How learning about ambiguity brought more clarity to public health for Elizabeth Sajewski ‘13

Tuesday, Mar 6, 2018
by Erin Wispelwey

In this Spotlight, we talked with Elizabeth Sajewski about her experience working with epidemiologists in Kathmandu as an undergraduate, how storytelling and mathematical modeling go hand-in-hand in the creation of health risk assessments, and why you should explore broadly in public health.

Erin: As an undergrad, what did you value most about the GHP experience?

Elizabeth: I really enjoyed the classes I took as a GHP student—as an engineer we had a really heavy course load and having these set electives and course requirements to incorporate different types of classes and perspectives was great. These courses introduced me to professors and topics that allowed me to design a thesis with a strong global health focus. Although I was in the civil and environmental engineering department, I had a second thesis advisor, Bryan Grenfell, who is in the EEB department and a GHP professor.  I looked at the influence of municipal water systems and seasonal precipitation on typhoid mortality in US cities at the turn of the century, which combined my engineering and health interests.

I also really enjoyed the GHP lunch and lecture series on Fridays—it gave me a chance to be exposed to a wide variety of topics and issues in global health beyond what I was exposed to in classes. The staff support and advising from GHP was also great. Talking with the GHP director at the time, Kristina Graff about my interests and goals helped me plan how to incorporate the global health program requirements to get the most out of them.

Erin: Do you have any special memories from your time at Princeton that are broadly GHP related?

Elizabeth: One of my favorite courses that I took was epidemiology with Joe Ammon. GHP put me in contact with students from other disciplinary backgrounds and, in epidemiology, in particular, Professor Ammon developed a class atmosphere that didn’t feel like a lecture or a class where we were just told things, but a class discussion, where we were addressing case studies and learning together. Another class that I have a lot of memories of and still reference frequently was a course on “Ethics in Global Health Policy” with Professor Jason Schwartz where we debated ethics behind public health policies. I particularly remember our discussion of smoking regulations and anti-smoking campaigns. Prior to this course, I had primarily been interested in infectious disease but this course opened my eyes to different challenges with chronic diseases as well as the social and political issues beyond the natural sciences that come with public health policy. 

Erin: Did you study or work abroad through GHP—or broadly GHP related?

Elizabeth: I had an international summer internship with Princeton Environmental Institute under the advisement of Professor Grenfell. I worked with Oxford University Clinical Research Unit in Kathmandu, Nepal (OUCRU). It was a great experience to be in an office full of professional epidemiologists and biologists and have the opportunity to talk to them about their work and learn about their research in infectious diseases. It was an influential experience in terms of my own self-reflection and thinking—“is this something I could be doing in the future?” Overall, the internship gave me perspective on public health in practice in the wider world, beyond the classroom.

My work focused on water quality and health, an area I’ve always felt passionate about and actually brought me to environmental engineering. In my internship, I collaborated with OUCRU and the Himalayan Climate Change Alliance to produce a report on the Bishnumati River, one of the surface drinking water sources for Kathmandu, which included research on water quality, including chemical and microbiological analyses, and interviewing people in health care clinics about perceptions on environment, water quality, and health.

I was based in Patan Hospital in Kathmandu, which was an eye-opening experience as I learned about differing practices and the unique challenges facing public hospitals in the developing world. One small example of differing practices was that they used autoclaved newspaper, rather than paper towels, and nurses often complained about getting ink on their hands. I also was able to attend Grand Rounds where different issues I had discussed in class, such as antibiotic resistance, became much more real and immediate as doctors discussed the changes in practice needed to combat these issues. In the highlight of the summer, Paul Farmer stopped by to give a lecture at the hospital. Reading Mountains Beyond Mountains was what interested me in global health initially, and being able to meet one of my public health heroes, ask him questions about his work, and learn how he was addressing health disparities in the environment where he was working was awesome.

Erin: Can you tell me what you’ve been up to since graduation?

Elizabeth: For about four years after graduation, I worked for Ramboll Environ, an environmental consulting firm, in human health risk assessment and industrial hygiene. At Ramboll Environ, many of my colleagues had public health backgrounds and MPHs and the work we did was public health-related, but in a very different way than I was expecting to get involved in public health work. We performed human health risk assessments for contaminated industrial sites and Superfund sites, evaluating the risk of exposure to chemical contaminants in soil and groundwater. We also performed occupational exposure assessments, monitoring workers to characterize their exposure and compare exposure levels to OSHA [Occupational Safety and Health Administration] standards. A lot of this was different from the infectious disease research I did at Princeton—this was more exposure science, toxicology, and chronic diseases. But it was very interesting—it expanded my idea of what public health was and it pulled on things from my classes that I hadn't thought as much about before. For example, in my global health ethics classes, we discussed how people of lower socioeconomic status often had greater potential for exposure for chemical contaminants and I saw in my work that many of the neighborhoods where superfund sites were located were lower-income communities. This introduces ideas about environmental justice and public health. This focus on chemical contaminants and human health was a shift from what I focused on as an undergrad but it also was in line with what we learned in GHP and gave me an extra layer of understanding of public health issues, as well as the different ways of being involved in public health.

This fall, I’ve started a PhD at Emory University in Environmental Health Sciences. Environmental health science allows me to combine the work I did as an undergraduate, focusing on infectious disease and water and sanitation infrastructure, with what I learned at Ramboll Environ.  I hope to focus on infectious disease modeling, particularly for waterborne and environmentally-driven diseases, and research the potential impacts of different interventions, such as vaccines or the expansion on municipal water systems, on disease dynamics.  I look forward to doing this with the backdrop of toxicology and exposure science to develop research to better understand how all these aspects of disease and health weave together.

