Archive for the ‘Research’ Category

Portrait of a team

December 4, 2008

Every morning at 8:15AM I meet the health home visitor team to crosscheck data collected from the previous day and to listen to how things are going in the field, among other tasks as needed. We meet at the “Brown House,” a place just outside Mulago hospital where research participants with tuberculosis come for care in various MU-CWRU research collaboration studies:

L-R (Micheal Angel, Hassard, Esther, Kezron, Joan, Sheila, Joan

Part of the CF team: (L-R: Micheal Angel, Hassard, Esther, Kezron, Sheila, Joan)

Kezron and Sheila work on another study; the “CF” (the study on which I work) and “Alcohol” study teams meet every morning in the same room. Joseline, Joyce, and Godfrey, other CF HHVs, were not in the room when I took the picture. Micheal Angel is our data manager, and he crosschecks my crosscheck.

After I finish there, I head up a hill to the MU-CWRU office. This is where I spend a bit of time currently. (It is the Medical Officers’ office.) The doctors below are principal investigators or co-PIs on studies here. If I am not in here then, I am either shadowing physicians or in the field, though I will not be doing the latter now until I have ethics board approvals of the study I described in the pilot study blog post previously.

 MO’s office:

L-R (Dr. Grace Muzanye and Dr. Phineas Gitta)

Medical Officers (L-R: Dr. Grace Muzanye and Dr. Phineas Gitta)

A research pilot study: stories, sickness, sputum samples and a stampede

November 8, 2008

After discussing with Dr. Chris Whalen and Dr. Juliet Ssekandi, my mentors, a possible research study, I wrote a concept outline for a pilot study to see if the study would be tenable as a project for my remaining time here. For about two and a half weeks, Hassard (health home visitor for the parent study) and I interviewed previous participants in that study for my follow-up questionnaire regarding chronic cough. (If you are more interested in the research project itself, please email me. Very basically it is follow-up study looking at chronic cough and tuberculosis that may have been missed or not evident during the initial study.) Needless to say, my survey was the simplest part of the whole pilot study process.

Most time was spent trying to relocate the participants while navigating the congested parts of town to which we traveled. As a result of the pilot, I had the unique opportunity to travel to zones and parishes in Kampala that foreigners do not visit unless they are doing community work of some type.

Rather than talk about my research as such in this post, for now I am going to tell some of the stories associated with the research. The first participant we saw worked at the edge of Busega parish in the Rubaga division part of Kampala. A Rwandan refugee from many years ago, we had only her mobile phone number for contact (the case for all of the participants). We found her at the home of a woman for whom she cleans. We interviewed her and then collected sputum for analysis after finding out she continued to have chronic cough. We forgot to give her the second vial for a sputum for the subsequent morning and did not realize it until after the 10 minute walk back to the vehicle. We walked back to the project vehicle to get another vial, but by the time we walked through the swamp’s clearings to get to the house, she had left to try and find more work. You see, the woman of the house said that the participant had just left in order to leave the city to find more work to support her and her children. Vial not delivered. Transient, struggling participant ailing. I shall come back to her full circle.

Bars are great places to find certain participants, especially men. Bars in the communities are not what one would picture in the U.S. They are wooden shacks with benches and do not have the overwhelming feeling a crowded bar in Chicago can have. Hassard and I met with inebriated men and women in them. One of the previous participants interviewed for my follow-up study ended up having tuberculosis. He had refused sputum collection a few months before when he was interviewed for the initial study but accepted this time.

The men were kind to me and quite the jokesters. One woman in one of the bars had declined participation in the parent study months ago but wanted inclusion now since her husband had died since then. She realized that her health might have been impacted – he died from tuberculosis, possibly co-infected with HIV. That day, thankfully, Joyce, another health home visitor accompanied Hassard and me. They had a woman’s heart-to-heart. The thing is that with one person sitting there with Tb in such close quarters, they were all vulnerable, not to mention the possible effects of alcohol on the immune system that may increase susceptibility to Tb.

Thankfully, the gentleman came in for Tb treatment. The next hurdle for him is that of medication adherence. I am worried about his ability to adhere to the medication schedule for his Tb given his use of alcohol. It is difficult enough for a sober person with an organized, stable life to adhere to such a regimen! It would take the combination of a good support system, personal desire, and structural support for him to treat his illness.

