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Beyond the Call of Duty

The New Physician January-February 2000
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Escaping the trappings of Western medicine—if only for a few weeks each year—
thousands of doctors volunteer their services overseas with medical relief organizations. The work is difficult. Yet, most agree it’s immensely rewarding. Little, if no bureaucracy, politics or paperwork. Just the chance to practice
pure medicine.



Roaming the streets of Sobral, Brazil, a loudspeaker perched on its back, the truck makes its way around the coastal city, spreading the word about a group of U.S. volunteer surgeons coming to open a temporary clinic. Television and radio stations broadcast the reports over the airwaves. Local newspapers publish advertisements. Patients are recruited from all over the area—many travel hundreds of miles, sometimes by foot or horseback, to see plastic and reconstructive surgeon Dr. Jack Demos and his Pittsburgh-based Surgi-Corps International crew.


To parents of disfigured children, the surgeons are little-miracle workers, repairing a cleft lip in a matter of hours. To an adult with severe burn scarring, left untreated for years, the visiting team makes an unspoken wish come true. For a couple of weeks, from dawn until way past dusk, the physicians consult, operate and care.


Depending on where they go, Demos and his team—which might include a general surgeon, a urologist, an anesthesiologist and some assistants—usually consult with a couple hundred patients and operate on 50. The conditions the physicians attend to are rarely life-threatening. Now and then they’ll come across a patient with a serious infection, but the team usually corrects “horrible deformities” that would have been tended to earlier had the patients had access to care, Demos says.


Demos founded Surgi-Corps International in the mid-1990s with the intention of creating a “hometown” medical relief organization. With help from friends and a few overseas contacts, he pretty much runs the group himself. Demos organizes local fund-raisers, collects supplies and equipment from regional businesses, and takes his family with him on many of the trips. He even speaks about his medical relief efforts at Pittsburgh-area high schools and has invited several students to travel with him so they can witness for themselves how other people live.


“I’ve always been interested in going overseas and doing charitable work like this,” Demos says. It’s a passion that has gradually developed as he has become more successful and secure with his own career. Half of the surgeries Demos performs at Pittsburgh-area hospitals are cosmetic. “I make a good living here, so this is a way of saying ‘thank you,’” he says.


Surgi-Corps is a tiny enterprise compared with Interplast, a large humanitarian organization also specializing in reconstructive surgery. Demos has no desire to, and couldn’t possibly, compete with larger groups. He says more doctors should be chiseling away at the boulder that blocks individuals from accessing decent health care.


Demos’ success with Surgi-Corps leads him to conclude, “Anyone can do this if they make the proper arrangements.”


They’d just need a little initiative, lots of interest, and oh, yeah, some cash. Like many well-established physicians who volunteer overseas, Demos can afford to spend the time and money. Travel costs for Surgi-Corps volunteers range from $2,500 to $4,000 per person, depending on the destination and recreational activity that gets tacked on at the end. The destination never really matters, though, because no matter where Surgi-Corps goes, the goal remains the same: to provide services where none or few are available.


Altruism is well and good, but it’s not as if there’s nothing in these missions for Demos and other volunteers like him. They love this work. In fact, it enriches their lives like nothing else. “This is what medicine is all about,” Demos says.


DR. FEELGOOD


What a great escape it is for physicians to practice the best medicine they know and not have to worry about lawsuits, paperwork, health management organizations, time constraints and patients’ fees. Physicians are the primary volunteer source for medical relief agencies, but sometimes medical students are able to create their own opportunities. (See “Dreaming of Kenya,” p. 34.) Working as part of a medical relief project, these doctors are liberated and savoring every minute of it.


“I just feel the best when I’m there,” says Dr. Peter Egbert, an ophthalmologist at Stanford University who has been traveling to Ghana, West Africa, with Christian Eye Ministry (CEM) for the past 12 years. CEM is a program of a Michigan-based non-profit, non-denominational Christian relief organization called International Aid (IA), which was established in 1980.


“I’m using my talents to do what I want to do. The lifestyle is simple.
There’s no paperwork or politics,” he says.


Unlike Demos, Egbert began his medical relief volunteer work early on in his career, when Yale University School of Medicine required him to do a residency in Haiti in 1972. “I just thought it was fascinating and wonderful,” he says. This fascination continued years after that with trips to Afghanistan, China, Honduras and Saudi Arabia.


All of Egbert’s journeys required a measure of initiative on his part. He learned of an Afghanistan hospital in need of assistance by asking his colleagues about opportunities abroad. On another occasion, Egbert wrote to the Western Samoan government, in the South Pacific, to inquire whether they needed his skills. It took them three months to respond, but the answer was “yes.” So off he went. Other medical relief efforts were the result of finding listings in a resource book the American Academy of Ophthalmology publishes for physicians seeking to go overseas.


