Stolley Travel AwardsThe Center for Clinical Epidemiology and Biostatistics (CCEB) is pleased to sponsor the Paul D. Stolley Travel Award. This award, named for the Founding Director of the Clinical Epidemiology Unit, which preceded the CCEB, provides an opportunity for medical students to study clinical epidemiology in an international setting.
Arrangements are made for the Stolley Travel Award recipient to work at one of the developing nation Clinical Epidemiology Units in the International Clinical Epidemiology network (INCLEN). This is designed to be a one month experience. Working with faculty members here and there as joint preceptors, the student will join the Host University's Epidemiology Unit seminars and conferences, work through guided readings, and attend selected meetings with their Host University faculty preceptor. The student also may work for a limited time on one of the research projects underway in the host Epidemiology Unit.
This is an annual award. The recipient is selected by a committee of CCEB faculty, based on an application and interview. Applicants must have successfully completed Mod1, Introduction to Clinical Epidemiology and Biostatistics, in order to be considered for the Travel Award. Generally, the application deadline is in early January each year. One Penn medical student, chosen from among the applicants, will receive the Award, consisting of paid round trip airfare plus $1,000 for living expenses. If desired, the Award recipient is eligible to receive academic credit.
The application process is announced/advertised annually in November. The process involves: 1) Identifying a potential faculty member in the CCEB by looking at their web page or contatcing John Farrar; 2) identifying an INCLEN site of potential interest by going to the INCLEN website; and 3) completing an application. For additional information and/or questions about the application process and Award, please get in touch with John Farrar (215-898-5802, email@example.com) or Sandy Masiak (215-572-7223, firstname.lastname@example.org).
The official deadline for applications will be Friday, February 14, 2014 at 5 pm.Read about the experiences of previous winners of the Stolley Travel Award
- 2010 Recipient Ernestina Nyarko
- 2009 Recipient Katherine Dillon
- 2008 Recipient Nataniel H. Lester-Coll
- 2007 Recipient Andrew Renuart
- 2006 Recipient Melissa Simon
- 2005 Recipient Cynthia Bartus
- 2004 Recipient Caitlin Rollins
- 2003 Recipient Monika Goyal
- 2002 Recipient Camille Henry
Stolley Travel Award 2010Ernestina Nyarko
This past summer, the Stolley Travel Award enabled me to travel to Gaborone, Botswana to learn about the conduct of clinical epidemiology in a developing country. While I was in Botswana, I worked with a research team with three ongoing projects. The first project is the Tlhomamiso study, whose principal investigator is Dr. Robert Gross. The primary aim of Tlhomamiso (which means "confirmation" in Setswana) is to figure out how a genetic polymorphism that is associated with slow metabolism of Efavirenz, an antiretroviral drug, affects treatment outcomes in HIV-positive patients since slow metabolism of a drug can lead to better response, higher toxicity or both of the above. The second study the team is working on is the Tsholofelo study, whose principal investigator is Dr. Gregory Bisson. Tsholofelo (which means "hope" in Setswana) is a study aimed at determining the relationship between immune recovery on antiretroviral therapy and outcomes in patients with HIV and tuberculosis co-infection. Both Dr. Bisson and Dr. Gross are UPenn faculty here in Philadelphia and they met with me to discuss their projects and to advise me about life in Botswana before my trip.
The third study the research team is working on is Botshelo (which means "life" in Setswana), a project that involves treatment of cryptococcal meningitis in patients with HIV infection. Cryptococcus is one of the defining opportunistic infections for advanced HIV/AIDS because it seldom infects immunocompetent people. Currently, the mainstay of treatment for cryptococcal meningitis in Botswana is intravenous amphotericin B, and then HAART is commenced 3-4 weeks later. The Botshelo study, headed by Dr. Mooketsi Molefi, is a randomized controlled trial comparing outcomes in those with standard of care (i.e. late HAART initiation and initial amphotericin B) as compared to those in the intervention arm (early HAART as defined by HAART within 7 days of diagnosis of crypto meningitis and initial ampho B). The clinical research team is a part of the Botswana-UPenn Partnership (BUP) in Gaborone. My in-country mentor was Dr. Andrew Steenhoff, a University of Pennsylvania faculty member and the associate country director and research director for BUP.
My first week in Gaborone, I travelled to clinics around the city with the research nurse for Tlhomamiso as she recruited patients for the study. Through this experience, I learned how testing and counseling for HIV infection are done in Botswana. At first I was concerned by the group counseling that was happening at the clinic because of the US medical system's insistence on patient privacy and confidentiality. However, I began to realize throughout the course of the week that group counseling had its benefits: it gave patients newly diagnosed with HIV/AIDS an opportunity to know that they were not the only ones with the disease. I saw a lot of support among the patients and they often encouraged one another to work hard to adhere to their treatment regimens. The first week also taught me about some of the difficulties of recruiting patients for research studies in Botswana. I quickly learned that my inability to speak Setswana would make it impossible for me to be of use in helping to recruit patients.
During the rest of my time in Gaborone, I had the opportunity to witness research projects in various stages of completion. I attended protocol presentations with Dr. Steenhoff at the offices of BOTUSA, a partnership between the government of Botswana and the US Centers for Disease Control and Prevention (CDC) to help stop the spread of HIV/AIDS and tuberculosis in southern Africa. The purpose of the meeting was to hear presentations from various researchers at BUP and Princess Marina Hospital to determine the potential of each protocol to become a project that could get support from the CDC. This meeting taught me about the camaraderie and collegiality that is required in clinical epidemiological research; as each group presented their ideas, the other researchers and reviewers critiqued them and made suggestions for making the ideas more robust and executable.
