Perspective
Playing on a Global Field
Like soccer, medicine unites young investigators from different parts of the world.
By Catherine Pastorius
“Vale, vale!” my teammate shouts as I dribble past a defender. “Gol, gol, gol!” an observer on the sidelines chants shortly after the ball goes into the net. One of my teammates, a cardiology resident with whom I work at the National Heart Institute in Lima, Peru, tips his invisible hat to me—a universal sign of congratulations for scoring a hat trick in soccer. The next day, while I am observing an open-heart procedure, the director of surgery approaches me and tells me he hears I am a very good futbolista. If there is one thing that unites people from different cultures it’s soccer. And my year-long National Institutes of Health/Fogarty International Clinical Research Scholars fellowship is teaching me there’s another—medicine.
As a Fogarty fellow, I am one of 30 U.S. medical students training in clinical research at sites in the developing world. The experience has allowed me to participate in eight different projects at four sites in Peru. Besides providing funding and mentoring, the fellowship pairs each student with a young local doctor who is pursuing a career in clinical research. I am matched with Romina Tejada, M.D., an incredibly intelligent, gracious, hard-working physician, and a leader in her field. She recently completed her master’s degree in epidemiology and is studying risk factors for mother-to-child transmission of HIV in Lima. Currently, Peru struggles with the unresolved problems of malnutrition and infectious diseases such as HIV, Chagas disease, and tuberculosis. It is also seeing an increase in cardiovascular disease (CVD).
Although most Fogarty fellows are studying HIV, my interest is CVD, and to my surprise on my first day observing at the National Heart Institute, I rounded on patients with both infectious diseases such as bacterial endocarditis and rheumatic heart disease and chronic diseases such as severe congestive heart failure. I heard more murmurs in that one day than I probably will hear in my entire career.
The first time I arrived on the cardiology ward, a well-respected doctor and friend of my Peruvian mentor introduced me to the directors and doctors as well as to the residents and nurses. In keeping with custom, I kissed every one of them on the cheek. These are the people who will be my new teammates—both in the hospital and on the soccer field.
After a long Wednesday in the operating room observing open-heart surgeries and trying to get our patient with a 14-cm by 12-cm abdominal aortic aneurism into the only functioning CT scanner in the 1,000-bed hospital, we trade scrubs for pinnies and run around under the lights on the soccer field, where we play to have fun (and to win), forgetting our roles in the hospital.
Early the next morning, I travel by bus through the heart of Lima, a city of 8 million, to the Ministry of Health’s public hospital. I pass the neighborhoods of Rimac and San Martin de Porres, where roads aren’t always paved, houses are made of mud bricks, and trash burns in the street. Stuck for over an hour in what is arguably the worst traffic of any major city in the world, I stare out the window at the bustling sidewalks and forget that I am in Lima until I see the fruit and juice vendors pushing their carts along the highway and newspaper stands with headlines of the Chilean earthquake on every corner. I get off the bus and flag down a mototaxi, a motorized rickshaw, which for the equivalent of 30 cents gets me to the hospital in time for rounds. “Peruvian time” is typically 30 minutes later than Minnesota time, so I actually arrive early.
At morning report, the senior resident presents a case of a young girl with anemia who is from Tumbes, a small city in the north of Peru. I remember a few months back to when I was working in Tumbes, taking children’s anthropomorphic measurements for a study on the effects of the 1998 El Niño phenomenon. That’s when I learned the difference between poverty and extreme poverty. A local field worker, who introduced me as “doctora,” even though I made it clear I was only a student, got me invited inside people’s homes. In most residences, curtains acted as doors, hammocks hung from porches, chickens pecked at dirt floors, and cachectic dogs scratched at fleas. The government had only recently constructed latrines.
To determine household income, we asked about assets like the number of animals and appliances a family owned. The richest of the poor, who were making around $100 a month, typically had a TV and refrigerator; but few owned a car.
