I am currently on a year’s leave from Mount Sinai Medical School to pursue a Fogarty Ellison Fellowship in Global Health and Clinical Research in Lima, Peru at a research training center that is run collaboratively by the Johns Hopkins School of Public Health and Universidad Peruana Cayetano Heredia. (see link for more info.)
The Boss Men
My overall boss is Bob Gilman from Hopkins, an MD who lived in Lima for 18 years with his family and now splits his time between the US and Peru. It’s hard to sum up the career or charisma of a man who can talk about immune fluorescence with the same facility as global economics or the American variety walnut tree. Most of his work is in clinical diagnostics and infectious disease. For my medical friends, I think he put the string test on the map with his work in typhoid. Needless to say, I feel lucky to be on his team.
Two other wonderful doctors from Imperial College mentor students and work closely together and with Bob at Cayetano. Carlton Evans is known for his work in micronutrients and tuberculosis and David Moore for tuberculosis diagnostics. Again, I feel lucky to be working with MDs who are such admirable people as well as doctors.
The fellowship began in July with a three week orientation in Bethesda, Maryland on the NIH campus that brought together fellows from the host countries (mostly foreign MDs) and the 27 medical students slated to work at each of the 18 sites. Course work ranged from ethical research to epidemiology to economics. Guest speakers ranged from the US surgeon general to a member of the French equivalent of the NIH.
After the orientation, I took my second board exam and then arrived in Lima on August 28 - unusually late for the fellows but necessary for personal reasons. I arrived on a Monday and began my lab rotation that Wednesday. Bob has all of the students who work for a year with him (6 this year, not including those who are here for shorter periods) spend 4-6 weeks rotating through the different laboratories at Cayetano.
The first month I spent mornings in language classes and afternoons in the lab. I rotated through Parasitology, the Helicobacter Pylori Group, the Immunology Group, and Tuberculosis learning a lot from many patient Peruvians. One of the first words I learned in the lab was “torpe,” Spanish for klutz. My lab rotation stretched across 5 and a half weeks as my language classes cut seriously into lab time.
I also visited different projects to see how various projects ran. I went to health posts and/or out with field workers in the shanty towns of Ventanilla, Callao, Villa El Salvador, and San Juan de Miraflores. I traveled to Ica, a city 4-5 hours south of Lima to hear David give a talk about a rapid and cheap new diagnostic test the Tuberculosis group developed (with Luz Caviedes at the head) called MODS – microscopic observation drug susceptibility assay. David was invited by a young MD, Cesar Munaiko, who is organizing a campaign against tuberculosis in Ica. They had an unusual outbreak of drug resistant tuberculosis a year or so ago. Here arise many questions (that my mother asked) that I hope to address later, like what the heck IS MODS? What is tuberculosis, anyway?
The Research Projects: 1 big, 2 small, 1 back up
My main project came out of the car ride back from Ica: to do a formative and summative process evaluation of the implementation of MODS in Ica. From what I understand at this point, process evaluation is often used in quality improvement studies and to analyze the effectiveness of behavioral interventions. We want to apply this critical approach to the implementation of a new diagnostic test in a resource poor setting. The goal, in my mind, is to come up with a few practical things: 1. A simple quantitative and descriptive method that health care providers who implement MODS in resource poor settings without huge numbers can use to ensure that their plans are carried out optimally 2. some sense of which components of the intervention are effective, for whom the intervention is effective and under which conditions it is effective.
In theory, I love this project. It focuses on bridging the gap between innovation and clinical practice. How good is your invention if it never gets to the people who need it?
It seems both intimidating and challenging to not be able to find a model in the literature for what we want to do.
I also plan to do a short lab project comparing the effect of two types of centrifuges – one very expensive, one not -- on MODS. I’ve also spent some time tinkering with different microscopes – or rather commandeering different microscopes so Luz Caviedes and her amazing Peruvian lab team can play around with them.
When there’s down time, I’m working with data on children’s poisonings that one of the other Fogarty Fellows, Joe Donroe, collected from 5000 homes in one of the poorer slums. The goal is to come up with an intervention addressing the problem of kids drinking bleach and kerosene.
I’m pretty much in charge of my own schedule, but also very much subject to others’ availability. In the beginning, I probably spent about 40% of my time in transit in this sprawling city and the rest in lab or language class. Needless to say that no matter how many surprising street scenes Lima has to offer, no matter how profoundly I enjoy taking the little buses called combis around (seriously), that much commuting quickly loses its charm. Fortunately now I’m not at the lab every day.
I have a great place to run and a fantastic running partner. I had the best visitor for two weeks I could have ever hoped for. I have recently acquired a gorgeous place to swim thanks to the guest pass of one my Peruvian friends. I have a lot of extremely nice Peruvian and international colleagues and there are more social events going on in a given weekend than one could possibly keep up with. My home situation, after some initial difficulties, is suiting me perfectly. I’m settled in. I’ve had the opportunity to see fascinating and beautiful new things.
I’ve been hesitant to write about what my daily life is like because it is so variable. I’ve been hesitant to write about my projects because of how they come along in fits and starts.
I have tremendous anxiety about not having a single finished product by the time I leave here, about not having done much more than set up some projects that would likely fizzle out if I left. I have been surprised that I was even capable of feeling as frustrated as I have at times. Example: Traveling 10 hours in a day on the bus to get some documents that could have easily been emailed to me.
There are the frustrations of relying on others for work and then there are the frustrations of being work for someone else because I can’t speak the language well. I am taking private lessons still but I can’t learn Spanish fast enough. I can get around the city, and make casual conversation, but it’s another thing, for example, to give a comment about something medical in front of a group.
It’s also hard to know when to throw yourself into something and when to throw in the towel.
Again, I could not ask for better mentors and I’m in constant conversation with the boss men about this; they are incredibly supportive.