I also traveled with the Tsholofelo team to see HIV/TB co-infected patients that were part of the study. Through my interactions with the Tsholofelo team, I learned about another challenge facing researchers in Botswana: since clinical research is a relatively new enterprise in Botswana, many Batswana are mistrustful of it. Because of this, it is sometimes difficult to recruit and enroll the desired number of patients for a study. Furthermore, I had the opportunity to help with quality assurance of datasets for both Tsholofelo and Tlhomamiso. Toward the end of my stay, I shadowed Dr. Doreen Ramogola-Masire, BUP country director and lead physician of the Women's Health Program at her bi-weekly cervical cancer prevention clinic. The clinic receives patients from outlying healthcare centers who are found to have cervical lesions suspicious for cervical dysplasia. During the clinics, Dr. Masire used pictures of cervical lesions (which I took) to teach me about the appearance of normal variations and abnormal changes in the cervix and I was able to see excisional treatment procedures for the lesions (LEEP). Another goal of the cervical cancer clinic was to start characterizing the most prevalent strains of HPV in Botswana, as there is almost no information about this currently in the country to inform policy about HPV vaccination for primary prevention of cervical cancer.
As you can see, my time in Botswana was filled with many enriching educational activities. I was able to observe research projects in various stages of completion and to gain some direct clinical knowledge. Additionally, I was able to meet many of the people that work at BUP and was impressed by the warmth and hospitality of the research team and the Batswana people in general. Furthermore, the World Cup was taking place in neighboring South Africa, so the feeling of excitement and universal humanity could be felt everywhere. I cannot think of a better way to have spent my first summer of medical school, and I am immensely grateful to the Stolley Award committee for enabling me to have this experience.
Stolley Travel Award 2009Katherine Dillon
This summer I used the Stolley award to travel to Thailand, where I worked at Siriraj Hospital in Bangkok. Located in a city of eight-million people, Siriraj is the largest public hospital in Thailand and is associated with Mahidol University, which was the first university in the country to establish a modern medical school. Siriraj is an important center for treating patients who come from all parts of Thailand.
Working under Dr. Supornchai Kongpatanakul , who was a fellow in pharmacoepidemiology and received his Master of Science in Clinical Epidemiology from the CCEB, my project focused on determining the rate of adverse reactions due to an in-hospital preparation of allergen vaccine for patients with allergies to dust mites. As Dr. Supornchai is the head of pharmacology at Siriraj, I also had the opportunity to work extensively with junior physicians in the department.
Siriraj Hospital has an on-site pharmacology lab that develops and produces vaccines for common allergens. Though many physicians working in the hospital’s otolaryngology clinic who administer vaccines claim that the dust mite vaccine has been used successfully for many years and is therefore safe, there had never been any sort of rigorous, qualitative study to provide definitive data on the rate of adverse reactions to the vaccination. While reactions to allergen vaccines are rare and sometimes manifest as little more than a rash, anaphylaxis and death are known to occur. And since in Thailand the reporting of an adverse drug reaction is not mandatory, how often these severe reactions arise is not clear. The current “optional” system requires physicians to report to hospital pharmacists who in turn contact the Thai FDA. What does and does not get reported is often left to chance.
My initial study design involved a retrospective chart review, hoping that many adverse drug reactions, if not reported to the pharmacy, would at least be recorded in each patient’s chart. However, this plan soon proved to be unfeasible, as an initial sample of patient charts revealed that many were often disorganized and missing, or that many patients had received allergy shots for more than one allergen in a single visit, making determination of which vaccine specifically had caused the reaction impossible. In the face of this information, my task turned from conducting a retrospective study to designing a prospective one that could be implemented after I left. This was the first experience that I had with designing a prospective study, and conducting an accompanying literature review, and it was a fantastic though challenging experience that added to my enthusiasm for epidemiology.
I also had a number of other interesting opportunities arranged for me by Dr. Supornchai’s staff. I was able to spend some time shadowing in the Ob/Gyn department, and also in the emergency department of a much smaller, rural hospital outside Bangkok. I visited the lab where the dust mite allergen vaccine is produced, and was able to observe for myself the step-by-step process of turning dust mites into an injectable vaccine. I also spent a day at Thailand’s FDA, learning about the adverse drug reaction reporting process and some of the challenges that the country faces in monitoring drug safety. Finally, I was able to sit in on the pharmacology department’s weekly journal club meetings, and also present my proposal to this group of students and doctors.
This was the first time I have conducted epidemiological research abroad, and I think it was extremely valuable for me to see first-hand some of the additional challenges that working in a developing country presents. I have always been interested in epidemiology and public health issues abroad, and this experience only reinforced my interest in clinical epidemiology and heightened my enthusiasm for working abroad someday. I am incredibly grateful to Dr. Supornchai and his staff for being such warm and generous hosts, and for taking the time to introduce me to the culture of Thailand- I hope to continue the friendships that I made with my colleagues for a long time to come. Thank you to the CCEB for providing this opportunity.
