NATURE

A researcher-exchange programme made me a better doctor at home and abroad

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Two people, one wearing a lab coat, talking to a man in a hospital bed.

Caleb Skipper (right) answers questions about lumbar puncture with translation help from Alisat Sadiq (centre) at Mulago National Referral Hospital in Kampala.Credit: Caleb Skipper

Caleb Skipper had his first interaction with African science in 2009, when he visited Ethiopia as an undergraduate at the University of North Dakota in Grand Forks. He spent a year working on a project to improve diagnosis of malaria with limited resources, which meant using his intuition to improvise. For instance, he helped to boost the diagnostic capacity of a health clinic in Binishangul Gumuz, a mostly rural area, by configuring a microscope that ran off solar power. He also helped to implement a process to detect malaria in the rural environment and taught local women how to work as basic laboratory technicians with support from several charities.

Those early experiences showed him that he could work in austere conditions and thrive in different cultures. They inspired him to seek research opportunities with other projects in Africa and Latin America as he pursued medical training.

In 2017, during his infectious-diseases fellowship at the University of Minnesota (UMN) in Minneapolis, he travelled to Uganda to study cytomegalovirus (CMV) as a risk factor in advanced HIV disease at the Infectious Diseases Institute (IDI) of Makerere University in Kampala. During a 2019–20 fellowship at the IDI funded by the US National Institutes of Health’s Fogarty International Center, he worked on randomized clinical trials of antifungal drugs and drug regimens to treat HIV-associated cryptococcal meningitis. Now an infectious-diseases physician at the University of Minnesota, Skipper splits his time between Minneapolis and Kampala. He tells Nature about the lessons he’s learnt during his collaborations.

How did you end up in Kampala?

Mostly due to my mentors’ relationship with the IDI. One of my primary mentors, infectious-diseases specialist David Boulware at the UMN, has had more than 20 years of collaboration with my other mentor, HIV and infectious-diseases specialist David Meya at the IDI. The collaboration includes annual exchanges of medical trainees between the two institutions. After my initial experience here in 2017, I was eager to participate in an ongoing collaboration with the IDI to broaden my knowledge of infectious diseases and learn more about how to ethically conduct clinical research in resource-limited settings.

We can do all the research here on site, and then the IDI owns the research findings. This is in contrast to collecting the data, taking it back and doing the analysis in the United States and then making the local institute just a minor partner. The partnership is key to building the local research capacity.

How does the exchange programme work?

Medical students, residents and other trainees at the UMN have opportunities to volunteer at the IDI, Makerere’s College of Health Sciences and Mulago National Referral Hospital in Kampala for sessions from one month up to one year. Some volunteers mostly see patients or teach, whereas others focus on research. I worked with David Meya and his team, learning from their expertise and observing how patient care and clinical studies are conducted the IDI. Likewise, Ugandan trainees and study-team members can do clinical rotations at the UMN, including attending the UMN tropical-medicine course, and have opportunities to learn new laboratory skills or present research at conferences.

What have you learnt from your experience at the IDI, and what are you working on now?

I am developing an assay at the IDI translational laboratory to detect certain viruses, such as CMV and Epstein–Barr virus. I am also developing improved techniques to study patients’ immune responses that will be useful for trying to understand how viral co-infections affect people with advanced HIV disease.

I have learned a lot through my time at the IDI. I’ve learned about a different culture, and how that difference can lead to both wonderful moments of learning and frustrating moments. For example, to diagnose and properly treat people with HIV-associated meningitis, we need to put a needle into their spine to do a lumbar puncture to determine the cause of their meningitis. Understandably, people can be quite apprehensive about this. Sometimes they will even refuse it. It has been valuable to learn about the patient’s perspective on why they might refuse this necessary procedure, and then develop educational materials that could help to address their concerns.

I have also become more skilled at making medical decisions without being overly reliant on diagnostic testing. And I’ve gained a better appreciation of the dedication of caregivers and family members, which are things we sometimes overlook in the United States. I hope that all Western-trained doctors will have experiences in places such as Uganda to help build a broader and more compassionate worldview.

On a fun note, I’ve enjoyed trying new foods such as a meal of matooke, the local cooked banana, eaten with groundnut paste, and learning to sail a boat on Lake Victoria.

Can you describe an achievement of the research exchange?

Our Ugandan team at the IDI had a major role in a randomized clinical trial called the Ambition trial, which was completed in 2021. The trial was for people with HIV who develop cryptococcal meningitis, a serious fungal infection of the brain, and the goal was to determine whether a single, high dose of the antifungal medication amphotericin B would be as effective as the standard treatment, a lower dose given over seven days and recommended by the World Health Organization (WHO). It was a multinational trial, mainly supported by the European and Developing Countries Clinical Trials Partnership, and involved five African countries: Uganda, Botswana, Zimbabwe, Malawi and South Africa.

The results were published in a 2022 study1 led by Joe Jarvis at the London School of Hygiene & Tropical Medicine, which found that the single-dose amphotericin B regimen was as effective as the standard of care. In addition, the single dose was associated with fewer serious adverse events such as anaemia and kidney injury. Owing to these findings, the WHO modified its international guidelines to recommend the single-dose amphotericin B regimen as first-line therapy. Because the single dose is easier to administer in resource-poor settings, it will help thousands of people living with advanced HIV worldwide to fight this deadly infection.

This interview has been edited for length and clarity.

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