Ghana Peter Winch
MSPH Program, Department of International Health, JHSPH
The overall 18 month project is an evaluation of the Affordable Medicines Facilitymalaria program, including five sites in Ghana (Akim North District, Ashanti Region; Akim South District, Ashanti Region; Kpone-on-Sea, Tema Municipality; Damango, West Gonja District, Northern Region; Shama, Shama District, Western Region). The project also includes operations research to develop an improved operational model for malaria diagnosis and treatment in Akim North and Akim South Districts. The program evaluation in all five sites will last 3 months, while the operations research will last 18 months. I will be one of several students assisting with the program evaluation component. Each of the students will assist with data collection in one of the five sites. In addition, each of the students will assist with data analysis and write-up for a specific topic using data from all five sites. My assigned site is Shama (Shama District, Western Region), and my chosen topic is illness recognition and treatment at the household level. Topics I will be exploring include: whether information about the new treatment guidelines has reached households, especially in remote areas; what conclusions people have drawn from the information disseminated through the mass media and whether that information has affected illness recognition and the decision to seek care. Personal Narrative:
My trip to Ghana was almost exactly two months. In that time I expected to learn about malaria diagnosis and treatment, supply chains, drug administration for young children, informal sector drug sellers, data collection, data management and training field staff. I also expected to learn Twi. Having just emerged from a year of sitting in a classroom and absorbing information from books and articles, I wanted to learn some practical skills for “doing” public health rather than reading about it. While I think this was a reasonable goal that was at least partially achieved I also came away from the summer with a lot more to think about. One aspect that I was particularly looking forward to was the collaboration with the University of Ghana team. The depth of the expertise present in the room at our large group meetings was really remarkable. I felt privileged to be included. On the other hand, organizing collaboration between nearly twenty busy people was a challenge. Though using technology such as online document sharing helped this process, there were varying levels of comfort with these tools. A key lesson learned from participating in this project was the need for clear documentation and consensus building in a group setting. I also think that this project was remarkable in its marriage of the technical and the sociological. The technical aspects of rapid diagnostic test development, combination therapies, supply chains and healthcare delivery systems were certainly all on the table for scrutiny, but the project also involved looking at stakeholders’ (physicians, caretakers, consumers) personal experiences of managing malaria. For example, the factors that convince a prescriber to switch to a new drug for their patients are not limited to those that can be investigated through a randomized controlled trial. The provider also has to consider the expectations of his or her patients and perhaps re-examine decades of personal clinical experience with the old regimen. Malaria control is a complex landscape and my experience in Ghana only convinced me that there is much more that is unknown and unmapped than fully understood. Clashes in perspective were also evident in the methodological mix encompassed by this project. My program at Hopkins had a large focus on qualitative methods and I generally take a social science approach. However much of the team was more familiar with and more comfortable with quantitative methods. Debating the relative strengths and drawbacks of each in the classroom was one thing but convincing a room full of physicians and malariologists of the merits of in-depth interviews was quite another. I think this experience is one I will encounter frequently in my career if I continue to specialize in qualitative work in public health. It was gratifying to know that my coursework paid off in this sense, as I felt prepared to be articulate on the subject. I realize I also had some unrealistic expectations. While there I attempted to learn Twi. I have formally studied Spanish, Italian, Thai and Nepali but found that Twi, with its tones and unpronounceable phonemes was at least as challenging as Thai and far more challenging than the Romance languages. Surprise, there were no cognates. Often I felt the words just wouldn’t stick because they were so far out of the range of words I’ve heard and read. Two months can feel very long, but they can also feel fairly short when it comes to learning new languages.
At the end of my two months, I hadn’t learned much Twi and due to delays in obtaining local human subjects research ethical clearance it sometimes seemed that I hadn’t done much “doing” either. However, I did expand my knowledge of malaria control in Ghana and, more importantly, I learned a great deal about the real challenges and rewards of conducting research in a developing country setting. Photo Album:
 | Meeting the Asantahene, the king of the Ashanti people as part of community entry in the Ashanti region |  | Artesunate Amodiaquine with the ACTm leaf logo found in a Licensed Chemical Shop |  | Community meeting in Asante-Akim North with Hopkins and University of Ghana teams |  | Sign of a Licensed Chemical Seller in Shama district |  | Shama district street scene with the ocean in the background |
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