Stolley Travel Award 2008Nataniel H. Lester-Coll
The Stolley award enabled me to spend a month working in São Paulo, Brazil at the Brazilian Cochrane Center (Centro Cochrane do Brasil) and the Federal University of São Paulo medical school (Universidade Federal de São Paulo; UNIFESP). The two institutes are located in proximity to one another in Vila Maria, a predominantly residential neighborhood of São Paulo that is not far from the busy city center.
I was invited to work with Dr. Alvaro Atallah, the director of the Cochrane Center in São Paulo. Dr. Atallah, a physician, studied epidemiology at the Center for Clinical Epidemiology and Biostatistics (CCEB) here at Penn and is currently trying to expand the practice of evidence-based medicine in Brazil by conducting systematic reviews at the Cochrane Center. Interestingly, Dr. Atallah also strives to disseminate the findings of the Cochrane reviews to the general public in Brazil via a television program. I was not assigned a specific project, but this enabled me to obtain a very broad exposure to systematic reviews and meta-analyses. Specifically, my duties included literature searches, extraction of data from published studies, basic statistical calculations, language translation and manuscript composition and editing. In addition, I attended and participated in several meetings at the Cochrane Center. My time at Cochrane provided me with valuable insight into the methods used to generate meta-analyses, which will significantly aid me in interpreting medical literature in the future.
After spending the mornings at the Cochrane Center, I worked in the Emergency Department (ED) at UNIFESP with Dr. Elcio Bakowski, an internist. This was primarily a shadowing role, where I observed, studied and discussed clinical cases in the ED with Dr. Bakowski and his team. I was also taught basic clinical skills. This experience enabled to me learn a great deal about the Brazilian health care system and the basic epidemiology and burden of disease in São Paulo. Heart disease was the most prevalent condition treated in the UNIFESP ED. The spectrum of heart disease was wide, ranging from paroxysmal tachyarrhythmias to congestive heart failure, occasionally caused by advanced Chagas Disease.
One the most challenging aspects of working in São Paulo was the language barrier. Few people spoke fluent English and this in general slowed the pace of my work there. This was most apparent in the ED, where I was occasionally unable to understand the nuances of cases. However, being immersed in Portuguese forced me to speak and practice, and I learned a great deal of Portuguese during my four weeks in Brazil. This was facilitated by already knowing Spanish, and self-studying the language, which I began doing regularly once I learned I was going to Brazil.
My colleagues in Brazil were incredibly welcoming and eager to include me in their work. I developed many close friendships with my colleagues, who acquainted me with São Paulo’s rich variety of food, art and music. I hope to maintain my friendships in Brazil and work with them again in the future.
While I had previously conducted research abroad with an NGO, this was the first time I collaborated with faculty in an academic setting outside of the US. It was a challenging but rewarding way to study and practice research methods, while at the same time learning a new language and gaining an inside perspective on the public health challenges that São Paulo is currently combating. I am extremely grateful to have been able to work with such warm and dedicated individuals like Drs. Atallah and Bakowski and the rest of the Cochrane faculty in São Paulo. This experience, made possible by the Stolley Award, has reinforced my desire to extend my future clinical practice and research endeavors beyond our borders. I’d like to especially thank the CCEB for arranging this unique opportunity
Stolley Travel Award 2007Andrew Renuart
This summer, the Stolley Award allowed me to spend approximately six weeks working in the College of Public Health at Chulalongkorn University in Bangkok, Thailand. Chulalongkorn University, founded in 1917, is Thailand's oldest institution of higher learning and consists of eighteen faculties and a number of schools and institutions. The College of Public Health was founded in 1992 and combines organized research with graduate education of health professionals. Graduate education at the College consists of English-language MPH and PhD programs, which draw students from dozens of countries around the world.
I was invited to work with Dr. Ratana Somrongthong, an Associate Dean of the College, whose current research interests include adolescent and reproductive health, border health, and rational use of drug therapy. My work was further supervised by Dr. Robert Gross from the CCEB at Penn.
Overall, my time at Chula provided me with a broad exposure to the types of work and education being carried out by the College.
Throughout my time in Bangkok, I attended the bi-weekly seminar courses for the PhD and MPH students, in which students presented papers in order to discuss the epidemiological methods used to carry out various research projects, and whether or not these methods would be effective in the context of Thailand or the other nations represented in the class. Once weekly, these seminars were conducted by Dr. Chitr Sitthiamorn, the founding Dean of the College as well as a past-president of the International Epidemiological Association. I was afforded the opportunity to meet regularly with Dr. Chitr to discuss my personal interests, including work by Dr. Gross on adherence to HIV therapy, and how similar research has been carried out and may be carried out in the future in Thailand.
I also had the opportunity to attend a number of lectures by visiting scholars from outside of Thailand, including discussions of the use of qualitative research in public health and how to conduct long-term research projects.
Additionally, I was able to travel to the field to observe the direct impact of work carried out by the College. Following the Tsunami of 2004 which devastated the western coast of Thailand, Dr. Ratana became involved in a study of childhood safety issues in the affected regions. During my third week in Thailand, I travelled with her and another senior researcher to the province of Phang Nga where they presented the findings of their research to various community leaders and also distributed safety materials which the College had helped develop to the local schools.
The bulk of my time in Thailand was spent working on a midterm report for a study of the control of infectious diseases along the Thai-Burmese border. This three year project, funded by the American Refugee Committee, was begun in February 2006 when researchers from Chulalongkorn conducted a baseline survey of communities in the regions of Chumporn and Ranong in order to identify the demographic characteristics of the populations in these areas, as well as the health needs, health problems, risk behaviors, and care-seeking behaviors regarding infectious diseases among these populations. The long term aim of this project is to decrease the communicable disease burden in the selected areas, which have particularly high concentrations of Burmese migrants.
