Gretchen Birbeck: I'm Gretchen Birbeck. I, as you can gather from the slides at the
beginning have spent almost 20 years and it's 20 years if you include the prep time
before my first trip working and collaborating with different people in primarily Zambia and
Malawi. And I'm going to speak to you about that a little
bit today as I look at the list of folks in the main room so far. Some of you probably have more international
collaborative history than I do. Dr. Silverberg. So I'm more than happy to have people pipe in
as we go. If you look there are some little icons below
your name. One of them is a raise your hand. There's going to be lots of time at the end for
people to make comments or ask questions. But if there's anything that I touch upon that
you'd really want to kind of chime in at that moment, please go ahead. You can do that by raising your hands. I'm not sure how easy it is for others to use the
microphone. It may be easier for you to put a comment
down in the chat section under -- type in a comment and I will read the comment
or question out for the group. So let me see if I can make these slides move
forward, yes. Okay. All right. And I should say I've put quite a lot of text on
the slides. More than I might have in a face-to-face
presentation but it was pointed out that this could be a bit easier for folks to
follow. I'm going to go through the different phases of
my interest in work overseas because my experience has been the
challenges that I ran into were sort of different at every level. And things come full circle now as I'm
supervising students, I could probably add to the challenge list having seen what's going
on in their world. But as a medical student I really knew that I
wanted to go and see how patients were taken care of
where there just wasn't a lot of advanced
technology. And I was also very interested in tropical
medicine so I decided I was going to do an international
rotation. It seemed like a simple enough thing to do
and I didn't anticipate some of the challenges that would result. It was quite difficult. I wrote more than 40 letters. This was in the day before email just so
everyone knows. And I only got 3 responses which at the time
really, really surprised me. In addition while I was trying to organize this
rotation, my dean was quite vocal that she wasn't in favor of me doing it. And the only thing that really allowed it to
happen for me and I think this is part of the serendipity, you know, lucky things
happen and grab onto the luck when it occurs, is that one of the 3 respondents was an
alumnus of my university who the dean
remembered. And she became much more comfortable with
the idea that I was going to go be supervised by a past graduate of the university. So that really made things much better. When I mentioned it had been 20 years of
work, you know, I really started applying for travel funds a full 18 months to 2 years
before I traveled and I was lucky enough to obtain some
funding. And so as a medical student I realized that I
was able -- I was able to realize my hope and go away and
do some elective time abroad. So it was quite fortunate for me. But the challenges I ran into and these are the
sorts of things I try to anticipate today with my own students is that there were no
international opportunities within my university. And I think if there's nothing structured in place,
it's difficult for central administration to get very enthusiastic about supporting
individual student efforts. The other thing that I discovered is that this
was where I was interested in working and I think this is certainly still true today, in
less developed regions of the world, communications infrastructure is very poor. One of the comments and advice I give to my
medical students who are emailing abroad, chief medical officers, etc. trying to find an
opportunity for an international rotation or an international collaboration is to really
keep their communications brief. Email access which we all take greatly for
granted as we sit in the U.S. on our rapid speed connections is not
guaranteed, not necessarily reliable, can be quite expensive, and it's certainly very
slow in many regions of the world. And so the medical students sending, you
know, 6 page emails with photos trying to persuade somebody that they should invite
them to come for a visit really is missing the point. People have limited access to these
communication tools and you should respect
that. When I finished this medical school rotation,
the next barrier that I ran into was that I had already orchestrated my residency in
neurology -- I was very enthralled with neurology and yet my
mentors in Zambia at that time really couldn't see a role for a
neurologist in their environment. And I think this comes back to the hopeful --
hopefully a myth that's being debunked but the kind of perception on the ground in
many regions that neurology is kind of an esoteric field that isn't applicable to the
average care setting. And a lot's being done by the World Health
Organization among other entities to sort of debunk that myth. But I do think we'd still be looking at that. But I did find my path. And one of the most important things I think is
if you really know what you want to be doing, what you need to be doing, you can weather a
lot of challenges. And from the very beginning I met a lot of
wonderful people, some of whom I continue to work with today and they really helped me
create later opportunities for work and collaboration. What I learned I think that was very important
for me is that the curiosity and opportunity for exploration are actually a really critical part
of academic and professional development. But these opportunities for exploration don't
happen when there's too much structure. So I would encourage everybody to really try
and build in opportunities for yourself and your trainees. So take these opportunities. Sabbatical if you're in a tenure system and can
do that is a wonderful opportunity. There are other ways of structuring it. So planning every moment and being on this
overdeveloped track of minute by minute expectations can really take away
some of the chance encounters and chances that could end up being the most important
ones. I mentioned that I was basically allowed to go
by my dean because of this chance letter from an alumnus of the university, I could give
many accounts of over and over in my path on this international work of these little
serendipitous encounters or events that have opened up entire corridors of
research and relationships. And so when you run into serendipitous events that give you new opportunities, grab them with
both hands. I discovered early on that there are lots of
doubters and obstacles that will get in your way, and you kind of have to expect that. If you are not coming from an environment
where international endeavors are the norm, you really should expect that people are going
to have some doubts about what you're doing. And don't be too disappointed when that
occurs and you really should push quite hard but you do have to be realistic about the
limitations about the environment that you're in. I said I was planning in 1992 for a trip in 1994
