Johns Hopkins Public Health Magazine

Some pitfalls are merely nuisances: bug bites, gastrointestinal distress, harsh living conditions, tropical heat, and so on. But less prevalent, more lethal threats are always there: infectious diseases, political upheaval, dangerous roads and drivers, shoddy airlines, robbery... The list goes on and on.

Sometimes public health investigators are safer because of their status as foreign researchers. Sometimes that just makes them better targets for an endemic virus or an opportunistic thief. They often lack fluency in the local language and a thorough understanding of cultural nuances. They depend on briefings, travel clinics, immunizations, local colleagues, experience, street smarts, their own sense of self-preservation, and that final bulwark against disaster: luck.

All the while, they have to set aside concerns and worries because, unlike tourists, researchers are not in a place to visit. They are there to work.

Cajoled into talking about their experiences, public health researchers are uniformly modest, reluctant to claim heroism, allergic to self-congratulation, and averse to drama. But sometimes they will relate their stories. Dean Alfred Sommer can tell you about his time in post-cyclone, crocodile-infested East Pakistan in the 1970s, or when he smuggled intellectuals in his car trunk past the Northwest Frontier Patrol there. Donald Burke, professor and director of the Center for Immunization Research, will talk about the onchocerciasis (river blindness) that he will have to battle for the rest of his life. Bonnie King, research associate in International Health, will calmly recount passing murder victims on her way to work and being harassed by gangs in Haiti's Cité Soleil.

W. COURTLAND ROBINSON
PhD Candidate, Population and
Family Health Sciences
Research Associate, International Health

I was in a guesthouse in the middle of town. I remember there was a storm, and the lights were going on and off. Then there were the sounds of feet running back and forth in the hallway. Booted feet. I heard the sounds of metal, like guns. Then I heard shooting and screaming very close, I assume in the courtyard. All this was interrupted by the thunder and lightning. I'm not trying to sound heroic. I was just sitting in my room. I felt a complete sense of helplessness in the face of this. Very much in my mind was a vision I'd had earlier in the day. I was taken out by a guy who showed me a well. As you looked over the rim, you saw bodies, partly decomposed bodies. This was the endless round of retribution, repercussions, and violence. I remember sitting in the room thinking, will I get out of this? Is the next sound going to be the sound of the door being bashed in?

Somehow sitting in that room brought home to me just what life is like there for the local people. Being surrounded by danger and not knowing what is coming. I might [be at] risk but it's not the day-to-day, lifelong thing it is for the people who live there.

I think the job we have is to alleviate some of the pain and suffering of that. And if we can't alleviate it, to try to document it and speak for the ongoing humanitarian responsibility and a permanent solution.

Just when we set the clinic up, within a week's time, the disease struck. People were bleeding through the nose, mouth, and bowels. We were fearing it was Ebola. We just didn't know. We would get reports of 20 deaths in a week. Reports were coming in so fast. Death would happen so fast. Somebody would develop a fever, then the bleeding, and within a couple days they would be gone.

In disease outbreaks the risk is always there. At first, we were not taking precautions of covering the nose and mouth and wearing gloves because we didn't have equipment or gear with us. We were just trying to capture as many patients as possible. And we tried to determine what the outbreak was as soon as possible.

There are very many different types of viral hemorrhagic fever. WHO [the World Health Organization] and other scientists right from the beginning assured us it was probably not Ebola. I wouldn't be here today if it was Ebola.

Within a week after sending specimens to South Africa and the CDC [Centers for Disease Control], they reported that it was most likely Rift Valley fever. It is transmitted to people by mosquitoes, by inhaling blood droplets, and by handling or consuming infected cattle, goats, and sheep. A survey later showed that in a susceptible population of 231,000 people in the Garissa district, 20,000 would have been infected with the Rift Valley fever virus during this outbreak and 100 people would have developed hemorrhagic fever.