From March to April of 2007, Dr. Ratana and her researchers from Chulalongkorn conducted a midterm survey which provided the raw data which myself and another senior researcher in the College used to compile our report.
Working on this report allowed me to gain a much stronger sense of what goes into an international public health project from the academic side. I was able to learn about how the study questionnaires were developed, how researchers from the College worked with local Burmese speakers to conduct the survey, and how this raw data is compiled and used, among other things. I was further able to gain some understanding of how the College collaborates with its funding organizations as well as the Thai Ministry of Health, in order to conduct such a project, and how this work could eventually decrease the burden of infectious diseases along the border.
In general, my time at Chulalongkorn University provided me with an excellent opportunity to gain a broad understanding of academic public health and epidemiology in an international setting. My experience further deepened my interest in the field of epidemiology and allowed me to see the types of roles it may play as I continue to advance in my career. I am extremely grateful to Dr. Ratana Somrongthong and all the faculty, staff, and students at Chulalongkorn, who warmly welcomed me to the College and helped provide me with such a fantastic educational experience. I am equally grateful to the CCEB at Penn for awarding me the Stolley and allowing me to have such a wonderful opportunity.
Stolley Travel Award 2006Melissa Simon
This summer, the Stolley Travel Award enabled me to work with clinical researchers in Buenos Aires, at the Instituto de Efectividad Clinica y Sanitaria (IECS, Institution for Clinical Effectiveness and Health). Although Argentina is considered a developing country, its capital, Buenos Aires, captures an international cosmopolitan personality. Its immigrant heritage and unique economic success for the region fostered the development of a large, sophisticated city, with impressive architecture, institutions, education, and quality of life for its middle and upper classes. Nonetheless, there is tremendous poverty in many of its neighborhoods and in the area surrounding it. Moreover, the country's rural provinces are significantly different from the Buenos Aires Province. The economic crisis ("El Crisis") of 2001, including massive deflation of the Argentine peso and nearly overnight loss of federal reserves and the population's personal savings, left the country and its medical community in a state of shock from which it is still recovering. This backdrop of education and infrastructure challenged by developing world populations and resources interested me in Argentina.
IECS is affiliated with the medical school at the University of Buenos Aires, the major university and medical school in its region. Staff members conduct clinical research on public health issues in Argentina. My supervisor, Dr. Fernando Rubinstein, is the Director of Research and Information at IECS and the Coordinator of Academic Affairs and Sub-director of the Masters Program in Clinical Effectiveness at the University of Buenos Aires. He completed medical training in both Argentina and the United States, and his understanding of my US background helped us decide quickly what skills would be most beneficial for me to improve and where my skills would be most useful to the organization. We decided that I would assist with the writing of part of a grant proposal for a tuberculosis study.
Tuberculosis remains a serious problem in parts of Argentina. A 2002 report from the National Academy of Medicine of Buenos Aires considered TB among Argentina's seven "most relevant" emerging infections, and in 2000, notified cases were estimated to be 32/100,000 inhabitants, nationally.1
From a global perspective, TB was first called a major public health problem by the World Health Organization in 1991. A World Health Assembly addressed this crisis with two targets to achieve by 2000 (postponed in 1998 until 2005.): (1) Detection of 70% of new smear-positive cases and (2) cure of 85% of these cases.2 A Directly Observed Treatment Strategy (DOTS) was recommended internationally in 1994 to accomplish these goals, and it included five components: (1) Government commitment to tuberculosis control, (2) diagnosis by sputum smear microscopy, (3) standardized short-course chemotherapy using first-line drugs, provided under proper case management conditions including directly observed treatment (DOT), (4) a regular supply of free drugs, and (5) a recording and reporting system with assessment of treatment outcomes.2
Since 1994, the DOTS program has been implemented in 182 countries.2 While the WHO unwaveringly advocates the DOTS program, debate over DOTS effectiveness has reached crescendo without resolution. The "universal" strategy is being implemented differently in various parts of the world, and specific features have not been controlled for in most trials. Results vary from trial to trial, few of which are randomized and controlled.
Not only can little be concluded about the universal effectiveness of DOTS from the medical literature, but even less can be concluded from its implementation in Argentina. Less global attention has been given to the Latin American region than to India, Africa, and Eastern Europe, which present a far more pronounced crisis. Yet without an accurate understanding of the state of TB prevalence, incidence, treatment strategies, and outcomes in Argentina, little progress can be made in its control. And control is very much needed in Argentina. Incidence rates in nine provinces were higher in 2000 than the 32/100,000 national Argentine mean value. These nine provinces present numbers that would be alarming on any continent. Furthermore, researchers admit that the economic crisis presents a problem for drug administration.1 This obstacle needs to be examined as well. Thorough evaluation of treatment data is a critical necessity in Argentina.
Dr. Rubinstein at IECS wishes to collaborate with researchers at the Instituto de Enfermedades Respiratorias, who have collected extensive national data on TB treatment and response. He is writing a grant proposal to investigate the way DOTS is operationalized and its effectiveness in some of the high incidence areas of Argentina. I researched and critically reviewed published and unpublished literature on the subject and wrote a paper to be used as the background section for his grant proposal. We are also planning to incorporate the review into an article for a secondary journal, Evidencia en la Practica Ambulatoria.
