"Doing" global health

People have been asking me a lot lately about if I want to do global health as part of my career and how I want to do it. That is something I have yet to be able to answer and part of being here and also coming back to Kenya in the fall to do research is in an effort to answer that question. Initially when I became interested in global health in high school, my dream was to do Doctors Without Borders. While that is still extremely enticing, as I’ve gotten older I’ve recognized how extreme of a life that is and how much you have to sacrifice to do it. The fact that it is all clinical care oriented and the mission and goals of the organization really appeal to me. One of the fears I have about working clinically abroad is the concern about becoming one of those western doctors that comes in and treats patients for a few weeks or months and then leaves without making any lasting (good) impact. This sort of situation can undermine local doctors and medical education and so it is critical for me to be able to work clinically in a way that helps to train and foster local medical students and doctors. But this is something I had yet to see done well until here. Because of my misgivings about working clinically abroad, I starting thinking that the best way to do global health was through research. In part this stemmed from working with Jen Friedman’s group in the Philippines – in the case she had helped develop a longstanding research project in Leyte that did clinical (and lab) research that seemed to have a direct benefit to the people who lived in this region. She studies schistosomiasis and specifically its impact on mother and child health. Her latest study was testing whether praziquantel was safe and effective in pregnancy. She spends a few weeks to years on site but in between she works very closely with the Filipinos running the study. Her research grants and funding through the hospital/university also allowed her to have an exchange program whereby students and researchers from Leyte could come to the US to get degrees and/or do research. This seemed like a great set-up to me so I started thinking I would do research abroad as the global health portion of my career.

But then Chandler went to Uganda and had a different experience regarding research there. It seems like oftentimes the researchers who work at the hospital that he works at are much more focused on research than on clinical care. The research is also less integrated with the hospital, and so the clinical care suffers. There are many great research groups, but there seems to also be a troubling amount of politics involved in getting things done in collaboration with the public hospital. The research process can be slow and prevent the output from feeding back to the patients themselves. It seems like some of the researchers are focused too much on their outcomes and papers published. Given, there are benefits of research, for example in his study his patients receive US standard of care (for free) rather than what may be available in a low resource setting. But this also throws into stark relief the difference in clinical care between the patients enrolled in studies versus those who aren’t. Not to mention the corruption involved in getting research approved and done in Uganda. Bribes are expected and often required to get things done in a timely fashion. That said, his mentor works incredibly hard to get things done the right way and he always has the patient’s best interest at heart. Unfortunately, the same cannot be said for many parties involved in the research process in Uganda, and this can result in effort and money spent in ways that do not directly benefit the patient’s themselves. And some disheartened peers.

In contrast, the partnership between Brown and Moi University/AMPATH is very clinically focused. The US physicians and students who come here work on the wards, they see patients in clinic, they teach the medical students both Kenyan and American. There is some research being done – all clinical as far as I know – but this is much less emphasized than actually working in the hospital. For example, the pediatrics team liaison here wants to start an adolescent HIV clinic, and as part of this she will do a research project to assess the outcomes of this program. So at its heart it is a clinical and organization project. I love being able to work on the wards here and feel like part of my team – it feels similar to being a medical student back at Rhode Island Hospital in many ways. And I get to learn from and teach the fellow students and residents. Some of the physicians who work here come for a few weeks to work and teach while others live here for years. And I could see myself as one of them.