It's not about you: perspectives from initial site visits in Karnataka, India
Emily MacLean (MSc, PhD Candidate)
One of the objectives of my doctoral thesis project is to determine the diagnostic accuracy of a new lateral flow biomarker-based Tuberculosis (TB) test. We are trying to understand how well it works to detect extrapulmonary forms of TB in hospital in-patients at two tertiary hospitals in India, KMC Manipal and KMC Mangalore.
Depending on the extra-pulmonary disease site, different tests (up to four or five in many cases) are needed to ascertain a diagnosis for TB, which places a large burden on the patient. Because this new biomarker test uses urine as a sample and provides results in less than an hour, it has the potential to substantially improve the quality of care of people with suspected extra-pulmonary TB. A fast, accurate diagnosis means that individuals can receive appropriate treatment in time and get their lives back on track. As this was my first trip “in the field” (this has always seemed like kind of a ridiculous term to me?), I was excited and nervous, but at least I had enough self-awareness that I didn’t really know what to expect. Most students in my lab have done primary data collection in India, so I’d heard from my lab-mates about their experiences and picked up helpful bits of information (e.g., buy the Odomos bug repellent cream when you get there (!!); bring a couple passport-sized photos; download ride-hailing apps before you arrive) before I left.
For a country as large and diverse as India, everyone has something different to say about it, and their experience will be different than yours. In my opinion, when going somewhere for “global health work”, it’s important to keep in mind that you’re going for work; it’s not a trip that’s all about you. In that context, many things are going to be different than your probably largely self-directed life, especially in workplace social norms and rules. And if you're a racialized person like me, your experience is likely to be different again. There are all sorts of things that are easy to know and hard to believe. The space between knowing something you’ve been told and deeply understanding it is quite large in global health. I suspect I’ll go through this iterative process again and again with each additional project in my career.
Most of my time at the two KMC hospitals was great, but it is hard to overstate how ignorant you are as a visiting student. You really don’t know anything practical, administrative, or otherwise. In my situation, I have an MSc in Microbiology & Immunology, but the most entry-level microbiology lab tech could identify V. cholerae under a microscope in about two seconds whereas I had no idea what I was looking at. I’m doing my doctorate in epidemiology, but I don’t really understand how critical a 2% drop in test specificity is for people making patient treatment decisions. Particularly as someone whose main research interest has always been infectious disease, everything I’d learned up to that point had been theoretical and, even if it was at the bench, largely inconsequential. Certain issues I’d previously thought trivial were now concrete considerations. This experience added a completely new dimension to my understanding of what counts as important in diagnostics.
At the same time, in the interest of scientific/study validity, at times it is important to stress that procedures must happen in the particular way in which the study protocol has specified. As a student, insisting on doing procedure Y in manner Z can be very uncomfortable. In my case, I was projecting onto others that they thought I was ungrateful for the opportunity I’d been given. But this highlights why it is important to have real partnerships with people and institutions that have the capacity and resources for research in a genuinely collaborative way. Having a study protocol that everyone designed gives you something to fall back on: everyone has already signed off on it.
Walking the line between cultural humility and scientific integrity is interesting and challenging, and as I plan to have a career in global health, it is something that I’ll be continuing to work on. Going forward in my studies and career, I think it is important to keep this frame of mind, i.e. humility as a learner and visitor, when engaging in global health work.
About the author
Emily received her MSc in Microbiology and Immunology from McGill; her thesis explored a parasitic Leishmania and viral coinfection. Still at McGill but now an epidemiology PhD candidate under the supervision of Dr Madhukar Pai and Dr Nandini Dendukuri, her thesis work focuses on TB diagnostics in a global health context. She is particularly interested in new tests for extra-pulmonary TB and novel biomarker assays, and ensuring their access in vulnerable groups.