The knowledge and professional experience that I gained this summer are multifaceted. I learned a tremendous amount about TB prevention and treatment, as well as debates among the academic and organizational medical communities. For the first time, I considered a WHO platform imperfect; I had been na?e about the relevant politics previously. Dr. Rubinstein encouraged me to think critically and creatively, and he helped me present my work to the department. He and his colleagues are warm and interesting individuals who welcomed me to participate in their community for my short stay.
Although I had worked abroad before, and I had participated in public health research before, I had never worked in healthcare abroad. It was a wonderful and novel wedding of my passions. I used and improved my Spanish language skills to understand how my colleagues and new friends perceive the state of healthcare in Argentina and its somewhat compromised place in the global health policy ladder. I saw that even at the most prestigious medical school in the country, and arguably in the region, resources were challenged. I appreciate how accessible information and resources are at a US medical school like Penn even more now than I did before. My time in Buenos Aires this summer was a unique opportunity, and I am extremely grateful to those who enabled me to have it. Not only did it confirm my interest in public health and international health, but it gave me novel and concrete experience on which to build. I am in touch with my summer supervisor and colleagues, and we have discussed the possibility of working together in the future. I am certain that receiving the Stolley Travel Award will positively affect my career trajectory in the long term. Thank you for granting me this tremendous privilege.
1Ortiz ZE, Pedroni E, Pasqualini C. The Burden of Emerging Infections in Argentina. Inter Academy Medical Panel. The Role of Academies of Medicine, 2002, 139-142.
2THE STOP TB STRATEGY: Building on and enhancing DOTS to meet the TB-related Millennium Development Goals. World Health Organisation: 2006.
Stolley Travel Award 2005Cynthia Bartus
This spring I spent just over 4 weeks, with the help of the Stolley Travel Award, in Santiago Atitlan, Guatemala. Santiago Atitlan is a town of about 40,000 people on the shores of Guatemala's beautiful Lake Atitlan. The people of Santiago are mostly of Mayan descent and are members of the Tz'utujil tribe. Tz'utujil is still the most common language spoken followed by Spanish. Very few of the natives of Santiago speak English.
I spent the majority of my time working with the Hospitalito Atitlan. The current Hospitalito Atitlan was opened in April 2005 after the original Hospitalito was abandoned approximately fifteen years ago during the Guatemalan Civil War. Tragically, less than a year after opening, the Hopitalito was destroyed by the mudslides caused by Hurricane Stan in October 2005. However, the Hospitalito was able to reopen at a new location within a few short weeks. The Hospitalito has since continued to care for the people of Santiago and the neighboring villages.
The Hospitalito is staffed mostly by volunteer physicians. The ancillary staff consists mostly of Tz'utujil workers. The Hospitalito is open 24 hours a day, seven days a week for emergency care. During the weekdays, there is an outpatient walk-in clinic in the mornings and various clinics in the afternoons. The afternoon clinics include follow-up visits, obstetrics clinic, ultrasound clinic, and a pediatric clinic. There is a functioning operating room in the hospital which is used primarily for caesarian sections. There were quite a few of these during my visit. There are also surgeons who volunteer at the hospital, but there were no surgeons on schedule during my time trip.
The first week of my experience at the Hospitalito involved making a series of health education videos to be played for patients waiting to be seen by the physicians. The project was a group effort with Penn’s Guatemala Health Initiative.
I worked closely on the video describing the proper use of an inhaler. Respiratory illnesses are a major issue for this population as many people still use indoor wood-burning fires for cooking. According to the hospital physicians, many of the patients do not use their prescribed inhalers correctly. Prior to leaving for Guatemala, we worked on developing the scripts for the videos with the help of the Hospitalito physicians. Once we arrived at the Hospitalito, we worked diligently to film the videos. To maintain the cultural integrity of the videos, we hired a local Tz'utujil family to serve as the actors, and the videos were narrated in both Spanish and Tz'utujil. The "How to Use an Inhaler" video was finished and ready for play by the end of the week. The other 3 video projects were near complete, but still needed further editing. As soon as the Hospitalito receives a television, the completed videos will begin playing.
There were many challenges and considerations that arose during this project that helped me appreciate healthcare in an international setting. We realized early on that the scripts would have to be in very basic English in part to keep the instructions simple, but also for the translations. We also had to work with the materials available in a third world country and a hospital that relies heavily on donations. The inhaler video needed to incorporate the use of a spacer, but the spacers used in the United States are not what are used at the Hospitalito. Instead, plastic water and soda bottles are used. Hopefully, these videos will achieve the stated goal and provide basic health education, especially in a community where many people are unable to read or write.
The latter part of my trip consisted of working on a study to better understand the epidemiology of skin disease in the population of Santiago. The study was a survey study in which people were asked (in Tz'utujil) a series of open-ended questions regarding their skin health. The study was conducted in the outpatient walk-in clinic. With the help of a Tz'utujil translator, we asked patients and anyone accompanying them if they would be willing to answer questions about their skin. The participants were asked if they had any current skin complaints, what they thought caused their skin condition, what bothered them most about the condition, what types of treatments they had used, and whether they felt others treated them differently because of their skin condition. I have yet to closely analyze the data, but anecdotally, it seemed that of those who complained of having a skin condition complained of having an allergy to the sun. This fits closely with a type of hereditary polymorphous light eruption that is thought to be an autosomal dominant condition in the Native American populations of North, Central, and South America. The study did have its limitations in that the population studied included only those people who visited the Hospitalito Atitlan outpatient clinic. It was also limited by the fact that specific diagnoses could not be made. However, the data will hopefully be of use to the Hospitalito physicians as they will have a better understanding of the skin complaints of their patient population including a general idea of the prevalence of specific complaints as well as a better cultural understanding skin disease in this population.
