by Tom Kawula, director of the Paul G. Allen School for Global Animal Health
Walking into a public hospital on the southern edge of Mombasa, Kenya, around eight o’clock in the morning, there were already 10–15 pregnant women, most with children in tow, sitting on benches outside the clinic waiting to be seen by a health care worker for prenatal care. It was the first of three hospitals that I was visiting where Allen School staff had set up surveillance programs to determine if there is a connection between a potential emergence of Zika virus infection and the high prevalence of birth defects in coastal Kenya.
As a scientist working on infectious diseases, I have read numerous reports describing possible cause and effect relationships between infection with a specific pathogen and some symptom or syndrome. For example, recent studies in Brazil led to the discovery of the connection between Zika virus infections of pregnant women and the developmental abnormalities in their unborn children. Visiting the Mombasa hospitals made me realize that I had greatly underestimated what it took to collect the kind of information needed to generate meaningful results that could actually be used to improve human health.
Studies such as these are relatively straightforward in affluent countries with well-developed health care systems and disease reporting requirements. However, the emergence of new or previously unrecognized infectious diseases occurs most frequently in low-income areas that lack the resources or infrastructure to collect and analyze even simple infectious disease data.
For the study, we needed to enroll qualified patients, collect personal information, evaluate patient health, collect blood samples, perform ultrasounds, and give explicit instructions to establish repeated visits to continue monitoring health, the Zika infection’s status, and fetal development. Before any of that could take place, we needed to get informed consent from the patients. I learned that in most cases it took our team roughly an hour to get a legitimate informed consent. A member of our staff would carefully explain each step of the process, then ask the patient to describe in her own words what the staff member had covered. To be formally enrolled, the staff had to be convinced that the volunteer clearly understood the purpose of our study, what we were asking her to do, the potential risks associated with participating, and the fact that she had the option of quitting the study at any time.
What struck me was not so much the thorough time-consuming enrollment and evaluation process. Rather it was how invasive our presence felt as our team of five worked in what was already an overcrowded and probably understaffed health center. I realized how even the simplest requirement, like space to do our work, was a significant hurdle to setting up our study and likely a nuisance to our hosts. These hospitals didn’t have a few extra vacant rooms for us to swoop in and set up shop. These observations made me wonder why the hospitals agreed to host and cooperate with our research teams in the first place.
At first my concerns were confirmed by each of the hospital directors. They were, in fact, initially ambivalent at best about helping with our study. But they quickly shifted and told me how delighted they were with how our team had worked with the existing hospital staff to establish procedures that were least intrusive to their operations. Even better, the WSU staff actively integrated with the hospital staff to assist them with interviewing, evaluating, and admitting patients. Our presence did put a squeeze on their space, but we more than made up for the inconvenience by contributing to the care of their patients. Each director left us with an open invitation to return for future studies. I could not have asked for a better outcome.
Now when I pick up a newspaper or journal article that states something about the percentage of children who were admitted to some hospital testing positive for brucellosis, I will be reminded of how that information came at great cost of inconvenience to the patients, and time and effort from dedicated health care staff.