and I continue to encourage people to plan ahead, way far ahead, planning a really,
really obnoxiously early is highly
recommended and appreciating the challenges of
communication for others who aren't in your
environment. The next little series of events was, of course,
residency. As I was very determined to use the elective
time that I had to go back to Zambia and to conducting research. Most of my colleagues were MD/PhDs with a
laboratory background. And my residency colleagues would disappear
into their labs for research electives and I
wanted to disappear into Zambia for research
electives and so that was really what I wanted
to do. But I had to first figure out how to front load my
clinical work so that I could spend a 6 month chunk of time
there and still meet all my residency and training and work requirements. And so it took quite a lot of juggling. I had to convince my chair and residency
director to support the idea and they did. But I think possibly part of why they supported
the idea is I had a very feasible plan laid out that made that possible. And to organize things on the other end, I had
to take advantage of the friends I'd made on my first trip so that I had things like housing
and logistics in place. One of the most valuable things that happened
to me at that point was someone suggested that I walk across Wolf Street and see
somebody in the School of Public Health to help me design the research project that I
was anticipating undertaking. In retrospect, I was quite cheeky and charged
into offices of some quite high level people who kindly did not throw me out but who, in
fact, spent a quite significant amount of time helping me develop my questionnaires. And so I was able to go back to Zambia and
undertake the work I wanted as a resident. So despite the Zambian interest perspective
when I had left as a medical student, there was just no role for neurology. When I went back as a neurology resident, you
know, the neurologic disorders were so glaring it
was impressive. It really reconfirmed that this was where I
wanted to work and that there was actually a need for
neurology here. I also appreciated at this point in time that if I
just dove into doing clinical work, I'd probably burn out and be dissatisfied. I wanted to do something that also had a
broader perspective. I wanted to mix the two. Especially with the capacity to do research that
might influence and then form healthcare
policy. So I learned, you know, the challenges of your
first research project is always the hardest and it took a lot of effort to convince people that
what I wanted to do was legitimate, not just sort of me trying to sneak off on a
vacation. And it was during the conduct of this research
project that I really started to understand some of the cultural differences and how these
differences impacted the care of patients, their health seeking behaviors. But I also started to realize that having gone
through this straight biomedical route, you know, of having an undergrad chemistry
major right into medical school right into
residency, you know, that I hadn't really developed any of
the background in sociology or anthropology that might have served me
well. In retrospect the most important thing about what happened during this residency
time abroad was that I spent lots of time building relationships. And I've learned especially with international
collaborations that can undergo quite a lot of stresses that are externally imposed
stresses, stresses in terms of grants administration and
in terms of local political issues, hospital administration, that spending time
building those relationships and building that trust and friendship really helped the work
weather tough times in the future. I'm very fortunate and I learned then that, you
know, sometimes asking the top person to help you and seeking expertise and advice
broadly actually works. People will be very willing to help you and I encourage my students sometimes to --
they're always shocked. They'll read a paper they like and they don't
understand something and neither do I and I'll say, well, call them. And they're like, What? But no literally, you know, people if what you're
doing is in their field then their interest will often
embrace helping you. And probably the most important thing that I
knew in advance but it certainly bore out in my attempts to work out a long-term
residency rotation abroad was that it's much easier for your supervisors and
your advisers to support your work if you've planned ahead and other people
aren't being required to absorb U.S. based responsibilities while
you're overseas. And again this comes back to that plan ahead
really, really obnoxiously early. And then fellowship came and I wanted to get
training in how to do research that would be valuable and relevant in Zambia. And so this meant not doing an EMU
fellowship and not doing an EMG fellowship
and I thought about a neuro ID fellowship but really what I'd
seen in Zambia wasn't entirely infectious diseases. And so I realized I needed sort of health
services work, implementation research, public health, all this kind of conglomeration of
skills sets, research methodologies that I didn't have but I really did not want to
absorb more educational debt so just going
back to school didn't hold much appeal for me. So it was quite a broad search that I put out at
that time to try to figure out how to gain the skill set that I needed. And after really searching high and low, I discovered the Robert Wood Johnson Clinical
Scholars program which is a really wonderful program. If you don't know about it, I can circulate the
website. But it's for physicians who've completed their
training and it's really a broad based training in
community based research. A truly excellent program. So part of what I -- the joy of fellowship for me
was that I found, you know, that I wanted to do something unusual and I
just had to look a little bit outside my field to make it fit. And I gained therefore the skills that I needed
to do the community based research along with this sort of MPH methodologic skills that
were needed on the analytic end of what I wanted to do. I actually as a fellow in my classwork
repeatedly went to my professors when they gave us sort of course final, end of
the year analytic programs or projects for our grade, and asked them, you know, I
have all this data I collected and thankfully -- thanks to the epidemiologists at John
Hopkins, it was pretty well structured data -- can I not analyze this data instead of this kind
of bold set of data you're giving everybody to play with. Universally all of my professors at UCLA said
well sure, you know, we can do that. And this allowed me to do the analysis and get
out several publications from the Zambian data I had collected as a
resident during fellowship. Again, you know, asking a bit of somebody,
these professors certainly had to spend more time grading my project than
they did with other people's projects working with data that they knew but they were all very
helpful on that front. And by the end of this fellowship I was able to
get a small medical education grant from the World Federation of Neurology which