During my visit, I also had the opportunity to meet with other students who had conducted or were planning further epidemiological studies in Guatemala. One student spent quite a bit of time working with the Guatemalan national government on the prevalence of leishmaniasis in Guatemala while another student was working on her Master's of Public Health on HIV testing and counseling in Santiago. Given the limited healthcare in this area for sometime and the limited supply of national resources, there are plenty of epidemiological studies to be undertaken. It was very helpful to be able to discuss study designs, study implications, resources, and limitations with both those who had already worked in Guatemala and those planning future studies.
On the days when I was not working on my study, I had the opportunity to work in the Emergency Department. During my 24 hour shifts I had the chance to observe how medicine is practiced in the setting of limited resources with substantial language and cultural barriers. It was truly a remarkable experience. I will always remember the patients who presented with diseases easily treatable in the United States, but were essentially death sentences in this environment. I will also always remember the amazing gratitude expressed by the patients and their family members for taking care of them in their time of need.
I am extremely grateful to have had the opportunity to travel to Guatemala and to have had this amazing experience. Although I had thought about practicing international health in the future, this experience has fully solidified this desire. I plan on working in an international setting in some capacity during residency and after. I hope to be able to do this as both a dermatologist and an epidemiologist.
Stolley Travel Award 2004Caitlin Rollins
The summer following my first year of medical school, I traveled to Gaborone, Botswana to work with Dr. Gregory Bisson, of the Center for Clinical Epidemiology and Biostatistics at the University of Pennsylvania and Dr. Tendani Gaolathe, Co-Director of the Infectious Diseases Care Clinic (IDCC) in Gaborone under Stolley Award sponsorship from Dr. Robert Gross. Botswana has been particularly challenged by AIDS, with the average life expectancy reduced from about 70 to 36 years old in recent years. Furthermore, nearly 20% of all adults and almost 40% of reproductive age women test positive for HIV. In response to this epidemic, the government has instituted one of the most progressive and comprehensive programs for tackling the illness by providing free antiretroviral medications to all its citizens who are HIV positive and meet specific criteria, namely a CD4 count of less than 200 cells/mm3 or an AIDS-defining illness. The IDCC in Gaborone was the first site in Botswana to dispense antiretroviral medications for the now nationwide program, is the larges public antiretroviral clinic in Africa, and is serving as a model for the international community.
The project which I participated in was a retrospective analysis of a large IDCC database and was designed to develop a clinical prediction rule for identifying patients with a high likelihood of obtaining an undetectable viral load six months after the initiation of antiretroviral therapy. Viral load is routinely evaluated at the six month follow-up visit for patients in Botswana’s national program as an important indicator of treatment response. However, it is an expensive test, and clinicians in Botswana estimated that the vast majority of patients achieve undetectable viral loads by six months of treatment. Thus, a rule with an acceptable sensitivity and specificity for predicting a patient’s viral load response based on less expensive clinical and laboratory data (e.g., weight, hemoglobin, or CD4 count) could obviate the need for routine six month viral load assessments in many patients. Ultimately, limiting the number of patients receiving these tests without compromising patient care would allow the government to reallocate funds, for example, to purchasing medications for a larger percentage of the population. Furthermore, if future studies documented generalizability to other countries with fewer resources, application of the rule in these locations could reduce costs making the development of additional national programs more feasible.
Over the summer, my portion of the project was to evaluate the quality of information in the IDCC database. It had been compiled by the IDCC staff and contained information on several thousand patients treated there since the program’s inception. Specifically, it included demographic information on each patient as well as the names of the medications dispensed, baseline viral loads, and all follow-up laboratory values, such as CBC and LFTs. Initial analyses revealed that while about 12,000 patients were included in the database, less than half of the patient records contained follow-up viral load values. We were concerned that the database may have systematically excluded patients with specific response characteristics, such as those who failed to achieve an undetectable viral load due to death or non-adherence. To assess for this bias, we conducted a retrospective chart review of the first 500 patients in the database to determine whether the response rates and clinical characteristics of the 35% of patients with follow-up viral loads in the IDCC database were representative of the population as measured by the 500 consecutive chart sample. If the response rates differed, the database would likely be biased and could not be used to develop a clinical prediction rule.
Ultimately, analyses showed that viral load response rates in the database did in fact differ significantly from those obtained directly from patient charts. We concluded that we could not use the larger database for a clinical prediction rule as it was likely to be systematically excluding patients who failed to obtain undetectable viral loads at six months. Though the database could not be used, through the validation process we gained valuable clinical information. In conducting the 500 patient validation chart review, we designed and constructed a new database incorporating information from these 500 patients. Because we collected the data with specific research goals in mind, we were able to include more complete information which in the future could be used broadly for outcomes research on the national program. Rather than simply excluding patients who were lost to follow-up, we developed a protocol for tracking these patients including phone calls and home visits. Because of this procedure, we were able to document outcomes in the patients who were omitted from the IDCC database. Additionally, we were able to construct the database to mirror a similar one being developed in the private sector. Ultimately, we were able to combine these two databases, and develop a clinical prediction rule as planned. We will publish the report in a scientific paper.