Every few days we would go to the local school and measure the kids who were enrolled in the study. I will never forget the teenaged boy who stepped on our bioimpedence machine and produced an “ERROR” reading. I reset the machine and had him step on it again; it showed that he had less than 1 percent body fat. His teacher teased him, calling him “flaquito, flaquito,” or skinny boy, and I could sense his embarrassment. I pulled him aside, told him about his results, and counseled him about eating more, especially meat. But he replied that his family couldn’t afford to feed everyone. The image of the young man’s cheekbones and tiny wrists hidden by his baggy school uniform will be imprinted in my mind forever.
On my last day in Tumbes, there was a big soccer tournament for all the field workers from another study. Our data- entry worker invited me to play on his team. I quickly changed into shorts and timidly joined the game that had already started. Within five minutes, I scored. A few dozen fans erupted in a roar; it was exhilarating. After the game, we had a big feast, and I got a lot of congratulatory sweaty kisses on the cheek. In three short weeks, I had learned about much more than how to do anthropomorphic measurements—I had learned about how people really live and why it is vital to have locals on your team.
In Lima, I work in a cozy one-room office at the National Institutes of Health CRONICAS Center for Excellence (COE), one of 11 COEs in the world. The center is starting a five-year longitudinal project similar to the Framingham Heart Study to create profiles of the cardiovascular and respiratory risk factors in residents of three cities: Lima, which is very urban, and Puno and Tumbes, both of which have populations of around 100,000 people. My role is part administrative and part young investigator learning the ropes.
Cardiovascular disease is one of the leading causes of morbidity and mortality in developed countries and is responsible for more than half of adult deaths in those countries.1,2 It is expected that by 2020, more than 80 percent of the world’s CVD cases will be in developing countries.3
Until recently, only a handful of studies had been done on CVD in Peru; much is still unknown about CVD here. Therefore, in order to develop prevention strategies, we need better documentation of the incidence and prevalence of CVD risk factors and of morbidity and mortality from CVD. The two main research projects that are looking at CVD risk factors in Peru are the PREVENCION (Estudio Peruano de Prevalencia de Enfermedades Cardiovasculares) study and the PERU MIGRANT study.4,5 PREVENCION is a population-based study of 2,100 people from Arequipa, the second-largest city in Peru; PERU MIGRANT is a study involving around 1,000 people that is investigating the differences between CVD risk factors in those who have always lived in a rural area, those who have migrated from a rural to an urban area, and those who have always lived in an urban environment. During the 1970s, political violence drove Andean peasants from their homes. About 120,000 migrated to Lima. The PERU MIGRANT study is demonstrating that migration can alter CVD risk profiles. I have been analyzing data from these studies, preparing manuscripts, conducting fieldwork, and getting first-hand experience in designing large epidemiological studies.
After seven months in Peru, my Spanish is rapidly improving, I’m spending a significant amount of time in the hospital seeing things that I never would see as a fourth-year medical student in the United States, and I’m playing soccer regularly. Through these experiences, I am building relationships with people like my Fogarty counterpart, Romina Tejada, that I hope will lead to improved health for the people of Peru and all nations. And I am learning that clinical research is very much a global field requiring the hard work and talents of an international team. MM
Catherine Pastorius is a fourth-year medical student at the University of Minnesota.
References
1. Lloyd-Jones D, Adams R, Carnethon M, et al. Heart disease and stroke statistics—2009 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2009;119(3):480-6.
2. Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJ. Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. Lancet. 2006;367(9524):1747-57.
3. Yusuf S, Hawken S, Ounpuu S, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet. 2004;364(9438):937-52.
4. Medina-Lezama J, Chirinos JA, Zea Diaz H, et al. Design of PREVENCION: a population-based study of cardiovascular disease in Peru. Int J Cardiol. 2005;105(2):198-202.
5. Miranda JJ, Gilman RH, García HH, Smeeth L. The effect on cardiovascular risk factors of migration from rural to urban areas in Peru: PERU MIGRANT Study. BMC Cardiovasc Disord. 2009;9:23.