allowed me to return to Zambia to develop some educational tools. And in retrospect I bugged them a lot. Maybe they just gave me the money to make
me go away but it ended up being a very productive time and I think the
tools that were developed at that time ended up being quite valuable. The challenges were that the Robert Wood
Johnson fellowship stipulated that the fellows
had to focus upon U.S. based projects to improve
the health and healthcare of all Americans. They were not interested in international work. So I was little bit divided in that I was spending
my formal fellowship time doing a stroke study in California where my heart really
was resting with the research questions I wanted to ask in
Zambia. But it served me well in terms of the skill sets
that I gained and the people that I met. Also the RWJ fellowship is not for
neurologists. It's for physicians in general. It doesn't allow you to maintain your clinical
skills. I worked a long time to get those skills so I had
to find external opportunities to do clinical neurology while I was a fellow. It wasn't difficult once I decided I really had to
do it but that was something I had to organize on
my own. And at the end of fellowship, I had to find a job but the Robert Wood Johnson Clinical
Scholars program, although I think it's quite
well known in internal medicine really was an
unrecognized entity among neurology
chairpersons, and convincing them that what I'd done with the
fellowship was a bit of a challenge. But the important things that I learned from
fellowship that I think remain very important today is that I
learned how to locate funding opportunities and this is just -- if you want to be able to
maintain an academic career with an international edge, knowing how to
locate funding opportunities and access funding is just incredibly critical. Because what makes it sustainable will be
that you are able to bring in at least some of the resources you need to do the work. If you're looking for your central administration
or your department or your unit to come up with those resources, they may be
able to provide you with seed money but academic institutions in the U.S. are not
geared towards supporting international endeavors. I was able to take advantage of the sort of the
required educational activities to actually further the research agenda by
asking people to give me a little leeway in these class
projects. And, you know, I really appreciated it by the end
of the fellowship that now I have the skills that I needed to go back and do some relevant
work. Research skills are just simply not part of the usual undergraduate or medical school
curriculum. And even if you're an undergraduate who does
a lot of research which I did, it's not the sort of hard-core training and grasp
of research that's needed to do work in a -- quite frankly at the MIH level. I think 20 years ago, 30 years ago people were
self taught and that worked, but the opportunities for self teaching and the
expectations, formal credentials has changed a lot. So I tell people who want do research that they
really have to anticipate doing some sort of training post-medical school if they've gone
straight through, if they haven't stopped along the way and got
some research skills, if they want to conduct independent research. Well, now it's time to go find a job. My first junior faculty job and my primary goal
was to try to find a way to get paid and still do my Zambian research and clinical
care. So a paid faculty position that wouldn't
completely penalize me for every moment I spent in Zambia. And once I had secured that, I planned on then
trying to find some extramural funding to support my
research there. I did have a sense that I would need a mentor
and that was sort of on my radar screen though I doubt I
appreciated the importance of that. So I applied to and interviewed at seven
medical schools for a faculty position in the neurology
departments. And six of these thought my international
interests were an interesting hobby and that was very much -- I think at one site, it was even said out loud it was an interesting
hobby. Clearly, I did not see this as a hobby. I viewed this as a professional path. One place offered me a position and said
upfront, well, you know, I can give you 3 months off-campus
assignment to start with and if you're able to get funding, we can expand that. That was Michigan State University where I
remain today. I had not even been in Michigan before that
interview. I hated snow but in a heartbeat I took the offer
because I realized that this was the one place I had visited that
actually saw the potential for my interest in work in Zambia to actually be a
professionally valid thing to pursue. Again, serendipity. I was very lucky that there was a local mentor
here, not in the neurology department, actually the -- in the epidemiology department,
Nigel Paneth who helped me write my first grant. And I think I have to say without a local mentor
none of that would have happened. I submitted it to the NIH as well as a couple of
foundations. I'm going to use the term pink sheets which
will date me but I mean the summary scores I received
were just -- at the time I think I felt
disemboweled and -- but that's not the first time nor the last
time that has happened I'm sure. And well NIH was not excited about my
proposal. I did get a Rockefellers Brothers grant that was actually more money than the NIH I
had applied for. So I had gotten started on the path of
extramural funding. So, you know, faculty, junior faculty success, I
was able to find a job that would pay me to do what I wanted to do and my first project
got funded. But again the recurrent theme of having to
struggle to get the international research interests
viewed as legitimate continued. And my own naivete about the NIH system
certainly played a role in my first grant being rejected. I don't think I chose well in the study section of
the mechanism but I did learn how to write a NIH grant. The later ones were successful. And I learned and continue to learn every day. You know, pulling together a grant application
is challenging on any topic in any environment but when you add the distance between
yourself and your partner -- if you're not on the ground and writing grants
on your ground, I think for other reasons is quite difficult. You've got a lot of communicating -- communication barriers; you've got competing
interests. It gets very crazy and again back to the
obnoxious suggestion that you really have to plan early and often and I mean really, really
early -- far earlier than you would if the grant that you're
pulling together is just U.S. based. Really planning early. One of the important things that I pulled away
from this and it's advice that I continue to give fellows and junior faculty who contact
me about the hopes of building research
career that has an international component is that to
be successful you really have to have a department, college, and university
that values your work. So if you want to put your heart and soul into an
international collaboration and, frankly, I think this is true whether you're on the U.S.
