STUDENT LIFE - IN SEARCH OF ADVENTURE
By Maryann Brinley

Almost all medical students can be called adventure-seekers, thirsty for knowledge, but some are gutsier than others. Douglas Berkman, a 25-year-old, second year student at UMDNJ-Robert Wood Johnson Medical School (RWJMS), is the lead author of a research paper, "Effects of stunting, diarrheal disease, and parasitic infection during infancy on cognition in late childhood: a follow-up study." Recently published in the esteemed British medical journal The Lancet, the piece is based on his work with children in a South American shanty town.

This is a big deal, especially for a student. Even a BBC News report mistakenly named Doug Berkman a doctor already though in reality, he has a few years to go.

"The Lancet is very international, with a major focus on public health," he explains. "When I asked my professor about chances of having the work accepted for publication in such a prestigious journal, he said, 'Well, not good, maybe 5 percent.' But I thought, why not go for it?" Berkman is the kind of guy who always goes for it. "I was surprised by what happened," he admits, in between bites of a tuna fish sandwich in the CABfare dining room on the New Brunswick campus during an escape from studying in the library. "No one loves sitting in a library for 12 hours but medical school is a challenge. Studying is studying and it's not always fun but I like knowing things," he says. "Actually, I like the feeling when I finish studying."

Picked up by news organizations all over the world, Berkman has become a voice of alarm, as well as reason, for scores of third world children at risk for multiple parasitic, bacterial and viral enteric infections. Up until now, research on the relation between cognitive function, diarrheal disease and stunted growth has been limited, especially any attempt to look at children over a long period of time. Yet, "risk factors that interfere with cognitive function are especially important during infancy because the first two years of life are an essential period of rapid growth and development," his study states. Estimates of the number of stunted children under age 5 run as high as 40 percent in underdeveloped countries and knowing exactly when the window of opportunity appears for the greatest positive effect on this human disaster makes Berkman's results remarkable. In the future, public health programs will have sound, scientifically based reasons to put their scarce resources in the right place at the right time: before kids turn 2. In fact, severe growth retardation between 12 and 24 months is associated with a 10 point deficit in IQ by age 9. The team of researchers, led by Berkman, have paved the way for a larger study and possibly, more funding for the problem.

Doug Berkman and his father and mother, Drs. Sheldon and Barbara Berkman

Yet, the real drama in this research and publishing coup d'état may lie beneath the surface of the printed Lancet pages. In fact, the journey to this big byline was anything but smooth.

"I always wanted to be a doctor and I really enjoy going to school here," he says. Now living in Somerset with four fellow RWJMS medical students, this Princeton, NJ native graduated from the University of Pennsylvania, then decided to pursue a master's at Johns Hopkins School of Public Health before applying to medical schools. By the spring of his first year at Hopkins, he was in search of a research topic for a thesis, and ready for adventure. "All I knew was that I wanted to do work internationally or go out of the country." The opportunity to spend three months in Lima, Peru, with Robert H. Gilman, MD, of the Hopkins' Department of International Health was perfect, even if it meant jumping into unknown intellectual and geographic territory. Berkman grabbed it but before hopping on the plane, he completed the first stage of applications to 12 medical schools and mailed them off.

Meanwhile, Gilman, who spends most of his academic year in Peru, had collected data on 239 Peruvian children from 1989 to 1991, following them from birth to age 2. The kids lived in woven thatch houses constructed from wooden poles in Pampas de San Juan de Miraflores, a pueblo hoven (transitional community on the outskirts of a city), where nutrition was less than ideal and water was trucked in to be stored in cisterns possibly contaminated with fecal matter. This was a community where housing conditions were defined by floor type – cement vs. dirt – and toilets could be silos or holes in the ground. The possibility of going back to test these children and examine various environmental factors in these kids' impoverished lives was tempting...if they could be found. They would be 9 years old.

With nearly a decade's distance from the original data, trying to track down 239 children might have been difficult anywhere but in a Peruvian shanty town with shifting populations, the task might appear to be insurmountable. Gilman dropped the germ of the idea into Berkman's lap, via e-mail, anyway. "There were really no longitudinal studies and I flew to Peru not knowing very much," Berkman admits, "I sensed that Gilman's guidance would be there but the legwork would be up to me. Basically, I didn't know anything...how I would follow through or where to start. I hadn't even spoken any Spanish in two years."

