2011 Grant Recipient 
Peru
MSPH Program, Department of International Health, JHSPH
Our team is seeking alternative methods of cervical cancer prevention in regions where current screening/vaccination is unaffordable. We have identified a geographical correlation between cervical cancer incidence and geohelminth endemicity. W hypothesize that the Th2 immunologic skew which is classically associated with helminth infection has broad impact on mucosal immunity, including the genital tract, and leads to a higher risk of HPV persistence and thus cervical cancer incidence. We are evaluating this hypothesis in an NCI funded study in a helminth endemic population in Iquitos, comparing helminth positive to helminth negative women age 25-45 as well as the total population in Iquitos to a population in a shanty town near Lima (non-helminth endemic). Personal Narrative:
As a second year master student in Global Disease Epidemiology and Control in the Department of International Health I had the opportunity to participate in a Global Health Established Field Placement (GHEFP) working on an epidemiologic study of Human Papillomavirus and helminth co-infection in Iquitos, Peru. Dr. Margaret Kosek and Mr. Pablo Yori lead a dynamic team at the Iquitos Satellite Laboratory. They are bright, talented, kind, inventive, and natural teachers and mentors. I was particularly impressed by their dedication to the health and wellbeing of their team, study participants, and community members. Dr. Kosek and Mr. Yori each consistently invested time in working with all three of the GHEFP awardees at our site. In the beginning of the summer we were in close quarters—seven people sitting in two offices—as we prepared to move to a new facility. As a student, I certainly benefited from this arrangement. I was encouraged by Mr. Yori and Dr. Kosek to ask questions about clinical practice, epidemiology and statistics and was surrounded by the on-goings of the diverse portfolio of studies in the lab. In this positive and energetic working environment, I was able to test the skills I had gleaned in my first year of coursework at the Bloomberg School of Public Health. In addition, Dr. Kosek and Mr. Yori constantly gave us opportunities to expand what we were learning. Mr. Yori taught a seminar on the use of GPS data in public health and gave me the opportunity to analyze data from nested case-control study looking at water contamination, water storage and Shigelloses. Dr. Kosek approached me with the idea for a social network analysis and I dove into the public health and statistical literature to propose a study design and analysis method. Gwen Lee, a current doctorate in my department and Iquitos resident of one year, frequently gave us insights into working with the Iquitos team, collecting and analyzing data and study design. Along with the two other GHEFP Awardees, Jacqueline O’Connell and Ben Powell, the four of us formed a collaborative and diverse student group at the IQTLAB and eventually decided to combine our skills for the social network analysis proposal. Being part of the ITLAB Research team gave me an opportunity to work in an international setting and understand the subtleties of working with people with whom I did not share a common language or background. My Spanish language skills were basic when I arrived, but working on this study required me interact almost exclusively in Castilian. I made a conscious effort to improve my skills by studying in my free time, preparing documents in advance of appointments in the field, making extensive use of pictures and diagrams, and consulting Peruvian team members for help with pronunciation and vocabulary. When I first met the “HPV team,” the primary field worker avoided me and purposefully discarded any documents I produced. Building a successful relationship with her was essential to our work on the study, because I had to communicate to her complex ideas about ethics, epidemiology, and study design. It was important to me to show her I was there to help and to learn, not to create more work for her or attack her in any way. Slowly she began to trust me as I volunteered to go with her to collect stool samples, asked and incorporated her feedback, and communicated to her that I recognized her unique talents and value to the team. Eventually, she and I developed a strong working relationship and friendship. My work with the participants was some of my most challenging and rewarding moments of my experience. Like many women I have met in the US, most of the women who required colposcopy due to positive HPV or Papanicolaou test results misunderstood the diagnosis, immediately assuming that positive preliminary tests indicated that they had cancer. This fear was amplified by the fact that two young women in the community had died from cervical cancer during the previous year. Therefore, my first priority while working with the participants was to treat them with respect and dignity and to give them the best possible care. I had the opportunity to accompany all of the women that required follow up to the private gynecologist for colposcopy. I did my best to ask them questions about their families, interests, and answer their questions about the procedure as we travelled to the specialist in a nearby town. I found that though having better Spanish would have been an asset, my ability to connect with the women, to calm them and empathize with their fear and anxiety, was far more useful. Compassion is a universal language. During my GHEFP in Iquitos, I expected to learn by applying theoretical concepts from courses in epidemiology, tropical diseases, statistics and international health and to be challenged physically, emotionally and intellectually. I expected to face many logistical challenges, to improve my language ability, and to make meaningful friendships. My experience in Iquitos fulfilled these expectations and reaffirmed my passion for the field of global health. But most importantly, I learned to always be prepared, because you never know when you will find yourself fleeing someone’s pet spider monkey while collecting stool samples in the jungle. Photo Album:  | Sarah Qureshi and Dr. Majia, OB/GYN debrief in the examination room in San Juan, Perú following the colposcopy of a study participant. |  | Sarah Qureshi and research team members of the HPV and Helminth co-infection study pose outside of the Iquitos field site in Santa Clara, Perú. |  | Residents watch with anticipation as a child speeds by in the hoop-rolling race sponsored by the Asociación Benéfica PRISMA during the annual Festival de Santa Clara. Winners received a bicycle and school supplies. |  | Data management… Sarah Qureshi uses unconventional methods to organize participant files early one Saturday morning at the Santa Clara field site. Validating data was important to ensure that all patients received proper care and follow-up. |  | A view of the Nanay River in Santa Clara. Many community members make their living fishing or logging, as evidence by the lumber in this photograph. |
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