end or you're on the non-U.S. end, your department, college, and university really
have to value your work. If it's viewed as a hobby that you're doing in
your free time, it is almost certainly doomed to fail. Identifying a mentor when you go from
fellowship where you sort of by design have a
mentor into your first faculty position where you think
you don't need one and you probably need one more than ever. It's just critical. And most of the work that we do today is multi-
disciplinary so I don't even think you need a mentor. I think you need a team of mentors and as
important as all other aspects of finding your first faculty position are that
team of mentors is just critical. And then when you've got U.S. responsibilities
and you've got responsibilities elsewhere, you really need -- there's a lot of competing
interests. So the best -- the better job you can do
delineating what your chair wants from you, what your colleagues expect from you, what
your students need from you, what the department administrators expect,
understanding all of those things so that you can sort of set yourself up for
success and not being a failure because you didn't appreciate what they
wanted is really important. And that maybe a negotiation process. If you can get everyone to explicitly state what
they expect of you and then sit down together and say, yeah, there's one of me and we've all
agreed I'm going to do some of this international stuff, you may be able to
negotiate that better. It may seem like the safe thing is to kind of
keep your head down and just assume you don't really know what
they want from you, but ultimately that will blow up on you. You need to be very explicit about it if it's a
position that you hope to hold for any period of time. Well, I'm not junior faculty anymore but I'm
certainly still learning lots of things. And one of the biggest issues continues to be
this kind of balancing act of trying to balance the U.S. based demands on me
with those of my international work and it's really at times quite a high-wire act. There have been certainly more than one
moment where I thought why am I even maintaining this
U.S. faculty position? I have a joint position at a couple of African
institutions. And I've thought about it on more than one
occasion of wouldn't it be easier if I just broke those ties. But, in fact, there's so many advantages to
maintaining my U.S. position. First of all, I'm able to maintain close
connection with colleagues in my field of neurology. There is one neurologist in Malawi. There's one neurologist in Zambia. There's not -- I can't walk into a room full of
neurologists and talk about the things that sort of we all may resonate on. And the importance of having those
connections really becomes evident when I'm
away six months and then I come back and I rejoin that
community and I realize how much a part of my own understanding of who I am and my
own profession comes from that and so that's important to me. It gives me an opportunity to train U.S. students
whether that be residents, medical students, or graduate students. And I have to say, you know, we have students
who have the best opportunities and often the best and the brightest migrate
towards this work and that's incredibly valuable. And so I would be afraid of losing that
opportunity. Importantly, being formally connected to U.S.
university also gives me access to the administrative infrastructure there and
this is really critical in the complex processes of handling U.S.
federal monies. So that's a huge bonus that I would be very
reluctant to give up. And, in fact, Michigan State University has been
very supportive of building the research endeavor and so
there's been lots of infrastructure into the program here at Michigan State that's
been put into place by MSU, not by extramural research funding and not by
my foreign colleagues. And so those connections have been very
valuable in that infrastructure building. But there are challenges to maintaining the
sort of dual identity and spending half your life working in the field
and half of it in the U.S. And part of that is, you know, is that to be part of a U.S. based
team, I have to make contributions to that team and that includes, you know, clinical care,
teaching, and committee work so that's part of the balancing act. Again, that's what I suggested before. Really trying to be very clear about everyone's
expectations and having these delineated in advance can go a long way toward making
that balance doable. It's much easier to have a very rational
discussion with people in advance about what expectations are and delineate
those rather than have that discussion after you've failed somebody's expectations
and now they're upset with you or they have an emotional involvement in what
you're doing. So doing it in advance helps a lot. But it comes back -- being able to maintain that
critical balance really comes back to being somewhere that values your
international research and international endeavors whether it's
research or other activities. It has to be valued where you're at or I don't
think it's possible to maintain that balance. For people who are working in the U.S. and
trying to build an international program or collaborate closely with an international
program that already exists, I have to say maybe the most important thing
that you need to remember is that you've got to know your grants administration people. You're going to need to help them to learn the
ins and outs of international grants administration if they
don't know them already. You may be at an institution where there's lots
of international work going on and the grants administrators are very
comfortable with that. But if you're not, you may have to take the role
of helping them figure things out. They've got a lot of other things on their plate. What you may find is, you know, you're in the
department of neurology and your neurology grants administrators don't
have a clue how to handle an international grant. But if you're at a large institution, look around
and you may find that the epidemiology department or the public
health or I've even seen the agriculture department,
their administrators do know. And then when you recognize that body of
knowledge within the institution, it's a lot easier to have it transferred to your
unit, either personnel transfer or somebody in that unit mentoring and assisting somebody
in your unit. If you're working with NIH and you're not
working with Fogarty but you're working with another institute and you hit brick walls on
something you're trying to accomplish from an administrative perspective -- I found that the Fogarty grants administrators
are very helpful in talking to and thinking through the process and helping come up with
ways to work through their system in a way that meets the system needs but also allows
you to do what you need to do. I see this error over and over again which is
probably why I'm pounding it so much here. But unless you're joining a very established
research group, and by that I mean they've got -- they've worked
at this site, they've worked at this site for a long time and they know what they're
doing and, you know, basically you can just
waltz in and do your science, you really need to be very
involved in the administrative work with regard to your
research. You can't just advocate the budgeting and the
logistical planning and that to other people. The reality is that your U.S. colleagues and administrators don't understand the
international setting where you're trying to conduct the work. There's no reason why they would understand
it if they haven't been there and they haven't
worked there. On the other hand, your international
colleagues and administrators don't
appreciate the level of accountability, the bureaucratic infrastructure
of your university, the complex systems involved with handling
federal funds in a valid way. And so you have to be the bridge that makes
these two things happen. And if you think that you can just write a pretty
piece of science and walk away from those things -- I've seen many, many
wonderful research projects that died on the vine because that was the investigators
perspective. What about institutional support in the U.S.? Well, if you have it, again, be certain that you
understand what they want from your international work and what it's going
to bring to their institution. So everybody in your department says, great,
we're going to do international work and you want to do research in Timbuktu and
they want you to set up a medical student
rotation in Haiti, that is not the same thing and that will
not end well. So be very explicit about what you're bringing to
the mix. If you don't have institutional support, first try to
educate the people you're working with. Trying to engage the folks that are in your
department and above you because really the support's going to have to
go at least to the college level. If you still can't really get the support you need,
look more broadly within your institution. You may find that there's international studies
program or an engagement provost. If, regardless of your best efforts, you really
can't seem to make any progress, my advice is to start looking for faculty
positions somewhere else. Because if you can't get support at your U.S.