At another bar in a different zone, we came across a man not in our study but who had been known to the home health visitors. (He was enrolled in another study of the Tb Research Unit. He was not improving after having been on 2 months treatment. I think a fear of multi-drug resistant Tb jumped into all our minds, and when we went back to Mulago hospital we found his pharmacist to determine in which study he was enrolled so we could let the appropriate person know. As we left visiting this man in the Nalukolongo bar, another man came out. He looked me in the eyes and said, “we’re sick, too. We need care. Why can’t you give us care?” Of course, he was right. Again, this is another situation where the research and clinical domains of the medical field collide. I told him I understood that he needed care and where he could go. In a way, it was the politically-correct, ethically defensible health care answer. But a lot of people in these infrastructure-poor communities need more active access to care. I knew even before I said it that my answer was grossly insufficient. But I needed to say something. He smiled, stopped smiling, and then watched me even until our project vehicle left his view. Whether I created it or whether it was imparted on me, I felt as if a global challenge I keep feeling over the years hit me through the voice of this one man.

In another part of Busega parish, Kigwanya zone, we interviewed for follow-up a Rwandan man (refugee from the 1994 genocide) who was living HIV. He spoke French, English, Kinyarwanda, and some Luganda. Hassard conducted the interview in English, a rare occurrence. This gentleman is sero-discordant with his wife, meaning he is HIV+ and she is HIV-. There are a number of interesting issues biologically and socially with discordant couples, beyond the scope of this post. Suffice it say, they use condoms to protect themselves and he takes his anti-retroviral medications on schedule, thus decreasing his chance of passing the virus to her.

His neighbors started laughing and yelling in Lugada to Hassard while we were leaving. They were done having children and needed condoms to use with their husbands. According the UN World Population Prospects Report of 2006, Uganda ranks 8th in the world for population growth with a rate of 3.24% – meaning the country would double its population in 21.6 years. Uganda’s current population is 30.9 million (2007), up from 24.4 million in 2002.

Fertility is such an important cultural value here, as it is in so many places. Uganda has numerous expensive fertility clinics, here in a country with thousands of orphans and an upwards spiraling population. There are fertility planning campaign billboards around the city and countryside but such campaigns are only so effective. One inn owner here feels that the president likes the increased growth rate and expansion of cities that such a growth rate produces. His subsequent analysis delves into some interesting theories I’ll spare here. Needless to say as I finish this tangential paragraph, we came back during another visit with condoms for the women and their husbands.

Hassard said I should take pictures of the places we were going to show people back at home how adventurous I am for going in these parts of town. It’s not adventurous. And I do not and have not in other similar settings feel comfortable taking pictures unless I have a really compelling and personal story to tell. The places we go to should not be allowed to have the infrastructure they have (or lack really). But there was an adventure for sure in Nalukolongo. And it involved steer and cattle. And I definitely wished I had a camera that day.

We were talking to some funny women in hopes of locating a former participant. (We ended up not being able to go to her because a cess pool-type flood washed the path out.) The women offered me a girlfriend in the community after a disturbing Q&A session on HIV. I politely declined. We were in an alley this whole time, no more than the width of 2.5x my body width. All of a sudden a long-horn steer peeked its head around the corner.

The women started running into feeder alleys to this alley. I laughed. It’s just a steer. Then I saw a second. The women started yelling and Hassard already around the next alley corner said calmly that I should move. Then a woman yelled, “Mzungu, run!” The last time I heard that exclamation police aimed tear gas canisters at our section of the stadium. I rounded the next available alley corner and moments after, the steer stampeded down the alley. And about a dozen of them. Any of us could have been gored. The women yelled at the herder right behind them. Apparently, children have been injured badly when these herders do not watch their cattle close enough. I learned my lesson. When a Ugandan says, “Mzungu, run!” you just listen. I will have it down by the third time I hear that line.

