R:Ed: can you tell us a bit about yourself and what you do?
My name is Rashida Ferrand and I am a doctor by training. I specialized in HIV and sexual health and I also trained in epidemiology. I now work as a clinical researcher in Zimbabwe. I am a professor at the London School of Hygiene and Tropical Medicine, but as a result of my work I have been living and working in Zimbabwe for the past 18-20 years or so. In Zimbabwe I have multiple roles, but my biggest role is to direct a research programme which is a partnership between my employing institution, the London School of Hygiene and Tropical Medicine, and my local institution in Zimbabwe, which is called the Biomedical Research and Training Institute. The research programme conducts different types of research such as observational studies and clinical trials, with the aim of improving health and addressing the major health problems in Zimbabwe, and in the region. We focus specifically on certain areas particularly HIV, sexual and reproductive health, adolescent health, chronic diseases and chronic complications of HIV among children, tuberculosis, general infectious diseases, and particularly antimicrobial resistance. Our programme consists of about 100 staff, which includes not only people who are conducting research (the field staff), but we also have a very big emphasis on training people in research, so we have PhD students, masters students and postdoctoral students. A very key component of what I do is trying to strengthen academic capacity in Zimbabwe.
R:Ed: what first drew you to working in the area of epidemiology?
Essentially I started my career as a lab scientist, so I did a first few couple of years doing work on immunology of tuberculosis, about 20 years ago, and found that I was actually not very good at it and that it didn’t really interest me. But what I have always been interested in is looking at health from a population basis. When I was studying medicine I didn’t actually realize that there was a specific field called epidemiology, but I have always been interested in looking at public health and developing health initiatives, from a population perspective. When I was doing immunology at the London School, that’s when I began to appreciate that there was a discipline called epidemiology and, given my pre-existing interest, that then drew me to doing a master’s in epidemiology and developing a further interest from there. I never started out wanting to have a research career, it happened by accident. I came to Zimbabwe to get work here because I’d really fallen in love with the country, and I then realized how important it was to measure and understand disease from a population level. But also when I was on the wards I was working before the treatment for HIV was available, and I was seeing a lot of people presenting with AIDS and dying with AIDS, and there was no treatment available. What specifically hit me was that, while being an adult physician, I was seeing a lot of older children and teenagers being admitted to adult wards with what looked like advanced HIV. The question then came to mind was about whether this was actually sexually transmitted, because many of these adolescents had been sick pretty much all of their lives. This then raised the question: “could it be that we are seeing children surviving to adolescence with HIV, even without treatment?” That was the big question for me. At that time, the understanding was that most children who were infected by their mothers through mother to child transmission would die in early childhood, that was the received wisdom. But then it didn’t quite match with the clinical picture I was seeing on the ward where 10 or 13 year olds were coming in with AIDS. We knew that in adults it could be many, many years before an individual developed AIDS, so then I assumed that these children would also have caught it a long time before. It therefore seemed unlikely that it would have been sexually acquired. That is where my previous interest in epidemiology came in, and led to my research career.
R:Ed: have you faced any challenges in your area of work, and if so, how did you overcome them?
There are several challenges in the work I did around children and adolescents with HIV. The biggest one was that there was very little recognition amongst policymakers and programmers and the HIV community, particularly the international HIV community, that you could have somebody who was 17 years old with HIV, who could actually have got it from their mother. We now take this for granted, but that was certainly not the case about 20 years ago. So even getting a grant application to study this was problematic, because I was really challenged by reviewers who assumed the children only got HIV through blood or through sexual abuse. There was no concept that this was happening at a systematic level, that a proportion of children that were infected by their mothers would then make it on to childhood. The second challenge was that, because of the lack of perception that children could survive, there had been very little focus on all the children in HIV programmes. If, say, an 8 year old came in with things that could be suggestive of HIV, testing was not offered to them. HIV programmes for children were focusing largely on infants, and on preventing mother to child transmission. The third big issue was that these children had very difficult social backgrounds. The vast majority of them had some sort of minor illness going through childhood that hadn’t been recognized. Many of them were orphaned, or their parents were away, and there was no recognition that one should test all the children of parents who were living with HIV. The fact that many were orphans meant that they were living with either uncles or aunts, or step-parents or grandparents. Sometimes there was neglect or a lack of recognition, and sometimes other children in the household would be prioritized. Some of them had, frankly, been kicked out of their homes. There was also a real silence around HIV, because if you diagnosed any child that would mean that you were also automatically diagnosing the mother with HIV, and that was a very difficult thing to negotiate. Also the actual numbers of adults with HIV is so much higher than the number of children with HIV, that to get focus onto them and their social problems was very challenging. There is also a huge amount of stigma, which was particularly true in those days. In schools, although nobody spoke about it out loud, there were features like skin rashes or these children being short, that automatically marked them out as being HIV positive. Nobody would have tested them, but they would be stigmatized, they would be discriminated against, they would be marked out – and that was a really difficult thing. Many of them were very ill and missed school frequently, so educationally they were compromised. There was no child in the clinics where I was working in Zimbabwe that had a straightforward history, and having a supportive family was often the exception then, rather than the rule.
