Days 12, 13 – NIH training (Tuberculosis, NLM, presentations)

Our last “State of the Science” lecture covered tuberculosis, my field for next year. Christine Sizemore, PhD of NIAID discussed the burden of Tb, current treatment modalities and future studies, and the need for more R&D. Since I’ll probably write a fair bit on Tb throughout the next year, I’ll truncate my blog on this talk for now!

Before we started our afternoon presentations, we received a tour of the National Library of Medicine, a phenomenal facility and the largest health library in the world (http://www.nlm.nih.gov/). The building, built during the Cold War era, is rather invincible and built to withstand major attacks in order to protect the works. I don’t recall exactly how many football fields big it is with many levels underground. The exhibit we paid the most attention to was called “Against the Odds: Making a Difference in Global Health.” (See: http://apps.nlm.nih.gov/againsttheodds/index.cfm) Well done, and I saw a few familiar student and physician leaders and advocates in global health in the exhibit’s pieces.

Our presentation on a diagnostic modality for identifying Tb (called MODS: microscopic observation and drug susceptibility assay) went well as did the other presentations. They were impressive! The collaboration the project cultivated gave us a very small taste of what international collaboration looks like for putting together a proposal. On Day 13 after the last presentation we had a farewell/send-off talk from a few of the NIH and Vanderbilt Institute of Global Health directors. Saying goodbye to new friends felt melancholic, but they Fogarty Center people convinced us that our paths will surely cross again in the future. I hope so! I know I’ll see a few in the East African region over the next year, and I’m excited for that. Ali packed up to head back to Uganda on Sunday, and I did shortly after. Coming home, my brother’s wedding is now my biggest responsibility before getting a week to pack, organize and readying myself for departure! I hope you enjoyed the NIH training posts and found some interesting articles to read. Stay tuned…

Day 11 – NIH training (Health economics, tobacco research)

We started the day off with a lecture from a global health economist from the Center for Global Development, Rachel Nugent, who is married to Congressman Brian Baird. She gave a lecture covering some basic economic theory and the relationship between economists and physicians, one that traditionally has been viewed with discord. I enjoyed her talk immensely and asked some questions about the concept of moral hazard applied to health care (see a piece on this by Malcolm Gladwell: http://www.newyorker.com/archive/2005/08/29/050829fa_fact). We had a good discussion between the audience and her about issues in calculating DALYs (disability-adjusted life years–a metric for determining cost effectiveness; see: http://www.who.int/healthinfo/boddaly/en/index.html) in projecting health cost-benefit analyses. As a politics and The Economist junkie, I find it interesting, although not at all surprising, how powerful a role economics plays in global politics – it’s certainly a religion in some ways or at least treated as a moral framework. Although inherently amoral (and not necessarily immoral), economic projections seem in the calculus of many decisions to somehow make cost-benefit analysis a moral value in situations where it arguably should not be, and one that conflicts with principals of ethical frameworks. For many health care workers, the discord can lie there within. 

We discussed how modifying life-expectancy values in order to make the DALYs (and by extension, cost-benefit ratios) of certain interventions in low- and middle-income countries “more fair” can be tricky. I felt that we should use the metrics as they stand, rather than tweak them to seem more attractive for justifying an intervention, and then impose a moral/justice-based argument to justify certain interventions rather than modify the economic metrics to appear to alter the cost-benefit ratio so that it alone is persuasive. As a result, you preserve the role of a moral value/framework rather than try to make the economic ratio a moral value in and of itself or at least the guiding one. (And yet, I know limited resources always exist and that could be a prudential concern for any moral argument.) For example, say you “save” 15 DALYs because of an intervention for a person in Togo. Yet, the same intervention in the US generates 50 DALYs because the life expectancy in the US is higher. Rather than alter the value for life expectancy in Togo using some other variable in order to increase parity for interventions there compared to the US, why not use the disparity to justify the intervention investment on other grounds, not necessarily economic. I, of course, need to finesse the argument (and to fully explain what I’m saying here I need more than a blog post) after studying some econ next year, which I hope to do through some reading, but my basic point as I thought through the lecture is that I prefer economics in health care decision-making at least, to remain amoral, which it is increasingly not in health care. These are some hasty thoughts, but I wanted to unpack them a bit as I think about it more longterm.

