.