AAMC Reporter: December 2004

Students Expand Medical Horizons in Fellowship Program

"Much of the world is transitioning into hyper-dense urban slums and with this urbanization comes a whole new set of emerging infectious diseases." -Peter Marcovici, Columbia University College of Physicians and Surgeons

Peter Marcovici, a medical student at Columbia University spending a year in Brazil, stood next to the freshly removed skin of a goat for a three-hour ritualistic dance.

Jose Hagan, a student at Vanderbilt University School of Medicine, was asked to prove to government officials in Botswana that he was not "a feeble-minded person" before being granted residency in the country.

And Michael Kinzer, another Vanderbilt student, was surprised to find that many of the rooms in the South African hospital where he works are outdoors. The three medical students are part of a group of 20 fellows receiving training at top-ranked National Institutes of Health (NIH) centers in developing countries.

They are participating in a new Fogarty International Center and Ellison Medical Foundation fellowship, a one-year program for third-year medical students and other graduate students in health professions. Students are scattered internationally including countries such as Botswana, Brazil, Haiti, India, Kenya, Mali, Peru, South Africa, Thailand, Uganda and Zambia.

"It is important to identify potential researchers early in their careers and encourage them to consider doing clinical research," said Aron Primack, MD, MA, program officer with the Fogarty program. Besides exposing students to excellent training at foreign sites, the program allows them to study illnesses and public health issues that are uncommon in the United States.

Urban Afflictions

Marcovici is researching a condition affecting the urban poor in Salvador, a large city in Brazil's northeastern region. Leptospirosis, an infection previously associated with animal handlers and rural inhabitants, is undergoing an emergence in the region, striking those who do not have access to clean water.

"Much of the world is transitioning into hyper-dense urban slums and with this urbanization comes a whole new set of emerging infectious diseases," Marcovici said. "It is amazing to look at our group's 50-year sequence of aerial photography of this city and watch it literally transform from rural to urban."

Marcovici is beginning a study that will determine whether individuals have different levels of vulnerability to the same bacteria strains. Researchers have concluded that with other infections, such as HIV and malaria, genetics can determine whether an individual becomes seriously ill, if at all, Marcovici explained.

The genetics component of his study could help answer many important questions about the disease's origins and discover possible new targets for its treatment and prevention.

To conduct the community-based part of his research Marcovici ventures into the Salvador slums, where he witnessed what he describes as the city's "strongly polarized sense of haves and have nots."

During one of his visits to these poverty-stricken areas, Marcovici experienced a disconcerting situation — he found himself running away from a group of men who threatened to steal his shoes.

"I'm not sure they would have, but at that moment all I wanted was to live in a place of less extremes," he said.

HIV Prevention

Bonnie Baker and Jeremy Schwartz, both Fogarty Fellows in Uganda, wear standard attire of a busuti for women and a konzu for men.

Extreme conditions are the norm for Fogarty fellows. In Botswana, where approximately a one-third to one-half of the adult population has been infected with the HIV virus, Hagan has been working on AIDS research.

This year, Hagan will analyze the blood samples of HIV-infected mothers who were given an antiretroviral regimen to prevent transmission to their babies. The goal of his study is to identify the dynamics of mother-to-child transmission and to explore the viral load markers that predict transmission at various stages.

Conducting AIDS research in a country that is heavily affected by the illness has given Hagan a different perspective on his assignment.

"This awareness adds a level of urgency to the work that is easy to lose when conducting research in a more sheltered environment," Hagan said.

Hagan's living situation is also not as sheltered as what most American medical students experience. Because he and his wife had a difficult time finding affordable housing in Gaborone, they searched for housing in a village nearby.

"We found a beautiful thatched cottage on top of a hill that had gone unoccupied for a long time because most local residents are quite afraid of snakes," Hagan said. "Our stunning view of Gaborone in the distance is more than worth the 15 kilometers' commute, and we still have not found any snakes!"

In South Africa, Kinzer and his wife are also renting a guest cottage, which costs them $450 a month. They bought a used car for $2,200 and have driven to Botswana to visit Hagan.

"I also have a bike that I ride to and from work, but that is because of my death wish," he joked, referring to Pretoria's hazardous traffic.

As part of his fellowship, Kinzer is attempting to determine the seroprotective effect of hepatitis B immunization in children with HIV. He is also studying the efficacy of a nutritional supplement sponsored by the South African government for children infected with the virus.

"Children provide a real opportunity for someone trying to make a difference, because they have boundless potential and because HIV/AIDS is a disease that has changed and will continue to change the entire world," Kinzer said.

Another fellow doing AIDS research is Bonnie Baker, a medical student at the University of Rochester. Baker is working in Uganda on a randomized, controlled trial with patients who are co-infected with tuberculosis and HIV. She will study the clinical presentation of tuberculosis in HIV-infected patients and compare that with their CDA T-cell counts, which are used as a measure of the HIV virus' progression.

"My site in Uganda is primarily a TB research institution," Baker explained. "Because nearly half of TB patients in Uganda are HIV-positive, there is increased attention toward studying co-infection."

Local Living

"It is important to identify potential researchers early in their careers and encourage them to consider doing clinical research." -Aron Primack, M.D., M.A., program officer, Fogarty International Center

Baker is living in a fully furnished one-bedroom flat located in a compound where both Ugandans and expatriates live. She often walks to the hospital, the local market and the center of town, all of which are conveniently close to her flat.

Such interesting cultural experiences have convinced people like Kinzer, who grew up overseas and worked for several years in West Africa, to continue doing clinical research internationally.

Kinzer was granted a military scholarship and plans to take two years off to do clinical research at one of the Navy's overseas facilities after the first year of his pediatrics residency. He will then return to the U.S., finish his residency, then spend two more years at an overseas research facility, he said.

After his commitment to the service is over, he will decide whether to do a fellowship with the Navy or as a civilian.

"Either way, my wife and I plan to spend the rest of our lives living and working in the developing world," he said. "Wanderlust is, fortunately, a terminal disease."

- Suria Santana

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