A Long-Distance Year Off from Medical School

By Adam Marcus
TO HER SURPRISE AND RELIEF, SARA AULD DOES NOT HAVE tuberculosis. At least, that was the case in early January when the 26-year-old P&S student was tested for the infection during a trip home to New York City from Durban, South Africa, where she has been spending the school year — and where TB is a major occupational hazard.
     A fellowship from the Doris Duke Charitable Foundation is enabling Ms. Auld to work with the Center for the AIDS Program of Research in South Africa (CAPRISA), a group with strong ties to Columbia. She is studying metabolic changes in women recently infected with HIV as part of an ongoing project funded by the National Institutes of Health to study acute HIV infection.
     “It is now becoming clear that people who have established HIV infection are at higher risk for diabetes, heart
Rural community outside Durban
Rural community outside Durban
disease, and strokes,” she explains. Some of that increased risk is attributable to antiretroviral drugs and how they interfere with the body’s ability to process fat, cholesterol, sugar, and other nutrients. But the virus also appears to have a direct effect on metabolism — an effect that has not been well explored in the early stages of infection.
     “No one has investigated whether these changes, or precursors of these metabolic changes, are evident in acute and early infection or, if so, whether the presence of metabolic derangements early in infection predicts the development of diabetes, heart disease, and other complications later on,” Ms. Auld says. “Early identification of at-risk patients could potentially allow for early intervention to prevent the complications.” The problem — and the need for a solution — is becoming ever more pressing as the number of HIV-positive patients who survive without progressing to end-stage AIDS continues to grow.
     P&S is one of 10 medical schools in the United States with 12-month clinical research fellowship programs funded by the Doris Duke Charitable Foundation. The foundation supports classes of medical students who take a year off from medical school to receive hands-on clinical research training. Students work with leading physician-scientists who serve as mentors. Most Doris Duke fellows stay close to the campus that selected them. The Doris Duke Foundation funded, as part of a new initiative in global health, Ms. Auld’s project in South Africa. She developed the research proposal with the help of her mentors, P&S infectious disease experts Scott Hammer and Magdalena Sobieszczyk, who are both involved in the CAPRISA project. CAPRISA (www.caprisa.org), was founded by the Universities of KwaZulu-Natal, Cape Town, and the Western Cape; Columbia University; and the National Institute for Communicable Diseases. Ms. Auld attributes the success of her project to the guidance and support of Professor Salim S. Karim, the director of CAPRISA, Dr. Koleka Mlisana, and the CAPRISA staff.

Hardest Hit
KwaZulu-Natal is the South African province with the highest rate of maternal HIV infection. According to a 2004 study, nearly 30 percent of pregnant South African women carried the virus, while in KwaZulu-Natal the rate was 40.7 percent. Estimates put the overall rate of HIV infection in South Africa (for everyone over age 2) at about 10.8 percent. In KwaZulu-Natal, according to Ms. Auld, unpublished reports suggest the figure may now be as high as 50 percent in certain regions of the province.
     Meanwhile, TB — the leading killer of AIDS patients in South Africa — is alarmingly rampant as well. South Africa
 Sara Auld in the Drakensburg Mountains
 Sara Auld in the Drakensburg Mountains
in 2002 ranked ninth among the world’s 22 most TB-afflicted nations, according to U.S. Agency for International Development. That year, nearly 250,000 people, or 558 per 100,000, had the infection. Roughly 2 percent of South Africa’s new TB cases that year were resistant to multiple antibiotics. Much of the burden of the disease falls on the sagging shoulders of KwaZulu-Natal.
     The bulk of Ms. Auld’s day-to-day efforts have focused on analyzing data collected through a study of women who are likely to become HIV positive. In analyzing data, she has learned about the clinical management of HIV and tuberculosis. She also has gained insight into the challenges of patient care without access to costly laboratory tests and imaging technologies that most American medical students take for granted.
     Ms. Auld, however, acknowledges that her education carries a steep price: Most of her clinical insights come courtesy of a woman who has contracted a potentially life-ending virus. “I am able to rationalize it by saying to myself that one, at least they’re finding out their status; two, they are gaining access to care and services as a part of this study; and three, given that there are thousands and thousands of infections happening every day, it is important to conduct research that might help stem the tide of infection and death. It’s tough, though.”
     Dr. Hammer, the Harold C. Neu Professor of Infectious Diseases in the Department of Medicine, professor of epidemiology at the Mailman School of Public Health, and chief of infectious diseases, says Ms. Auld’s project has potential to generate significant science. “It’s important and relevant. The information she’s gathering will be of broad interest in the field of AIDS research.”

