Interviews from The Field #1: “Mum’s the Word” – with Nicole Yan
I catch up with former classmate Nicole Yan, who is working out in rural Kenya on a project aimed at improving health outcomes for pregnant women and their future babies. But how did she get this gig? Why is it so important? … And can we do anything to help?
Nicole, you were in my cohort at the London School of Hygiene and Tropical Medicine in 2012/13. What did you study there and how did you find it?
I had finished an MPH at the University of Hong Kong and was still feeling lost as to what I wanted to do. One evening, I saw a documentary of an epidemiologist investigating an outbreak of anthrax among hippos in Uganda on TV and thought that is the job I want! So I studied epidemiology at LSHTM. I loved every brainy moment of it. It is very deductive and it made me feel like a little Nancy Drew solving puzzles with a great team of enthusiastic people.
Did you enjoy living in London for the year?
Regrettably, I didn’t get the most out of London because the program was very demanding. But knowing you have the world’s finest culture at your fingertips is very exciting! London is also very eclectic and artful. The School is full of brainy scientists and so the city museums and music scene really provided a good balance. As students we’d dig out special offers for plays and concerts. Weekend food markets were also excellent for the bargain foodie.
From the bustling metropolis of London you moved straight to rural Kenya! What encouraged this big switch?
After the program, I felt like I had the skills to go back to the developing world. I was offered a position with the Liverpool School of Tropical Medicine as a research co-ordinator for a maternal health study in Kisumu, Kenya at a big research collaboration between the Kenya Medical Research Institute (KEMRI) and US Centres for Disease Control (CDC). The year at LSHTM was very theoretical and it was the perfect opportunity to get my hands dirty with field work.
What’s the PhD about?
About a year into the research, I saw the opportunity to turn it into a PhD project. The PhD is about implementation. We have the science and technology, but how do things translate into effective delivery on the ground? I want to assess the feasibility of delivering a package of rapid diagnostic tests to screen pregnant women for HIV, syphilis, malaria and anaemia in rural low resource facilities in western Kenya. In these low resource facilities, women are referred to bigger facilities for these tests (except HIV which is done at point of care) and many of them do not go resulting in missed opportunities. So by offering testing at the most basic facilities, we capture the women the moment they enter the healthcare system.
So the PhD aims to understand the process of implementation, and the ease and challenge of the current health system to absorb new programs.
Historically, clinical studies in pregnant women have been an overlooked area of science, particularly in the tropics. Why is using RDTs in antenatal screens for HIV, syphilis, malaria and anaemia particularly important?
The 4 conditions I mentioned above are part of focused antenatal care that the WHO and Kenya ministry of health recommends. This is because they need to be screened for and treated as early as possible to prevent adversely affecting the developing foetus. The HIV virus, which affects 20-25% of pregnant women in this area, can be prevented from passing from mother to child if she is put on anti-retroviral treatment early. Syphilis affects 1-2% of the Kenyan population and in pregnancy causes congenital syphilis resulting in gross abnormalities of the baby which can be easily prevented by screening and treating with a single dose of penicillin. Malaria affects 1 in 4 pregnant women, risking low birth weight babies and miscarriages and over 60% of women walking into antenatal clinics are anaemic, which is a major risk factor for maternal death.
These are not conditions we see frequently in the developed world. It is easy to forget we have such simple solutions for them.
Not all tests are infallible. How do you address the issue of ‘false positives’ for diseases like HIV or syphilis within a clinical study in low resource settings like Rural Kenya?
There is an algorithm for HIV testing that is part of Kenya ministry of health policy. Three rapid diagnostic tests are used to confirm HIV infection. If the first screening test is reactive, a second confirmatory test is used. If the confirmatory test is also reactive then the women is declared positive. If the confirmatory test is non-reactive, meaning the screening and confirmatory test are discordant, then a third tie breaker test is used.
Syphilis screening is not as detailed. Syphilis is caused by a bacteria called Treponema pallidum and there are tests that detect biomarkers that are released during infection (non-treponemal tests) and tests that detect antibodies specific to the treponema pathogen (treponemal tests). Ideally a non-treponemal test such as RPR or VDRL is used to screen and a positive result confirmed with a treponemal test like the SD Bioline rapid syphilis test. However, non-treponemal tests require laboratory equipment which are not available in low-resource facilities. So the treponemal rapid syphilis test is the only test we use, likely resulting in over-treatment.
Did you always envision doing a PhD someday?
Not at all! I’m not a big planner who has 5 year plans laid out. I just follow my intuition and this is where it’s led me. I let my curiosity guide me.
Where do you hope your new arsenal of research skills will take you post-PhD? ….Or is that still to be decided?
Hehe…I guess my intuition will tell when I get there! But I know it will be in the area of translating all our grandiose ideals into concrete effective benefits.
How can people support this great project?
Sadly there have been recent problems with the usual channels of project funding out here. I’m not the only person to be affected. With only 2.5 months left of field work, I am trying to think positive and garner support from helping hands through crowdsourcing. A little goes a long way! What we need most are supplies of rapid diagnostic tests for syphilis and cuvettes for testing anaemia. A box of syphilis tests costs $36 and can last a facility for almost 2 months! Without these, testing cannot go on and so I hope we can all be part of ensuring the 7 pilot facilities where the program runs are well stocked. The evaluation will give us valuable information on how it worked and how to improve when we want to scale up. People can donate to support this project on my crowdsourcing page, here.
Finally, do you have any words of wisdom for people interested in pursuing research or work in this field?
Grit. You cannot do anything without really wanting it. When times are tough, your core reason for doing what you do will shine through. Make sure you know what that core is saying. So take time and reflect! Self-knowledge is key.