Egbert didn’t have to take action to begin his work with CEM, though. The ministry approached him. Dr. Frank Winter, who founded the program in 1983, asked for Egbert’s help, and it has been a beautiful partnership ever since, Egbert says.


Egbert enjoys giving his time and skills, and Ghanaians have access to a type of care that is rarely found in Africa. On average, Africa has one ophthalmologist per 1 million people. Volunteers like Egbert have allowed Ghana to enjoy better care.


The country has three CEM clinics, with 50 local staff spread among them. “The clinics came during a time of regrowth in the country,” Egbert says, referring to the late 1980s. About 20 eye specialists travel to Ghana each year. A typical two-week trip costs volunteers around $2,500. “Some go only once and never go back,” Egbert says. “Others return, like me.”


Dr. Milton B. Amayun, IA’s vice president for international programs and a public health physician, concludes that physicians like Egbert keep coming back because “they have a life-changing experience. They come back to [the United States] much more thankful for what they have.” And, Amayun explains, volunteers like Egbert are being exposed to an entirely new culture. “The [volunteers] are establishing relationships with people that they had never known before and are making long-term contacts.”


It usually takes Egbert three to four months to prepare for the journey, spending much of this time obtaining medical supplies and equipment from pharmaceutical and ophthalmology companies.


For each trip, Egbert and his wife stay one month in Ghana, living in a small cinder-block guesthouse. He works at each of the clinics, treating patients and performing surgery. CEM and its volunteers have worked hard to equip the clinics with the proper tools necessary to Egbert’s line of work—a luxury few medical relief workers experience. “We can offer quite good medical care,” he says.


And the work is steady—to say the least. “Patients are lined up in the morning and don’t go away until night,” Egbert says. “It’s impossible to turn people away.”


At the clinic, patients pay what they can afford. A typical Ghanaian family’s two-months’ salary is about $70. Requiring some form of payment is common in several areas of the medical relief world, especially where groups are trying to turn their clinics into independent facilities. “You have to have an economic base,” Egbert explains. Still, care is never denied. The emphasis on payment only exists as a way to strengthen a community’s reliance on their own health care.


PASSING THE TORCH


Along with treating patients, Egbert spends a lot of time training Ghanaian physicians to eventually take over the clinics’ practice.


“It usually takes two to three years to teach the physicians the specialty,” Egbert says. He has already seen the training begin to pay off. “One of our clinics is self-sustaining now, with only minimal support from Christian Eye Ministry.”


The transferring of skills is an important component to many medical relief organizations. It requires a longer commitment, however, and not all groups have the resources to do it.


Dr. Michael Rich, an internist pursuing a master’s degree in public health at Harvard University, spent six months with the 1999 Nobel Prize–winning Doctors Without Borders (DWB) specifically to train physicians in Karakalpakstan, an autonomous republic of Uzbekistan. It was his first medical relief mission.


“There’s a lot of illness [in Karakalpakstan],” Rich says. It’s an area that suffers from some severe environmental problems. The shrinking Aral Sea—called a “disaster zone” by the World Bank because of its polluted and evaporating waters—has contaminated the drinking water. When people drink from the area’s ground water, they’re consuming a liquid that has as much salt as a can of soup. As a result, there are a lot of sanitation problems, kidney diseases and hypertension, Rich says.


But one of the biggest threats to public health is tuberculosis (TB). “It’s at epidemic proportions,” says Rich. “TB is such a problem there, because with the lack of government resources, people were only given partial treatments.” And this made TB more resistant to drugs, making it incredibly difficult to fight, he says.


Rich, who had been in the Peace Corps before attending medical school, was the DWB physician in charge of training the volunteers. He did very little clinical work. “That can be disappointing for some people,” Rich says. “But, to me, I really liked the public-health aspects.”


Five DWB volunteers comprised Rich’s project team—a nurse, a trainer, a logistician, a lab technician and an epidemiologist. The team’s primary objective was to teach physicians how to recognize TB and treat it effectively. Team members also taught Karakalpakstan physicians about treatments for diarrheal diseases. Rich says the medical relief effort is aimed at giving Karakalpakstan physicians the knowledge and skills to take care of these illnesses on their own.


The republic had many TB hospitals, so project teams used their labs to conduct the training. This gave Rich the opportunity to tour the wards and witness what a lack of resources and space, combined with an epidemic, can do to a care facility.