Adapting to South America's slow pace, Berkman soon realized that what might seem like a reasonable daily to-do list was just crazy there. Not only are people laid back, but even computers take longer to boot up and get to work. He scaled back expectations but dove into the assignment. Conducting background research wasn't easy in Peru and it took him a month to get up and running with his ideas. "I would say to myself, 'You can't do this in one day but you might be able to do it in a week,'" he laughs. "I consider myself an impatient person and everything moves very slowly there."

Doug Berkman's adventure in research and publishing began in a shanty town in Peru where local residents came to his rescue occasionally.

Lack of language skills put him at a funny disadvantage. "Even when I thought I was speaking really clearly, you should have seen the expressions on the kids' faces." Where adults might try to be patient, children shrugged as if he were loco. With Sonia Lopez, his field worker, he began tracking down children in the old neighborhoods of Pampas de San Juan de Miraflores, an hour away from Lima where he lived. "These really nice kids would follow us around and climb into the back of our pickup truck." Yet, even as his dialect improved, nothing came easily. A group of psychology interns he had enlisted from a local hospital to administer tests tried to quit. "I was really nervous because I needed the data, couldn't do it all by myself and they decided that being paid in lunch and transportation wasn't what they bargained for." A friend with better Spanish skills talked them into staying on the project but "it was pretty scary," he recalls. Even standard IQ testing materials weren't available. "Parts of this Wechsler Intelligence Scale for Children (WISC) test require little blocks of wood and we only had one copy so a couple of Dr. Gilman's nurses, their sisters and others brought in balsa wood. We had to improvise and fashion our own WISC pieces."

As the project came together, he was able to gather data from 143 of the original 239 children, a significant figure because with a smaller number of subjects, his study would not have been as important. "I was lucky because the pueblo hoven had become a more permanent community. Some families were at the same addresses in the original data set." In the back of his mind, however, the summer could easily end up as an adventure to write home about but not for a publication like The Lancet, considered tops in news of international public health. "I liked the topic and I was out there working every day but the bottom line was: if there weren't any deficits in cognitive function, I might have very little to show for my efforts. Doing research is fine but can be scary."

In the meantime, he received good news and bad news from home. The secondary applications to medical schools had arrived and that meant lots of essays and answers to be written in Peru, at night, on a snail-speed computer. "For weeks after being out in the field all day weighing, measuring and testing kids, I'd drive back to Gilman's office in Lima, work on my essays, and fax them off to my mom. She would type, cut, paste, fax and re-fax everything back to me. If she wasn't there, I don't know if I'd be here."

Berkman's work on the statistical data he gathered that hectic summer in Peru as well as the writing, analyzing and editing continued for two years. "I realized that I had something good and I knew I had to write the paper but it was a constant matter of plugging away," he recalls, "and finding time." While completing class requirements for his master's, writing his thesis, interviewing for medical schools, and then starting classes at RWJMS, he nudged the project toward publication amid continuous rounds of critiques, which are consistent with any major journal protocol. At first, he found himself constantly writing, rewriting, editing, e-mailing and using instant messenger as he coordinated comments and suggestions from co-authors Andres Lescano, a doctoral candidate in International Health at Hopkins, Maureen Black, PhD at the University of Maryland, and Gilman.

The Lancet has in-house editors but to decide if an article is good enough for publication, they also rely on a panel of outside reviewers. The news that his work was being sent off to this outside group arrived in the middle of his first year of med school but that meant more rewriting, commenting and incorporating even more changes.

By the summer when these reviewers wanted feedback on myriad aspects of the research including his statistics, he was with a colleague of RWJMS Professor Abel Moreyra, MD, doing cardiology research outside Buenos Aires, Argentina. Once again, he found himself confronted with a long distance puzzle to solve and a parent who would come to the rescue. "It was funny to repeat the same kind of challenge of being away in South America but forced to work on material under pressure. This time I asked my dad to go into my computer, look for specific logs of data sets, fax or e-mail them to me. When you do statistical research, you keep a folder of each day's log so I had hundreds of them. I'd be talking to him on the phone, he'd be searching through the computer, trying to figure out where to go and what I needed."

The Lancet published his eight page article along with a commentary from London's Institute of Child Health in Feb- ruary but not before pulling Berkman into one more adventure. On December 23, the night before departing for a family vacation in Colorado, galleys arrived from the editors with the instructions to get corrected proofs back to England in two days. With med school exams over, "in the middle of that time of year...holidays, vacations, New Year's," he says. "I wanted to call them up to ask why. But you can't do that. You're just happy it's getting published." He jumped in his car, drove from Princeton to Somerset where everything was stored in the computer and worked straight through until 5 am. Then, he raced back in time to catch the flight. "I just made it," he says. Yet, for someone like Doug Berkman, there was just no chance of not making it.

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