People who are poor are transient and hard to locate. People who are poor and sick may even be harder to locate. Some women participants with HIV left town. It could have been stigma or a number of other things. One HIV negative woman that we had located by phone and location ran away moments before Hassard, the community guide, and me had arrived. Apparently her neighbor, a HIV-positive woman, told her we were coming back to do more tests. The community guide said the HIV-positive woman told a story that we lied and the participant was really HIV+ and that we were not going to tell her and instead do some more tests or delay telling her a HIV diagnosis. The participant would not answer our subsequent calls.

Here’s another somewhat related tangent. Poorly done research sensitization in these zones can be a huge hindrance for our research. In one zone, Wakaligga B, apparently previously researchers did interviews and tests but never returned with results or explanations. This created mistrust for our home health visitors in our study, which I believe is well-explained, transparent, and comprehensive for participant concerns. Myths and bad experiences set up what we experienced with the woman who ran from us.

To move on to a different domain, I had another research-clinical divide experience in Kigwanya. As we were searching for a participant for the follow-up survey, a wife approached us about her husband (both NOT participants in our research study). We went to their delapidated mud home and he came to the doorway with swollen eyes and an extremely suppurative exudative leakage from a swollen, erythematous right eye. (=pus) His left eye was crusty and also shut. The right eye and orbital facial area looked absolutely AWFUL. I had my Washington Manual of Internal Medicine with me randomly on this day but found nothing on orbital or periorbital cellulitis. My concern was about blindness and this infection going throughout his body. Already he was febrile, photophobic, and with headache. They could not go to the hospital until they received money from a relative the next day. Well, I wanted to give money on the spot. It was ridiculous that he had not been to a doctor yet. Hassard really emphasized to me why I should not give money, all for sensible reasons. Everyone around watched quietly how Hassard and me were handling the situation. I was clearly upset but we spoke in low voices.

I regret not giving the family money, although I understand the issues it could have created in the community. The next day when we came back here to continue interviewing other participants, the husband and wife had left for the hospital. I do not know the man’s fate. Role-playing and compartmentalizing in medicine does not come without its costs. Sure, had I not been there at all there would have been no burden of knowledge of this and other situations where a person can do something to address a particular injustice or illness. But I was there, and in the amoral march of time when someone’s life is in the balance, time does not care about good intentions or deliberation about how to handle a situation.

As I wrap this point up, I come back to the first participant. Driving around the city to find people, like one man in a truck yard where I was then offered to buy a truckload of sand or a lumber yard where men swarmed around us thinking I would buy something, I saw people at work, home, and in bars. I saw aspects of everyday life in a new way. We found the Rwandan woman sweeping a newly constructed road. Certainly she was not making enough money for her children and her from this, miles from her other place of employment. And she looked and felt very sick. The second sputum sample was now an after thought and 2 weeks since collecting her first sample, she did not have a chronic cough anymore anyhow to necessitate it according to protocol.  We drove her to a clinic, the last action on the last day of our pilot. It was the right thing to do.

Now I am writing up the pilot for inclusion into the parent study. It will be one of my projects for the remainder of the year after it gets the necessary approval from the regulatory bodies. What I like about it beyond its scientific and hopefully clinical/public health value is where it takes me. To the community. My little Luganda language skill gets me far with people as does playing with their children when Hassard is interviewing. I will continue to blog more stories that touch me along the way.

Uganda-CWRU Research Collaboration 20th Anniversary Celebration

October 2, 2008

Yesterday I had a fortunate opportunity to get a broader sense of the important history and work occurring at my research site, a once in a decade opportunity in fact.  On Monday and Tuesday, scientific meetings were held at the Hotel Africana in celebration of the 20 years Case Western Reserve University has been in partnership with Makerere University/Mulago hospital. I was able to attend yesterday’s events.

 

Everyone affiliated with the collaboration was invited to yesterday’s events – literally everyone – including janitorial staff for the Case/Mulago offices. I think in a way I had unknowingly taken for granted this collaboration until I learned its uniqueness according to those who presented, last of which was the Vice President of Uganda. For example, you’ll see Dr. Christine Sizemore’s (chief of the Tuberculosis and other Mycobacterial Diseases Section in the NIAID Division of Microbiology and Infectious Diseases) name in my “NIH training” posts since she gave a tuberculosis lecture in Bethesda in July. I had the chance to meet her again yesterday after her presentation about the collaboration from an NIH perspective. She told me afterwards as we were walking that the Uganda-CWRU TBRU (Tuberculosis Research Unit) collaboration is one of the most unique in Africa for the NIH. She said the Ugandan leadership in general has been a gold standard. Whereas at many other NIH-funded research sites internationally the US researchers lead the majority of the research work, Uganda is a shining distinction in that the Ugandan researchers are exceptionally trained (they receive training here and in the US) and lead the majority of the research in the collaboration.