institution, you're really fighting a losing battle in my
opinion. So establish a meaningful research program
or collaborate in one that's already established or co-established one, however the
circumstances are. I think you need to be prepared to spend a
significant period of time in the field in the setting where you want to work. For my fellows I mandate three to six months
and I encourage them to try and do a full year. I'm not sure it can happen in the U.S. but I
know that in the international settings I've been in,
you cannot build meaningful relationships that have only been built upon telephone calls,
e-mails and Skype. You really need to spend some face-to-face
time with people. Once you've done that, ongoing
communications through those modes is fine. But so many research sites that I've worked
with have already had the bad experience of
sort of research mercenaries who sweep in and
befriend everyone and rapidly collect data and swoop out never to be heard from again. This only has to happen to people once or
twice and they're done with collaborating with U.S. researchers. So you may be walking into a setting in which
you actually have to sort of be part of a wound healing process and people really
have to have some faith that you're partnering with them; you're not just scavenging and
going. The most successful programs will address
local problems and issues and the more time
you spend on a site, the more time -- the more you'll be
able to see what these local problems and issues
are. It's a little difficult though because in reality you
have to let the researching agenda go. You have to let it evolve into whatever it's
supposed to be based upon the local problems and
issues. And that may not be where you wanted it to go. It may not be work that you imagined you would
be doing. But if you can let that go, you will probably find
that the project takes on a life of its own that's far more meaningful than
anything you could have created. The most important, I think, is that people
shouldn't be arriving with a pet project in hand and expecting everybody to jump on board. That's just not how it works. And being willing. If you go somewhere and your skill set is
appreciated and people like what you're doing, inevitably other faculty, junior researchers,
students are going to come to you with their own projects they want to undertake. And sometimes these will be part of a course
work or a degree program; sometimes it will be just something they're
interested in. As much as this will take quite a lot of your
time, I would encourage you to embrace these opportunities because,
again those, projects have come out of local
problems and local issues and you may be astonished
at the value of them even if they're fairly small scale projects. Select your U.S. collaborators and students
carefully. I've witnessed this sort of explosion and
interest in international work and that's been good in some ways, but it's
been unfortunate in others. I think the proportion -- the number of people
coming who want to get involved but who are
not at all realistic is much higher than it was 15
years ago. And I'm not kidding. You know, at least once a month somebody
wants to contact me to come out for two to four
weeks and they need a publication by the end of that,
and this will be a grad student or a medical student, sometimes even a
faculty member. Like, really? I don't think so. It doesn't work that way. People -- you really need to make sure if you're
engaged with people that are going to come spend time at your site that they're
realistic about what they can expect in terms of the infrastructure and what they can expect
in terms of an academic product. And then there are lots of students interested
in working and learning and I've had the privilege of working with some
fabulous students. But there is a tendency at some institutions
that offer students international electives and it doesn't take five minutes in talking to the
student and you realize what they're looking for is an international holiday where they get
elective credit. And I don't have a problem with that but not at
my site. If that's what you want to do, do it. But I'm not signing off and I'm certainly not
organizing your trip. And it does take a little bit of face-to-face
conversation if possible and certainly at least a telephone call to feel out what
people's interests are and expectations. Know your international colleagues. I have had talks with people who are really
struggling because they feel like they're not successfully engaging their
colleagues, their non-U.S. colleagues in the work, that their non-U.S. colleagues are
not as available as they had hoped, etc. One of the things that's become very
evident to me is that the mound of responsibility and the challenges that some
of my colleagues face at Zambia Malawi is really daunting. It really swamps anything that we have in the
U.S. You know, they have more clinical work than they could ever possibly do and there's
not -- it's not like they can define it by clinical days. It just swamps them. They get loaded down with administrative
responsibilities and then they have all the infrastructure
challenges that we already know about. It helps a lot if you know what metric is used in
their setting to determine their academic success, who's
evaluating them on an annual basis. Is it their chair? Is it their dean? How are they being evaluated and how are -- what do they need to produce to be considered
successful? Because the project you're working on is
clearly something you want to advance your
career but it should also be advancing their career. But that's only possible if you know what's
required for their career to move forward. And at every opportunity you get using the
research program you have ongoing and the resources associated with that to help
facilitate their local success -- it's just -- if you do that, you will find your colleagues
much more engaged in the work when it's not competing with their other
responsibilities. Spend significant time in the field and become
an important part of the team locally. You know, wherever you go you're going to be
one of the most highly trained and skilled persons in that setting. And it's almost certainly going to be a setting
that is professionally underresourced. If you walk in and you say I've got this project
and I'm going to do this project and this project is all I really care about, you will be the only one who cares about that
project. That's not everybody else's issue. And it's not appropriate. Getting involved in every level of teaching,
clinical care, etc. identifying opportunities for capacity building at whatever level and then
balancing these activities against your research may be challenging, but
it -- that sort of investment is what it takes to have