The next lecture on “Tobacco Research in the World” included some staggering statistics. Did you know that 330 million men in China smoke? From a public health perspective, it is astounding how many DALYs are lost, how many lives are lost prematurely, how many families become impoverished further, and the increase of health care expenditures occur all do to tobacco around the world. Certain global markets, especially in Southeast Asia, China, and India are only being tapped now with women in low-income countries the untapped party for targeted advertising. This was one of the most compelling presentations of the two weeks for me, researched very well, and attached with an important health message and warning. If I come across the slides, I will post some more facts that will probably surprise and astound you.

During the rest of the day we had a talk on “Translational Research to Create Technology Innovation in Global Health Practice” and social entrepreneurship in that realm and finished with group time to work on our hypothetical Request for Application proposal for our presentation.

Day 10 – NIH training (NIH Division of AIDS)

We started today with a lecture from the Fellows on how to lead a journal club as a resident. I actually learned a lot and took many notes. Ali and I are likely going to be leading journal clubs at Mulago Hospital, so I can start practicing for residency journal clubs now.

The key content area for the rest of the day concentrated on HIV/AIDS science. We heard lectures from the NIAID/AIDS Coordinator, Director of the Division of AIDS, the Epidemiology Dept of DAIDS, and Microbicidal Research Branch, International Maternal Adolescent Pediatric Branch, Vaccine Clinical Research Branch, and Program Operations. The Division of AIDS has the largest direct aid and research budget in the world for AIDS. Thirty-five thousand people are enrolled in an HIV-related trial at any one time under its auspices. The Division covers HIV vaccines, current clinical management of HIV/AIDS, prevention of mother-to-child-transmission (PMTCT), translational research, and HIV prevention. Some interesting facts we learned include: (1) 22% of cases of HIV in India are in housewives with a single partner; (2) need for new technology to diagnosis HIV early during acute retroviral syndrome; (3) the results and future of microbicidal and oral HIV prevention modalities, especially through the microbicide trials network studies.

I picked up my visa from the embassy after lunch and arrived back in time for a talk on the Global Health Fellows Program through USAID. Although it is called “Fellows” it is in fact a job appointment that includes opportunities ranging from clinical care to implementation of health programs in low- and middle-income countries. Fellows are paid according to their degree level and type of degree and jobs last 2-5 years. Most of us at the talk were quite intrigued by the possibility in the future. And yet another potential avenue to consider pursuing in the distant future! There was particular emphasis placed on knowing another language, and I hope I can learn Swahili this year in some meaningful way!

The evening ended with what many of us affectionately called Fogarty Prom, a dinner with NIH/AAMC/Vanderbilt staff and all the international and US scholars and fellows. We had good fun, great food, and most important, amazing company. My table covered politics in a quite lively way! The director of the Fogarty Center, Dr. Glass, came to each of us and spoke with us also. Here’s a picture of Ali and me:

Fogarty Dinner - Ali and Justin

Day 9 – NIH training (USAID, World Bank)

The morning started off with more epidemiology and biostatistics lectures and Q&A from lecturers from the Uniformed Services University and National Cancer Institute. Do I have a lot to learn in those arenas this upcoming year! We had group pictures after the morning lectures and then celebrated the 40th anniversary of the Fogarty International Center of the NIH with birthday cake at the Chiles House on campus.

Our afternoon general session titled “World Decision Making in Health Delivery and Research” included speakers from the Fogarty Center, World Bank, and USAID. (The World Health Organization speaker could not attend.) The World Bank speaker talked about the future of the World Bank and health. He inferred the growing influence of the Bill and Melinda Gates Foundation and others as a big reason the World Bank is in many ways losing influence and clout in the health care arena. One of the scholars asked him a tough question about health care improvements in lights of Structural Adjustment Programs that were more popular in the 1990s and harmful for many low- and middle-income societies, but possibly worked in others. The global health community has been skeptical of SAPs for many reasons, many concerns I also felt after studying them in graduate school. He concentrated on the Health, Nutrition & Population programs of the World Bank, which sound excellent. The Bank is doing amazing work in many areas. Here’s a link to the site: (http://www.worldbank.org/hnp/).