 

I had not realized this. I just assumed what was happening here, the type of partnership, hierarchies, and delineations of US/Ugandan divisions of responsibility, was the same elsewhere. Apparently, that is not the case. Dr. William MacKenzie from the US Centers for Disease Control (CDC) further emphasized the uniqueness and success of the Uganda TBRU. It is one of only 4 international sites funded by the CDC for the TBTC (Tb Trials Consortium) and one of 2 in Africa period. One of the US researchers presenting called it the “most efficient Tb research site internationally” with 90% of patients enrolled in one particular study being enrolled correctly to protocol and with Ugandan research participants accounting for 47% of the study patients from this multi-site international trial. That particular speaker summarized the Ugandan collaboration this way, “Good science, good clinical care.”

 

We heard presentations from a number of Ugandan professors and researchers as well as researchers from the USA.

Dr. Alphonse Okwera presenting

Dr. Alphonse Okwera presenting

 The speakers were not just from the biological sciences either. We had 3 presenters talk about the twenty years of social and behavioral studies in light of the collaboration’s funding of social science work surrounding HIV issues. One of the US researchers present at the formation of the collaboration, for example, researched Ugandan attitudes towards vaccinations in preparation for an AIDS vaccine trial. Combining social impacts and assessments of research is important to the collaboration.

 

 

 

 

The intersections of cancer, HIV, and Tb were discussed much yesterday. As HIV becomes more chronically managed here, issues of HIV-related malignancies become more and more relevant. Discussions of research mapping the intersections between infectious disease and oncology highlighted new directions in research. Implementation research is still needed for delivering quality HIV and Tb treatment to all, but the future will be in chronic disease research, as it currently is in the USA right now.

 

A number of well known researchers were present or referenced throughout the day. One of the speakers scheduled Dr. Peter Mugyeni, stood on the President Bush’s left when the PEPfAR bill was signed originally. One speaker referred to Dr. Sten Vermund, one of the directors of the program that brings my colleagues and me to our respective Fogarty sites around the world this year. The last speaker of the day was the Vice-President of Uganda, Dr. Gilbert Bukenya who was surrounded by security detail and all.

Uganda vice-president Bukenya

Uganda vice-president Bukenya

He emphasized the importance of the collaboration in light of its history which he was a part of from the outset. (The VP was a former dean and professor at Makerere University School of Medicine.) There was a lot of to-be-expected “patting oneself on the back” in the celebration, and as the day went on, it was clearly appropriate, to say the least, given the challenges, risks, and extremely hard work of the Ugandans and Americans over the past 2 decades. When the collaboration started back in the late 1980s Uganda was not in an ideal state politically or in terms of infrastructure – the collaboration was a risk, but one that has ultimately benefited study participants/patients, health care capacity building and research training for Ugandans, and the furthering of scientific knowledge, especially in Tb and HIV.

Ndere troupe performing in between speeches

Ndere troupe performing in between speeches

 

I have to say that the glue that holds the collaboration’s success together, from what I could tell from people’s comments and my short time here, is the Fogarty AITRP (AIDS International Training and Research Program) and state of the art laboratory facilities available through the NIH funding. To date this program has allowed 53 Ugandans to train at CWRU for masters and doctoral level programs in immunology, anthropology, epidemiology, microbiology, and virology. Fifty of the 53 have returned to Uganda. The relationship between the high caliber of research and those leading it, most who were part of the AITRIP training, could not have been clearer. My mentor, Dr. Chris Whalen, has been an instrumental and crucial part of that program. Today I learned that the risks have paid off thus far in the dividends of capacity building and quality research. This collaboration has “trained the trainer” and because of it, its productivity and sustainability (provided international funding continues) is strong. One of the Ugandan researchers call for more AITRP funding received resounding affirmations from the audience. The collaboration has resulted in AITRP trained individuals co-authoring over 389 peer-reviewed journal articles, 115 of which had AITRP trained Ugandans as first authors. There is always a tug of war actually and conceptually between clinical emphasis and research emphasis when working in resource-constrained settings. Yet, the research here has translated into better patient care at the very least.