R:Ed: how your work has changed in Zimbabwe since the coronavirus pandemic?
The major impact that Coronavirus has had is that we have had lockdowns, so it has sometimes been very difficult to implement the research that we have been doing into communities. For example, one big trial that we are doing right now is called the Chiedza trial. The intervention that we deliver in the trial is a package of HIV and sexual and reproductive health services. We do HIV testing, we provide treatment, adherence support and then we give menstrual hygiene products, contraception, condoms, risk reduction, counselling, family planning, essential treatment and screening for sexually transmitted infections. Where there has been a lockdown we haven’t been able to go out into the communities to do this very easily. The trial is also specifically designed to provide a very adolescent-friendly environment and to in-build social activities, which is difficult to do when there is social distancing and lockdowns. The other issue is that we have had to change the way we work to minimize infection. Our infection rates have actually been very low, but we have had to put a lot of measures in place which have disrupted working patterns. Staff have been very anxious about catching the virus and what would happen to them if they got COVID. At a broader level, I’ve been seconded into providing and setting up a COVID treatment service for the largest public sector hospital in Zimbabwe, so I established the first COVID treatment unit last year and managed it over six months. You may be aware that Zimbabwe has a very fragile health system with healthcare workers on strike, so we had to work out a way to set up and manage the unit and see patients, particularly patients in the context of a lockdown, when many of them could not come to hospital because all public transport was gone. A lot of my time last year was spent trying to set up a functional unit to manage patients with COVID, and in a lot of the policy and advisory work to support the national COVID efforts, so that has disrupted my work a great deal. And obviously there has just generally been a lot of fear and anxiety in the country, particularly given that our health system is so weak.
R:Ed: what is your favourite aspect about your work?
Zimbabwe is an incredibly beautiful country and it’s very rich in terms of human resources. I work with just an absolutely outstanding team, I mean they are superb, proactive, they put their hearts and souls into their work. That is just a privilege and that was what drew me to working in Zimbabwe, and what has kept me here. That, for me, is the biggest bonus. I also have a cohort of doctoral or PhD students, master’s students and postdoctoral students who are training to be academics. I have to say that without exception we have got an absolutely outstanding group of students who are doing research proactively and tackling the problems of their country. I have no doubt that many of them will go on to become research leaders and put me out of my job. That’s the second biggest wonderful thing about my job. The third really great thing is that there is a real capacity to change things and see the impact of that very immediately, which you cannot always see in places where there are established systems. For example, the COVID treatment unit came about from nothing, and it has been seeing patients and has made patients better. We moved from a place where many in the country thought that if you got COVID you would die, to now having a place to go to. From that other providers grew confidence to start treating COVID, so it’s a really visible change that one can see in the job. And just living here generally, it’s a really rich country in terms of resources, in terms of people, in terms of the warmth and friendliness. I have loved, and still love, every day I work here. All of these things make my life and my job very rich.
R:Ed: what advice you would give to someone who wants to go into the area of medicine, or epidemiology more specifically?
I think sometimes it’s very difficult to know what you want to do. One of the things I tell people is that it is fine to explore and take a circuitous route. I didn’t end up doing medicine and then deciding I wanted to be an epidemiologist and then deciding I wanted to do HIV and adolescence, it has been a really long route. Some people take a very straightforward route and know what they want to do. I sort of had a vague notion that I wanted to work with infections and that I wanted to work in public health, but I didn’t really know what that would transpire to in terms of career, I didn’t know that I wanted to be an academic, so it’s fine to explore. I think what exploration does is it makes you more mature, and makes you get to a fine, granular level about where you want to end up. One thing to say is that I think it is fine to have an adventure. Sometimes it’s very scary when you’re younger and you think you have to be where other people are. We are all part of a very big rat race, and once you have finished your bachelor’s degree or your medicine degree, you’re almost programmed to be on a conveyor belt. I got myself off the conveyor belt and, to be honest, have had a wonderful adventure that is still ongoing. So, for me, the biggest advice is to follow your heart. The second thing I would say is to talk to lots of people to find out where you want to go or what you want to do. Sometimes it can take time, and having a good mentor or a good person to talk to who is going to listen and who is not going to shove your ideas away is really important. Also it is important to develop self-belief, which is very difficult when you are with people who are going along the traditional pathways and going from doing medicine, for example, to then becoming consultants very quickly. By the time I finished my clinical training the colleagues I had started out with were probably earning twice the amount of money I was, and had already established jobs and mortgages. But it is important to be true to your ideas and true to what you want to do, and that sounds like a luxury but sometimes it can mean making sacrifices, which I think has served me really well.