Saturday, September 24, 2011

MDR-TB in rural Western Cape, South Africa

I’m spending this month at Brewelskloof tuberculosis hospital in Worcester, a small town in South Africa’s Western Cape province.  It’s just a bit over an hour’s drive from Cape Town, but it’s a completely different world from that fairly cosmopolitan city.  It’s a farming town – lots of vineyards, some other fruit, a few livestock – and there’s not much else going on, although the setting is beautiful: grapes growing everywhere, ringed by mountains, spring wildflowers currently in bloom.  I’m gathering data on a cohort of patients with multidrug resistant tuberculosis (MDR TB), so I spend most of my time combing through paper hospital charts, doing my best to translate Afrikaans, and typing into a clunky Access database.  Not particularly exciting work, but the data is beginning to tell a few interesting stories. 

This population – at least the subset of people from these farming communities who get MDR-TB – is really disadvantaged.  Walking through expansive upscale shopping malls and trendy organic markets in the city (Cape Town, that is) on the weekends, it’s clear that there’s money in this country somewhere.  The hospital in Worcester is also immediately surrounded by lovely homes and estates.  The typical MDR-TB patient we read about, though, lives in a shack without water or electricity, has about a 6th grade education, is trying to make ends meet through seasonal farm work, and binge drinks heavily on the weekends.  The tricky thing is that the same social factors that breed and spread MDR (poverty, crowding, and malnutrition that predispose to TB, and home and work instability and frequent intoxication that make it hard to take your TB drugs every day for six months) make it even hard to complete the two years of more-toxic treatment required to treat drug resistance.  

I’m also observing long delays before patients with MDR TB in their sputum got onto appropriate treatment.  Cultures take several weeks (and AFB smears, we’re told, tend to be reviewed hastily here and rarely come back positive), and then drug susceptibility testing take more time.  But besides waiting for lab results, there also must be other delay somewhere along the process of realizing a culture shows MDR, notifying the clinic, finding the patient, and getting them into treatment, because we are often seeing gaps of 3, 4, even 6 months between when a sputum is collected and when appropriate MDR treatment is started.  Plus, while waiting for the DST results, sometimes patients get a single drug added, or are started on treatment regimens with only 1 or 2 drugs that turn out to be active, which is exactly what you don’t want to see.  Starting first-line therapy after a positive smear or culture is automatic here, I’m told, even in patients with risk factors for drug resistance, but I’m curious to analyze whether these first-line regimens negatively impact either MDR outcomes or transmission of MDR within patient’s households and communities.

Finally, on a somewhat related note, all this reading of paper charts makes me appreciate electronic medical records.  But not everyone here views computers the same way.  We were talking today with South African collaborators about electronic records, about plans for expanding our electronic database to capture a broader slice of hospital’s data for research purposes, and even about the possibility of transitioning to a electronic medical record for clinical use.  The rural clinician in the group was puzzled about how this would work: the doctors would have to go back to their offices at the end of the day and type in everything they had done?  The idea of placing computers within the ward blew him away.  Another researcher mentioned that he’d been abroad and seen a clinical pharmacologist with an iPad, who was able to look up information about pharmacokinetics to show the team as they rounded; he’d been amazed.  But none of them really have a vision for what computers could add to their clinical or research work.  My American mentor/collaborator and I tried to convey the potential usefulness of an electronic record for prompting doctors to enter data that the hospital wants to collect, for keeping track of outcomes or adverse events in real time, or for retrospectively answering questions that no one has thought of yet, but I don’t think we got through.  I imagine that the push toward electronic charting isn’t so far away for a country like South Africa, but it will be a tough transition in isolated pockets like this one.  For one thing, they need to get internet; here in Worcester, I can’t connect long enough to find the CoE blog, so I’ll be posting this in a few days once I get to Cape Town for the weekend – where internet is still spotty, but slightly less so.  

Emily Kendall
PGY-2, Internal Medicine

Thursday, September 1, 2011

Hurry Up and... Teach?

Mark Siedner
August 31, 2011
Mbarara, Uganda

It was with a rolling boil of enthusiasm that I landed in Uganda three weeks ago. In the four years since I returned from my last prolonged international trip, my pager and chiefs afforded me only the briefest glimpses of foreign shores. On June 30th, like for thousands of other residents and fellows, those days (and nights) of regimented educational servitude ended. Abruptly. As soon as my funders and wife allowed, I shoe-horned my life into two suitcases and arrived here in Mbarara with a polished study protocol, approved ethical reviews, and just enough grant funding to just maybe execute my project: a study of the acceptability and feasibility of using cell phones to communicate critical laboratory results to patients in resource limited settings.