 

What does this all mean? Well to me, capacity-building means more Ugandans caring for Ugandans with the state-of-the art arsenal of knowledge to do so in a resource-constrained environment. It means local approaches to research design and implementation and more of a truer sense of “collaboration.” And it turns challenges parental arguments from high-income countries that low-income countries cannot undertake such endeavors. Additional implementation methods of transparency and accountability further solidify this project’s success.

 

Uganda’s advancement during the past 20 years was noted in the same way. Twenty years ago the discussions were about “no care which to access” to present discussions of securing “access to care” for all Ugandans. I think the most important of the public recognition made on several occasions thanking the patients/participants. At the end of the day, for all the successes and markers of success, the event was patient-centered.

Accompanying the home health visitors (HHV)

September 23, 2008

Last Tuesday, I had the chance to go to with the home health visitor (HHV) team to one of the community zones where our team is surveying chronic coughers. Kampala is divided into 5 divisions, 128 parishes, and many, many more zones. The main research project on which I work is surveying individuals in the Rubaga division. One this particular day, I accompanied the team – Hassard, Joyce, Kezron, Sheila, Joanna, Mustafa, Joseline, Esther, and Stella – to the field. We went into Wakaligga B zone in Rubaga division, Rubaga parish.

Let me tell you how the process for going to a new zone goes. Two weeks before starting in a new zone, someone from the project meets with a community leader (not quite mayor) for a particular zone to get permission to survey in that zone. (At the division and parish levels, permission has already been granted.) Community guides are then selected to accompany the research team. The first day in a new zone is an orientation day. The Ugandan HHV team goes out subsequently to interview the pre-calculated proportion of zone residents using a geographic sampling strategy to cover the zone.

Not knowing Luganda other than for a few phrases, my presence was more spectator than anything else. I had a great time spectating, though. First of all, a mzungu (me) knowing any Luganda usually shocks people, especially kids. So when kids asked me “how are you doing?” as we passed a school, and I responded with “I’m fine. Oli otya (how are you)?”, a roaring chatter and laugh ensued.

As I’ve written in mass emails from other trips, I then experienced being the Pied Piper of Hamelin. Kids followed me, daring each other to get to as close to me as possible and then running away or holding my hand while walking. The attention given warmed me up quickly given I probably was understandably met with some suspicion. Meanwhile, the HHVs were doing the hard work getting informed consent, explaining the survey, collecting sputum and performing rapid HIV tests on the spot.

One child humored me greatly. Probably near 2 years old, she kept chasing a chicken and hitting it until her mother kept reprimanding her. The chicken was not thrilled as the child still continued to harass it. I couldn’t stop laughing – the child was just so curious at the chicken’s response to her hitting it.

The whole HHV experience gave me insight into the data monitoring I do every morning on the template forms that the HHVs fill out the previous day. One woman, during the informed consent process, was hung up on the use of “East Africa” in the address of the project. Of all the potential issues needing explaining in the informed consent document, she was most concerned about whether or not she was going to be calling “East Africa” if there was a problem. The health literacy of those I saw surveyed varied, and the HHVs do a fantastic job explaining the trial and basic health information to the participants.

Sometimes people are shy about volunteering to be surveyed. Some mistrustful. Others wait until the HHVs have been here for awhile and then volunteer but usually after the cap has been met. Men are particularly difficult to interview because some are working during the day (ideal in the ultimate sense but not for research purposes), some may be lying about their incomes so that their wives/girlfriends do not find out, and some are shy about the process.

Wakaligga B does not see many mzungus I came to find out. It was moderately crowded for a place with lower socioeconomic status (as opposed to the “very crowded” distinction used in the project). Hassard said he wished I could have been at a previous site that was more “slummy.” I will in time, and I told him that I bought some furniture from some carpenters in one of the squatter community Katanga, near the hospital. I cannot say that I am morbidly curious to go to such an area after time spent in the Kibera, Mathare, Mukuru, and Kawangware squatter settlements in Nairobi. But, I was glad for the people we saw and interviewed that they had better living conditions than a left-behind squatter settlement. Make no mistake, the poverty still overpowers.