I attended the HIV Vaccines elective session in the afternoon, and we covered some of the trials in HIV vaccines and discussed the biological reasons HIV vaccines are difficult to engineer currently. Yet, hope pervades.

For dinner, a group of us, including Ali, ate dinner at Tabaq, an excellent Moroccan/Spanish restaurant on U Street that has a rooftop glass enclosed deck overlooking DC. Oh, the seafood risotto hit the spot. We had such a great time!

Dinner at Tabaq

Day 8 – NIH training (NTDs and Malaria)

Starting our second week of training, our first lecture was a Q&A session on “Tips for Living Abroad.” Safe health practices and being careful with transportation were the key messages. Note to self: Justin be careful when driving! And yikes, Ugandans drive on the opposite side of the road than we do in the US.

The first General Session of the day covere “Innovation for the Control of Neglected Diseases in Developing Countries.” The speaker Peter Hotez from Dept. of Microbiology, Immunology, and Tropical Medicine at GWU gave a dynamite lecture. He recently came out with a book “Forgotten People, Forgotten Diseases” and co-started the journal on the lecture matter (http://www.plosntds.org/). Among the most astounding things he discussed and taught around neglected tropical diseases, we learned of the NTD disease burden in our own country. Please visit the article – “Neglected Infections of Poverty in the United States of America” – (http://www.plosntds.org/journals/ntd/article/info%3Adoi%2F10.1371%2Fjournal.pntd.0000256).

Our next lecture on “State of the Science: Malaria” from Tom Wellem, MD, PhD, Chief of NIAID, provided an update on malarial research and treatment. I’ll definitely write more on malaria in posts when in Uganda. We were fortunate to hear a lecture from a leader in the field of malaria.

The rest of the afternoon I spent my time at the Embassy of Uganda initiating my visa for the year, so I missed the afternoon session this particular day. I finished the evening with scholar friends at the showing of “Dr. No” on a screen put on the National Mall lawn.

Day 7 – NIH training

Today we had a free day for touring Washington DC. Jared, Brooke, Ali, and I did a nice tour of many monuments. We started in Georgetown after driving past a decadent-appearing wedding at the National Cathedral. We toured the high-end shops with Ali and people watched, something easily done in Georgetown. We stopped by the river to relax, and Jared and I walked around the Patagonia Outdoors store, one of our guilty pleasures in life.

We then drove to the National Mall and started with lunch at the National Museum of the American Indian. That cafeteria has to be one of the best museum cafeterias in the country. They use different, non-mainstream American, Pacific Northwest, and Meso-American grains, roots, and vegetables to make delectable, well-presented dishes. Ali and I headed to the Capitol Building steps for a picture and gazed off at our day’s endgame: Lincoln Memorial. Next we headed to the US Botanic Gardens. The different climate zones and flora were arranged spectactularly. I enjoyed taking pictures there, including one attached to this post. We trudged along in the 95F hot, humid weather to the Washington Monument on our way to the National World War II Memorial. Resting in the shade we took pictures and hydrated before continuing on past the Reflecting Pool to the Lincoln Memorial.

Flowers - US Botanic Gardens

We all rested again and then continued on to Einstein Monument (also pictured here). The memorial has Einstein looking down at the sky with a constellation orientation of the sky on the night Einstein discovered E=MC^2. I learned through the monument story placards how committed to social justice Einstein was during his life. He became all the more impressive to me. The story of the National Academies of Science’s (http://www.nas.edu/) creation fascinated me, especially the Institute of Medicine, as told at the monument. The vision of Congress in that era has resulted in many essential and productive branches of the NAS that I probably have taken for granted. The NAS plays an enormous role in science and technology development and policy.

Einstein Monument - Washington DC

Next we went past the Vietnam Veterans Memorial and then headed back towards the car just when the afternoon thunderstorm rolled in to offer relief from the scorching heat and humidity. All of us headed back to Bethesda and met my friends Andy and Kristy for dinner. All of us were exhausted after a good day!

