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Planes, Trains, Automobiles and Yaks

The New Physician September 2004
Physicians travel to the remotest corners of the globe to volunteer their services among those who need them most.


The rules for Dr. David Dyck’s annual trip to Guatemala are simple: Pack lightly; bring lots of heartburn and pain medications, plus pediatric vitamins; don’t forget your camera film; don’t drink the water except in the hotel; don’t travel in groups of less than three at night; and whatever you do, don’t even joke about buying drugs while you’re there. That will land you a nice little stay in a Guatemalan jail, where torture is most certainly an option.


An associate professor of family medicine at Kansas City University of Medicine and Bioethics, Dyck has led groups of physicians, nurses, pharmacists, medical students and residents on annual medical mission trips to Guatemala for DOCARE International, an osteopathic organization providing charity health care throughout Central America, for the past four years. For him, and for many physicians like him who travel to the ends of the earth to provide care to those who don’t otherwise have access, the reasons to volunteer his skills are pure, but most have a thread of self-interest in them as well: It’s just plain fun. Docs tired of practicing medicine in the defensive, U.S. style look outside the country for rejuvenation.


It’s like camping—really serious, perched-on-a-mountainside camping in some cases—but with medical instruments. They get to take a little vacation, travel to an exotic place and practice what many call “pure medicine”: no complicated tests or expensive machinery, no forms, no insurance companies, no lawyers, nothing but them and the patient. And maybe they’ll even care for a patient with a disease they’d never see in such an advanced stage in the United States. It’s hard work done with great joy.


MIXING BUSINESS WITH PLEASURE


You know those people you see in camping goods stores? You know the ones. They’re tanned and sinewy, wearing brimmed hats that look as if they’ve been through the bush a few times. They’re wearing sensible, outdoor shoes and pants with more zippers than a suitcase. They know how to keep bears from eating their trail grub and what to do when face-to-face with a cobra.


That’s the image one conjures up of Dr. Sue Abkowitz-Crawford after a few minutes conversing on the phone. She’s actually eaten a cobra heart while it was still beating, just one of many cultural delights she’s experienced while offering her services as an internist to Health Volunteers Overseas (HVO).


A bullet-speed talker, she begins ticking off her biennial trips: three months in Indonesia in 1991 “that was an insane experience, looking back on it”; then two months in Bhutan in 1994 and again in 2000; South Africa in 1996; Vietnam in 1998; and Tanzania in 2002. Plus, she’s just back from Kenya, a trip she took for another group, the International Medical Equipment Collaborative (IMEC). “I’m holding out for Ethiopia or Cambodia with HVO,” she says.


You could say the travel bug has bitten her with an unyielding jaw. “I grew up traveling a lot,” she says, and her orthopedic surgeon husband, Dr. Glen Crawford, earned a Rotary Scholarship after his undergraduate years to study anthropology in Tanzania. The two Stanford University School of Medicine graduates then spent the final months of their fourth-year rotations at the Kilimanjaro Christian Medical Center in Tanzania.


“It was just a great experience because they had so few doctors, so we saw incredible stuff. People came in with lion maulings or tuberculosis. You did what you could,” she says.


HVO now sends Abkowitz-Crawford and her husband—with their three kids in tow—around the world to help educate local medical personnel. The organization’s teaching mission is different from many other overseas charitable medical groups: Instead of focusing on treating as many patients as it can in the areas it operates, HVO attempts to establish a medical infrastructure that will be in place long after HVO volunteers leave the field. So, while Abkowitz-Crawford lectures on such diseases as tuberculosis and HIV, Crawford, armed with his suitcases full of orthopedic plates and pins, performs complicated surgeries to teach local physicians techniques of the trade. In doing so, “we’ve experienced a lot of different systems of care,” which is interesting, she says.


For example, in Bhutan, a tiny Himalayan nation of 1 million people, Crawford would teach orthopedics to the handful of Thailand- and India-educated physicians, while Abkowitz-Crawford, who brought the country’s internist count up to three, would discuss such topics as cardiac disease and typhoid.


