Joseph Zunt, MD, MPH, knew as a medical student that he wanted to study NeuroAIDS and brain infection. When he interviewed for an infectious disease fellowship at the University of Washington, which would place him in Kenya, the program director told him: “If you're interested in brain infections, we have no CT scans here in Kenya — you'll never know what's wrong with the patients. Instead you should talk to King Holmes.” Unbeknownst to him, that conversation would set the course for the rest of his medical career.
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King Holmes, MD, PhD, chair of the global health department at the University of Washington, who was working in Peru at the time, told an eager Dr. Zunt: “We don't have much NeuroAIDS in Peru, but we do have this infection called HTLV-1 [human T-cell lymphotropic virus type 1], it's a strange retrovirus that often causes problems with the spine. And we have a big cohort of female sex workers with the infection. If you'd like, I'd be happy to support you in doing your study down there.”
Shortly after, Dr. Zunt, Dr. Holmes, and neurologist William Longstreth, MD, wrote a grant together — and it was funded by the Fogarty International Center. In 1995, Dr. Zunt completed his neurology residency at the University of Washington and then, during his second year of the infectious disease fellowship, Dr. Zunt, his wife, and his seven-month-old son moved to Peru for ten months.
“That was the transformative experience that really solidified my interest in combining neurology with international research,” Dr. Zunt told Neurology Today. “Because, having spent that period of time there, I developed great friendships that actually continue to this day.”
After 15 years, Dr. Zunt — now an associate professor of neurology and global health, and adjunct associate professor in epidemiology and medicine (infectious diseases) at the University of Washington — continues to draw on those friendships with neurologists from his fellowship years, expanding their range of work and influence in the country. “We've really moved quite a way from just studying retroviral infections of the central nervous system to all sorts of neurologic and medical diseases,” he said. “We are also starting to work in the slums and investigate other predictors of health that affect people living in impoverished conditions.”
Dr. Zunt now directs the Peru site for the University of Washington Fogarty International Clinical Research Scholars & Fellows program, which is funded by the NIH and coordinated by Vanderbilt University. About 40 scholar-pairs — one each from the US and Peru — are provided with mentors for ten months in Peru on how to do clinical research. The program is based in Lima, but pairs are working in sites across the country.
Among the unique projects, one Fogarty scholar, Dr. Isaac Alva, who is very interested in medical anthropology and indigenous communities, which comprise about 45 percent of the Peruvian population, is traveling up the Amazon 12 hours by boat to work with communities. “He is developing video-based prevention interventions [to increase condom use and motivate HIV testing among crewmembers] that will also be available to people traveling on these boats,” Dr. Zunt said. Riverboats that travel in the Amazon basin are common venues for unprotected sex, and “often those people traveling are migratory and can move into areas where there's a high risk of sexually transmitted infection,” he explained.
Working in a pueblo joven — a slum — another scholar is using radio broadcasts in one of the schools to teach kids about sexual and reproductive health. “They would develop these little vignettes and they would broadcast them over the school grounds during breaks and talk about fairly taboo topics — and the parents loved it, too. It has continued to blossom.”
These projects have enabled Dr. Zunt and his colleagues to partner with these same groups and push their work into new arenas: looking at the health of the children, trying to install a school-based health center. Now, he continued, “we're looking for funds to rebuild the school — bit by bit — in a way that's healthier and takes into consideration the lack of water and sanitation. It's very exciting, but it's a far cry from where I started looking at just neurologic diseases.”
Much of the work that Dr. Zunt and his colleagues have done in Peru has focused on participatory design with the community. We are “working together — Peruvians and U.S. trainees — to make health better in areas where the need is greatest,” said Dr. Zunt.
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WHAT ABOUT NEUROLOGY?
With all that he does, neurology is still the focus for Dr. Zunt's work. Among his projects, he is creating a network of neurologists across Peru who are enrolling patients in a study of meningoencephalitis, an inflammation of both the brain and the meninges, to define the etiology of the disease. As a participant-incentive, the researchers are bringing in IV-acyclovir, which they don't have in Peru, in hopes that one day it will be available through the Ministry of Health, said Dr. Zunt.