sustainability and to really make a contribution. And when you are part of the integral team,
your research becomes part of their agenda and you'll get much more support in the work
that you're doing. But it's important to recognize that there will
also be competing interests. These are two small examples but I could
scale it up to country wide level and think about
this when you're planning activities abroad, there is
limited housing for medical students at my hospital. Every time I accept an U.S. medical student for
a rotation and book them into the housing, that is one less slot for Zambian medical
student. And I've got the only neurology rotation they
have access to. They don't plan ahead like U.S. medical
students so it would be very easy for me to fill the housing completely with U.S. medical
students and there would be nothing -- no housing available for the Zambian medical
students. So I have to balance that out and it needs to be
thought of in advance. Another example at my hospital there's very
limited transportation. If you don't come in with your own vehicle, there really are limited opportunities for
transportation. The hospital has a small pool of vehicles for
rental. Outsiders pay top dollar and the local
employed physician pays a rate that he or she
can afford. If visitors are coming in nonstop and paying
top dollar to rent the hospital vehicle to go on sightseeing tours and, you know, see the
local villages, etc. the reality is that some of local doctors can't make their shopping trip
for the week. That's the sort of competition for resources that
occurs that if you're not attentive to it you may actually
miss. So this is just small scale stuff but trust me it
happens at much higher levels. Ultimately a successful research program
belongs to the country and people where it's
conducted. It's not yours. So it's really a privilege to be possibly the
originator, you know, or the caretaker or even a participant in that work for a period of
time. But it is ultimately the country or the people that
own that project. When you're conducting research everything
that you find should be presented, discussed and disseminated locally first. It shouldn't be at the AA end that everybody
sees it, at the AA end before the population and the professionals that you work with to
collect the data haven't heard. Whenever possible when you're working with
your team, relinquish the limelight. Make sure everybody on the project gets
opportunities to present the work and at MSU, faculty are given a small budget for travel
funds. I try to use those for my dissemination and we
try to reserve the grant money travel funds to allow my colleagues to travel and present
the work. If the work is worth continuing beyond a grant
cycle or two, you really should make a local succession
plan. Who's going to do this work when you're pulled
in another directions or who's going to be taking it over over time and if at all possible there should be locally a plan
for that. And, you know, trying to make yourself
available to support projects and activity that may fall outside of your principal interest,
part of the giving back to the environment that's supporting your work. A few practicalities if the environment -- yes,
thank you. A AAN -- if the environment where you're
working is politically unstable, you may want to diversify your research
portfolio and this is advice given to me ages ago. I've been very -- I have home bases primarily in
Zambia but I do have a home and research project in
Malawi. I had colleagues who told me ages ago some
horror stories about working 20 years in a single country and when things became
unworkable in that country, they really didn't have anything else in place. So there may be advantages to diversifying a
little bit. Knowing your international IRB is critical and I
worked with IRBs in poor countries and they're very different entities in every one. Understanding the limitations of the
administration, the banking system itself, etc. They're going to be limitations for your
work so understanding them is important. But here's a key point. Yes, there are problems with grants
administration, banking, roads whatever you
want to picket, save the wailing and moaning for
your U.S. friends and spouses. Wailing and moaning to your foreign
colleagues about this when these are systems problems they have
to cope with every day, they don't need to hear your wailing and
moaning. Save it. Learn to work within the systems you
have and, you know, if you're really lucky, you can have moments where these problems
actually become opportunities for capacity building. So with that I will open it up for questions or
comments. I know there's some very engaged workers,
international researchers and collaborators on this -- in our main room here and so I will
open it up to any questions. You can type them. I don't know that you can speak them. Jeff, can people ask questions verbally or do
they need to write them? Jeff McAllister: I'd like to first of all thank you,
Gretchen Birbeck, for a wonderful presentation. And at this point if anyone -- if you have any
questions or comments, feel free to type those into the chat window
below. We advise that users only type their questions
just because there may be audio issues in case they don't have a microphone properly
set up. So at this point feel free to type in any of your
questions and comments into the space below. Krystyna Isaacs: Hello, this is Krystyna Isaacs. I have a question while people are typing
because I know my mic works. So we're -- our company is the one that is promoting the virtual meeting room here
and providing it for Fogarty. I'm just curious what kind of internet kind of
activity you have when you're out in the environment and are people using
virtual conferencing to connect back with their U.S. colleagues at all? Gretchen Birbeck: We do. So in my Zambian site, we actually have
satellite-based internet connections that's really pretty fast and allows us to do internet
conferencing. We tend to use Skype and we tend not to use
videos because videos slow things down. And what we've discovered especially with
video is that the connection is only as good as your
weakest link. The most effective situation we have is we can
use the Skype conference call that allows us to call in our colleagues from all over and their
cell phone. And so for a Skype out fairly small amount of
money you can -- you know I can pull eight people in from eight
different countries and talk for an hour and it's like $5. And they're on their cell phones and in
countries outside of the U.S. you don't pay to receive a cell phone call so they're not
paying to receive that call. They're actually able to take the call free of
charge. Cellular connections are brilliant. I have better cell service in Zambia than I've
ever had in Michigan. And so we take advantage of the U.S.
