Park, Ju Nyeong
Malawi-Documenting the scale-up of maternal, newborn and child health programs in Malawi
This study in Cameroon will focus on size estimations of the SW and MSM populations, a mapping of HIV prevention services, and a triangulation of HIV prevention, treatment and care data to inform content of programs and policies and the allocation of resources. The project is supported through the Research to Prevention (R2P) program which is a 5-year HIV prevention project funded by USAID and led by the Johns Hopkins Center for Global Health and implemented by faculty throughout the University. It is managed by the Center for Communication Programs (CCP) in the Department of Health, Behavior and Society at the Johns Hopkins School of Public Health. This study is conducted collaboratively with the Center for Public Health and Human Rights, in the Department of Epidemiology at the Johns Hopkins Bloomberg School of Public Health. Despite low HIV prevalence among the general population, relative to other regions of sub-Saharan Africa, West and Central Africa contribute a significant proportion of new HIV infections to the global burden due to their large population. While national HIV prevalence ranges from less than one percent to five percent in the region, prevalence among most at risk populations (MARPs), including sex workers (SW) and men who have sex with men (MSM) is significantly higher. This work will focus on female sex workers though prevalence of male sex work will be characterized as a component of the studies focusing on MSM. For instance, HIV prevalence among SW is 30 times the general population prevalence in Niger and Senegal; HIV prevalence among MSM ranges from 13% to 37%. Public health workers need methods to estimate population sizes of hidden high risk groups, in order to lobby for appropriate interventions that are large enough to meet the needs of the population, and efficiently allocate resources. UNAIDS suggests triangulating the results of different methods – including multiplier methods such as the unique object identifier and service statistics - to estimate population size. However, few data are available on the absolute size of these most at-risk populations. Data that do exist, especially in submissions to the Global Fund to fight AIDS, Tuberculosis, and Malaria (GFATM), are not collected through rigorous study and lack technical quality. As highlighted in its HIV Regional Strategy, USAID West Africa is best positioned to provide support for evidence-based data collection and use of these data, a pillar of its Regional HIV Strategy. This study will assist countries to strategize, prioritize and define how much investment should be planned for MARPs groups based on the population size and level of HIV risk behavior.
Cities in Cameroon are rarely quiet. Everywhere you go, you will hear the honking of taxis, music being blasted from bars and restaurants, or people laughing and talking on the street. Or you may hear harmonious singing from groups of joggers passing you by on the street, the local church choir or your neighbour’s house.
Several aspects of Cameroon surprised me. This is a country of diversity; approximately 280 distinct ethnolinguistic groups have been documented across Cameroon. Diversity is also reflected in the landscape – the great jungles, beaches, mountains and desert landscapes are breathtaking. Christianity and Islam co-exist as the dominant religions but many other spiritual and religious beliefs permeate the country. Most regions of Cameroon today are Francophone and some regions are Anglophone, however, many people are bilingual; this is a result of previous Great Britain, Germany and France colonization, however, Cameroonians gained independence in 1960. Today, the country is considered relatively peaceful and politically stable.
An aspect of Cameroon that did not surprise me were that almost everyone I met was welcoming and very friendly, including my very awesome colleagues who always took the time to say hello and chat in the mornings. I should mention here that most people in Yaounde spoke French – and I did not – so for the first few weeks of my internship, I was saying the same greeting every morning (“Bonjour, ça va?” “ça va bien, merci!”). Although my French did improve slightly over the course of the internship, I found hand-gesturing and my phrase-book very helpful for communicating, especially when I got invited to my colleagues’ houses. I was thankful to also have colleagues who were bilingual and that could help me get to know the country and cultures in more depth.
The citizens of the country face many challenges when it comes to health and access to healthcare. Though GDP is higher than most sub-Saharan countries, the inequitable distribution of income is irrefutable. Approximately 30% of the population experience poverty and the risk of infectious disease such as HIV, Malaria and Tuberculosis is high. Due to the lack of a health insurance system, patients must pay for most healthcare services out of pocket and often, must acquire medical supplies and bring them to the hospital for their procedure. Basic needs such as clean water, access to medications and antenatal care require much improvement, particularly in rural areas. It is in this context that HIV prevention planning must occur.
My experience in Yaoundé, the country’s capital, was largely facilitated by having American and Australian colleagues who had lived in Africa for over a decade, who helped me settle in and gave me tips on making local friends, safety and where to buy food. I was really thankful that the regional project coordinator had organized transport from the airport as I arrived at night, and had secured a house before I arrived. I was also lucky to have a friend who was also a student on the same project to share the entire experience with.
More resources were available to me in Yaoundé than I expected – the caveat being if you could afford it. I had access to water, internet and electricity on most days, there was a western-style supermarket nearby and there were several restaurants offering international cuisines. But it was easy to see that our experience was not shared by most locals. Nicer areas with big houses, paved roads and high fences inhabited by international researchers, NGO-workers, corporate workers, members of congress, and the Embassy folk, were always adjacent to poor neighbourhoods. I was also shocked to learn of the wages earned by locals who were working very hard to keep their job. I’ve been telling myself to be grateful for the clean water, good food, electricity, health, access to healthcare and generally wealth that I have since returning to Hopkins.
This internship experience taught me a lot about myself and my life. I quickly learned that the concept of time is more relaxed in other areas of the world and that I had to learn to be less impatient, despite having limited French skills thus not being able to fully participate in meetings without someone to translate into English. When you are new to a country and culture, you have to respect it, learn as much as you can and try to “fit in” while also realizing that these things take time. I am certain that this would have been much more difficult had I been in a rural village and the only Asian person in that village.
Stakeholder engagement and feedback during protocol and survey development is highly valuable and crucial to project success and this was a key focus of the internship. We had the privilege of hearing the stories of brave men who have sex with men and female sex workers from representatives of these marginalized groups. I also provided technical support for the monitoring and evaluation section of an existing national USAID-funded HIV prevention program run by our project’s partner organization. This allowed me to expand my technical research experience, as the methods used in the study were new to me, and provided me with an understanding of the logistics, administration, and time that study development takes in an international setting, which will be useful for future research positions.
Visiting Mefou Primate Sanctuary run by Ape Action Africa (www.ApeActionAfrica.org) was a memorable experience, perhaps heightened due of my interest in HIV research. While the first documented case of AIDS in the United States was in the year 1981, there is building consensus among scientists in the HIV field that HIV most likely originated from wild chimpanzees in Cameroon. To be precise, the hunting and butchering of wild nonhuman primates resulted in the Simian Immunodeficiency Virus (SIV) being transmitted to humans multiple times throughout the 20th century and mutated into HIV in humans, a form that was transmissible to other humans. As we learned on our visit to this sanctuary, there has been much advocacy to support the ban on the hunting of primates for consumption, which is great from a public health perspective! They are also our closest ancestors and deserve to be treated with respect in my opinion (and not sold overseas as pets, for example).
The food was also fantastic. To document my trip in a more light-hearted perspective, I have posted my experiences with Cameroonian food in the form of a two-part blog, which can be viewed at the following link: http://deeeats.wordpress.com/2012/10/24/guest-post-by-ju-park-je-voudrais-avoir-le-poisson-sil-vous-plait/
I was encouraged by friends, family and mentors to pursue this opportunity and I am glad that I did. An experience like this will stay with you for life, and may inform the direction of your career. The GHEFP program strengthened my passion for HIV/AIDS research, particularly in serving marginalized populations. My one piece of advice for students would be to try to learn as much about the country and language as possible before leaving the U.S., as well as information on your project.