A New Hat in Southern Africa

By Brittney Sullivan, Nursing PhD student

“Many hands make light work” – Tanzanian (Haya) Proverb

Stepping off the plane in Johannesburg, I was thankful my WhatsApp was working so I could text the project manager who had arrived from Atlanta just 15 minutes prior to me. We had exchanged contact information in early July during our one-day meeting at Johns Hopkins, where the project and principal investigator is based. 

Without hassle, we ran a few necessary errands (buying SIM cards, a GPS system, and getting Rand currency at the ATM). We met up with two PhD students at the airport hotel for dinner before waking early the next morning for our 5am flight to East London, where we would spend our first two weeks. I was excited to start our trip in the Eastern Cape province, as I had studied abroad at Rhodes University in the Eastern Cape while in college.

I am in South Africa this summer conducting my research practicum for five weeks as a research assistant on one of my mentor’s studies. I'm traveling with two other students to four intervention sites as part of a cluster randomized control trial examining nurse case management for multi-drug resistant tuberculosis (MDR-TB). In South Africa, the HIV epidemic has fueled the resurgence of TB across the country. It now has the 3^rd highest burden of TB in the world and 5^th highest burden of drug-resistant TB in the world (SA Department of Health, 2013). The Eastern Cape and KwaZulu-Natal Provinces have the highest rates of DR-TB in the country. Hence, the reason we are spending our time here, and why the RCT is being conducted here. 

This time in South Africa has allowed me “on the ground” experience after finishing my first year of PhD studies at Duke University School of Nursing (DUSON). It is helping me gain a contextual perspective to my area of interest and has allowed me time to contemplate the variables I will use to measure my dissertation outcomes. I spent a year in Malawi teaching pediatric nursing in 2013-14 and was just in Rwanda and Kenya through a global health Bass Connections project in June, so this is not my first time “in the field” per se. However, this has been my first time in Southern Africa wearing the hat of a researcher with the intent of scrutinizing data, variables and study documents. Thankfully, I have made friends along the way to keep me sane through the arduous process!

Our task has mostly focused on quality control and quality assurance at the intervention sites. This has meant diving deeply into patient hospital files, outpatient charts, lab results, nurse case management notes and audiology charts, as well as talking to the nurse case managers to understand their role in intervening with patients. This translates into hours (upon hours, upon hours!) interpreting healthcare provider handwriting and interrogating—at times with microscopic precision—the entire written story of a patient’s illness in order to validate the recorded results of each enrolled study participant. 

At times, the other two PhD students I’ve become close with and I have become exasperated at the slow pace of chart reviews, yet we have learned a lot through the process and have garnered very useful and practical knowledge. For example, I naively assumed the majority of patients with MDR-TB and HIV co-infection would have already been started on HIV medication (since treatment is free and recommended for individuals with opportunistic infections such as MDR-TB in South Africa); however, now I have designed a research question focusing on time to HIV medication initiation since many patients do not initiate HIV treatment until after MDR-TB diagnosis and treatment.

Working as a team with the other two PhD students has been such a blessing. Although we knew each other only via e-mail and one meeting prior to our arrival in country, we have meshed incredibly well. Despite some hectic driving experiences, challenging work days (ending at 9pm after waiting 4 hours for photocopies to be made …), and confined living quarters 24/7, we have kept our attitude positive and minds flexible. Relying on each other to patiently and critically think through difficult study-related scenarios, re-check the Standard Operating Procedure for the 27^th time together, or run down the hall for an extra form to help each other out has build incredible solidarity between the three of us.

Besides building relationships with my two compatriots and spending time with our PI and project manager, another highlight thus far has been meeting the nurse case managers (NCMs) for the study. Zolisa is one NCM who works at one study hospital where we spent two weeks. During our visit, she enrolled multiple patients into the study. As she gave us a tour of the hospital, it was obvious she had built strong relationships with all of the staff, from nurses and physicians in the wards to the kitchen staff and the outpatient social worker. Another NCM was unable to spend a day with us because he was conducting home visits for patients who had missed clinic appointments and they potentially needed social support and an adherence intervention in order to prevent default from their treatment. 

Although my interactions with patients have been limited to brief “hellos” in hospital hallways, and the clinician in me is struggling to cope with the lack of patient interface, the researcher in me has definitely found this to be a productive and enlightening experience. Undertaking global health research is challenging and generally lacks the glamour I think is sometimes touted. Many of my friends and family are envious, excited and awed that I’ve been to Africa twice this summer—which I am incredible thankful for, excited about, and also somewhat in awe about as well—but it’s not to tour around and go on safari. I’ve been hard at work during the Southern Hemisphere winter, head buried in the charts, and eating PB&J sandwiches to squeeze in as much work into each day as possible (and to learn a little bit about grantsmanship management and budgeting!).  Although we are diligently at work, we are doing it together, and we're learning from the experience and one another. 

Nkosi! Thank you!*

*Thank you to DGHI for their generous support through the Doctoral Certificate Fieldwork Grant, which has allowed me to partake in this worthwhile endeavor.