Being There

I'll never forget the argument I had with a famous clinical endocrinologist in 1971.

He reviewed grants for NIH and was internationally respected. I was a lowly resident just back from the jungles of Malaysia, where I learned tropical medicine by treating the indigenous Orang Asli people.

I told him I was eager to resume research in a developing country. "Why would you want to spend time in a place where you lack the resources to really look at a pathogen?" he asked. "I can go to a country and get the specimens I need in two weeks and come back here where I can examine them better."

He was right in many ways; the developed world's technology is amazing and essential in many instances. And it's true, I can't do x-ray crystallography in Peru, where I've been working for the past 23 years. (For that, we ship specimens to Brazil or the United States.) But if I just worked in labs here, I think I'd miss out on real-world insights.

Science, after all, isn't about technology. It's about solving problems. To do that, you have to understand the problem. I've found the best way to understand the problem is to be surrounded by it.

Most of us scientists assume that the big scientific challenges will fall like dominoes once we acquire enough education, grants and lab space. We forget the role of serendipity—of being in the right place at the right time. For the past 35 years, the "right place" for me has been the world's developing countries.

When I finished my internal medicine residency, I promptly ignored the endocrinologist's advice and moved to Bangladesh to study diarrheal disease. From there, I went to India on a Fulbright. After that, my family and I landed in Lima, Peru. My two kids grew up there. They see things from Peruvian and American perspectives, and I do as well. It's hard to live in a place like Lima and not have it rub off on you.

A cosmopolitan, desert metropolis of more than 7 million people, Lima is bordered by the Pacific and ever-expanding pueblo jovenes. The "new towns" are permanent shantytowns that sprout up on sand dunes overnight. They are beset with high rates of diarrhea and malnutrition.

When you're "there," the issues hit you right in the face. Local colleagues know the problems inside and out. The solutions we look for are not the most technologically advanced. If it can't be done in Peru and other developing countries, it's not terribly relevant to us.

I'll give you an example. Some years back, a U.S. pharmaceutical company developed a fast and effective method for detecting antibiotic resistance in tuberculosis patients. But it cost $60. That's OK for the United States or Peru's private clinics, but it's simply too expensive for the public hospitals. My colleagues at Universidad Peruana Cayetano Heredia and I wanted a cheap, quick test.

We were especially worried about the HIV-positive patients co-infected with TB. More than 40 percent of them had multidrug-resistant TB. Their mortality rate was 50 percent at two months, but it took four months to get test results that would tell us which drug therapy would work. While investigating a somewhat better dye-based technique, Luz Caviedes, a Peruvian microbiologist, told me, "I don't know why you're bothering with the stains. I can look at it in the microscope and detect it much faster." She was right. We refined and validated the method—now called microscopic-observation drug-susceptibility, or MODS. It was faster, cheaper and more sensitive than the previous gold standard tests in developing countries. MODS results were available in seven to eight days. My colleagues David Moore and Carlton Evans have further developed the method and proved it can work in other settings.

We wouldn't have been looking for this simple method if we hadn't been living and working there.

Such scientific breakthroughs aren't the only benefit of performing lab research where the problems are. You help build the local people's capacity to solve their own problems. Peruvians working on our projects journey to Baltimore to earn their MPH and doctoral degrees. (I count 11 PhDs completed or under way thus far.) And more than 250 American medical and public health students have studied with my Peruvian colleagues. There's a lot of interaction (and a few marriages, too).

As I write this, my colleague Hector Garcia is teaching in our tropical medicine summer institute course in Baltimore. Hector and I first began working together in 1987. He understands Peru and how to get things done there better than I ever will. When he tells me that I don't know what I'm doing, I usually follow his advice. Since earning his PhD at the School, he's become the global expert on cysticercosis, a parasitic infection that is a major cause of neurologic disease (including epilepsy) in developing countries.

One last story. Hector's cysticercosis research would probably never have happened were it not for a visit to Peru by a USAID consultant in 1989. "Bill" was an acquaintance of mine and happened to be reviewing my grant proposal for cysticercosis research. When he was in Lima, Bill told me, "We're not going to fund this proposal because the disease is too exotic." I said, I only want you to do one thing: Go make rounds with the physicians at Peru's top neurology hospital. He did. He saw how pervasive the problem was and learned how cysticercosis is responsible for a third of cases of adult onset epilepsy in rural areas.

Then he did a nice thing. He tore up the review and wrote a new one. We got the funding.

He had learned the importance of "being there."