The residency director at a prestigious U.S. medical school looked Dr. Stephen Parker in the eye and told him this about his dream of doing neurosurgery work in east Africa: "Steve," he said, "you're going to have to have another dream if you want to work in neurosurgery. It's basically non-existent in east Africa."
That was in 2005 when Parker was shopping for a neurosurgery residency. Other institutions were equally honest with their assessments of what they suggested was a pie-in-the-sky desire.
Even Duke told Parker he most likely would have to wait until after his six-year neurosurgery residency to fulfill his industrious and benevolent ambition.
But Parker came anyway, moved by a gut-level feeling that at Duke anything is possible even fulfilling a dream that seemed implausible, if not impossible.
"I felt I was not going to be discouraged at Duke for wanting to try something different," Parker says. "I knew Duke was very progressive."
Indeed.
In 2006 Duke launched the Global Health Institute (DGHI) with a university-wide commitment of working to reduce health disparities around the world. Opportunities for overseas education, training, and research bloomed.
By summer 2007, Parker was in Uganda in a program launched by Dr. Michael Haglund, associate professor of neurosurgery, performing life-saving spinal cord and brain surgeries.
That same year Parker was named one of four physicians in the inaugural class of the Duke Global Health Residency Program a joint program of Duke's Hubert-Yeargan Center for Global Health (HYC) and the DGHI. It further opened opportunities for Parker to work in east Africa. Last summer he spent seven weeks there on a second neurosurgery trip, visiting Uganda, Tanzania, and Kenya. He will return this summer for a third time.
His hunch about Duke obviously was spot on, and Parker frames the dichotomy of 2005 and today this way: "I'm truly living a dream come true."
Significant Contributions
Across the Duke medical education spectrum, students, residents, and fellows are involved in world-class, career-defining global health opportunities that they say are unavailable at other institutions.
This academic year the DGHI, HYC, and the school of medicine have placed students, residents, and fellows in Rwanda, Thailand, China, Uganda, Tanzania, Kenya, Cambodia, South Africa, Haiti, India, and Nicaragua in programs that allow them to make significant contributions to health care by directly treating patients or by conducting research and service that has the potential to impact health care worldwide.
"U.S. medical students have the privilege of training in well-equipped, well-funded facilities," says Dr. Michael Merson, director of the DGHI. "A field experience in an under-resourced area like those offered here at Duke allows students to better understand the realities and challenges of treating and preventing disease in vulnerable and underserved populations."
The full menu of global health opportunities at Duke is attractive to some of the nation's best medical students, residents, and fellows.
"That Duke is willing to let students do their third-year research abroad shows the confidence they have in us and in the curriculum," says third-year medical student Susan Emmett, who is one of just 65 medical students nationwide to receive a prestigious Howard Hughes Medical Institute Research Training Fellowship for 2008-09.
This academic year she's in Moshi, Tanzania, where Duke has a long-term relationship with Kilimanjaro Christian Medical Center. Emmett is studying the intersection of health policy and health science in HIV/AIDS and conducting a second study looking for inexpensive clinical predictors of when antiretrovirals have begun to stop working.
"You can't do international policy from afar," Emmett says. "You really need to be on the ground doing work that will actually have an influence. Duke has a fantastic research operation in Moshi and this is a unique opportunity for me."
With support from DGHI, third-year student Sarah Lofgren, also in Moshi, is studying whether dry blood spots can be used instead of blood plasma to accurately follow HIV viral loads and diagnose HIV infections in infants under 18 months of age.
"If plasma is used for these tests it must be frozen within six hours of getting the blood," Lofgren says. "In rural Tanzania and other parts of the world, this just isn't possible, so many people are not able to get these important tests."
She's also working on a pharmacokinetics study looking at the interactions between HIV and tuberculosis medications in children.
"I have always been interested in international work and trying to figure out how that might work in my career," Lofgren says. "Coming to Moshi was a great match for me. I am seeing all levels of many clinical trials and learning a lot about Tanzania, HIV, research, and myself."
