August 31, 2011
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