“The hospitals are very crowded. There are eight or nine [patients] to a room,” Rich says. These packed facilities exceed Uzbekistan’s maximum occupancy codes, and the government fined many physicians for the conditions. “Ridiculous,” Rich says. The government was responsible for providing more space, and since none existed, “What were the doctors to do?”


The frustrations that came with these conditions didn’t stop Rich from enjoying the experience. “What I did in those six months—I had more impact on people than what I did in my years working in the U.S.,” he says.


WORKING FROM WITHIN


DWB isn’t the only organization focused on health and training that earned notable recognition last year. The African Medical and Research Foundation (AMREF) Inc., based in Nairobi, Kenya, won the 1999 $1 million Conrad N. Hilton Humanitarian Award.


AMREF specializes in bringing health education and medical care to some of the continent’s most vulnerable people. It is an example of an operation that began primarily as a voluntary medical relief group, called The Flying Doctors, and developed into a full-fledged organization focusing on health policy and education work as well.


In the 1950s, The Flying Doctors flew to remote African locations, performing reconstructive surgery and conducting health clinics. After some time, the founders recognized that “the solution really is in getting communities more informed and more involved in managing their own health care,” says John Batten, Ph.D., AMREF’s director general, who has been working in developing nations for more than 25 years.


Now with programs in more than 10 African countries, AMREF has broadened its work to include public policy debates, improving water and sanitation facilities, training indigenous health professionals, publishing health education manuals, conducting disease research—all the while continuing to provide health-care services to nomadic African populations. With such a heavy program load, Batten says, “We can always use directed, skilled volunteers.”


“The conflicts that are around, in the Third World in particular, are really a result of large numbers of very vulnerable people. And they’re vulnerable because they’re not informed. They’re sick. They’re not well educated and so on. So, we believe that it’s not just good health that we’re actually facilitating here. We’re providing a process that empowers people to be stronger actors in their own development,” Batten says. Pushing communities toward self-reliance is the only way to improve conditions, he adds. “The solution for Africa is to produce more skilled people at home.”


‘MACGYVERS’ IN THE BUSH


The rule of thumb for physicians volunteering overseas is to “bring all of the appropriate technology,” CEM’s Egbert says, emphasizing the word appropriate. “The Third World is littered with expensive equipment that no one knows how to repair,” he says.


Then there’s the added challenge of dealing with frequent power outages and bad plumbing. It might also be very hot and dusty or extremely cold and damp. All of these difficulties could make an impatient and inflexible person incredibly frustrated. But veteran relievers like Egbert aren’t phased. “I like [the challenge] actually,” he says. “It tests my wits.”


Encountering new forms of illnesses is another obstacle faced by U.S. physicians abroad. Demos and his Surgi-Corps crew frequently encounter diseases they’ve never seen before. “We try to figure out the best way to treat them,” he says. But in many cases, Demos admits, “You kind of fly by the seat of your pants.”


The ability to go head to head against a variety of challenges often leads a physician toward greater and faster skill development, AMREF’s Batten says. “[These doctors] are thrust into an environment where… there’s no other doctor around, and they have to deal with everything right off the bat.”


Batten’s colleague Dr. Pat Youri, a native Ghanaian who has been a physician for the past 27 years, agrees. “In Africa…because of the lack of laboratory and other support services, a doctor’s clinical acumen is relatively much more developed than many counterparts’ elsewhere who have access to supportive services,” he says. “Improvisation is the name of the game here.”


OFF THE BEATEN PATH


Dr. Heather Papowitz, an emergency physician, has volunteered her skills all over the world and now works at becoming a medical relief expert as part of Johns Hopkins University’s international health graduate program. She understands the need for creative thinking.


Papowitz’s craving for this work began in medical school with an international health elective in Belize, Central America. She did a rotation in a rural clinic. Armed with only her stethoscope and drugs like aspirin and penicillin, Papowitz had to rely on herself. “It was a relief, in some cases, because you didn’t have 100 drugs to choose from, and you could learn how to use basic treatments better.”


Papowitz says her experience “sparked me to think that there [were] other avenues out there for doctors.”


After completing medical school at Tulane University and a residency at Mt. Sinai Hospital in New York City, Papowitz dusted off her passport again. First she headed to a city hospital in Bangkok, Thailand. Next, she flew to India to volunteer in a rural clinic. Papowitz says that this experience led her to understand-
ing the connections between her patients’ illnesses and the environment in which they lived. But treating the same diseases over and over again—malaria, hepatitis, tuberculosis, leprosy—sometimes made her feel helpless. “They need educational and development programs, and that would take years,” she says.


CARING IN A CRISIS


Papowitz’s most life-changing experience came from a two-month stint with Doctors of the World (DOW) in the spring of 1999, when she cared for refugees at a camp in Senekos, Macedonia. “It just opened up my world,” she says.


