Not Your Average MD- Service Abroad w/ Paula Hertel and George Ferry

April 3, 2006
Not Your Average MD- Service Abroad- Paula Hertel (Zambia and Sri Lanka) and George Ferry (Bolivia)

Dr. Paula Hertel,
Gastroenterology, Hepatology, and Nutrition, Texas Children’s Hospital pmhertel@texaschildrenshospital.org

Background

She’s gone on 6 1/2 mths-2wk service trips

§ Undergrad: music/psych/research assistant with sleep disorders=stimulus for being a doctor

§ Med school (Uof MN): 1yr basic science research in Houston; clerkship 2mth in Zambia= permanent effect “formative experience”

§ Baylor TCH residency: 1 mth Rio Hondo, Guatemala (two docs from there set up a hospital, still ongoing program for TCH residents); 2wks Montero, Bolivia; 1 mth in Gaborone Botswana: city hospital, mostly AIDS work

§ Fellowship: GI/Hepatology/Nutrition- good mix of different levels of illness; good specialty to work overseas in; good people; 1yr flight transport physician at TCH (1992-3); 1yr overseas with MSF, studied Spanish in Guatemala 6wks then 6.5 mths in Sri Lanka. (they’re very picky about placing new volunteers)

§ Motives for Service:

1. learn about life for other people in other places

2. help where it’s greatly needed= feel indispensable

3. learn about diseases not common to US

4. broaden sense of world outside US

5. decrease guilt about living an affluent lifestyle in US

6. be an ambassador for the US

Senanga, Zambia: Rural Public Hospital

-high AIDS rate, orphaned kids, TB, drug-resistant malaria; no treatment for AIDS was available and diagnosis of AIDS carried huge stigma= pts refused blood test for HIV

-was wealthy until 70s, copper industry went downhill

-government frustrating; 2 exhausted physicians; high amt morbidity and mortality “I was horrified the first time I walked in”;

Lessons from Zambia:

1. need to be part of a team, by yourself, you’re not very much good

2. resources need to be used appropriately; having them not enough

3. corruption is the biggest enemy of most poor people in the world

4. doing your best, even if it doesn’t save a life, is often very meaningful to a grieving family

5. stigma of AIDS is a huge barrier to solving the aDIS problem

6. the guys that take dugout canoes down the crocodile-infested Zambezi are extremely skilled and brave

7. “I gave my heart and soul, but I still gained more than I gave”

Sri Lanka with Doctors Without Borders (MSF for Medecins Sans Frontieres)

- totally different, very good team that reacts quickly (MSF); ceasefire in 2002 after almost 20yrs civil war b/n a Tamilese Liberation mvmt (Tamil Tigers) and the government;

-hospitals gone, electricity gone;

-country has potential b/c people educated with good work ethic and resources; lots of refugees

-minimal pathology (normal illnesses; not like Zambia)

-local staff very honest and well-educated

-MSF: France, Belgium, spain, US offices (relatively independently); usually work in conflict-ridden areas, esp. underserved; in Sri Lanka for 17yrs

-mobile clinics: meds, etc. in car, go see pts at house or old clinics, get permission to use it and go!, drive back; some work in a hospital

Lessons from Sri Lanka

§ it’s awkward sometimes to be a “Have” in the “have not” world; efforts can also seem like just a drop in the bucket

§ working in a team (ex. MSF) magnifies effect of person alone

§ don’t worry about getting murdered; danger is in car accidents

Questions-

Q. What’s it like for volunteers in Doctors Without Borders with families?

A. Those volunteers can work in cities with amenities needed;

General Advice-

1. Infectious Disease is very useful in international medicine
2. It’s great to have training in common procedures like obstetric surgery, etc.
3. Avoid medical tourism: think about making a sustainable impact; teaching people how to care for patients or making a return visit
4. Be humble; remember that you’re a guest in someone else’s country

Dr. George Ferry
Gastroenterology, Chief of IBD (Inflammatory Bowel Disease) Clinic, Texas Children’s Hospital
gdferry@texaschildrenshospital.org

Background

-He didn’t have any opportunities to go abroad in med school or residency; his daughter was in Public Health in International Health and Nutrition; she worked with the Mennonite Central Committee in Bolivia (jungle community in central Bolivia- they worked on latrines, wells, nutritional projects, etc.)

