Diaspora Stories: Creating a New Context for Latin America's Trauma Epidemic with Clinical Research

We do what we do because we believe that the diaspora have already started giving back to health systems and want to do more. One of the things we're learning as how creative they can be in the ways they do so. Below is an example of how research can be leveraged to support health systems at home.

Dr. Juan Puyana is a trauma surgeon and Associate Professor of Surgery, Critical Care Medicine, and Clinical & Translational Science at the University of Pittsburgh. He is the Past President of the Pan-American Trauma Society and Director of Global Health for the Department of Surgery. A Colombian himself, he won multiple Fogarty grants and trained 14 Colombians who have returned to support trauma capacity and clinical research in their country, all while being instrumental in the development of the country's health infrastructure himself. Read our interview below, lightly edited, to see how he did it. 


Let's take a step back and learn a bit about how you came to the US to begin with.

Transient

So I graduated from medical school in 1984.  I left Colombia because I didn’t think I would get properly trained there. I was wrong about that, but you’re young, and I knew English, and I lived in the United States when I was kid, and I had this sort of dream that I would come back to the States at some point. And all I wanted to do was pass the exams and get a residency. But when I was in Colombia, they offered for me to do research at McGill. I started working in the lab, an opening came and I was allowed to stay and finish my residency in Canada. 

I came to the States to do a fellowship in Trauma. I went to Yale in New Haven, CT, which at that time in the 1990s was a drug hub--there were gunshots there every day. I met my wife there, she was a nurse, I married her, and I decided to stay in the United States. My kids were born in Worchester, I worked at UMass, and then I went to the Brigham and Women’s Hospital in Boston for four years, then I came here to Pittsburgh. And over all that time, I always felt that I wanted to do something for Colombia despite not having gone back to work there as a surgeon.

[The NIH Fogarty International Center] has a mechanism called the D43 training grant, which is the main mechanism by which the NIH has trained people all over the world. For many years, the focus of the D43 training grants were all on infectious disease, mainly AIDS, malaria and tuberculosis. Infectious disease investigators around the world have been very successful in procuring grants and philanthropic support to carry on important work in LMICs. Trauma surgeons, on the other hand, have done a lousy job in convincing public opinion and important international NGOs to support training and clinical research for trauma care. 

But in 2006 the first injury based training search program was created by the FIC. I put a team together with trauma surgeons from Colombia, submitted a grant, and obtained $750,000 for capacity building in Colombia.  We partnered with [La Universidad de Valle] in Cali, which is one of the best trauma centers of the world.  I had gone to Cali once or twice a year, operated with them, and had seen how these guys do what we do here with a tenth of the blood and half of the ICU beds--and their patients survive with few complications. 

Any global health effort needs to be done in a well-informed manner... “Oh, we just went to this place, we operated on ten kids...and we left”. What did you leave behind? Surely you left behind 10 happy kids, but could you have left something else?

So we developed this program and trained a  number of people that went back to Colombia. Some PhDs, a couple masters, some of the trauma surgeons, these  people got here, learned what it’s like to be in an academic center, what’s it like to collaborate and write papers, basic knowledge on clinical research and research methodology. They all returned to Colombia and now are  writing and submitting papers. Never in the history of the American Association for the Surgery of Trauma were there any papers submitted from Latin America, except for maybe one from Brazil every few years. Since 2006 there hasn’t been a year  that Colombian trauma surgeons trained under these programs  haven’t had one, two, even four papers in the AAST. It’s all team work and I’m happy to have been a piece of the little endeavor. Another grant came in about bioinformatics, and not knowing a lot about informatics,  we created a new team with the DBNI at Pitt and partnered with a different university in Colombia, this time in Bogotá.  We also obtained a third grant that was the product of work performed here at Pitt by one of our first trainees. He’s now a neurosurgeon and he wrote a grant on decompressive craniotomy, which we are now completing in Bogota. 

    Dr. Puyana teaching medical students in Ecuador. From  El Mercurio,  2013.

 

Dr. Puyana teaching medical students in Ecuador. From El Mercurio, 2013.

We just received another grant two months ago. This is to develop an Electronic Medical Record for trauma so that we can develop a trauma registry for these busy hospitals which have no trauma informatics infrastructure. We are going to do it with the help of a team of innovative programmers from the University of British Columbia, who had developed a similar application for Cape Town.