I was at risk, but that's what public health is all about. You have to take some risk. But when we went there, we saw the risk was much greater with the people.

CHRIS BEYRER, MD, MPH
Associate Research Professor
Epidemiology
Director, Johns Hopkins Fogarty
AIDS International Training and Research Program

I think the scariest place I've ever been is Manipur, a state in northeast India. There has been an insurgency going on there since the 1950s.

There are two Manipuri state security agencies, five Indian national army and police forces, and 14 ethnic insurgency groups operating there: 21 different armed forces. I have never been anywhere where there were more guns. One group, the Assam Rifles, had this Gatling gun mounted on the back of a truck and drove by aiming at women in the market and at me.

I was there in 1998 investigating the situation with heroin trafficking. The state has the highest rate of HIV in India. When we arrived in Manipur, we said that we were professional bird watchers. There's a famous wildlife preserve there. They wouldn't let us in. They wanted to put us right back on the plane. But we were meeting a member of the Indian parliament from that state. He was able to get us in.

We went to a place where we could talk and set up our itinerary. The entire compound was surrounded by his armed guards with Kalashnikovs [assault rifles]. There was one every three to four feet. I thought: We're just trying to have a conversation about public health.

This is an ethnic minority state with an insurgency going on — like Kosovo five years ago, or Chechnya. If you go to look at the public health problems in Grozny, the Russians wouldn't want that information out, but the Chechens would be thrilled. The Indian government would be happy to have us studying HIV in Bombay, but not Manipur.

Some people feel that public health should be apolitical. My feeling is you can't escape the fact that political realities affect health. If you want to help people, you have to be on their side.

GILBERT BURNHAM, MD, PHD, MSC
Associate Professor
International Health
Director, Center for International Emergency,
Disaster and Refugee Studies

I've spent most of my life working in Africa. The only time I've been really frightened was not in Africa, but Albania. It was actually between the port city of Durres and the capital Tirana. An Albanian colleague and I had been working near the coast and were on our way back to Tirana. It was dusk. We were following a vehicle with no license plate. We guessed it was a bank van because it had a police escort. We thought we were safe following the police. Just as we were entering a patch of woods, automatic weapons opened up on the van from the woods. Then police piled out of their vehicle and started firing their machine guns into the woods. It was pretty sustained fire for a minute or two. We didn't get hit, but automatic weapons fire is not all that fun to be around.

I don't know much because I was lying flat on the floor in the back seat. One of the police shouted at our driver to get out of there. The driver just backed up furiously and turned around and we headed in the other direction. I asked my colleague if she was frightened. She said, "Oh, a bit." Growing up in Albania, she'd been in scarier times.

I don't want to make too much of this kind of thing. It's the vehicle accidents that put you at higher risks. In some developing countries where roads are bad, the drivers are bad, and the vehicles are bad, the per-kilometer death rate can be 50 to 100 times what it might be in America.

But whatever risks we personally are exposed to are nothing compared to what the populations we study and serve are exposed to day in and day out, particularly in Africa. We can always return to the relative safety of our own homes, but they have no escape. Our job is to reduce those risks as much as we can through research and through our public health practice.

I was in Chiang Dao, a small town about 75 kilometers north of Chiang Mai, setting up HIV prevention in villages. I remember getting bit by a mosquito — the dengue vector is Aedes aegypti — during the daytime. I was so paranoid about malaria, but those mosquitoes feed between dusk and dawn.

About a week after getting bitten, I had flown home. I spiked a fever of about 103. My doctor said he didn't know what it was. As it turned out, there is no treatment anyway. It just runs its course. It is a major cause of mortality, but mostly in children.

I got more and more out of it. I was close to hallucinating. I couldn't get out of bed. About half my hair fell out. I started seeping blood through my hands and feet, just leaking. Right through the skin. You could see it on the sheets. I was purple from here [pointing to his mid-bicep] to my fingertips and from my mid-thigh to my toes. My wife said she'd never seen anything quite so bizarre. Its common name is 'breakbone fever.' The pain is unbelievable. I was so out of it that it didn't really bother me. I had really bizarre dreams probably due to the high fever.