infrastructure of the fast internet connection and then we tend to pull everybody in by cell
phone. That means sometimes our poor U.S. folks
are getting here in the wee hours of the morning trying to, you know, set
everybody up for a noon day conference call but that tends to be how we do it. We can't use video and once in a while on one
of our foreign sites, there'll be a good enough internet connection
for them to accept Skype calls but usually we use Skype to pull everybody in
by cell phone. But it's critical. I have -- there's probably 15 meetings a week
with different research groups that MSU hosts by a Skype that pulls all of the folks in on their
cell phones. I should say too there's technology that allows
you on the foreign side to put your cell phone into a big speaker system similar to, you know, it's a speaker system that a conference room
can use. It took us a while to find that technology so it
takes one cell phone and then you can have a whole group of user
speakers on the other end because land line phones tend to be pretty
poor. Krystyna Isaacs: And then I could read --
there's questions from or statements from
Cathy and then Louise Wideroff . So Cathy wrote if others don't have questions
could you tell us a little about the research you do and how it was
being received in the U.S. But since there is a question, I'll go ahead and
read that one first and then if you can get back to Cathy if there's no second question. So Louise wrote, have you subcontracted or directly received NIH funds at the Zambian
institution? How was local grants administration
infrastructure built to administer the funds? Gretchen Birbeck: So good question. Not NIH but we have been able to acquire U.S.
AID, U.N. AIDS and some foundation monies that have gone directly to the Zambian
institution and actually haven't been part of the MSU
infrastructure. So we have managed to do that. The local grants administration issue has
been huge from the very beginning and as I
had one of the Brain decoders R21s which is really
when the problem with grants administration on the Zambian side became so clear. Such a problem and I have to say we had one
wonderful people who were working with us but their training and their background was
really insufficient for what was being asked of them. I can honestly say I've seen entire health
system trying to function with accounting and administrative infrastructure less than, you
know, a small grocery store here in the states would
have. And it isn't that the people aren't willing. It's just they haven't been trained in how to do
certain tasks and they don't necessarily understand the
system that they're working in. For our R01 that came from the R21 and that's
an epilepsy associated stigma study in
Zambia, the key capacity building piece that we built in
was grants administration and training. And we actually had a team of grants
administrators here at MSU which included the project coordinator for the
project who was doing all the logistics on the project level to the unit administrator in
my unit to a person who had been the head administrator in our
contracts and grants office, all agreed to sign onboard as being the MSU
training team and they worked closely -- first, we had the Zambian grants
administrators come to the NCURA meeting which is a grants research administration
meeting in the U.S. So they all met and they worked together closely for a period of
time at that meeting. Then they did distance collaboration and
support through administering the grant. And then in the third year of the grant, my MSU
team traveled to Zambia and met with our grants administrators there
and worked with them on the ground. And what we did for that is rather than limiting
that capacity building opportunity to just the project grants administrators, we
opened it up and the accountants and administrators for each of the hospital
sites participated in that and it was a very structured -- some basic
tasks and some more advances things. So we are actually formally trying to train grants
administrative skills within the Zambian people that we're working
with and we're being able to do that because our MSU grants administrators
have been incredibly supportive including
traveling all the way to Zambia to do some trainings. I will look at some of the other questions. I hope that I -- Louise, did that answer your
question, Louise? Good. Okay. So let me go to the question after Louise. And I should say we do hope eventually that
they'll apply directly for funding. Poor Don is having trouble. Don, have you been able to get your question
out there? I don't see Don's question. I will go to Cathy's question unless and until
one comes in. And so the research that I'm doing is based
primarily out of Zambia. My principal interests are seizures and seizure
disorders. And I have work ongoing that's trying to
elucidate the underlying etiology of epileptic disorders in this environment. And that's work in Malawi looking at such
things as cerebral malaria. Within the Zambian environment my primary
focus is a kind of multi-faceted series of interventions aimed at improving epilepsy
outcomes for people in Zambia with a goal of decreasing stigma, decreasing morbidity
and mortality in the -- the interventions involve things like peer
support groups, healthcare infrastructure, training of healthcare personnel, working with
teachers to train -- to improve school curriculum with regard to
educating the school that teaches about
epilepsy but also improving the attention of children with
epilepsy in schools. We're working with traditional healers and
clerics. It's quite a broad-based intervention. We've also got an ongoing covert study of
seizures in people with HIV trying to better understand the issues that evolve
when people require both anti-retroviral and anti-epileptic drugs which in an
environment where the anti-epileptic drugs
tend to be all enzyme inducing agents is very
problematic. Oh, there's a storm in Zambia? Really? Surely it's not already raining. If it's raining already, that's impressive. Is it raining in -- that would be interesting. It would be very early rains. It could be just an electrical storm. That would not be unusual. Any other questions? I would love to hear from Don. I'm sorry we haven't managed to get his
question in. Krystyna Isaacs: One thing we sometimes do
at the beginning and I'm sorry I didn't actually
