Michela Cottini
July 24, 2020 · 4 min read

Ex Novo – Science behind the scenes

“Ex Novo – Science behind the scenes” is a series of articles born within ISA’s blog in collaboration with the Collegio Nuovo – Fondazione Sandra e Enea Mattei in Pavia, whose students community is marked by a strong presence of women in science. Science is research, long hours to carry out experiments in the laboratory or in the field, but science is also communication, grant writing, entrepreneurship, administration, teaching, project management, leadership and many other facets. We will post articles, interviews and short stories on these multiple aspects of the scientific endeavour. Should you like to contribute with your experience, do not hesitate to get in touch with Michela, ISA’s Head and Collegio Nuovo Alumna, here: michela.bertero@crg.eu

There is always method in research, even in emergency contexts

According to my experience, for some medical doctors, research and clinic work in daily practice run along two rails that rarely meet. However, when it happens, something interesting and sometimes unexpected can occur.

I am one of those medical doctors, I am a cardiologist and my daily activity is mainly divided between the Intensive Cardiac Care Unit and the Emergency Room, far away from the laboratory.  However, since I was a student, I cultivate two parallel passions: I am deeply interested in paediatric cardiology and in health issues in low-income countries. For these reasons, in 2013 I have started working together with Emergency, an Italian NGO.

Emergency is a humanitarian organization founded in 1994 to help civilian victims of war and poverty, offering medical care that is truly accessible, completely free of charge and of excellent quality. Since its foundation, Emergency has worked in 18 countries, building hospitals, rehabilitation centres, outpatient and mobile clinics. In 2007, they founded the Salam Centre for Cardiac Surgery in Khartoum, Sudan, the only cardiac surgery hospital completely free of charge available in Africa.

In 2013, I started my experience in the field, and I spent almost one year of my fellowship in Cardiology working at the Salam Centre. Here I could experience with patients affected by congenital heart diseases and rheumatic heart disease. The latter is an acquired condition in which the heart valves are permanently damaged by rheumatic fever. In western countries, this condition has been eradicated years ago thanks to hygienic condition improvement and antibiotic widespread.  However, in low-income countries rheumatic heart disease still represents a serious health problem that mainly affects children and teens, causing severe valve damage that often requires surgical treatment. Patients operated at the Salam Centre come not only from Sudan, but 16% of patients arrive from a network of 28 other African countries thanks to the activity of the Emergency Regional Programme. The Programme’s aim is to organize regular missions in all the countries where patients come from, in order to offer them the same possibilities of Sudanese patients.

I have started working with the Regional Programme in 2015, and since then I have taken part to screening missions in Eritrea, Uganda, Burundi and Nigeria. Usually, when we organize a mission, we move to a country with a very small team, including a doctor and a nurse. During the mission, we spend all the day between the screening of new cardiac patients, to evaluate if they require surgery, and the follow up of patients already operated at the Salam Centre. We travel bringing with us everything we will need to create a small, efficient mobile outpatient clinic in order to be able working in every challenging condition we might encounter. Wherever I have been, I have always found an atmosphere of collaboration with local colleagues; at every latitude, I have always learnt a lot from exchanging ideas. 

Michela at work together with local staff, sharing skills, ideas and experience.

The importance of data collection and analysis at every latitude

Something I found impressive during my activity with the NGO, first at the Salam Centre and then around Africa with the Regional Programme, is the importance that Emergency places in collecting and analysing the data. Although the high incidence of rheumatic heart disease in low-income countries, there are only few data in the literature about its features in these settings. For this reason, and to improve the quality of care, since the beginning of the cardiac programme, Emergency understood the importance of research, creating a large database and analysing the data with a rigorous method.

In the Salam Centre, as well as during the missions abroad, data collection is an essential daily activity. Even if you are visiting patients in the middle of the Burundian forest or lost in the north of Nigeria, without electricity, with the PC or the ultrasound connected to a car battery, you cannot finish your day without filling in the database with the complete data of every patient you visited. Besides data collection for research, this activity ensures that you are always in contact with the Salam Centre and, even if you are working in the field, you can easily retrieve information about the history of the patient and keep in touch with the staff in Khartoum for difficult cases.

The ultrasound instrument, connected to a car battery powering it. 

Last year, in order to improve my clinical and research skills, I attended a Master in Paediatric Cardiology at the University of Ancona, Italy, and in collaboration with the Scientific Department of the NGO, I presented a final thesis about the Emergency´s research in the surgical treatment of rheumatic heart disease in a paediatric African population. As in many research projects, I have been a player of a large interdisciplinary team. In particular, being a cardiologist, my primary activity in the project was the data collection in the field.

One could think that working in difficult settings implies doing your job the faster you can, but this is not true. During screening missions every single part of the patient’s visit requires time and method, every patient receives a clinical and an echocardiographic evaluation, and both parameters and images the doctor collect have to be in compliance with high quality standards, in order to be reliable and comparable.

When you work in the field, you can face unpredictable difficulties. It is not rare that you should stop your job because the patient does not speak a language that someone can translate or because you have to explain many times the importance of taking the therapy that you are prescribing and prevent them from selling the medicines they get, once out of the clinic. Even if this makes you lose time and the waiting room is full, you cannot skip any steps and you have to manage your activity exactly in the same way you would do in your western hospital. Working in the field taught me to be accurate and pragmatic at the same time, flexible and problem solver.

After years of hard work, it was really an honour to present the results of our research that is, to date, the largest data set available on paediatric rheumatic patients. In the literature, there are studies with only up to few hundred patients, and only a minority of them from Africa. Importantly paediatric rheumatic disease has a dramatic impact in low-income countries, and it seems remerging in the Western world. In our study, we described a population of more than 1.200 patients younger than 14 year-old operated during the 10 years of activity at the Salam Centre in Khartoum, in terms of type of valvulopathy, echocardiographic, clinical findings, and surgical intervention. Moreover, we carefully analysed their post-operative outcome and found some predictors of adverse outcome that could guide future prevention and treatment strategies. The thesis commission largely appreciated our research. Nobody could imagine that even in difficult contexts like those that you can find in low-income countries, doing serious, robust and methodical long-term research is possible. You have to believe in your project, do not give up if you have to fill in a database in the middle of a Ugandan typhoon, and always have a car battery to connect your PC.

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