And then they would spend their late afternoons and evenings seeing the sights. Bhutan allows only about 2,000 tourists in a year, but as guests of the government, the Crawfords—the kids spend their days in local schools wherever they travel—were treated like royalty. They were allowed to hike unguided, touring mountaintop monasteries as they climbed. They rode yaks and ate yak butter and cheese, took tea with monks and tried in vain to learn Dzongkha, the local language. “We find it wonderful family time,” Abkowitz-Crawford says, lamenting that it usually takes just 24 hours after returning from a trip for the kids to fall back into their harried American lives, shuttling from school to basketball practice to youth group meetings.


With her oldest child now in high school, however, Abkowitz-Crawford says the family doesn’t have a next trip planned yet. But there’s always an opportunity around the corner. Frustrated with insurance companies and paperwork, the internist gave up her Boston-area practice last year to devote more time to IMEC, which solicits donations for medical supplies and sends them to hospitals and health workers in developing nations. “So here I’ve spent all these years traveling and teaching and practicing medicine, and now it’s really great because I’m getting to send over all the stuff…. I know better than anyone what it’s like to practice medicine in a developing country without any stuff.”


And one imagines it won’t be long before the family is traveling together again. “We just love it. Not just because of the sense of fulfillment. It’s a lot more fun than practicing medicine in this country.”


If it’s February, Dyck is getting ready for a two-week trip to see friends and patients in Santa Maria de Jesus, Guatemala. “For me, it’s the opportunity to visit with these people. You make friends with people in that area, and those friendships continue to the next visit. It is also the opportunity to practice medicine for the sake of medicine.”


A group of osteopathic physicians who enjoyed piloting small planes founded DOCARE in 1961. They’d fly into remote areas, set up shop and treat the local population. Today, travel involves everything from commercial flights to bumpy trips on dusty roads in vehicles that might not pass muster in the United States. Volunteers pay their own way, just as they do for HVO, and like that group as well, sometimes trips become family affairs. Dyck has brought his wife and kids along to work in the team’s pharmacy. “We’ll take anyone we can get,” he says.


Santa Maria de Jesus is a poor community about 30 minutes from Antigua, where Dyck’s team stays, but DOCARE did secure a permanent physician to stay in the village and run a small clinic. The family practitioner says the longevity of the volunteer work has become important to his DOCARE service. “Our mission has always been to go to areas that are underserved, but that has evolved over the last decade. We see the value in having services in place,” he says.


But even with the satisfaction of seeing old friends and the year-round help in place, Dyck says the visit is also emotionally draining. “The difficult thing is seeing the level of care they’re getting and knowing there’s so much more out there they just don’t have access to.” The case that stands out the most to him presented at a clinic a few years ago in Mexico. Parents brought in their daughter with an apparent dislocated hip. The DOCARE chiropractor said her hip was perfect. So the volunteer surgeon took a look, and the bulge turned out to be a rare muscle cancer that had spread uncontrollably. “There really wasn’t much that could be done for her, and what struck me was how happy she was with life, and she was so unaware of her situation.”
The rewards, from even these helpless cases, come back tenfold, though. “Someone walks up to you and says, ‘Thank you for coming.… God bless you.’”


Dr. Frederick Roever is trying to get his new acquaintance to join him and other volunteers from Florida-based Medical Mission of Mercy (MMM) on their next trip to Jucuapa, El Salvador. “We’re leaving on the 16th,” he says. “We could arrange for you to come along, and it wouldn’t be that much money.”


His enthusiasm for MMM is infectious, but as enticing as the offer sounds, his acquaintance has to pass. Maybe it’s all the talk of the three armed guards that accompany the group 24/7—Jucuapa is in the mountainous, rebel-controlled region of El Salvador and “guns are everywhere,” he says—or perhaps it’s the luxurious travel accommodations on what Roever calls “TACA airlines.… You know what that stands for? Take a Chance Airlines.” Or maybe it’s the story about the vampire bat that bit his friend in the middle of the night or the one about the outhouses they use during their stay or it could be the cholera the volunteers treat and try not to get themselves.


No, thank you. But thank goodness for people like Roever, a Tarpon Springs, Florida, geriatrician and his daughter, a second-year at Ross University School of Medicine who has been volunteering with MMM since high school and encouraged him to as well. Calling himself a “socially minded old-timer,” Roever explains his frustration with the U.S. health-care system. “What inhibits the delivery of care is the bean counters. You have to have this form or that form…, so what has become important is not the treatment of the patient but the treatment of the chart. It’s no longer fun. So we go to El Salvador, and it becomes fun because we get to treat the patient, and they get well. We’re going to the heart of medicine. It restores my soul.”


