Alexandre Carvalho, MD, MPH, assistant professor in the division of infectious diseases, had wanted to develop a global health fellowship to bring students to the Amazon River in Brazil ever since he did part of his own residency training there in 2019. A native of Rio de Janeiro, he was struck by the rich learning opportunities offered by the region where the Rio Negro and the Rio Solimoes meet, called the encontro das aguas—the gateway to the Amazon.
“I didn't want to forget where I come from,” he says of his interest in the region. “I care a lot about the global south and inequality. Then when I got there, the strange pathogens, the fungi, the malaria—you get exposure to things you might not see in the U.S. in your entire career.”
In addition to neglected tropical diseases, his initial experience also offered rich opportunities to provide much needed primary care. Going up river in a boat that houses a medical clinic, doctors traveled to hard to reach indigenous communities to treat people who otherwise have very limited access to medical care, for free.
Ever since, Dr. Carvalho has been on a mission to bring more students and trainees to this area of the world, in the hope that they will have formative experiences of their own. This summer, for three weeks in late June and early July, his vision became a reality.
![From left, fourth-year student Luna Paredes, second-year student Nicholas Alegre, second-year student Kassandra Lanza, second-year student Allie Liebmann, and Dr. Alexandre Carvalho, aboard the Padma.]()
From left, fourth-year student Luna Paredes, second-year student Nicholas Alegre, second-year student Kassandra Lanza, second-year student Allie Liebmann, and Dr. Alexandre Carvalho, aboard the Padma.
Thanks to support from Albert Einstein College of Medicine’s Global Health Center, the division of infectious diseases leadership, and Joshua Nosanchuk, MD, a physician-scientist with collaborations in Brazil, Dr. Carvalho and four medical students spent two weeks at a hospital in the city of Manaus, before boarding the Padma, a two-story live-aboard boat, and heading up the Rio Negro. The fellowship is named Pah Muri Mansa, which means “people who’ve gone through a transformation” in Tukano, a language spoken by one of the tribes that lives along the Rio Negro.
“This offered a unique opportunity to learn about a totally different healthcare system, and do primary care in community settings,” says medical student Allie Liebmann, who is now starting her second year at Albert Einstein. “Also, it’s just a really cool place to get to go to.”
An Intensive in Tropical Medicine
The group landed in Manaus on June 17 and was quickly rounding on patients at Fundacao de Medicina Tropical Heitor Vieira Dourado, in Manaus, a city of over 2 million people. On their first day, they saw a child with meningitis caused by an uncommon fungal organism, Cryptococcus gattii. C. gatti is a yeast found in soil and certain trees and can cause severe illness, including meningitis, in people with otherwise healthy immune systems.
![The group at Fundacao de Medicina Tropical Heitor Vieira Dourado, a hospital in Manaus, together with medical students from Spain and Portugal.]()
The group at Fundacao de Medicina Tropical Heitor Vieira Dourado, a hospital in Manaus, together with medical students from Spain and Portugal.
They also saw cases of AIDS. “It was like a trip back in time to the 1980s,” says Dr. Carvalho. Luna Paredes, a fourth-year medical student, was struck by seeing complications from HIV that have become uncommon in the U.S. “While the hospital was well-resourced, the patients did not have the education and access to medications to manage their HIV and keep the virus from destroying the immune system,” Paredes says. “We saw a lot of histoplasmosis, TB, all the stages of syphilis, cryptococcal pneumonia. The disparity of resources was sobering.”
Students spent time rounding on patients in their areas of interest, as well as time in the ICU. “It was fascinating to see how the medical teams were able to provide excellent care with less access to technology,” says Kassandra Lanza, who is beginning her second year. “They have clinical strengths that allow them to work with the resources they have to serve people in need.” In one example, physicians there commonly perform lumbar punctures, a procedure now done in the U.S. almost exclusively by interventional radiologists or neurologists with specialized training.
Up the Amazon by Boat
After two weeks at the hospital, it was time to board the riverboat that would be their floating home for nine days, run by a Brazilian nongovernmental organization, Universidade do Amor. Their path up river cut through Anavilhanas National Park, one of the earth’s largest fluvial archipelagos and a world heritage site.
![The group lived aboard the Padma for nine days.]()
The group lived aboard the Padma for nine days.
Dr. Carvalho did his medical training in Brazil and has a valid medical license there, so he was able to provide care to people along their route. The communities along the river are isolated and for many, seeking routine or even more urgent care is not always viable. “There are some roads,” says Dr. Carvalho, “but after a while it’s just the wild forest and the river. Disease and health, goods, services, people all traverse the river waters. If you don't have a boat and access to gasoline, it can be very difficult to get what you need.”
This was the case for one patient the team found who overnight had become unable to speak or walk. His lungs were crackly sounding, and they suspected a stroke and possibly an infection. “If this person lived somewhere else, they would have been in the hospital already,” says Liebmann. The team was able to find someone with a fast boat to take the patient to Manaus, and Dr. Carvalho called the hospital there to communicate their concerns and ensure the patient would be admitted right away. After the group returned to the U.S., they got word that the patient was treated with antibiotics and eventually discharged back to his community. “We were there at the right time for this person,” says Liebmann.
![Student Nicholas Alegre with a girl from a community along the Rio Negro.]()
Student Nicholas Alegre with a girl from a community along the Rio Negro.
The villages they visited ranged from more traditional indigenous communities to those with greater access to technology and exposure to the wider world. Sometimes the group made house calls, while in other locations they made themselves available for medical consultations in a central location in the community. In one village, they saw more than 50 patients in a day.
Malnutrition is common, as are parasites, and eye disorders including cataracts and pterygium, a growth of the membrane that covers the eye, which can impair vision. Because each community is isolated, they would see the same viral infection in many members of the same village, something Dr. Carvalho calls “communal outbreaks.” In one village, a woman was four months pregnant without having known. For some communities in need, they also brought donations of food, medicine and clothing.
A Strong Start
Even in its first year, the program attracted more applications than it could accept. Due to academic schedules, it is open to medical students following their first year or going into their fourth. One important asset for students interested in applying is some knowledge of Portuguese or Spanish.
Dr. Carvalho is hoping to secure funding to eventually expand the program from four students to eight, and also to be able to bring more medications as well as solar panels to communities along the river. Albert Einstein’s Global Health Center is an instrumental partner. “It was amazing to have such support from the college,” says Dr. Carvalho. Another goal is to build partnerships between researchers at Albert Einstein and in Brazil, to learn more about some of the pathogens they encountered that are not well understood.
![Sunset over the Rio Negro.]()
Sunset over the Rio Negro.
Part of the program is that the students will present at Global Health Night at the Albert Einstein campus in September. In addition to packing in a lot of clinical learning opportunities, the fellowship provided other less tangible, but no less valuable benefits.
“Rio Negro means black river,” says Dr. Carvalho. “The water is black, acidic, and the sky reflects on it perfectly. You don't know where the river ends and the sky begins. The sunsets last for three hours. Practicing medicine, and studying it, demands a lot, and the pace of boat travel and the river landscape are restorative. It brings healing to providers, too.”
“The fellowship was the full package,” says Lanza. “We got to experience how a different healthcare system works, have cultural exchanges with welcoming people, and we got to see the beauty of the Amazon.”
Posted on: Thursday, August 08, 2024