Day 6 – NIH training

The directors made our Saturday schedule light. We started with watching “A Closer Walk” (http://www.acloserwalk.org). I’m glad that we had the exposure a narrative film like that provides. The researchers have done a good job personalizing their research throughout their presentations, but this movie comprehensively put a face on AIDS from stories in Russia, Uganda, USA, and India. Some of the Indian Fellows recognized the Indian doctors interviewed in the film. Ali recognized some of the Uganda physicians interviewed. I met one of the activists, Eric Sawyer, during our AIDS Week at Loyola in 2007. Even those in the room from the international sites were crying at times. For others, it dredged up memories from experiences abroad. Later in the afternoon, Ali and I had a conversation that spurred from the movie. He expressed his frustation watching people die of AIDS-related illnesses and his desire to see CD4+ cell counts (an indicator of extent of HIV infection) requiring treatment raised to 350 from 250 so that he can give medications earlier, so that “he doesn’t feel his heart torn” from those presenting with advanced disease who do not have low enough CD4 counts for treatment. The mental burden of HIV in clinicians can often go unnoticed. He told me other stories of the face of HIV/AIDS in his family’s life, Ugandan patient lives, and other things I’ll spare from here for now. The pediatric stories were tearjerkers. To say the movie reaffirmed our continued global health passion may be an understatement as the ensuing discussion among the group demonstrated.

The afternoon session after lunch provided manuscript preparation skills for our research findings. I’m looking forward to improving my science writing skills, skills and style vastly different from humanities/ethics writing.

My brother and Brooke (whom he marries on July 26th) came into town and I had dinner with them and our friends Kristy and Andy. We had dinner at Lauriel Plaza, which yes, is touristy and crowded, but has the best masitas de puerco this side of the Mississippi and great Latino flare. We had frozen yogurt (with a 10% discount because we named the 7 countries of the world beginning with “U”) at a new place in town to finish the night.

All day I had my upcoming experiences in Uganda on my mind in a different way. Ali ended his discussion with me earlier in the day with “you’ll see when you get to Uganda. You’ll see what I’m talking about.”

Day 5 – NIH training

A busy Friday filled with excellent speakers! We started by hearing a presentation by Mary Stanton, the Senior Maternal Health Advisor for USAID (US Agency for International Development). She provided us with staggering statistics, current and encouraging efforts to improve maternal and child health through the Global Maternal and Child Health Program, and social/economic influences on health.

The next speaker, Larry Laughlin, MD, PhD dean of the School of Medicine at the Uniformed Services University of Health Sciences, gave us a lively presentation on “Working in the Developing World.” He talked about his efforts conducting research on Bartonellosis (an emerging infectious disease) in Peru and culturally appropriate and collaborative ways he worked with the particular research cohort. He told us a fun story about the ultimate gatekeepers in town — a women’s organization that asked him a multitude of questions before they would let him proceed! The community’s interest and involvement in the research sounded exciting.

Our last speaker before lunch, Francisco Sy, MD DrPH, Director of Minority Health Disparities Research at the National Center on Minority Health & Health Disparities gave us a talk that essentially centered around a research method (not a “type” of research) called community-based participatory research (CBPR) and the research activities at NCMHD. As a lens to create and conduct research, CBPR intends to level the playing field some by using community knowledge to generate specific research questions and concerns at the outset and formulation steps of a research project. I used it with my team in Kenya to conduct needs assessments, for example. We emailed the community leaders there before we crafted our survey to see what things they were interested in learning about the community in a systematic way while we presented ideas we thought would be useful to examine. I had lunch with the speaker and others afterwards for further Q&A.