We put together a multinational team and we will do it in Cali this year, next year in Asunción, Paraguay, and the next year we will do it in Guatemala. So a week from today, Canadians, Paraguayans, Guatemalans will come meet me in Cali to watch the residents work at night, see what their work flow is and even develop a prototype for a tablet they can use. We will also have capacity building activities as part of this grant with a team of clinical investigators from Rosario, Argentina so that trainees are familiar with the many applications the data from a trauma registry may have. 

And that's what so empowering about this--it's this idea that a lot of the story of global health has been an issue of Westerners coming and setting the course of priorities and making advancements according to a foreign agenda. We want to change that, and with their own trauma registry data they will be able to set their own priorities and hopefully reach out to policy makers with real data.

A lot of people are now showing an interest for global health and there are many activities taking place under this rubric.  Clearly it is not enough for what the world really needs yet one still has to be careful. Even though people want to do well, any global health effort needs to be done in a well-informed manner. Just traveling for “adventure” and thinking that going to some place is doing whatever they say is "global health" may actually have adverse effects and not be seen as helpful by the local people one is hoping to help. So I’m very careful when everyone uses “global health” in a very loose way. As long as you’re helping, that’s good. Sometimes though what you’re doing can be seen in a different context while you’re thinking that you’re helping. And that’s when you can screw up really badly. “Oh, we just went to this place, we operated on ten kids...and we left”. And what did you leave behind? Surely, you left behind 10 happy kids, but could you have left something else?

 With delegates at the XXVI Pan-American Trauma Congress in Santiago, Chile.  (American College of Surgeons Committee on Trauma)

With delegates at the XXVI Pan-American Trauma Congress in Santiago, Chile.  (American College of Surgeons Committee on Trauma)

I go and learn from the people in Cali, and the people in Cali learn from here. I think that networking, having an open mind to all kinds of possibilities is key to being successful.

How did you develop these relationships?

Even if you don’t get the money, even if you don’t get the project, develop the history, as rudimentary as you can actually do it. An email, a contact, an address.

In my case it was easy because many of the trauma surgeons I have been collaborating with for years in Colombia were my classmates from medical school. In addition, the other thing that has made Pittsburgh an incredible place to create meaningful relationships in Latin America was that the Pan-American Trauma Society headquarters were based here for almost ten years.  Over these years we went to many meetings and annual Congresses of the society, we met a lot of people from across Latin America and we had the opportunity of visit their hospitals and learn about their needs and greatest challenges they face.

I think the success of these research programs relied on showing the NIH in our case that we already had a working relationship. That doesn’t mean that you cannot create new ones. If you show that small or not too ambitious collaborative efforts may have positive outcomes through exchanging experiences and mutual learning, it could go a long way.

So even if you don’t get the money, even if you don’t get a large project, develop the history, as rudimentary as you can. Start working and publish your findings and experiences so you can share them with the larger community.

Many students have great hopes of going abroad and engaging with international projects. Unfortunately these plans do not always come true. There are places who may benefit by having a student visiting for a summer but are not always these places are prepared to receive them-- in fact they may very well be overwhelmed and not prepared to host foreign visitors.  My advice for students is to learn as much as they can before committing to go and to ensure that there is an active interest both from home institution faculty and their partners abroad. 

That’s one of the operational hazards of international research.

Not everyone abroad is ready to receive a young student. They’re clinically busy. They surely don’t have protected time for research --they don’t get paid for it, and they may not even  get recognized academically.  For these reasons any potential visitor needs to be sensitive of their presence where ever they go and be sure not to become a burden.

Going back to the big question in my case. I believe that in order to substantially change the way we provide care and at least in trauma and emergency medicine, you don’t need a lot of money. Learning how to put a chest tube can actually save a life. Such interventions are clearly less expensive than treating someone with AIDS or providing chemo for cancer or even managing diabetes.

Trauma is a big killer, taking more people than malaria, TB, and AIDS together. We could probably achieve greater outcomes if we organized and systematized our efforts in order to train people, and adjusted to local resources in order to have a greater impact in these countries. That’s what actually moves me.