Dr. Zunt and colleagues are also currently working on a stroke training program. They plan to resubmit a grant to work with Peruvian universities to train local neurologists in research methodology to increase understanding of stroke epidemiology throughout the country. The next step will be to examine the effects of different geographies in the country — the coast, the mountains, and the jungle — on stroke. “To look at not only genetic differences between those groups, but also what happens when you have someone up in Cuzco who has a stroke — are there any other predictors of stroke at that level as opposed to sea level?” said Dr. Zunt.
In addition, the Fogarty program has collaborated with the Peruvian government on the International Clinical, Operational and Health Services Research Training Award in AIDS and tuberculosis (TB). Dr. Zunt and colleagues are working with the Ministry of Health to look at the barriers to implementing care for HIV and TB at every level — not only institutionally and nationally, but also in small, rural villages. Dr. Zunt said this project will ideally expand to deal with TB and HIV when they get inside the brain, as well.
There has been some progress in access to medical technologies over the years in Peru, though much of it remains in Lima, Dr. Zunt said. When he first arrived, there was only one MRI in the capital city, and now there are more.
Although Peru is working to improve public education around health care, there is still not enough focus on public awareness. Currently, Dr. Zunt explained, “It's based more on what they call ‘campaigns.’ The Peruvian ‘Grupo Stroke’ has made a great effort to go out in the community and have talks — special days when they talk about brain health — but there is still a great need to increase nationwide publicity to [for example] encourage people with neurologic deficits that would be consistent with stroke to look for care.”
Necessary treatments, such as tissue plasminogen activator, are also inaccessible due to the exorbitant costs. “The awareness of the public as well as the availability of some medications at lower cost are two striking differences [between the US and Peru],” he said.
The biggest obstacle for Peruvian neurologists? Time, said Dr. Zunt. “Once they graduate from residency, they have little dedicated time to perform research.” He added that the neurologists do not receive extensive training in research methodology, which makes them unsure of how to approach research and more likely to avoid it.
Peru doesn't have a national agency like the NIH to provide research funding, said Dr. Zunt. “Fortunately with the Fogarty program, the majority of neurologists I've trained have been Peruvians. And we're able to give them a stipend that allows them to have dedicated time away from work.”
“There's such a wide variety of conditions [in Peru] that we don't see here [in the US]. For instance neurocysticercosis, malaria, dengue, leptospirosis, TB, the other retroviruses — it really provides a unique opportunity to look at co-infection. What happens with HIV or HTLV-1 or HTLV-2 co-infection to treatments, to incidence of opportunistic infections? What happens when you mix the retroviral infections with TB or malaria?” said Dr. Zunt. Not only are these comorbidities “exciting to study” and “never-ending,” but they also create rich teaching and project opportunities for students and young health professionals with varied interests, he said.
Dr. Zunt's work in Peru continues to change and surprise him all the time: “I'm never sure from one day to the next what I'm going to be focusing on and I just love having that unpredictability,” he said.
HOW CAN US NEUROLOGISTS GET INVOLVED IN GLOBAL HEALTH?
Joseph Zunt, MD, MPH, remembers a time when he was one of very few neurologists working in the global health setting. Now, he said, “It's really amazing how many people find out through the grapevine that I do neurology mixed with global health — and I'll get e-mails, I would say every other week, from young neurologists interested in combining these fields.”
Dr. Zunt said the first step is to learn the language of the country. “For my trainees, I really require that they speak Spanish. I think not having the language puts you at a disadvantage even if you have a translator readily available.” Of course, there are also global opportunities in countries where English is well understood, he said.
For neurologists who want to do direct service work, we do not have a great model to date in Peru — mainly because we're limited by liability insurance, he said. If a US neurologist comes to Peru, he will be allowed to shadow a Peruvian doctor, just as the reverse applies.
And short-term global work? There are two ways visiting neurologists contribute in Peru, Dr. Zunt said: participating in conferences — that also provides an opportunity to meet with Peruvian colleagues and to offer them education and expertise; and serving as mentors for Peruvian students and trainees.
For more information about the Fogarty Scholars program, visit: www.fogartyscholars.org.
NEUROLOGY: ENHANCED COVERAGE OF INTERNATIONAL NEWS
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