The national program in Botswana has become a model for other countries developing HIV treatment programs in resource-limited settings. However, few studies have examined actual outcomes achieved and internal data suggesting response rates of up to 80% have largely been based upon the IDCC database which may not accurately reflect response rates due to poor follow-up. Hopefully, the new database which we created will serve as a starting point for future research studies on the program.
On the whole, I had a wonderful time in Botswana and was able to learn a great deal about HIV treatment, medical care under limited resources, and clinical epidemiology methodology. I attended KITSO, a training program for all medical professionals in the Botswana national program, which taught me basic facts about HIV as well the specific approach taken towards treatment in Botswana. I also learned how to develop a clinical epidemiology research project in an international setting. While being flexible in any research project is important, I was struck by the particular need to re-evaluate and revise research plans in an environment where often the data are collected by clinicians treating patients under urgent conditions and are not of the same quality as we are able to collect in the United States. While I often found it difficult to be confronted daily with the reality that so many people around me were so sick, my experience in Botswana also opened my eyes to the enormous number of epidemiologic questions that need to be answered. In an environment where simply providing medications to the largest number of people in the fastest time possible is the priority, information regarding basic outcomes and cost-effectiveness is desperately needed but few have the luxury of spending time to obtain it. International epidemiologists and physicians have the potential to contribute enormously in such a setting, and I hope to be able to do so as I move forward in my education and career. I am extremely grateful to the Stolley Travel Award for providing me with this opportunity.
Stolley Travel Award 2003Monika Goyal
In a country of 1.6 million, an estimated 260,000 people in Botswana live with HIV. With a prevalence rate of 36.5%, the second highest in the world, life expectancy is only 39 years. If attention to this epidemic is not addressed, by 2010 Botswana will have about 200,000 orphans, from the current 60,000. At the Princess Marina Hospital in Gabarone, one of the only two tertiary care centers in the country, close to 90% of the pediatric deaths are due to HIV/AIDS. With these alarming statistics, one would think that this country is on the brink of extinction. However, as a result of this crisis, the government of Botswana has become the first African country to provide free highly active antiretroviral therapy (HAART) on a national scale.
Thanks to the Stolley Award, last March, I had the privilege to join the Baylor-Botswana Pediatric AIDS Initiative at their Children's Clinical Center of Excellence. This site is staffed collaboratively by US and Botswana health professionals. They provide primary and specialty medical care as well as social service needs to HIV infected children and families. Most of the children are treatment naive and under the age of 5. In addition to providing clinical care, education, research, and training activities are integral to their mission.
There were several research projects ongoing at the Center. One such research project in which I participated was the BANA 2 trial. This study is a randomized comparative trial of continuous versus intermittent HAART in HIV-infected infants and children in Botswana. The aim of this study is to evaluate 2 treatment strategies. Children randomized to Arm 1 receive standard, continuous protease-inhibitor containing HAART. Children randomized to Arm 2 receive the same drugs on an intermittent schedule dictated by CD4 counts. Once they achieve normalization of their CD4 counts, HAART therapy is discontinued until the CD4 count becomes abnormal. The primary objectives of this study are the following:
- To compare Arms 1 and 2 with respect to rates of drug-associated toxicity or intolerance and HIV disease progression
- To compare Arms 1 and 2 with respect to rates of emergence of antiretroviral drug resistance
- To compare Arms 1 and 2 with respect to cost
During my time at the Center, one of my roles was to assist staff in the recruitment phase of the trial. As part of recruitment, I was obtaining informed consent from potential subjects. It was at this time that I realized the central role of communication in obtaining informed consent. Although I have always understood that barriers existed from obtaining informed consent, it became even more apparent in a foreign country. First, most of our patients did not speak English. Therefore, we had to rely on our nurses to adequately translate the information we were giving them. Often, what we had taken 10 minutes to explain, was translated in a mere 2 minutes. When we would ask the patients' families what they understood about the trial, they would reply "I will get my medicines for free, get free transportation and food." When a country is so devastated by AIDS, I realized that people do not care about the potential long-term consequences, as long as they get their medications now.
In addition to working on the BANA 2 trial, I also cared for patients on the wards. I was amazed that most of the patients we admitted were either already diagnosed or had suspected diagnoses of HIV/AIDS. The face of AIDS in Botswana was different than that in America. These children were emaciated and affected by opportunistic infections rarely encountered in the U.S. because of such depleted CD4 counts. Moreover, it was extremely difficult for me to see children die on a daily basis.
Through this ward experience, I also gained cultural experience through interactions with children and their families. Here, the word family took on a new meaning as most of these children were orphaned and being taken care of by their grandparents, aunts, uncles, and even friends and neighbors. I supplemented this experience by volunteering at an orphanage in a neighboring village. In addition, I visited other sites where research was being conducted by fellow institutions. And it was through all of this that the global impact of HIV became more apparent and my involvement with the trial became much more meaningful.
What I appreciated about the Baylor-Botswana Institute, was that it was a project collaborated on by both staff from Baylor and from Botswana. This combination of multicultural backgrounds created the foundation for a sustainable initiative. Through this endeavor, Botswanan staff have become empowered to help their community by having the capacity to contribute their local expertise and learn from visiting health professionals.