A few of the participants knew English a bit, so I talked with them when possible. One mother explained how her daughter had chicken pox. Happiest baby I have ever seen with the chicken pox as I took note of her skin lesions. The language of the body provided most of the conversation today. Smiles, laughter, a few phrases and the joy of children. I left to have a late lunch at a local joint with the HHV team after we all ate tangerines bought from a man riding a bike driving around a gigantic bag of them.

The HHV team took good care of me and included me whenever they could. I look forward to going to the field once each zone!

Research and lab time

August 22, 2008

As the orientation has continued on, I am gradually getting a better picture of how I can be involved in different studies. I will briefly describe the major studies here in light of my knowledge of them thus far.

 

One study is examining the use of punctuated anti-retroviral therapy (HIV/AIDS treatment) in patients with tuberculosis with CD4 counts (a type of white blood cell targeted by the HIV virus) ABOVE the range normally necessitating HIV/AIDS medications. Tb and HIV exacerbate each other. In light of this dual relationship, one of the central questions for the study is: can you more effectively treat Tb in an HIV positive person if you treat the HIV at the same time as Tb treatment while preventing the worsening of HIV due to the Tb infection? (Hence “punctuated” HIV anti-retroviral medication given only during Tb treatment since her/his CD4 level is higher than the “standard of care” level when medications are usually started.)

 

One of the studies I am most likely going to work on will look at cost-effective ways to diagnosis tuberculosis in a community. In this study community health workers are going out in a community in Kampala known to have a high prevalence (cases) of Tb. Rather than wait for someone to come to the doctor sick, this study seeks to actively seek out the sick as diagnosed by “chronic coughing” for more than 2 weeks. There is an extensive work up consenting individuals, household contacts, and first degree relatives then undergo if they are “chronic coughers.”

CWRU/UGa Tuberculosis Research Unit (TBRU) clinic at Mulago

CWRU/UGa Tuberculosis Research Unit (TBRU) clinic at Mulago

 

Related but reversed, is another study that examines known index cases of people with Tb and studies their household contacts and first degree relatives in a particular community. This study has been going on for many years and has gathered much data covering many issues that may impact Tb. This study also takes into account genetics, immunology, and other laboratory-based investigations.

 

The last study about which I know the least but am increasingly drawn to is studying the relationship between HIV and alcohol consumption. There are social and immunologic/genetic dimensions to this study’s analysis. I hope to get involved in a psychiatric issue (e.g., alcohol use) in addition to my involvement in one of the Tb studies.

 

We spent 2 days in the Joint Clinical Research Centre  this week, which is a 15 minute drive from Mulago. Here is a traffic jam that we caught on our way there:

Goats en masse while we were driving to the JCRC

Goats en masse while we were driving to the JCRC

Ali and I hitched a ride with the driver who brings over sputum and blood samples three times a day. Karen Morgan, PhD, a US microbiologist working there, gave us a phenomenal tutorial and tour of her work with Tb in conjunction with the studies. We learned different diagnostic techniques for Tb in patients and viewed cultures where Tb was growing. We also spent some time with the microscope looking at acid-fast bacilli (e.g., Tb) and its characteristic cording. We also received a tour of the different projects other institutions are conducting. The technology and types of machinery in the lab were impressive and many were completely new to me! I can readily say that there is some amazing laboratory bench science being done here that builds upon the clinical research in the field.

Pierre at work

Pierre at work

 

One example of the lab projects that I can explain is an aspect of the aforementioned studies. For those without an immunology background, let me try best to explain as simply as possible. When a person is infected with tuberculosis, the immune system reacts by attacking the Tb bacteria (called mycobacteria). Some of the body’s immune cells “present” part of the Tb bacteria to other immune cells that in turn help contain/destroy the bacteria. In order to make better treatment and vaccines, it is thought that targeting what is “presented” on those cells may be the future of Tb therapy and prevention. So how does one know which bacterial part causes the immune system to react? One of the chemicals the human body releases when Tb antigens are “presented” is IFN-gamma, a “marker” in the blood that infection has been recognized. So in one of the laboratory studies, the researchers are looking at which Tb antigens – the parts of the mycobacteria “presented” to the immune system by other “defense” cells – cause the release of IFN-gamma. IFN-gamma levels in the blood can be measured with the current technology so the researchers are limiting which antigens are possible candidates in the future for targeted, more efficacious Tb therapy.