Eve Puffer, the first-ever DGHI postdoctoral fellow, says "a lot of trainees don't have the opportunity in a post doctoral position to build a research career on global experience." She splits her time between Duke and Muhuru Bay, Kenya, where she is conducting mental health and HIV/AIDS prevention research among adolescent girls and young women. "Duke has given me an opportunity I never would have had at the other universities that offer clinical psychology post docs."
Parker's Impact
Parker had been up all night when he arrived at the Duke North cafeteria to talk about his recent experiences in east Africa. Sporting a russet-colored full beard, blue hospital scrubs, and a small black backpack slung over his shoulder, he looked every bit the part of a clichéd on-the-go surgical resident. He was barely recognizable from the photograph of him in a Ugandan hospital where, clean-shaven and white-coated, he poses with a smiling 70-something-year-old Ugandan man. Parker had operated to remove a huge growth on the man's head. When the man first looked in the mirror post-surgery he gleefully thanked Parker because he no longer was ugly.
Parker had just come off an overnight neurosurgery shift at the Durham VA Medical Center and was headed to UNC later that morning to take classes toward a masters in public health degree something three of the four Duke global health residents will earn by this spring. He will spend more time overseas this summer. His longest stint overseas will be for about six months in 2011.
Parker says he owes much to Haglund for opening the door to Uganda to him. Haglund began the Ugandan neurosurgery program after his church was serendipitously visited by a Ugandan pastor who pleaded for medical help in neurosurgery for his country. Within weeks Haglund had assembled a team of 28 medical personnel and $1.3 million worth of discarded but working medical equipment donated by the Duke University Health System's Global Health PLUS program, to go to Kampala, Uganda. He tapped Assistant Professor of Neurosurgery Ali Zomorodi T'96, MD'00, HS'00-'06, and an eager Parker as co-organizers, and Parker's wife Jenny as trip logistics coordinator.
"As a couple they are an inspiration," Haglund says. "They bring a passion for helping others and have wonderful hearts about touching people who are hurting."
That first summer Parker helped perform 35 surgeries. He returned last summer with Haglund, Zomorodi, and a Duke team of 50. Duke now has an established program that teaches Ugandan neurosurgeons more sophisticated surgical techniques, like pituitary gland surgery through the nose.
"With the new equipment and training they are now capable of doing this type of surgery," Parker says. "Before, they wouldn't even attempt it because they knew the likelihood of harming the patient was greater than the likelihood of helping them. Within a week, that completely changed."
Eighteen-year-old Shafiq is one Ugandan patient who was helped by this advanced type of pituitary gland surgery. He had developed gigantism because of a tumor. He was growing abnormally tall and had developed very large hands and feet. Shafiq had already lost vision in one eye and his remaining vision was compromised.
"He obviously wasn't going to be able to provide for himself or his family if he went blind," Parker says. Under his and Haglund's supervision, two Ugandan neurosurgeons removed the tumor.
"It is a great success story," Parker says. "His lost vision will not return, but the surgery stopped the progression of the disease."
A 16-year-old Ugandan girl presented with deteriorating mobility and was no longer able to move her legs. Parker and Haglund removed a large tumor on her spine, but did not expect her to walk again. Within days, however, she regained some leg movement and within weeks she was walking with small crutches. The girl and her mother were tearfully grateful that the girl will be able to live a normal life.
"You can make a difference in the world if you really want something and are willing to work for it," Parker says.
Global Health Residency Director Nathan Thielman, MD'90, HS'90-'93, says that after Parker's residency, "Steve will be well-positioned to conduct important operational and clinical research in the field of global neurosurgery a field in which I have no doubt he will be a leader."
Emmett, Lofgren Adjust to Tanzanian Culture
Goat meat.
Emmett's words came through with LAN-line clarity over a tenuous Skype internet phone call from the other side of the world. Goat meat is definitely something she never thought she would eat.
"In fact," Emmett says light-heartedly, "I don't always know what I'm eating." That's not true most of the time. Rice, beans, and bananas have become her staples and provide a familiar connection to the Western world.
