Jonathan Golub
Brazil
School of Medicine, MD program
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Tuberculosis is an ongoing global health problem, especially in the World Health Organization’s targeted countries for TB control, a list which includes Brazil. One factor that impedes TB transmission control is a long time interval between the onset of symptoms of active, pulmonary TB disease and the beginning of TB treatment. Other studies performed in resource-poor areas have associated a longer time interval with a higher death rate, a greater extent of disease in the lungs, and a more extensive transmission to contacts. One factor that may contribute to a delay in beginning treatment may be barriers to access to care, whether due to structural inefficiencies or individual perceptions. This ongoing, cross-sectional study focuses on patients with active, pulmonary TB who seek medical treatment at one urban and one rural outpatient health center in Nova Iguacu, Rio de Janeiro state, Brazil. Specifically, it uses a questionnaire to gather information regarding basic patient demographic information, the presence and duration of symptoms of pulmonary TB, and perceived barriers to seeking treatment sooner, as well as medical evaluation of the TB case. The study seeks to provide an operational and quantitative evaluation of the time interval between onset of active tuberculosis symptoms and the beginning of treatment among patients who seek medical care at these two centers, along with the enumeration of variables associated with a possible delay in TB diagnosis and treatment, in order to identify targeted interventions for improved TB control.
 While in Brazil, I shadowed doctors and epidemiologists, both in a large tertiary care facility in Rio de Janeiro and several periurban primary clinics outside the city. As a medical student with an interest in public health, I gained great insight into patient evaluation and follow-up, the daily work of clinical trials, and the social barriers to the provision of health care. I had a unique opportunity to engage with many different health professionals, including pharmacists, nurses, and administrators and policymakers, while working on tuberculosis research and treatment. This project also forced me to be independent and proactive in innumerable ways: reading X-rays with no previous experience, relying on my limited Portuguese to gain access to hospitals, and exploring a new city on my own.
 Of course, one of the most personally rewarding components of my project was the setting itself, Rio de Janeiro. Rio is a place in which extremes of geography are jammed all into one place: the mountains touch the sea, forming breathtaking natural landscapes. The built environment, too, seems shoehorned into the space as well, with sixteenth century monasteries nestled in among twenty-first century skyscrapers, and favela slums smashed up against guarded, gated communities. The idea of this collision of extremes is, I found, reflected in the diverse groups of people in Rio. There are few places that can top Rio's unique mingling of samba bar musicians and rap battlers, the see-and-be-seen crowd at Leblon and Ipanema Beaches and the Bohemian t-shirt vendors, street kids and well-heeled professionals. Attempting to understand what this mix means was intimidating, but ultimately my trip energized me to continue my career in global health.
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