Hobbins, Elisabetta

South Africa

MDR-TB (research placement)

Mycobacterium tuberculosis (TB) remains the leading cause of death among persons living with Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) in southern Africa1. Drug-resistant TB remains a growing threat to public health despite advances in treatment and diagnosis over the past decade2;3. South Africa has the world’s highest rate of TB/HIV co-infection and ranks fourth worldwide for both multi-drug resistant (MDR) TB incidence and HIV prevalence.

This is a cluster randomized study evalauting a nurse case management intervention for MDR-TB / HIV.  It will occur across 2 provinces (KZN and Eastern Cape) in SA and 10 hospital-based sites.  

South Africa ranks first in TB/HIV co-infection and fourth in both MDR-TB incidence and HIV prevalence. Since tuberculosis is still the leading cause of death for HIV/AIDS patients, TB research is vital in resolving this major syndemic and saving countless lives. Like many countries, South Africa has a massive doctor shortage that contributes to the issue. Needless to say, the country is in dire need of an intervention. The purpose of the Nurse Case Management of MDR-TB study is to determine whether specially trained nurse practitioners can initiate and manage MDR-TB cases effectively so as to bridge the detrimental gap between patients and providers, as well as to improve patient adherence and health outcomes.

This past summer, I worked as a research assistant and travelled to the control sites to conduct quality assurance and quality control of the collected data, scan all of the CRF binders, and enter them into the REDCap database. Given that all of the medical records are handwritten by different people, disorganized, and often missing, QA/QC at these sites was much more like detective work than I had initially thought. If there is one lesson that I will never forget from this experience it is that if I ever become a doctor, I will take time to write legible notes so that others can actually read them! Learning about MDR-TB and treatment strategies was intriguing, but what was more interesting was its inseparable connection to the HIV/AIDS endemic and the roles the South African health care system and cultural factors play in treatment outcomes.

 In my eyes, the greatest determinant of health outcomes and the reason for the tuberculosis endemic in South Africa is the silo-ization of the health care system. The miscommunication or lack of communication between nurses, doctors, pharmacists, and patients is the biggest issue from a systems level standpoint. This is the very problem this research project addresses and seeing it firsthand every day was a constant reminder of why I was there. As a control site research assistant, it was so frustrating to see mistakes, oversights, and “not my problem” attitudes from every level of healthcare because there was absolutely nothing I could do about it. What was more disheartening is that it could have been as easy as walking up to the pharmacist and showing him the doctor’s note. I knew that this would be a dilemma I would likely face as a global health researcher, but experiencing it every day definitely intensified my urge to intervene.

This experience reaffirmed my calling to be the one making a difference at the clinical level in developing countries and equipped me with the tools to focus on holistic and systems level treatment strategies. Global health workers have an aptitude for working tirelessly without always seeing tangible results. This is a skill I have always aspired to and can now fully respect. I applaud all of those, like my PI, who dedicate their lives to making big changes in the global health field and I hope to someday contribute to a project similar to this one.  

For anyone considering applying for Global Health Established Field Placements, know that this is an opportunity unlike any other. No matter where you go and what you do, you will learn more than you could have ever imagined. Not only do you get to work alongside some of the greatest global health researchers in the country, but you also get to experience a country in a very authentic and dynamic way. You will engage and invest in communities and thus experience the culture, language, food, people, and places in a way a tourist never could. Above all, go in with an open mind and make the most of your experience!  

An X-RAY of TB infected lungs of one of the patients enrolled in the study at King Dinuzulu TB Hospital in Durban, SA:

This summer's team of research assistants and graduate nursing students, the project's head RA, in-country coordinator, and the nurse case manager at King Dinuzulu:

Cough booths are used as areas to collect sputum samples to test in order to avoid the spread of different strains among patients within each ward and to protect health workers (King Dinuzulu TB Hospital in Durban, SA):

Sign posted outside the outpatient TB clinic at King Dinuzulu Hospital in Durban, SA. Most TB patients are seen only through this clinic. Only very serious cases like advanced MDR-TB and XDR-TB are admitted to this hospital due to the high volume of patients and lack of available beds:

Special container used to avoid spilling sputum samples collected from patients, which are taken to the lab to test for presence and strength of Mycobacterium tuberculosis and resistance to different drugs. Leaked sputum samples are common results for these tests (King Dinuzulu TB Hospital in Durban, SA):

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