did it. If everybody could write in the instant
messaging box where they're from and then we can capture that information. So if everyone just types in that chat box where
they're coming in from today and then hit return. And there is a question now, Gretchen, from
Susanna. Sorry. Can I ask about your first research
project in Zambia. It was a small scale and how did it fit into the
research structure there? Gretchen Birbeck: It was very small scale. My first -- my very first project was a hospital
based period prevalence study so very, very small. I may be quite atypical in that my very first
projects all began at a rural hospital that had no research infrastructure and no
history of research. So there really wasn't any. And the research infrastructure at the hospital until maybe five years ago was entirely what
we built. And so it was only as our rural site became
successful in research, and then we expanded to other rural sites so that we had bigger
numbers and a broader representation of the population that sort of ten years into this
we starting collaborating with the teaching hospital so it sort of grew up
from the rural hospitals and then reached out and began collaboration with the teaching
hospital. So it grew in a perhaps unusual way. Krystyna Isaacs: Gretchen, did you talk about
using the supplement mechanism to get started with projects? I was at a NIDA international meeting and
several of the PIs stood up and said that's how they started their first
international project. Gretchen Birbeck: I did not. So my -- I started basically with small projects
that were funded by foundations. So my very first, I had the medical education
grant from the World Federation of Neurology but that was very much to develop educational
tools for local healthcare workers. The first research project I had which was a
prospective covert study of seizures and long-term outcomes in Zambian children
with complex seizures that was funded by the Rockefeller Brothers fund as part of the
Charles E. Culpepper Clinical Scholars
program which was a fair amount of money but it was
foundation funds. And so I had two foundation grants that really
helped me build infrastructure and get training -- publishing track record and
build a pretty meaningful team. And at that point we were able to compete successfully almost
simultaneously for an R21 and my K23. So I -- the supplement money -- now there was
a supplement that came out for NIDS and that's been very helpful for fellows and
junior faculty I'm working with. So we've used that supplement money to start their research projects but that is not
how I started. Krystyna Isaacs: And Edith wrote, you would
like at Fogarty. There is a lot of U.S. government interest in
orphans and vulnerable children. Are you able to include this population in your
studies? Gretchen Birbeck: Yeah. We actually have to include that population in
our studies. One of the strikingly sad things about stigma is
that sort of burden that stigma will distribute itself along existing
power lines. So if you are already in a disempowered
group, if you are already a vulnerable child or an orphan or a widow, you will have
disproportionate amount of stigma for the same condition that a wealthy man will
suffer relatively little from. So we do -- there are subprojects within the
easy study, our epilepsy stigma study. A number of the subprojects are actually
geared specifically at children, specifically at
women. And so that's a yes. In the malaria work and the HIV work, we work
quite a lot -- the malaria work is almost entirely children
because the nature of the disease. And we have substudies within the HIV work
looking at access and adherence issues in
women and vulnerable children which are very
problematic so we haven't done anything -- any specific project just for those groups. But within the broader projects, there are
subanalyses and subwork with those groups that's just an inherent part
because they are such a critical part of the patient population that isn't accessing
care appropriately. Krystyna Isaacs: There's another question, I'm
sorry, from -- what funding resources do you tap into to get
U.S. and Zambian students on board in your research projects? Gretchen Birbeck: So yeah -- so we have funds
for staff or for research support within the -- we have funds for research support within the
grant monies that can be used to support -- for instance, if I need a -- I've brought people
with -- students, U.S. students who have skills in
chart abstraction in the U.S. or they're familiar with Zambian charts because they've been
there before, bring them to Zambia as part of the monies to pay for research data
collection and then also pay students locally to work with
them. And I tend to try to pair Zambian students with
U.S. students so that they work as a team because it's very complimentary. They're still sets of complimentary and it
seems very helpful. So you can write and I have it written
specifically in graduate students spots but it's often much more fluent to have just a
chunk of money that says this is line item
funds to pay stuff for data collection and travel. And then when you meet the right students etc.
that's the person who will undertake that activity. So that's how I've done that. There are, in addition, you know, we've been
quite lucky. I've had two or three Fogarty students I've
worked with, I've had a couple of Fulbright students. If you get a keen student which is really
committed and I have plenty of partners on the Zambian side too who are happy to
write support letters etc. There are nice pools of money for longer terms commitments from
students. And those can be pretty life-changing events. It's rare a good Fogarty or Fulbright student will
almost always choose a lifetime involvement in international work so I think helping them
apply for their own funding is often an even better
idea. Krystyna Isaacs: Well, I think we're at the end
now and I'll just read out loud Cathy's signing
off words which were, "Thank you very much, Gretchen,
for being our first speaker. A wonderful kick-off to our Brain Disorders in
the Developing World (BRAIN) webinar series. Please feel free to contact us at the Fogarty or
the speaker with any further questions at the www.fic.nih.gov and the FIC office
number is 301-496-1653." And I'd also like to say thank you from our side. It was a wonderful talk. So thank you very much, Gretchen. Gretchen Birbeck: Thank you.