Then, like so many of those first days of medical internship when we realize that no textbook can prepare us for unbridled sickness, I was overrun with humility. As the sheen on my proposal faded, the finality of ethics review waned, and the tensile strength of my budget unwound, I became increasingly befuddled and was oft sighted wandering the sand-blown alleys behind papaya stalls and chapatti wallahs mumbling things like, “Sub-contracts cannot be cost reimbursable,” “You forgot to charge indirects on your fringe,” and “Did you really you think you could pay for an IRB fee with a bill printed before 2005?” I would be remiss to bore you with the list of missteps, oversights, undersights, and unmet expectations I have experienced since my arrival. But I would also be shirking the chance to build invaluable empathy with my peers and possibly even prepare the incoming international study-minded residents and fellows by keeping quiet. So forgive me as I attempt to list a handful of the preparatory hiccups I choked on in the past few weeks:

a)    Grants afford me the chance to bid on a ticket. They do not get me on the plane and certainly don’t get me within a hemisphere of my destination. When working (and spending money) at a foreign site, the grant will first need to be agreed upon and signed by your home institution and funding organization. This requires finalization of budgets (likely before you are sure of your costs), IRB approval (for funds to be paid), and a whole lot of time spent hurling epithets on a system called InfoED (for you MGH folks) where all this information is entirely non-intuitively entered. I would say the whole thing is a bit like learning a new language, but that would only be true if that language was neither written, spoken, or heard by anyone aside from (I’m convinced) a pernicious little computer programmer who has made his or her life’s mission to avenge the rage at failing a quantum mechanics class in college on grantees and administrators like us. Once this process is completed, a sub-contract between your home institution and foreign site needs to be arranged. Given that the foreign site is likely in a resource poor setting and cannot pay up front and be reimbursed, a quarterly payment schedule will need to be arranged. Once these are completed (in my case, I am told to expect about two months, and am still in the beginning stages), a judicious waiting period to hire any needed research staff and procure materials should be expected. In short – congratulations on winning a grant. Now hurry up and do something else for a while.

b)   I would be in a more serene place now if I was more flexible with my initial budget projections (perhaps a motto for academic research?). As it stands, I have all the serenity of a hot rod without a muffler. My cost projections were a bit like those of a toddler just beginning to grasp the nebulous concept of worth. As I would then alternatively think a cheeseburger was worth either 16 cents or twelve million nickels, I’ve been caught budgeting translation fees as both 25 and 2,000 dollars on the same budget. As if not knowing that printing a piece of paper here cost a dollar but photocopying one runs you 4 cents was not enough, predicting the volatile exchange rate has forced me into fits of pseudo-seizures. A $600 wire transfer for IRB fees last month converted into local currency is worth exactly $502 today, the day the fees are to be paid. In hindsight, my advice to myself would be the following: Have patience, wait as long as possible to finalize your budgets (preferably once you are in country), and whatever you do, do not buy cell phones in the US or computers in Uganda.

c)    Administrators are like the brown sugar in chocolate chip cookies. At first I took them a bit for granted – bypassing their names in my email inbox for Groupons. But that day you’re asked to do it yourself, you’ll suddenly appreciate how there is no sweetness in life without them. There is no money, no approval, no study, no publication. There is only dry, tasteless dough. Buy them flowers and scotch. Get them out of jury duty. Babysit. Just make them happy. For Pete’s sake open their emails first! If I remember nothing else from this experience – I hope I remember this key ingredient to the research recipe.

So what have the last three weeks brought me aside from a new diagnosis of hypertension? Incredible opportunities. I’ve spent three weeks working in the HIV clinic, seeing over fifty patients and more with cyrptococcus, tuberculosis, and unidentifiable skin conditions that I did in my entire clinical fellowship year. I‘ve had the incredible opportunity to teach medical students, yearning like sea sponges for every last bit of medical knowledge in this over-constrained education setting at rounds each week. I have organized a journal club and connected the faculty to a web-based monthly international HIV clinical conference. I am mentoring a small group of residents and staff on development of research projects, all locally grown. We are developing new protocols for infection control precautions and in the exploratory phases of designing a hospital antibiogram. This is of course, I remind myself daily, why I came here. Because the need is so great and though I am not the best person for any of these jobs, I am also all we’ve got! And I am so incredibly honored to have the privilege to work where the challenges are so great, but the interactions with patients, colleagues, and local mentors are so incredibly rewarding. I’ve gotten nothing I wanted to done. And so much more.

Mark Siedner MD MPH
Infectious Disease Fellow