Pereira, Amanda


Study of stroke prevalence in a resource poor setting with daily exposure to biomass fuel smoke

The World Health Organizationhas identified stroke as a high public health priority in low- and middle-income countries. Stroke prevalence and related risk factors unique to low- and middle-income countries are not well identified.  Household air pollutionfrom exposure to biomass fuel smoke is believed to be a highly prevalent risk factor that likely contributes to cerebrovascular disease. Nearly one quarter of all premature deaths due to stroke (i.e. 1.4 million deaths of which half are in women) can be attributed to the chronic exposure to household air pollution caused by cooking with biomass fuel, however, evidence to support this is lacking. We hypothesize, that through evaluation of stroke prevalence and establishment of a longitudinal registry to study stroke incidence in Puno, Peru, a region with high utilization (>95%) of biomass fuels for cooking in rural settings, we will be able to evaluate the association between stroke risk and exposure to household air pollution.  Further, we hypothesize that the Framingham Stroke Profile will predict the increased prevalence and incidence of stroke in this population. The Framingham Stroke Profile has not been validated in Latin America. We aim to characterize the relationship between household air pollution and stroke to better describe the epidemiology of this potentially important risk factor in low- and middle-income counries. We propose a two-year project in which we start with a cross-sectional study to evaluate stroke prevalence in Puno, Peru; and develop a continuous prospective stroke registry to determine the stroke incidence in this population. Laying the foundation for an ongoing research operation will provide the capacity to conduct intervention trials, for example by utilizing improved cookstoves to reduce stroke risk.

Global Health Mentor: William Checkley, MD, Medical Director, Johns Hopkins Medicine International

Upon landing in Puno, I immediately started looking for signs of altitude sickness. At a height of about 12,500ft, many told me that dizziness, headaches, vomiting, and nausea, would likely greet me shortly after arriving in the mountainous city. Fortunately, these symptoms never arrived. Instead, I stepped out of the airport into intense sunshine that pierced the fresh, brisk air and shifted my focus from within myself to the amazing landscape around me. This amazing landscape, consisting of modest buildings dotting worrisomely steep and picturesque hillsides, would capture some of my most treasured experiences surrounding international health.

Puno is a small city in the Southeastern region of Peru. Sitting alongside Lake Titicaca, Puno is frequented by tourists throughout the year that seek to visit the lake and the “floating islands” that sit on top of it. For many Hopkins students, though, Puno is the site in which they get to learn more about the presence, prevention, and treatment of non-communicable diseases such as asthma and stroke in a low-income setting. As a well-established research site, I was excited to be among this group of students with such valuable opportunities.

The global health project that brought me to Puno aimed at identifying the influence, if any, of biomass exposure on the prevalence and incidence of stroke in Puno and its surrounding rural communities. As a student interested in the unique barriers to prevention and treatment of non-communicable diseases in low and middle-income settings, I looked forward to the opportunity to learn about stroke in a city where it had not been studied before.

My work involved data collection and management of prevalence and incidence data from September to December of 2015. My experience with data collection in Puno was eye-opening as I experienced many of the challenges typical of international health projects. Participants were difficult to locate and equipment frequently malfunctioned, forcing myself and the staff to often make repeated visits to the same communities for data. Unique to Puno, perhaps, was adjusting to participants’ schedules in rural communities. We would leave as early as 3:30am in order to complete visits before participants would start their workdays. The climate only added to these challenges as our early mornings were met by piercing cold weather that was unforgiving both outside and indoors, as many of the buildings had no heat or insulation.

Despite the physical challenges, I consider my experience to be invaluable as I learned a great deal regarding the people of Puno, work in international health, and myself as a future public health practitioner. Regarding the people, the overwhelming majority of research participants were kind and inviting, eager to participate in the study in hopes of learning more about their own health. Although our study focused on the physiological issue of stroke in elderly individuals within Puno, it exposed me to a somewhat forgotten issue faced by many elderly individuals worldwide: social isolation. A number of times we would be the only people that visited our participants for an extended period of time, prompting warm and excited greetings once we arrived at their homes. Outside of the isolation, I was always amazed at the amount of strength our participants showed as they endured backbreaking work in harsh weather conditions at high altitude. Working with this population made me appreciate the importance of good research staff when working in international health. I was fortunate to work with a talented group of research assistants whose good rapport with rural and urban communities allowed us to reach recruitment goals during my time in Puno. In reference to my future as a public health practitioner, I learned a lot about my physical endurance. Living and working in a high altitude setting like Puno was definitely an unforgettable experience that allowed me to surpass my own perceived limits. The most valuable lesson I took home, however, was that which came from seeing the challenges that our study participants faced in maintaining their health, first-hand. Although my classes at JHSPH and previous travel to low and middle-income settings gave me a basic idea of some of the principle issues facing chronic disease prevention and treatment, my field work in Puno provided detailed and specific information that will hopefully inform my own research into the effective reduction of chronic disease in low-resource settings.

A view of my “commute” to work; taken on the way to the rural area (campo) on one of the hills at the edge of the city of Puno, overlooking Lake Titicaca;

At times we took measurements in creative places. Here, I am administering an EKG outside as a participant lies on the ground;

One of the many alpacas we encountered out in the campo;

The view of the campo itself and the trusty truck that took us to all our visits;

The team! Many of the staff in Puno have been working at the site for years;


September 2022



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