Rites of Passage: Docs and Nurses in the Developing World

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Ophelia Dahl - Vogue

A new rite of passage is taking hold among ambitious young doctors entering modern practice in a new century. It can take a year or two after medical school: working far corners of the poor world, and sometimes later years split back and forth between a community clinic in rural Malawi and a neurology fellowship at Mass General in Boston. The trend is striking: of the new medical doctors coming out of US medical schools in the mid-80s, one in twenty had spent some real time abroad in healthcare.  Ten years ago it was one in 5. Last year it was one in 3.  So more and more doctors, yours and mine, acting locally, will be thinking globally, with many implications.

Our radio conversation is about the lessons that flow both ways.  Some have to do with technology and drugs, but many more with building ground support in community clinics; also with the training of nurses, even with refining the bedside manner and hands-on, make-do skills of American doctors who arrive, as they say, with “sandals on the ground.”  They come back “thinking different” about who needs what kind of doctoring in the States. Consider this, for example: Bill Gates’s foundation report this winter predicts there will be no more poor countries by 2035, that’s two decades out; we’ll just have an awful lot of poor people in middle-income countries.   We know that problem in the US, and we haven’t turned it around.  But there are clues out there in the developing world and lessons coming home with the young doctors: lessons in community care outside the big hospital ERs; lessons in “accompanying” care, lessons in prevention, in doing more with less and getting sharply better outcomes, also in putting moral urgency behind more effective care for everybody.

Guests

  • Ophelia Dahl is the executive director and a co-founder (with Paul Farmer, Jim Kim, the late Tom White, and others) of Partners in Health, the Boston-based non-profit that has taken as its mission to bring great health care to the world’s poorest people and “to serve as an antidote to despair”.
  • Dr. Daniel Palazuelos is PIH’s chief strategist at its site in Chiapas, Mexico, and directs their efforts to ensure the success of their community-health workers, who are charged with the “accompaniment” of patients.
  • Pat Daoust is the chief nursing officer at SEED Global Health, an organization dedicated to training a new generation of health professionals for work in the developing world. Daoust has served as one of the leading figures in HIV/AIDS nursing for decades, first with the AIDS Action Committee, then with the Harvard AIDS Initiative in Botswana and Ethiopia.

Reading List

  • In “Partners in Help,” Paul Farmer gives an ethos of “accompaniment” to those working with the poor and the ill — work tirelessly, with an open mind, and until you’re no longer needed:

There’s an element of mystery, of openness, of trust, in accompaniment. The companion, the accompagnateur, says: “I’ll go with you and support you on your journey wherever it leads; I’ll share your fate for a while. And by ‘a while,’ I don’t mean a little while.” Accompaniment is about sticking with a task until it’s deemed completed, not by the accompagnateur but by the person being accompanied.

  • Slow Ideas,” Atul Gawande’s latest essay in The New Yorker, tells us that the important changes in medicine will depend not on easy technological fixes, but on big and sometimes grueling social change.
  • In “From Haiti to Harvard,” on WBUR’s own Commonhealth blog, Rachel Zimmerman tells of the difficulties that community health workers in Boston face every day — and of the promise they represent for the American medical establishment.
  • Our guest, Dr. Daniel Palazuelos, wrote a short piece about the myths and realities surrounding community health workers abroad.
  • And the 2014 annual letter of the Bill and Melinda Gates Foundation looks forward to the hoped-for end of global poverty as we know it.

  • Larry Scripp

    Another super-relevant topic on a superb radio show!

  • Father Bruce

    Medicine is ultimately a person to person encounter.
    Though a Science Medicine is also an art that can only be learned by the feeling and texture of the relationship of patient with doctor or nurse. True healing is embodied in the mystery of this relationship.

    • Doc2

      No longer is medicine a person-to-person encounter.

      The advances in computer technology and programming are reducing personal contact each day.

      From the sophisticated testing that puts a patient in with impersonal technicians to medical programs that diagnosis and suggest treatments based on patient input, the “personal” is disappearing fast.

      In fact, the only way medicine can supply needed care without bankrupting the country is by relying on technology to replace people in providing medical care.

      Look at what has happened in other areas: banking, directory assistance, telephone call centers, travel agents.

      The personal touch is reserved for the very wealthy who can afford concierge medicine’s high price tag. Other get one size fits all.

  • Darian Leta

    First time here and I am very inspired by this conversation. I am a senior finishing my BA in Biology right now. I am one of the few young minds that live to serve the less fortunate around the world. It was very fulfilling and assuring to hear my thoughts exactly from 3 special people that I admire to be like in the future. What they work for everyday and what I strive to do with this degree and my further education is what the future is. More and more young minds need to understand this and understand that health is essential not just something to study in order to be one of the best paid human beings on the planet, but to save the lives that one promised to do with his/her degree. Thanks again

