School of Medicine - Emergency Medicine
Little is known about the cause of acute infectious illness in South Africa, a country with a high burden of HIV, TB and malnutrition. I hope to spend a month in July 2017 leading a research team performing a prospective observational study to identify predictors for mortality among patients presenting to the ED with acute infectious illness in two hospitals in Mthatha, South Africa. I will work with researchers from the United States (medical and public health students), and local research assistants to enroll patients in these settings. This work will then inform potential strategies for sepsis management in South Africa and elsewhere.
This research will have several benefits for my training, and will be an integral component of my career development. First, I will gain practical experience in data analysis, database creation, and data management in the developing world. This is particularly difficult in a system with less resources devoted to medical record keeping. The opportunity to develop skills in these research methods in resource-limited settings is a crucial element of my future career in international Emergency Medicine. In addition, the chance to work with an international team of researchers will provide me with the experience and connections to build a career in the field. Despite my numerous field experiences in the developing world, this will also be my first research experience in my intended field, Emergency Medicine. The unique challenges of caring for acutely sick individuals requires familiarity with resource opportunities and limitations, and this experience will provide the groundwork for those endeavors.
Mthatha District Hospital and Nelson Mandela Hospital | Mthatha, South Africa
While this was not my first time working in the developing world doing clinical research on ways to optimize care in resource limited settings, the opportunity to travel and work in Mthatha, South Africa afforded both intellectual discovery and personal growth. Between July 1st and 30th 2017, I worked in Mthatha, the capital of the poorest in the Eastern Cape, one of the poorest provinces in South Africa. There, I designed an implemented a prospective cohort study of patients presenting to a district hospital with suspected infectious illness. We followed these patients through heir hospital stay, and with the help of local research assistants called each patient and family back at 30 days to evaluate if they had passed. This provided both important data that informs the epidemiology and risk for mortality of infections in this area, but also provided immense personal growth and understanding for my future career.
First, study itself was very successful, and added to our understanding of infections in Mthatha, an underserved region. In total 300 patients were enrolled during the study period, and 165 were successfully followed up during the study period. Surprisingly, 25% of patients with infections died within 30 days, an amazingly high number in comparison to the US, where less than 5% of patients with infections in the ED die within 30 days. In addition, over 50% of these patients were HIV positive, and over 30% had previously been diagnosed and treated for TB, surprisingly high numbers that point to the vulnerability for HIV and TB patients to gain opportunistic and secondary super infections. In addition, our research demonstrated that HIV was an independent risk factor for mortality in these patients, accounting for diagnosis, other past history, or ED management strategies. This data adds to recent literature which has demonstrated that high co-infection with HIV complicates management strategies of patients with infectious illness in sub-Saharan Africa, and demands that providers re-think the model that had been created for sepsis management in the developed world. In addition, this study lays the groundwork for a larger study across the Eastern Cape region, which I will hopefully be leading in the coming year.
Left: Nelson Mandela Academic Hospital. Right: Overseas visitors fresh off a busy day in the casualty ward!
In addition to the practical results from the work itself, the experience of leading a study in the developing world was enlightening. While I have traveled and worked in Ghana, Kenya, Tanzanaia and South Africa before, Mthatha was unique. The economic gap in South Africa is striking, and my experience in wealthy urban Cape Town was little preparation for the poverty I experienced in Mthatha. Despite South Africa’s general status as an upper-middle income country, I was struck at the lack of basic health care in Mthatha, where over half of patients enrolled in my study were HIV positive, yet most were not in treatment. Also, because of my experience in English speaking Cape Town, I thought that language would not be an issue in Mthatha. Unfortunately, the vast majority of my patients, who were mostly elderly and poor, did not speak any English, and translation became a daily hassle and complicating factor in consenting, enrolling and following up. I relied on my research assistants and local collaborators more than I anticipated.
While I had worked as a co-investigator for many other studies, to design and execute my own independent research project was a valuable experience. I already knew that my career was going to involve applying Emergency Medicine in underserved areas around the world, but the experience to lead a research study doing just that laid a foundation for a future career in the area.
Study team, including local research assistants.