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    • African woman gives oral vaccine to boy while another boy looks on

Fighting Disease in Remote Territory

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As leaders of a vital epidemiological study in the Democratic Republic of the Congo, two PhD students have overcome challenges unlikely to be found in any textbook.

Map of Democratic Republic of Congo

Nicole Hoff’s car was stuck in the mud, and the Fielding School PhD student was a long way from home.

Since 2011, Hoff’s classroom has been the Democratic Republic of the Congo (DRC), where she and classmate Reena Doshi (who joined her in August 2012) have shared an apartment in the capital, Kinshasa. With generous support from the Faucett Catalyst Fund, their faculty adviser, Dr. Anne Rimoin, has established a training program for her students to gain hands-on field epidemiology experience in low-resource, logistically complex settings such as the DRC - the world’s 11th-largest country, and one of the poorest. Under Rimoin’s tutelage, Hoff and Doshi have helped to implement an epidemiological study covering the entire DRC, including its most remote, difficult-to-reach areas. Their work regularly takes them to villages with no electricity, refrigeration, running water or outside communication. In a vast country with relatively few roads - travel essentials include motorcycles, small boats and the ability to cover long distances on foot - covering a few hundred kilometers can take a full day when you factor in the river crossings and walks through marshes or forests. And if there is a misstep, as when Hoff’s car ventured into unfit terrain, all bets are off. “Something like 40 people came out from the nearby village and spent eight hours helping to dig our car out and push it through the mud,” Hoff recounts. “They asked for nothing in return.”

images of children in the DRC, Nicole Hoff with Reena Doshi, woman organizing medical supplies and man marking a map
Under the tutelage of their FSPH faculty adviser, Dr. Anne Rimoin, Hoff (shown upper right, right) and Doshi (shown upper right, left) have gained hands-on field epidemiology experience in the low-resource, logistically complex setting.

Doshi and Hoff are members of a DRC-based leadership team (part of Rimoin’s UCLA-DRC Research Program) tasked with determining the extent to which the DRC population has immunity to vaccine-preventable diseases. Worldwide, immunization against tuberculosis, diphtheria, pertussis, tetanus, measles, yellow fever and polio, among others, saves millions of lives every year and is among the most cost-effective public health programs. But one in five children globally fail to receive the most basic vaccines, and an estimated 1.5 million children die each year from vaccine-preventable diseases. The majority of these deaths occur in low-income countries such as the DRC, which besides being one of the world's poorest nations, has been devastated by war and corruption for much of its 50-plus year history.

Reena Doshi
”There has been a big push to vaccinate in the DRC in recent years. But given the inaccessibility of so much of the country, it’s hard to know how successful it’s been. Getting to participate in this study from its conceptualization to the end has been so exciting.”  – Reena Doshi

“There has been a big push to vaccinate in the DRC in recent years,” Doshi says. “But given the inaccessibility of so much of the country, it’s hard to know how successful it’s been.” Instead of relying on what the child’s mother remembers, which has its shortcomings, the study checks blood samples for antibodies to vaccines that are included in routine immunizations. Rimoin received funding from the Bill & Melinda Gates Foundation to join with other partners in the study, which is being conducted as part of the larger Demographic and Health Survey funded by the U.S. Agency for International Development, World Bank, Global Fund, UNICEF and others. In addition to determining rates of immunity - and potentially identifying geographic areas with low rates that can be targeted in vaccination campaigns - the survey is contributing to the worldwide polio eradication effort. 

The Fielding School students have played an integral role in the survey’s planning and implementation, including training survey-takers; supervising them in the field to ensure proper administration of the questionnaires and collection and storage of the blood samples; and working with the Kinshasa School of Public Health and U.S. Centers for Disease Control and Prevention (CDC) in coordinating the laboratory analysis. Ultimately, they will analyze data from the study and present findings to the Ministry of Health and other lead organizations.

images of boat, students treating patients

Many of the challenges they have encountered along the way are unlikely to be covered in any textbook. During the now-completed data collection phase, Doshi and Hoff supervised and frequently joined team members in transporting questionnaires and medical supplies long distances for 2-3 week stays at a village destination (504 sites in all), operating within strict budget constraints. The blood samples that were collected had an expiration date - if they remained in the field too long, they were no longer viable - so considerable coordination was necessary to get the samples to the labs in a timely fashion.

Nicole Hoff
“I came here with little experience outside the classroom. I’m leaving with the confidence that my work can make a big impact on people’s lives.”  – Nicole Hoff

Despite the many obstacles, the survey was completed in February of this year and the research team has begun analyzing the data. “Getting to participate in this study from its conceptualization to the end has been so exciting,” says Doshi. For someone interested in a career identifying and controlling the spread of emerging infectious diseases in a global setting, she can’t imagine a better training ground than the DRC, where scant resources and the large swaths of undeveloped, sparsely populated land create the potential for infectious diseases to lie dormant. Nor could Doshi imagine a better adviser than Rimoin, whose DRC-based research program, established in 2004, works closely with the Ministry of Health, Kinshasa School of Public Health and DRC National Reference Laboratory to identify emerging infections and improve general disease surveillance and immunization in the country. Rimoin has also given her students - the first two who have been funded to join her DRC research group - freedom to participate in activities outside of her project, and Doshi and Hoff have found time to serve consultancies for the CDC and World Health Organization on studies assessing the efficacy of just-completed measles and polio vaccination campaigns.

“It has been extremely gratifying to watch these two young women blossom into bonafide field epidemiologists, with the skills to design and implement important research studies in logistically challenging settings,” Rimoin says. “Not only have they learned a great deal, but in the context of their training they have contributed significantly to public health in the Democratic Republic of the Congo.”

“It has been extremely gratifying to watch these two young women blossom into bonafide field epidemiologists, with the skills to design and implement important research studies in logistically challenging settings.”  – Dr. Anne Rimoin

Hoff, who like Doshi expects to graduate later this year, knew she wanted to train under Rimoin from her first year as an MPH student at Tulane University, where she read a National Geographic article about the outbreak of monkeypox in the DRC that highlighted Rimoin’s surveillance efforts. “I came here with little experience outside the classroom,” Hoff reflects. “I had never been camping, never been without electricity, and I wasn’t used to not having the Internet at my fingertips when I needed to look something up, much less riding on the back of a moto through the jungle or meeting a minister of health. I’ve gotten to see how ideas are developed and come to fruition, and I’m leaving with the confidence that my work can make a big impact on people’s lives.”