Andrew and Joy decanting supernatant at JCRC

Andrew and Joy decanting supernatant at JCRC

 

I have to admit that FAR more things are going on in the laboratory than I can remember or explain, and I really parsed down the explanation of that one particular lab research project directly above. I’m not doing the lab justice! After two days at the JCRC, I came away with a deeper appreciation for laboratory bench science in general and Tb microbiological and molecular genetics in particular. Such science is a cornerstone of modern medicine and will certainly be even more in the future as we better understand molecular genetics of human disease. Continued and increased research in these areas in general is CRUCIAL!

Caring for dad

August 15, 2008

Some of my afternoon lectures were rescheduled so I have time to write now. Yesterday we started with observing the screening procedures for tuberculosis in the wards of the hospital. Many people are co-infected with HIV which can result in an atypical presentation of the disease, i.e., chest x-rays may not have the characteristic “cavity” finding or hilar lymphadenopathy (enlarged lymph nodes in a particular region of the lung seen on x-ray) and other constitutional symptoms may be lacking (such as drenching night sweats, fevers, cough productive of phlegm often with blood). We happened to see mostly patients that were HIV negative as we screened. I wore my N95 mask for those worried about my exposure J

 

Patients undergo Tb and HIV health counseling before the medical officers (=physicians) see them. Eligibility for studies and informed consent occur before or after they meet with us depending on if they’ve been seen in the TBRU clinic (Tb Research Unit) first. All the patients we saw already had x-rays taken, which we held up to the ceiling light to read. I saw a number of disseminated Tb cases. Disseminated Tb occurs when Tb affects other organs. One woman had likely Tb of the kidney; another man had Tb of the abdominal region with mesenteric (an abdominal region) lymph node enlargement.

 

The most saddening and touching story for me of the day (and many of them are) was a 10-year old boy who came to the clinic. But not for himself. His dad is dying of AIDS-related illnesses, including widely disseminated Tb and Kaposi’s sarcoma (a type of cancer seen on the skin), and sent his son to get instructions from the medical officer. The boy will likely be an orphan soon. He had the innocence of childhood in his mannerisms that it appeared he didn’t realize yet how sick dad was and the outcome. So the doctor reviewed the most recent x-rays and the chart and wrote a note for the father that he gave to the son. The boy then walked out of the room with his father’s chart and x-ray, which was more than half the size of him and went to the chart room to drop it off. I talked with the boy and worked on making him laugh despite his shyness. Ali lost his father to an AIDS-related death and told me how HIV has affected his childhood. He quietly explained that he knew this boy’s future, one far too common still in Africa despite improvements and increasing access to HIV medical care.

 

I had lunch next at the medical school canteen. One of Ali’s colleagues, a physician named Fred, spoke with Ali about the “brain drain.” Both have spent time training in the Yale Medical system and discussed how frustrated they feel when docs leave Uganda to practice in the US or Europe. The three of us had a very good discussion and I asked a number of questions. Since this issue of brain drain has been important to some of my AMSA and PHR colleagues and classmates, it was a good opportunity for me to talk with people on the other side of the issue. More on policy measures being considered for addressing health care worker shortages in a later post.

 

The last event of the day was a general meeting of all the community health research workers gathering for the weekly status updates on a number of projects. They run quite a program here to say the least. I learned of a Alcohol-HIV study that I investigate further.

 

Last night Matt and I walked up to Kisimente so I could look at ads for roommates and flats in which to live. No such luck, but I bought some fantastic coffee that I tried this morning in my French press mug. Feeding the addiction once again! He and I walked through a flashy part of town called Kololo, and I found a few restaurants to try out and a Green Tea House. Excited about that one. He and I then ate dinner at a Korean restaurant here that had very cool Asian contemporary architecture and great food. We discussed religion, social issues, and literature which made for an enriching dinner time.