By the time we finally figured out what it was, I was fine. I had dengue the same time Dick Morrow was in the hospital with malaria. Our provider was pretty busy.

Things happen. It certainly modified my behavior. When we send people overseas, first we send them over to the travel clinic. We pay for their meds, make sure they have all immunizations.

What else would I do differently? Probably put on DEET and smack every mosquito within 50 centimeters of me.

I know exactly where I acquired it: at the source of the Nile on Lake Victoria. We went in the evening to Jinja. A romantic spot, but there were certainly plenty of mosquitoes around. I had purchased chloroquine in Kampala at the major chemist's shop in town. I took it prophylactically as I always had done. A week later I did not feel well. I suspected I had malaria but I felt reasonably safe because I was on chloroquine. On the three-day journey home, I kept getting sicker. I didn't have the shaking chills, but I just felt rotten in the evenings. A very serious sign: I didn't even want to look at a beer. I came home on a Wednesday evening and had a high fever. Thursday, I went in to the office and did some work and called my physician and made an appointment for Friday.

When the blood work came back, I was suffering from anemia. I was also jaundiced. I had virtually no platelets and 12 to 15 percent of my red blood cells were infected with malaria. I was immediately hospitalized. By Saturday morning I was out of it and I remember almost nothing of the next five days. Clearly the treatment of choice is IV quinine. The hospital did not have it. By 11 p.m. that night they found oral quinine. By Sunday, the most critical problem was the acute respiratory distress syndrome, which has 70 to 80 percent mortality. Basically I had no functioning lung. I was on oxygen given by CPAP [continuous positive airway pressure] for five days. When I woke, the nurse wanted to give me a shot of morphine. I said, I don't want morphine. Apparently I'd been in a lot of pain all the way through.

It turns out the chloroquine I was taking in Africa was not chloroquine. It was analyzed, and it was acetaminophen, which actually costs more to make than chloroquine.

I think the benefits of public health work far outweigh the risks. The satisfaction, the sense of knowing one's made a difference. But eternal vigilance is required. I was not vigilant on that particular trip. And I am fortunate to have survived.

In 1986, Joanne Katz and colleagues Jim Tielsch, Keith West, and Kate Burns had embarked on a major community trial in the Philippines to confirm findings from Dean Alfred Sommer's vitamin A study in Indonesia. Two years of work, 30,000 trial participants, and hundreds of thousands of dollars invested in establishing the project evaporated almost overnight when a local political group began broadcasting propaganda against the study.

There was a lot of political turmoil at the time. It was 1986, the year when the Ferdinand Marcos government fell. There was a lot of anti-American sentiment because the U.S. had supported the Marcos regime. The political situation was very fluid. Keith, Kate, and I were in Legaspi City, an eight-hour drive from Manila.

Everybody knew who we were and where we lived. People were going on the radio saying these people are experimenting on your children, killing your children. My feeling was, this is a very bad thing. I did fear for my life. Having grown up in a country where you see a lot of violence, I know these things can happen. In South Africa there were people who opened the door and someone assassinated them. You can't fool around with these things.

I felt if people were worked up into a frenzy about it, there was a potential for the local population to come after us. We said we'd monitor the situation. That was on a Thursday evening. By Saturday I said, I think we should get out of here. We packed up personal belongings in a hurried way. We went to the office. We just put the computers in the van and drove to Manila. I never went back. We did a survey later asking people in the area if they would let us give their children vitamin A. A large percentage said no. That was the point when we looked for another place. And that place was Nepal. We shipped those computers to Nepal and we've had a terrific run of it there.

We estimate vitamin A is saving 30,000 kids' lives a year just in Nepal. In some small way, my part is helping save the lives of those 30,000 kids. That makes all the difference. That's what makes you do this stuff.