Science the Goal, but Thirst for Experience
Ms. Auld spent a stretch of her childhood in Tokyo, where her father was assigned to a Bank of America branch, and went to high school in Dallas. She attended Stanford University as an undergraduate, majoring in history “because I figured I should study something I really enjoyed while I still had the chance. I would have the rest of my life to immerse myself in the sciences.”
     For her senior honors thesis she chose Charlotte Blake Brown, one of the first women doctors in California. Dr. Brown opened a children’s hospital in San Francisco during the 1870s, managing to overcome the widespread bias against female professionals that marked the times.
     It was also during her senior year that Ms. Auld found a job coordinating a series of biweekly conferences on the intersection of medicine and the humanities. Subjects of these talks ranged widely, covering medicine in the novels of Henry Fielding and Samuel Richardson, the death of a twin, and much in between.
     “The two physicians in charge of the series were very supportive of my entering medicine as a field,” Ms. Auld says. “I was also able to meet physicians from across the country who had melded medicine and life outside of medicine as poets, writers, artists, activists. I was struck by how they all turned medicine into something very personal, both for themselves and for their patients.”
     After graduating from Stanford, Ms. Auld took a year off, hoping to gain exposure to more of the world before embarking on medical school. She spent the first part of that year working at Planned Parenthood in San Francisco, then moved to Colorado for a more leisurely stint as a waitress feeding a snowboarding habit.
     When the ski season wound down, Ms. Auld signed on for a six-week medical mission in Ecuador, through Child Family Health International. “I had traveled extensively but had never spent time in a foreign medical setting,” she says. While there, Ms. Auld and her colleagues spent a few days at a public maternity hospital in Quito. She recalls her shock at seeing health care being delivered in deep squalor. “The women, some of whom were as young as 15, were just lined up next to each other with their legs spread wide. The doctor would walk down a row and point at which ones were dilated enough to be taken into the labor rooms. The conditions were terrible, there were no epidurals, the women were all crying.”
     Although Ms. Auld had volunteered at Stanford’s Lucile Packard Children’s Hospital, her experience in Ecuador
Sara Auld, left, and fellow P&S student Lisa Bebell’08 in Hluhluwe game reserve
Sara Auld, left, and fellow P&S student Lisa Bebell’08 in Hluhluwe game reserve
was completely different. “For the first time I was seeing patients who were poor, uneducated, uninsured, and in a clinic or hospital with limited resources and funds.”
     Meanwhile, the replies to Ms. Auld’s medical school applications began coming in. “I chose Columbia because I figured it would be a place where I would get good clinical exposure to a wide range of patient populations and a place where I could take advantage of any free time to explore the city,” she says.
     Ms. Auld completed three years of medical school before her Doris Duke year and is now scheduled to graduate with the class of 2007. The grind of the first two years was not what she expected. “I don’t think I really hit my stride until the third year,” when regular patient contact begins to occur, she says. “But I was finally able to see what all of the hard work had been for.”
     Last fall, when her classmates were choosing specialties, Ms. Auld found herself uncertain. “I was drawn to internal medicine, to pediatrics, and somewhat less to OB/GYN,” she says. “I approached Dr. Hammer and expressed to him my interest in spending a year in Africa doing HIV research,” she says. “I knew that I was interested in HIV/AIDS and it seemed like Africa was an obvious place to spend time to see if that interest would turn into a career.”
     For his part, Dr. Hammer recognized a solid fit. “She came to me already with a lot of obvious intelligence, talent and dedication, and an interest in international health. I thought she would be the perfect candidate to pilot a Doris Duke overseas fellowship.”
     While Ms. Auld had not focused much on AIDS, she had always tried to stay abreast of international health issues — including spending a college summer working on AIDS policy issues for the Clinton administration.
     “Now,” she says, “I’m at a point where I’m so far immersed that I can’t remember what it was like to think that HIV wasn’t the single most important health care issue facing the world.”
     She credits Dr. Hammer with helping her focus her interest and with encouraging her to apply for the Duke fellowship. “Columbia has never sent a [Duke] fellow overseas before and so it took a lot of convincing and reassurance that I would be appropriately mentored and that CAPRISA was equipped to give me a worthwhile experience.”
     Ms. Auld is grateful for Dr. Sobieszczyk’s day-to-day guidance on everything from general reassurance to help with interpreting, synthesizing, and presenting data. Sometimes, their conversations involve personal safety, not an inconsequential topic in Durban, where Dr. Sobieszczyk also spent time working with CAPRISA. Ms. Auld, Dr. Sobieszczyk says, “has become an incredibly valuable member of the research team. She is very mature and has been able to navigate the local research and clinical environment with incredible finesse.”
     Despite the long days, Ms. Auld has managed to see a fair bit of South Africa. She has taken several treks in the spectacular Drakensburg Mountains, which the Zulu call the “Barrier of Spears,” gone on safari (complete with a charging elephant), sampled wine in the vineyards near Cape Town, and toured Robben Island, where Nelson Mandela and other political prisoners were jailed during apartheid. One trip to KwaZulu-Natal included a special treat: the annual Reed Dance festival, during which more than 10,000 virgins parade before the king.
     She also has been preparing for the Indian Ocean Marathon, which involves training runs in scorching heat and withering humidity over hilly terrain. “It’s a far cry from Manhattan, where the biggest hills are in Central Park,” she says.
     “This experience has definitely confirmed that I want to do a residency in internal medicine and likely head on to a fellowship in infectious diseases,” Ms. Auld says. “I cannot imagine a more worthy and rewarding path for myself.”

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