The 4,000 patients they treat each trip walk as far as 10 miles through the mountains to see the U.S. physicians who arrive annually in Jucuapa. There are a few local physicians in the area—Roever says the best is actually the leader of the rebel group—and MMM is in the process of raising funds to build a clinic for volunteer organizations and for El Salvadoran medical schools to use. MMM’s presence is “an extension of American foreign policy whether they realize it or not. We’re doing a service to our country, too. This creates an American influence in [El Salvador].”


Although MMM is a relatively small group of volunteers, its effect on the locals is enormous. In 2001, an El Salvadoran congressman nominated it for a Nobel Peace Prize, which helped to increase the organization’s donations and funding.


But even the financial boost can’t help all the patients the team cares for each trip. Roever, who thought he was prepared to see poverty after serving in the Vietnam War, says the paucity of care is shocking sometimes. “It’s absolutely devastating, and as an internist, I rarely cure disease. I can’t cure hypertension. You realize how impotent you are. I just put a Band-Aid on [the problem].”


General surgeon Alan Lefor has paid $1,400 for this excursion to Guatemala and taken a week’s vacation from his position at Cedars-Sinai Medical Center in Los Angeles. But after 13 hours on a bus—six hours of those on dirt roads at 8 miles an hour—one begins to wonder how much of a vacation the trip really is.


For Lefor, though, it’s worth it. “I love medicine, and I love travel, and I wanted to find a way to put the two together,” he says. The group he volunteers with, HELPS International, allows him to take short trips—about nine days—each year and provides him with some opportunities to see the sights.


But at the end of the bus line there will be 300 patients waiting at the front gate of a U.S.-built clinic from the Reagan era. No one but HELPS uses the nine facilities scattered throughout the country’s highlands now, because Lefor says Guatemalan physicians don’t want to practice in the remote areas. During the next four days he’ll do as many as 96 operations, and together, the other physicians, nurses, dentists, ophthalmologists and pharmacists will treat about 1,300 patients. The team even brings its own cooks—food and water are so contaminated there that the team can’t afford to risk sickness by eating with the locals.


And while some of the cases are disheartening, “for example, I saw a kid with polio. You see things there that you would never see,” Lefor says the satisfaction of practicing “pure medicine” is worth it. “There’s no bullshit. A patient has a problem. We fix it.”


This instant gratification comes easier for surgeon volunteers than for internists. While Roever says he can’t cure patients’ hypertension because he’s not there long-term, Lefor can go in, fix a hernia or remove a gall bladder or an appendix and leave knowing the patient will have a better life.


And for those he can’t help—like the woman who needed a total thyroidectomy but couldn’t have one because she didn’t have access to the drugs she’d need to take for the rest of her life—he says he tries to remain realistic. “I can’t fix the whole world. Our success is one patient at a time.”


You might think pediatrician Caroline Dueger has found the fabled fountain of youth. Last year, at the age of 68, she cycled across the United States to raise money for a bacteriology lab for an HVO site in Cambodia.


“It was good fun. It was something I had been thinking about for a while, and I didn’t want to not have some good come out of it,” Dueger says.


Maybe it’s just something in the water at all of the places she’s conducted medical missions. Along with her internist husband, Dueger has been to Cambodia four times, St. Lucia, Brazil and South Africa—and that’s just with HVO. She has also volunteered in Kenya and in Nepal, where she trekked five days up a mountain to get to the village where she would see 50 to 60 patients daily before falling into bed in a hut with no plumbing. And she most recently returned from Guatemala, where a small religious organization is working to develop the economy among the Mayan people.


She says it is a grueling lifestyle, and it is time to slow down, but it’s been the right thing for her since 1993, when she quit her practice to volunteer full time. “There’s an adventure to it. It’s a challenge—you’re working with different cultures, so there’s all that to learn—and it’s fun. You get to travel and see the world.”


She certainly has. The most rewarding experience has been in Cambodia, where she travels repeatedly to teach young Cambodian medical graduates pediatrics skills. An on-site coordinator and Dueger arrange for visiting professors to come teach. “They have really taken the ball and run with it,” she says of the fledgling program.


