Infrastructure: Fiction Techniques and Shaping Public Health

Infrastructure: Fiction Techniques and Shaping Public Health

by Lise Saffran

April 5, 2011

To an American college student, there is nothing more invisible than the infrastructure that supports public health on the environmental level. Except in rare occurrences (a cancer cluster, a catastrophic oil spill, a nuclear disaster) the systems that protect the air we breathe, the water we drink and the food we consume are invisible to most students and because they are invisible, they are taken for granted. When no one is burning plastic garbage outside your window, it is easy to forget about the money, political will, engineering know-how, the sheer community effort that went into making that so.

It is in great part to make that invisible infrastructure visible that I have begun leading a study abroad trip for students of public and community health. Last January I brought my first group of 23 Missouri undergraduates to Ghana. It was clear that the learning began just as soon as we emerged into the humid and overcast Accra morning.

For long stretches on the trip from Accra to Cape Coast we sat unmoving in traffic while people overtook us on foot, carrying on their heads plantain chips, clean water sachets, peanuts, hardboiled eggs, sandals and even, in the case of one middle-aged woman, a microwave oven. All of them picked their way around piles of garbage, open sewers, standing water, goats, chickens, cars and more garbage.

Like other developing countries, Ghana is struggling with a lack of basic and environmental sanitation systems. There are over four million people in the country without access to toilet facilities. Ample evidence of this is provided by the beaches which, though picturesque from a distance, are littered with human feces. When garbage is collected, it is burned. The air smells like smoldering plastic day and night.

After less than an hour in the country, the young woman sitting next to me — who had never been overseas and would see the ocean for the first time from the coast of Africa — turned and asked, “So what do we do with our garbage, anyway?”

I’d been nodding off, allowing my head to bump against the window with each jolt, but suddenly I sat up straight. “Well, if it’s not recycled it goes to the landfill. You know, the dump.”

She thought about this for a moment. “Couldn’t we run out of room?”

For this student, the previously invisible community effort that is at the center of public health began at that moment to shimmer into focus. For me, Associate Director of the Master of Public Health Program at the University of Missouri and author of the novel, Juno’s Daughters, I sensed the two strands of my professional life overlapping like train tracks at a switching spot.

Public health infrastructure is something that, like a work of fiction, is made and not found. Readers often approach novels as if they were objects unearthed at a dig, rather than the accumulation of a thousand selections, omissions and initial stumbles. They’re supposed to. In a good novel, a reader is left feeling that the story could not have unfolded any other way. The effort that writing the story took is, and should be, invisible.

Invisible does not mean absent, however, as the student on the van ride had begun to recognize. A novel may be experienced like a dream, but only if the writer has spent the necessary hours revising under a bright light. The mechanisms that protect the air we breathe, the water we drink, the land we occupy and the food we eat require an equally clear-eyed vigilance; they can begin to unravel if we neglect them.

For the duration of the Ghana course, this student and her classmates worked with community-based organizations providing health education and services to mothers and children and people living with HIV. They struggled to understand the context in which individual choices were made in a culture and environment very different from the one they knew. They strived to see the story behind the story. They began to see social, political and economic systems as ways in which human beings organize themselves, rather than accidents of nature. And they began to understand how the story could be rewritten.

People often assume that the imaginative work lies entirely with the fiction writing and that the public health job is, by comparison, practical and dull. It is far from true. In a novel or story, I aim to strip away preconceptions and clichés and assumptions and write about human experience as it really is. Public health professionals, and I hope to include my students among them someday, work to create the world as it could be. Depicting fictional characters without the ability to imagine alternative stories is difficult. Changing the world we live in without understanding how we have made it in the first place is impossible.

Lise Saffran is the author of the novel Juno’s Daughters. A graduate of the Iowa Writers’ Workshop, she has received fellowships from the MacDowell Colony and Hedgebrook. Her short fiction and essays have been published in a variety of literary journals and in the magazine, “Poets and Writers.” Since 2007, she has served as the Associate Director of the Master of Public Health Program at the University of Missouri. Her website:

Also see A Tribute to Barbara Seaman: triggering a revolution in women’s health care in this edition of On The Issues Magazine.

See “Acting As if Future Generations Matter” by Carolyn Raffensperger in this edition of On The Issues Magazine.