In the southern part of Asunción, Paraguay's capital, a slum called Bañado Sur sits in the flood plains of the Paraguay River, next to the city dump. Once a desolate swamp, it's now one of the city's most populous neighborhoods. Most families there make a living sifting through trash piles for recyclables. 

One in six people worldwide live in informal settlements like this one. "These communities are incredibly challenging in terms of health issues," says Karen Andes, a global health researcher who has studied the explosive growth of urban slums in Latin America.

"People can be really creative and enterprising, and there's tremendous solidarity. But they're also very poor, with substandard housing that's flood-prone," she says, noting that during last year's flooding, 90 percent of Bañado Sur's residents had to evacuate.

"Millions of people live in these situations, and it's not clear what the solution is."

A focused approach

A political scientist who came to public health through demography and family planning issues, Andes began working in Paraguay 10 years ago as a researcher with the U.S. Centers for Disease Control and Prevention.

She's now assistant professor of global health in Emory's Rollins School of Public Health, and one of the first recipients of the Fulbright Scholar Program's new Flex Award, which funds multiple short-term stays in a country over two or three years. This is the first of three summers she'll spend working with Instituto Nacional de Salud (INS), Paraguay's national public health institute. 

"The summers are brilliant. Being able to go for six or eight weeks each year is just phenomenal," says Andes, who has a 13-year-old son.

Bañado Sur's health challenges are wide-ranging and overwhelmingly complex, and Andes' focused approach starts with teen pregnancy rates and successful transitions to adulthood.

"For young people in the slums, their prospects of making a positive transition to adulthood are already hindered by where they live. Generally, they have poor educational outcomes and can look forward to joining other families collecting recyclables out of the trash," she says. "In these situations, an unintended pregnancy can be devastating." 

Sharp divides 

Paraguay's maternal mortality rate is among the highest in Latin America. The country's adolescent pregnancy rate is 68 per 1,000 women, but the birth rate among poorer teens is much higher — more than double that of the middle class. 

In other words, if you're a young woman with aspirations in Bañado Sur, the odds are stacked against you. 

Teen pregnancies are also an economic burden: A recent World Bank study estimates they cost Paraguay $63 million each year. Yet few, if any, evidence-based adolescent pregnancy interventions have been implemented there.

"Paraguay is an under-researched place," Andes says. "The dictatorship lasted a bit longer than in the surrounding countries"—Alfredo Stroessner fell in 1989 after a 35-year rule—"so it was closed to the outside for a long time. It doesn't have fancy natural resources, although it's the fourth-largest producer of soy in the world." 

Beyond these burdens, in Paraguay's conservative political climate, "any attempts at getting a national curriculum around sexual health have always been hard to pass," Andes says. Paraguayans are sharply divided over reproductive rights, and the recent case of a pregnant 10-year-old allegedly raped by her stepfather has heightened tensions around the country's abortion ban.

All of this leaves Andes grappling with a daunting challenge: How do you design an effective intervention for a devoutly Catholic society where talking about sex has long been taboo?

A thousand partners 

In 2012, Rollins' Global Field Experience program brought Brianna Keefe-Oates 13PH to Asunción to run an acceptability study of an intervention called Families Talking Together. She spent 10 weeks working with Mil Solidarios ("a thousand partners"), a local organization that keeps students in school by providing small scholarships, about $25 a month—"just enough to keep them from having to work with their families collecting recyclables," Andes says.

Mil Solidarios already had a regular parent group, so Keefe-Oates invited them to participate in a trial run of the Families Talking Together activities. The intervention targets parents of youth ages 10 to 14 in an attempt to reach them before their children become sexually active, and it offers role-playing sessions so they can practice talking with their kids about sex and pregnancy prevention.

"Most parents wanted to talk about it, but they had never discussed it as kids, so it was hard for them to know what to do," Keefe-Oates says.

She found that families were interested not just in the mechanics of preventing pregnancy, but also in psychosocial factors like what a healthy relationship looks like. She also discovered that parents spoke to their children in gendered ways, focusing more heavily on sexually transmitted infections with boys and on pregnancy with girls.

These nuances are one reason Andes and her multidisciplinary student team are working with Mil Solidarios. "Partnering with a community-based organization has really expanded our reach into the community," Andes says, and it will also ensure the program's sustainability. She expects local staff members to begin running the workshops after next summer.

In the meantime, three Emory students funded by the Emory Global Health Institute (EGHI) are in Pilar, about five hours south of the capital, to do trial runs of related interventions. Mario Correa 16G, a student in Emory's Master's in Development Practice program, is adapting Promundo's Program H (for hombre), which has a unique approach targeting men and boys.

"It's designed to challenge traditional conceptions of masculinity," Correa explains. "The prevailing discourse around gender inequities tends to focus solely on empowering women." That's important, he says, but "it leaves a void in considering what the role of men should be."

A ripple effect

Andes plans to expand the intervention to nearby communities, particularly Bañado Norte, which is close to the national public health institute. "I'd love to see these couple of years guide [the national public health institute] into a community partnership with a neighborhood they could work with for years to come," she says.

After co-teaching a University Course on informal settlements last spring, she's also starting to work with slum communities outside Paraguay. "It was an occasion to broaden my horizons from the community I've gotten to know there to a more academic look at what's happening worldwide with communities like this," Andes says.

She has another EGHI student team in Nicaragua this summer, working with a resettled community that once lived inside and around the Managua city dump. "Looking at comparable communities in different places can help give us the empirical base to understand the benefits and disadvantages of different strategies for dealing with these issues," she explains.

But for the time being, Andes is fully invested in on-the-ground operations in Asunción. Almost half the population there is under 25, she points out. 

"This is the first generation of young people that has not lived under a dictatorship," she says. "Having this kind of dialogue now could have ripple effects well into the future."