In any country, HVO is careful to work within the confines of local customs, Dueger says, which makes it different from teaching residents in the United States. For example, the Cambodian students never raised any questions in the beginning, a cultural difference that took some getting used to. “That’s a great thing to teach them—to ask questions. You know, in the United States, they’ll question everything!” But there, as here, it’s rewarding to watch students grow and evolve in their education, she says.


SERVING CAREERS AND GOD


Not all the benefits of international volunteer work are grounded in a rejuvenating vacation or a pleasure in practicing basic medicine. Other physicians find the rewards can be more long-term—volunteer opportunities help shape future careers, and in Dr. John Greene’s case, the benefits are for eternity.


As Greene’s Baptist faith blossomed in the 1990s, so did his interest in volunteering. Quoting scripture commanding him to “‘go ye to the ends of the earth’” to use his talents, he says God has called him to use his medical skills to attend to the world’s physical and spiritual needs. The religious aspect is essential to him, he says. “Personally, I wouldn’t go on a trip…unless it had some spiritual value.”


His travel temporarily stymied by the demands of his two young children, Greene, the chief of infectious diseases at the University of South Florida’s H. Lee Moffitt Cancer Center and Research Institute, has traveled during the past 15 years to Guatemala, the Dominican Republic, the Ukraine, Tibet, Brazil and Africa to treat patients suffering from AIDS and other infectious diseases, and to build churches.


Yet while the evangelism is important, he says it is secondary to treating the basic medical needs of his patients. “You can’t [always] help people with their mindset for eternity because they’re just surviving day-by-day.”


Greene works with several medical missionary groups but has traveled most extensively with the Association of Baptists for World Evangelism and the Christian Medical and Dental Associations. He fronts his travel costs, and the organizations feed and house the volunteers in the host countries. Local missionaries tend to secure medicines and equipment, although Greene takes some antibiotics and other medications he knows will be hard to procure. “A lot of these clinics have no structure; a lot of times it’s just a room. Sometimes you just set up under a tree with your stethoscope.”


It is at those times, away from noisy hospital equipment, pagers and phones, that Greene says he does his best work on his relationship with God. “‘Be still and know that I am God,’” he says, quoting more scripture. Under the tree in the sweltering heat, he says he certainly does.


Early in her career, Kenyan physician Lulu Oguda did a calculation of her patients: About 70 percent had HIV. Struggling with their treatment, she wondered if the Médecins Sans Frontières/Doctors Without Borders (MSF) folks, with whom she spent two weeks volunteering during medical school, had a program that might help her determine the best treatment. “I called…, and she said, ‘Yes, we’re starting a program in Malawi.’ And I said, ‘When are you going?’ And she said, ‘Tomorrow.’ And I said, ‘I am going.’”


Two weeks later, Oguda was in Malawi serving in a one-year field director position, providing HIV patients with antiretroviral therapy and offering training to local health workers.


She, too, honed her clinical skills and learned management techniques. “We’ve forgotten our skills; we’ve forgotten our touch. If you give your all to the patient, you see them recover very quickly…. It makes you happy to see them get out of their beds and get back in their gardens.”


Unlike many other organizations, MSF pays its volunteers a small stipend. But even given that, Oguda says she doesn’t see herself going back to the organization. “You have to pay the bills, girl.” Instead, she’s parlayed her Malawi experience into a position with the Maryland-based International Partnership for Microbicides, which is working on a product to prevent HIV transmission to women during heterosexual sex. She’s managing the testing process in Africa.


But Oguda says she enjoyed her time with MSF, which is highly regarded in the areas it works. “Because they’re emergency-oriented, if there’s a problem, they’re going to fix it.” Such was the case with a patient brought into Oguda’s Malawi HIV clinic. The young woman had been found unconscious by the roadside along with her 2-day-old baby. After a few tests, she was diagnosed with meningitis—often a death sentence in the area. “I was determined this woman is going to wake up, and she will go home with her baby.” Three days later she regained consciousness, and two weeks after that she went home, having also begun the antiretroviral therapy she needed for her HIV. “A month later…her mother is saying, ‘Thank you, MSF, you saved my daughter’s life.’ [So], we prevented that little boy from becoming an orphan—from never even meeting his mother. She really sticks with me. I always remember her.”
Jennifer Zeigler is a senior writer with The New Physician. Direct comments about this article to tnp@amsa.org.