-His daughter became the regional director after 4 yrs there. She brought Dr. Ferry down 10 years ago

-1^st trip: survey of communities in central Bolivia to see what a pediatrician could do that was sustainable

Working in Bolivia

-Problems in central Bolivia, especially in jungle communities: no medications dispensed, no treatment for chronic illnesses; people can’t go to cities for treatment b/c property would be stolen or b/c they had no transportation; people had drastic health problems that received no attention; example: woman with broken clavicle/dislocated shoulder for 3yrs

-Jungle communities: a chieftain’s hut with families scattered remotely in the jungle; they could set up clinic in chief’s hut

-Lowland communities (Montero): crowded barrios, water was clean but no other basic amenities. No health service available except for kids to receive immunizations for a month. However, one clinic had a director who was very involved in surveillance but many people move in and out of his community, so he had no control on the reintroduction of TB, for example.

-First trip after survey trip: didn’t want to return for a third trip because the 2nd trip was too short and he didn’t have time to connect or interact with patients; 3rd time, took more time and found that interaction with patients greatly increased his enjoyment of the trip and desire to return

- 2006=9^th year to make the annual Bolivia trip; they take about 20volunteers/yr: Rice students, med students, nurses, nurse practitioners, doctors…all specialties were useful; one neurologist made a huge impact with amount of diagnoses he made. (doctors in Bolivia had a hard time giving pts negative diagnoses; this neurologist was able to honestly communicate the difficult problems he saw)

- Eventually they had to start fundraising.

The Bolivia Annual Trip Grows

- Non-physicians got involved: they made new projects like building brick homes to get rid of Chagas’ disease after getting clean water supplies and some health education (clean water reduced 50-person community infant death toll to 0); the non-medical volunteers also share in medical work by doing home visits

- The volunteers’ working environment: mainly work out of one clinic which has good rooms and great office staff; they all review chronic patients at day’s end and talk about how to care for them when Ferry’s group leaves

- Sugarcane is a large industry there; burning and pollution of factory are problematic; they took a eco-tourism jungle trip but the blood-sucking insects left them dripping (good anti-coagulant); accidents still high;

Programs

- About 1/3 pts need chronic care; Dr. Ferry’s group is starting to see patterns such as a high rate of asthma, no preventive asthma care there; they started a preventive program with huge success; it was very gratifying to see patients a year later with positive results

- They began some ambulatory service to get patients from the jungle

- They work with a girls orphanage: most were abandoned, some parents can’t afford to take care of their girls but still visit them in the orphanage. Dr. Ferry’s group takes down books, makes parties, etc. They’ve worked in the orphanage on construction, started a sewing project, and more.

The Good, the Bad, the Ugly

- a boy with cleft palate received plastic surgery in a larger community (they paid for it); 3mths later, surgery was infected and destroyed the lining of his mouth and exacerbated his condition greatly (can’t speak, more problems eating, more embarrassment, etc.). he met visiting US plastic surgeons, had 5 sponsored surgeries and he’s finally talking “sometimes you want to do so much good, but you can’t”

- some patients try to manipulate the system (so listen to groups you’re working with)

- (Paula Hertel speaks of a woman in Sri Lanka who absolutely convinced her to cut into her toe because she felt a piece of shrapnel there, there was nothing as Dr. Hertel thought; the women later asked her to sign papers allowing her compensation from the government for a war casualty)

- (Dr. Ferry again) one husband refused the tube-feeding of his baby b/c tube-feeding took away from mother’s working time; no legal child protective services system are available (and girls aren’t really valued); the clinic tried to convince the dad, no effect, baby died

- With every trip, “I get more out of it then I give” it’s a joy to work with people there and to share projects with others.

- Giving free medicine is a problem b/c most people are superstitious, so clinic charges nominal fee; bringing medicines is worse than putting dollars into Bolivia than buying meds there, so they buy what they can in Bolivia (b/c they’re able to get most common meds)

Questions

1. Who funds your trips?

Most people pay their own way; if he has extra (personal or departmental) funds, he uses them to help students go. The clinic there is connected with a US NGO, Curamericas, that works in Bolivia, Mexico, and more; now Curamerica charges too much for trips so the volunteers organize their own trips independent of Curamericas. They are going out the first 12 days of July this year. If interested, email gdferry@bcm.tmc.edu to discuss possibilities.

2. how did you clean the water of one community?

By digging deep enough and chlorinating the water and delivering clean water.

Foreign volunteers lead communities in discussion of needs and organization to address them.

3. So what was the water like before?

It was tap water from the city, collected rainwater (but dry season); the water was kept in dirty receptacles on floor, etc.

General Advice

1. There are lots of opportunities for multi-faceted medicine: committees, clinics, book chapters, teaching
2. Interact with your patients
3. Have a very open mind and adapt yourself to the way your host community works