DOW has been in the Balkans since 1992—vaccinating children against polio, combating the rising TB problem and promoting health education—so when the Kosovo crisis broke, they were one of the first organizations to arrive on the scene.


Not normally an emergency medicine relief agency, like DWB is, DOW quickly learned how to provide care in a crisis, Papowitz says.


And in the process, it became the “Cadillac of refugee camps,” says Dr. Drew Fuller, an emergency physician who also volunteered in the camp that spring and was a little wary, at first, of what he would encounter on his first medical relief operation. Plus, everything happened so fast.


“I only had a week to get things together,” Fuller says, “and [the trip] wasn’t confirmed [by DOW] until two days before I left.” Fuller’s first glimpse of where he would be spending the next month was surreal. “As we’re driving up to the camp, I look at the wire fence and the tent-city and think of the people trapped inside. It was strange. I asked myself, ‘Am I going to be able to handle what’s going to come at me?’” he says.


Surprisingly, even during this emergency situation, Fuller ended up playing the role of the village doctor and wishing he had more primary care experience. The problems Fuller treated were routine—colds, lacerations, upper respiratory tract infections, gastrointestinal ailments. He had a few special medical concerns to look for, like the spread of infectious diseases, but otherwise his work was back to the basics.


And the “basics” are what the 3,000 refugees needed. Forced out of their homes, separated from family and friends, they looked to these foreigners for strength and security.


Fuller made “tent calls” on the elderly and fragile in the predominantly Albanian camp population. He became close to several families. “They’re a very warm group of people,” he says, surprised at how well they were holding up during their time in the camp.


“I felt more like a physician than I had in a long time. You didn’t have all of these distractions that you have in Western medicine,” Fuller says.


Surgi-Corps’ Demos agrees. “Overseas medicine is pure medicine,” he says.



DEVELOPMENTS IN MEDICAL RELIEF


According to experts, attention to the mental and emotional health of a vulnerable population constitutes a new element in medical relief work. Treating psychosocial disorders is one challenge medical relief organizations must tackle in the 21st century, says IA’s Amayun, who, for the past 30 years, has worked all over the world.


When Amayun was in Cambodia in the late 1970s, mental health problems “were not an issue,” he says. But by the time the Bosnia crisis erupted in the early 1990s, psychosocial disorders “were like a gaping hole that wasn’t looked at properly by medical relief organizations.”


Now many organizations are focusing on how to address mental health issues and what sort of policies they’ll need to help these populations, Amayun says.


Developing practice protocols have become necessary as well—marking another change in the medical relief sector’s development, Amayun says. “Physicians can no longer go with their regular work styles.” They have to operate within specific ethical and practice guidelines developed by a consortium of organizations, he says.


And, as the number and size of organizations grow, the competition increases, says AMREF’s Batten.


“Ten years ago, [the competition] wasn’t that great. Organizations in Third World countries would work together,” Batten says. But today, many medical relief groups compete for such resources as grant and project funding. And, through their work, some organizations may actually be stealing resources from the very groups they are trying to help, he says. “They only work from the outside, occupying space that prevents local growth.”


Another change in the medical relief field is the growth of violent attacks on organizations and its volunteers. When Amayun began practicing medicine, medical relief groups maintained an existence of neutrality and were relatively safe in volatile environments. “Now, in Bosnia and other areas, [United Nations] workers and [non-governmental organizations] are targets of violence. Health workers are murdered in their homes,” he says.


Amayun has survived his fair share of dangers. “I have been the victim of a kidnapping attempt in the Sahara Desert,” he says, declining to go into the details.


Hazardous situations are common. Surgi-Corps’ Demos was accused of being a “military spy” when he was stopped by a military blockade while heading to a Nigerian airport to return home. He narrowly escaped arrest. “I thought I was going to die,” he says, still remembering the rifle pointed at his face.


DOW’s Papowitz realized she was in the middle of a war when she worked the night shift at the refugee camp. “I could see the missiles in the sky,” she says. Although Papowitz wasn’t exactly the specific target of an attack, she says the tension between the various political powers and the one she represented was still very alarming. “Macedonians hated NATO. It was never really comfortable.”


Politics can be dangerous. AMREF’s Youri says that when the organization’s workers provide health care to both sides of a warring nation, some governments accuse them of being rebel allies.


Bombs, military men and epidemics pose serious threats to medical relievers and their patients, but these dangers won’t keep the volunteer physicians away. Both Demos and CEM’s Egbert plan to do more volunteer work after retirement. “Yes, there are risks,” Demos says. “But does that mean we stay at home? Life is meant to be lived.”