I finished the afternoon doing more research for the first half in the NIH Library and then heard a presentation from a Fogarty Fellow who spent 2005-2006 serving with Doctors Without Borders (Medecins San Frontieres) in Darfur. He has quite an interesting background, having a master’s in international studies from Columbia after medical school, internal medicine residency, time in Darfur and now he is an infectious disease fellow at University of Washington. He’ll be in Kenya doing his research next year. He told many powerful stories and had wonderful pictures. Many scholars/fellows have considered MSF in their equation for the future, and not surprisingly, the room was crowded and the questions were plentiful. There is no doubt there exists a difficult reality underneath the romanticism of MSF. Yet the work they do is so crucial and needed in the conflict or post-conflict areas where they serve. He saw about 10% of patients suffering from direct assault and rape and the remaining 90% were displaced people suffering from the ongoing genocide and attacks there.

About 20 of us went to the Nationals vs. Astros game in the evening. Ali came along for his first baseball game. The fireworks after the game and each of the Nats homeruns entertained one and all. I even had a sloppy Ben’s Chili Bowl half smoke dog for those who know that famed DC establishment! We finished the night with fun dancing around DC. What a day!

Group of FICRS Scholars at Nationals Game

Day 4 – NIH training

We started the day hearing a presentation on a virtual conference program for researchers around the world. It’s like a private chatroom where people can display papers, slides, etc., while group members are talking and typing. There were some pretty impressive details that I am forgetting as I write this post 4 days after the fact. The remainder of our morning session centered around bioethics with various cases presented by some members of the NIH Bioethics division and group discussion/debate following. Each of the scholars and fellows had to submit a case for discussion and the speakers picked a few of them and then moderated as we participants engaged in ethical analysis and decision-making. During the afternoon I started working on research for our upcoming research trial application presentation. Another scholar, Colin, and I went to the NIH Library at the Clinical Hospital building. There I saw cancer patients, families, and a beautiful facility. Our presentation group met for the remainder of the afternoon before the group chowed down a BBQ meal outside afterwards. I finished the night at a lounge in DuPont Circle with 3 other scholars, and we discussed some of the richer stuff of life — family, friends, religion — with a few laughs thrown in the mix as we sipped caipirinhas and mojitos on a warm summer night.

Day 3 – NIH training

Wednesday started off with a “How to Interact with Your Mentor” talk in preparation for working with our US mentor (aka “Principal Investigator” in the research realm) and any foreign site local mentors. Since I’ve met my mentor, Dr. Whalen, in Cleveland in April, I already have begun to get a sense how to “interact” for the upcoming year. The remainder of the morning consisted of didactics in learning how to use the world’s largest scientific resource for health – PubMed (http://www.pubmed.gov). Most of the US scholars and fellows are well versed in its use, but we now have a few more tricks up our sleeves for using it. The session was held at National Library of Medicine, which is a beautiful building and the largest health library in the world. We’ll have another tour of it next week for a Global Health exhibit tour. During the afternoon we had “country break out groups”. My group consisted of the international and US scholars/fellows from Kenya, Mali, and Uganda. The group talk was exceptionally energetic and idea-generating. The topics spanned US policies such as PEPFAR (President’s Emergency Plan for AIDS Relief) and the African Health Capacity Investment Act to African politics and poverty impacting research infrastructure building in their countries. It became clear to me that there exists both a need for foreign aid and a strong desire to become autonomous from it. The conversations among the African scholars/fellows about aid dependency versus necessity juxtaposed with political corruption in certain sub-Saharan African countries were a unique learning opportunity for me. Additionally, the interconnectedness of national leadership and poverty to every other part of civil society, although intuitive, became clearly evident in terms of barriers and pathways for future growth. The last hour of the afternoon I met with another group of fellows/scholars for a global health presentation I’ll be part of next Friday. We are writing a mock NIH grant application for a research project that we propose. I think by the end of the experience it will be a small, but useful, exercise in international collaboration and project designing. Dinner Wednesday will be memorable. Sixteen US scholars plus 2 international scholars headed to Kramer’s Books & Afterwards for dinner to celebrate the birthday of one of our friends in the group. We had some great meals and desserts and stretched the meal out for three-and-a-half hours. Lots of laughs and stories. I’m not getting much sleep, but in staying awake I’m meeting a lot of people and become better friends with others. Truly the internationality of the group and diversity of the US scholar group has made it all the more interesting and unique from my every day life.