 

Today we had a meeting with one of the mentors on site for Ali and me, Dr. Kamya. He researches the HIV and malaria relationship with a University of California – San Francisco collaboration. I also met one of the Yale collaboration physicians who tracks many infectious diseases here. I hope to visit the a sleeping sickness treatment center in the eastern part of the country at some point with the Yale team.

 

I toured some of the hospital wards today. I thinks there’s a vigorous debate between Westerners here with staff here on the status/practices/conditions in the hospital. Unlike one of the hospitals I visited in Kenya, there was only one person per bed in the wards I visited today though. I met some other friends and colleagues of Ali and they were very gracious. The hospital is quite large, and I’ll post pictures at some point.

 

New foods (or old Kenyan favorites) of the past two days: posho (maize flour), chapatti (bread-like pancake of goodness), and a curry pea concoction. This weekend I’m going to explore the city and continue flat hunting!

Orientation part 1 + “cheese and babymarrow pizza”

August 14, 2008

Today I started orientation. Ali and I met with Dr. Luzze for a bit, and he explained our responsibilities, learning goals, mentors, and peripheral related activities. All of it sounded exciting to me. Additionally, Ali and I will lead journal clubs (explained later to non-medicine folks) later in the fall. We met with Miriam next and then sister Juliet. Note to self: sister does not mean nun. It means nurse. A few laughs directed at me ensued when I asked after reading the day’s schedule if we were meeting a nun later in the day! At the Tb clinic Juliet gave us a tour and explained the processes of Tb/HIV screening, vitals, informed consent and counseling, evaluation, and treatment. The research protocols have inclusion and exclusion criteria that are ascertained at the outset of patient presentation to the clinic. Some patients, donned with facemasks, were receiving health education on Tb while we received the tour. The patient intake room had UV lights throughout it, presumably to kill air-floating Mycobacterium tuberculosis (the causative agent of tuberculosis). The clinic staff members were very kind in taking time out of their busy day to explain things to us. I will be working in this clinic. We had 2 hour orientation meetings in the afternoon, and I learned about the research studies in more depth and started to get an idea how to select a research question to pursue.

 

Everyday when I come to the office at the hospital, I pass through a walkway of the Ugandan children’s cancer ward, the only one in the country. I saw what I later found out was Burkitt’s lymphoma (a lymphoma correlated with EBV infection found very rarely outside Africa) in the jaw (appears like a very swollen jaw/tumor in the jaw area) in a few of the children. Two Brazilian hematologists training in hematology in the US are staying at the guesthouse and told us tonight some stories I have not the heart to write on the blog just now in terms of the health consequences of resource-constrained settings in the cancer ward. The sick children smile at me every day with their beautiful white teeth.

 

Ali took me to the medical school canteen for lunch. I had tea, fried cassava, matoke (mashed, cooked bananas), and samosas. Ali and I ate for about $1.60 for the two of us. Lunch will be had here again.

 

My friend Marc from Yale Divinity School has a friend working in Fort Portal (western Uganda) in an orphanage for children living with HIV. Matt, the hematologists Ana and Luciano, and I met her and her entourage from Fort Portal in town for dinner. I had a scrumptious pizza at an Italian restaurant clearly popular with expats. Ok, I know. I had deep dish Gino’s East exactly one week ago in Chicago. But really, can you pass up pizza when it’s rarer outside the US? And it was decent pizza at that. Also on that note, there was a pizza that had just the following ingredients listed: “cheese and babymarrow.” None of us even wanted to know that meant and none of asked for or about it.

 

My small victories of the day included: (1) buying a cell phone for $37 since T-Mobile failed to give me the SIM unlock code yet; (2) befriending Stephen, a taxi driver in the city who charges below average rates for the Fogarty students and who will eventually help me find a good used car to buy when the time comes; and (3) walking around Wandegeya community and getting excited about getting my own place so I can buy the local fruits and veggies to prepare!

 

P.S. Monkeys play in the trees outside my bedroom window, and there are these giant grotesque birds the size of toddlers that look like storks bred with vultures and pelicans. They cannot keep their mouths shut, and they eat garbage. Do not pet them.