I would like to thank the committee of the Paul Stolley award for allowing me this incredible opportunity to enrich myself. Although I was gone for only a short period of time, the knowledge I gained will last a lifetime. As a future academic pediatrician, it was educational for me to witness firsthand the complexities of running a trial from proposals to recruitment, especially in a foreign country. In addition, being involved in caring for children so severely affected by HIV, gave me a brand new perspective on health, something often taken for granted in the United States. To think that the endeavors the Stolley award afforded me to participate in may begin to affect positive change in a nation demolished by HIV, has inspired me to continue similar efforts in my future career path. I hope that my experience will spawn new ideas and open new doorways for others interested in international research and clinical epidemiology.
Stolley Travel Awards 2002Camille Henry, MS2
Class of 2005
My 2002 Stolley Award took me 5,000 miles away to Kenya. This summer I was fortunate to work with Dr. Dorothy Mbori-Ngacha, Professor of Pediatrics at the University of Nairobi. Dr. Ngacha's research investigates Mother to Child Transmission of HIV (MTCT), especially via breast feeding. I spent 6 weeks working with her research team at the Kenyatta National Hospital, the largest government hospital in Nairobi.
During my first few days, I was fortunate to participate in a 3 day Bioethics Workshop hosted jointly by the Kenyatta National Hospital and the University of Washington. This workshop attracted HIV researchers from all over Kenya. I had the opportunity to sit in on discussions and learn about important issues/concerns affecting clinical researchers in a developing country, such as inequalities associated with overseas collaborations, misuse of subject data, and inappropriate research on vulnerable populations (such as abandoned HIV-positive children, impoverished people, etc). I also received a certificate of completion at the end of this workshop.
For the rest of my time, I worked with Dr. Ngacha, whose work on breastfeeding HIV transmission is of particular importance in a developing country, where breastfeeding carries risk of HIV infection, but bottle feeding carries a significant risk of morbidity and mortality due to gastrointestinal diseases contracted from unsanitary water sources. The study follows both HIV positive mothers and their babies who have freely chosen to breastfeed or bottle-feed, after education on the risks and benefits of feeding options. The purpose is 2-fold: 1) to study characteristics of cytotoxic T-lymphocyte production that confer protection from HIV in breastfed babies who do not seroconvert and 2) to follow mothers' disease progression over 2 years. This latter aim arose from a previous study in which post hoc analyses demonstrated that HIV positive mothers who breastfed had higher mortality rates, and is an attempt to further investigate this phenomenon.
I had several roles in this study. During my stay I was able to attend the daily research clinic, observe physicians treating mothers and children, and assist with medication dispensing (no pharmacist was available in the clinic). I also worked on my own project. During the course of the study, all mothers receive nutritional counseling from physicians as well as a full-time nutrition counselor. Many of these mothers come from very poor neighborhoods in Nairobi, where brick houses, pipe-borne water, and private household toilets are luxuries. Mothers who choose to formula feed are also given instruction on hygienic preparation of infant formula. As of this summer, there had been no examination of the effect of this nutrition counseling on the health of the babies in the study. I used chart and log review to examine the socio-demographic features of mothers opting to feed infants on formula feeding, to assess if mothers were adequately prepared for formula feeding and to correlate the baseline features with infant outcome. I examined 49 formula feeding mothers (55% of the mothers opting to formula feed) and compiled data on household sanitation, water availability, education levels, financial stability, as well as infant growth characteristics (length and weight for age) at month 6. I performed cross-tabulations using Pearson's Chi Squared test. My analyses showed no significant effect of maternal education or living conditions on morbidity and mortality at month 6 (alive/dead; above or below 5th percentile for weight and height). Our theory is that the nutrition counseling these mothers received have helped them overcome socioeconomic barriers which could negatively impact the health outcomes of their babies. There are undoubtedly flaws in this small project, but it is a good beginning for examining this issue. This research was also helpful to the study as a whole because in my chart reviews I discovered several issues with data collection and interpretation which I brought to the attention of the research team. I hope that I have been able to help them further improve the study design and implementation. Finally, my hope is that the database I created will continue to be updated by study staff and could be used for further analyses of the formula feeding cohort.
I also had the opportunity to visit other research sites. I spent a week with another HIV research team in a nearby district clinic that is investigating the effect of couples counseling during pregnancy on infant outcomes. I was also able to visit their HIV testing lab and observe the difficult limitations. I spent a few mornings with the study's HIV counselor as she visited government outpatient clinics and did pre-and post- test counseling with pregnant mothers. I witnessed her give HIV-positive results to 2 young pregnant women and was able to see the devastation that this news caused. My plans included a visit to a district hospital in Kisumu (in Western Kenya) but logistical problems prevented this visit.
My overall experience was a very positive one - I was warmly welcomed by Dr. Ngacha and the rest of the research team. I also had an opportunity to experience some of the difficulties of doing research in a setting distant from the developed world: the electricity supply even in a large hospital was not always reliable, slow internet connections made communication and internet research difficult, and the woefully inadequate medical library limited my access to recent articles. (In fact, I was so appalled by the condition of the library that I donated my microbiology textbook to their stacks.) Nevertheless, I am quite impressed with the quality of research that is completed in these settings, as well as the dedication of the research team to the improvement of the health and wellbeing of their patients. I hope to return to Nairobi during my scholarly pursuit to do further research on Dr. Ngacha's team. I am very grateful to the Stolley Award Committee for this incredible experience that has made me eager to pursue work in international clinical epidemiology in my future career.