Adjusting to the sometimes exotic cuisine, however, is a cultural challenge that is easier to overcome than language barriers, Emmett and Lofgren say.
"None of the patients speak English," Emmett says, "but luckily English is the primary language of the care providers in the hospital." She and Lofgren are tutored nightly in the language of Swahili.
Lofgren says the slow pace of life in Tanzania is a welcome change to the rigors of her second year in medical school, but can be frustrating.
"Tanzanian time tends to be slower with people taking breaks more often," she says. "If something comes up at home, people just leave." That can make scheduling meetings and patient visits a nightmare.
Other small nuisances, Lofgren says, include frequent power outages, slow or inaccessible internet connections, and occasional plumbing problems in the large house next to the medical center that she and Emmett share with other short-term Duke staff.
But collectively, all challenges are insignificant when measured against the big-picture benefits of living in a foreign land, both women say.
"It's a very beautiful country," Lofgren says. "I can see Mt. Kilimanjaro from the doctors' compound. The people here are very friendly. My Swahili teacher says that Tanzanians say ‘You are my friend until proven otherwise.'"
The two friends try to go exploring every Saturday. They hiked five hours to see a spectacular waterfall and took a safari to Arusha National Park that Emmett calls "one of the coolest experiences I have ever had in my life. We saw giraffes, zebras, cape buffalos, baboons, and wart hogs everything except elephants and lions."
As a Howard Hughes Medical Institute Research Training Fellow, Emmett will return to Washington, D.C. twice during her third year to meet with other fellows and report on her research progress. She was in D.C. in November and will come back in May.
While she has not yet chosen a medical specialty, Emmet says her time in Tanzania has convinced her of at least one thing: "I definitely want international health care to be a part of my career."
Puffer Surprised by Kenya Results
Sitting at her desk in her simple Trent Building office, Puffer says she was not so much surprised as she was stunned by what she found in the fishing village of Muhuru Bay, Kenya over the summer.
The research project planned by Duke's first-ever Global Health Postdoctoral Fellow was to assess the level of psychological trauma suffered by girls and young women because of sexual exploitation, then develop a plan to help them.
What she found instead was that transactional sex for fish or money is so engrained in the culture that "there was not a lot of (psychological) trauma. The dynamics of the situation stunned me," Puffer says.
That's not to say her work there is done. With HIV infection affecting 15.3 percent of the population of Muhuru Bay the highest in all of Kenya Puffer has retooled her postdoctoral research to focus on HIV prevention and increasing women's self esteem to help open up more opportunities for them.
Like farming. Or starting a small business.
"The men and boys can fish, but it's a cultural taboo for women to fish," Puffer says. "If women have the capital they can start a small kiosk to sell cookies, crackers, and soap. Women also can pool their money to plant a larger amount of crops to sell at the market."
In her Trent Building office Puffer is analyzing the interview data she collected over the summer in preparation for a return trip from May through August. A large part of her time there will include involving the community in analysis of the data and helping to determine what can be done to change the "sex-for-fish" culture. Puffer will begin a pilot trial of interventions in December.
Possible programs include: teaching sex education and safe sex practices to parents, children, and fishermen; educating about the dangers of HIV/AIDS and how to reduce the number of partners; teaching about dangerous abortions; teaching parents to talk more openly to children about sex; educating women about work opportunities; and helping young women improve their self-esteem.
"My goal is to work with parents and churches, religious and civic leaders to create a community of support," Puffer says.
She was particularly inspired by an 18-year-old Kenyan woman she befriended. Like most of her peers, the woman had fallen into a lifestyle of transactional sex at an early age and faced a future of little opportunity. But her parents encouraged her in school in hopes of providing a path to something better. She came through the local school system with decent grades, and at a community meeting the young woman emotionally announced she had been accepted to college.
"This meant so much to me," Puffer says, "because for so many here there is just complete hopelessness. But if you have a supportive community and a strong self esteem there is a way out."