Erin: Which components of the program have stuck with you post-graduation? What sort of skills—hard or soft—that you gained through GHP have translated to life after college?

Elizabeth: In terms of concrete skills, the mathematical modeling we learned in Professor Grenfell’s class has provided a useful framework for the modeling I did as an environmental consultant and I hope to also apply to the research I do for my PhD. Additionally, through my GHP classes, I strengthened my ability to critically read academic papers, and search for answered questions or unsupported assumptions. Critical review helped strengthen my writing and editing skills, as well as my ability to thoroughly review the literature and find new questions and area of research.

The GHP program also helped me think about problems in a different way than the engineering problem-solving approach to which I was accustomed. One of the challenging things with the issues we discussed in GHP, was that there wasn't always a clear solution—or that there was never a clear solution! There were always more aspects of the issue to consider, like cultural or anthropological influences into which treatments would be successful and all of the more human aspects that go beyond the physiology and biology of diseases to affect what public health responses are needed. Considering the many different ways to approach public health issues and the multi-faceted nature of these issues changes the way I think about and discuss public health, as well as providing additional insights into possible solutions.

Erin: What did you love about your job with Ramboll Environ? Is there anything you didn’t like as much?

Elizabeth: I really loved the storytelling aspect of my work as an environmental consultant. It was a surprise to me that storytelling was such a dominant part of risk assessment. We would come up with a “story” of how people were exposed to a toxin or hazard and then model that story. For example, let’s say we have an industrial site that contaminated a river. What if neighborhood kids come to swim? For how long? Will they wear shoes? And we develop this picture of people that may come on site, model the exposure pathways, and combine this with toxicological data and site-specific chemical concentrations, moving from our narrative of possible exposures to estimates of health risks. I really love working with large sets of data, but being able to use that data in a somewhat creative process to illustrate potential risks is something I really enjoyed. I think there are a lot of opportunities to work with data in creative ways, to use storytelling to help figure out analyses, in public health because you have to think a lot about how people are exposed to something and then you come back and crunch some numbers—I’m looking forward to continuing this type of work with modeling in my PhD.

One challenging aspect of working in human health risk assessment and remediation was that it often felt reactive, rather than proactive. The chemical spill or contamination has already occurred and, though our work is important to limit exposure, it doesn’t prevent the contamination from happening.It was frustrating at times to have the role of cleaning up the messes we’ve already made.

Additionally, we worked with industrial clients to develop reports for EPA and state environmental agencies. In environmental advocacy and environmental groups, I feel like industry is often seen as the “bad guy.”I realized that's not really true. In the end, like all things related to public health, the problems are much more complicated than just “bad guys” and “good guys,” as industry balances working with environmental agencies and stakeholders with remediation and, if possible, continuing to provide jobs that are vital to the local communities. There are a lot of complex elements that affect health and health-related issues and considering this complexity is essential for creating responsible actions and decisions.

Erin: I know it’s only a few years out of school, but are you headed in the direction you expected?

Elizabeth: When I was at Princeton, I thought, after graduation, I would immediately go work internationally for an NGO and save the world. But then I ended up working in an office in New Jersey in the private sector for four years before applying to grad school, where I am now. I hadn’t expected to work in consulting, or to work in the private sector at all, but I’m really glad I did. This work gave me a different perspective and a different set of skills I may not have acquired otherwise. Working with industry has helped me to develop a more nuanced understanding of the challenges presented in the real world when there are always many different stakeholders to balance. As consultants, we often acted as an intermediary between industrial clients and the EPA or state environmental agencies, a position that provided great insight into the priorities on both sides, as well as opportunities to be advocates for creative problem solving and strong science as the drivers for solutions. Working in consulting allowed me to have exposure to a lot of different projects and clients, as I developed and diversified my skill set. I learned to manage client relationships, strengthened writing and communication skills, gaining field experience, learned to work with different regulatory programs, and developed a love of working with large datasets. My work experience strengthened my applications to grad school and gave me more clarity on what I wanted to do, and the environment that I want to be in. I’m glad I had the opportunity to work in private sector and have that work experience

I always expected to go back to school. I was considering med school for a long time, but, after working for a few years, I realized that I was more interested in going in the direction of research and evidence-based policy and these interests would be better facilitated by working on a PhD. Part of that realization involved learning that I loved working with a lot of data and wanted to dive deeper into data. I also wanted the opportunity to use research to find where the system is broken and design ways to fix it, to drive policy that hopefully prevents people from getting sick in the first place.

Erin: Any final thoughts, advice, words of wisdom for current GHP students?

Elizabeth: I would say get to know your professors; they are awesome. At Princeton, we have direct access, through classes and lectures and research opportunities, to leaders in the field of public health. I wish I had taken greater advantage of that while I was at Princeton. As you are exploring different interests and career paths in public health, talk with your professors. Their experiences and networks are amazing resources. Even now, I continue to see the importance of the connections I made while in undergrad as I develop my own network in public health. Also, explore a wider range of courses than what you think is within your immediate field of interest. Take a few courses that are not exactly aligned with your current goals. It will help you to broaden your perspective and give you exposure to a wider range of topics in public health and beyond that may be relevant and will feed back into your main interest.