  • http://cambridgeforecast.wordpress.com/ richard melson

    This ROS offering was uplifting by communicating a sense of “magnificent obsession” (to borrow the name of the various movies of this name) on the part of the guests.
    Here are some associations and echoes:
    1. There’s a charming scene in the British movie classic “Brief Encounter” circa 1945, where the doctor played by Trevor Howard gives his lady friend (Celia Johnson character) the “short course” on the need for preventive medicine, coalminers diseases such as silicosis and pneumoconiosis, and how a doctor must, like a priest, be a person who has a genuine desire to do good in the world.
    2. The Nun’s Story is a 1959 Warner Brothers film directed by Fred Zinnemann and starring Audrey Hepburn, Peter Finch, Edith Evans and Peggy Ashcroft. Based upon the 1956 novel of the same title by Kathryn Hulme, the story tells of the life of Sister Luke (Hepburn), a young Belgian woman who decides to enter a convent and make the many sacrifices required by her choice. She devoyes her life to tropical medicine and nursing. However, at the outset of World War II, she finds that she cannot remain neutral in the face of the abject evil of Hitler’s Germany.
    The movie has key scenes which show the nuns studying the microscopy of tropical diseases.
    The book was based upon the life of Marie Louise Habets, a Belgian nurse who similarly spent time as a nun. A major portion of the film takes place in the Belgian Congo, site of location shooting, where Sister Luke assists Dr. Fortunati in surgical procedures at a mission hospital. The location was Yakusu, a center of missionary and medical activity in the Belgian Congo.
    3. The ROS recommended reading list for this show mentions:
    “Slow Ideas,” Atul Gawande’s latest essay in The New Yorker, tells us that the important changes in medicine will depend not on easy technological fixes, but on big and sometimes grueling social change.
    This “grueling social change” is one basic theme of the novel and movie, “The Citadel,” by A. J. Cronin:
    Archibald Joseph Cronin, (19 July 1896 – 6 January 1981) was a Scottish novelist and physician.
    His best-known novel was The Citadel, about a doctor in a Welsh mining village who quickly moves up the career ladder in London. Cronin had observed this scene closely as a Medical Inspector of Mines and later as a doctor in Harley Street. This book promoted controversial new ideas about medical ethics which largely inspired the launch of the National Health Service.
    Influence of The Citadel
    The Citadel, a tale of a mining company doctor’s struggle to balance scientific integrity with social obligations, incited the establishment of the National Health Service in the United Kingdom by exposing the inequity and incompetence of medical practice at the time. In the novel, Cronin advocated a free public health service in order to defeat the wiles of those doctors who “raised guinea-snatching and the bamboozling of patients to an art form.” Dr. Cronin and Aneurin Bevan had both worked at the Tredegar Cottage Hospital in Wales, which served as the basis for the NHS. The author quickly made enemies in the medical profession, and there was a concerted effort by one group of specialists to get The Citadel banned. Cronin’s novel, which was the publisher’s best-selling book in its history, informed the public of corruption within the medical system, planting a seed that eventually led to necessary reform. Not only were the author’s pioneering ideas instrumental in the creation of the NHS, but historian Raphael Samuel has stated that the popularity of his novels played a substantial role in the Labour Party’s landslide 1945 victory.
    4. The masterful book by the great British epidemiologist, Michael Marmot, “The Status Syndrome” gives one an understanding of social aspects of disease and inequality as a deadly pathogen of its own invisible kind:
    At a time when good health has become one of the most pressing issues of civic life, The Status Syndrome points toward a way to close the gaps, and so will alter how we think about health and society—and how we live our lives locally and globally.
    http://cambridgeforecast.wordpress.com/2010/09/14/the-status-syndrome-professor-michael-marmot-book-on-health-and-society/
    “THE STATUS SYNDROME”: PROFESSOR MICHAEL MARMOT BOOK ON HEALTH AND SOCIETY
    Amartya Sen comments:
    “Michael Marmot’s pioneering work has already had a major impact on our understanding of the far-reaching social demands of public health. This wonderfully engaging book explains in an entirely accessible way how social inequality can have such a devastating effect on our health and mortality. It is a profound contribution to an extraordinarily important subject.”—Amartya Sen, author of Development as Freedom and winner of the 1998 Nobel Prize in Economics
    6. Also see:
    • INEQUALITY AND SOCIETY: “THE SPIRIT LEVEL” BOOK …
    cambridgeforecast.wordpress.com/…/inequality-and-society-the-spirit-lev…‎
    7. For the arithmetic of inequality, medicine, nutrition and metabolism, see:
    https://cambridgeforecast.wordpress.com/…/waaler-curves-nutrition-phys
    WAALER CURVES – Cambridge Forecast Group Blog – WordPress …
    https://cambridgeforecast.wordpress.com/…/waaler-curves-nutrition-phys…‎
    Jan 28, 2010 – Not only does overweight status generates health problems, being underweight is also linked to poor health.
    What is the causal link between an obese West and a malnourished “Rest”?

    This thought-provoking Radio Open Source discussion raises all of these issues.
    richard melson

  • NJ

    Mr. Lydon,

    I am an internist practicing in Boston, and was an ardent listener of The Connection. I want to congratulate you on returning to the air. I loved the last three shows on David Foster Wallace (who I had not heard of), inequality, and
    Boston noir.

    I hope this next statement comes across in the gentlest way possible, and I am of course not a journalist and know nothing about radio, but I do believe this show missed the mark. I tuned in expecting to hear about how we can apply the community health worker model to the United States, which I don’t believe was thoroughly discussed.

    I think you tried to cover too much in this show. A long conversation in the community health worker model OR accompaniment OR stories of personal experiences of health practitioners abroad could have made for a more engaging conversation.

    Ophelia defines what accompaniment is in the beginning of the program, but the question of whether accompaniment would work in the U.S. is never answered. Could this system work at home? Who would pay for it? Would doctors be the main accompaniers or nurses or community health workers? What are the benefits? Does it only work in countries with virtually free labor and unlimited amounts of time?

    If you had the luxury of unlimited time and money, of course you can do home visits (but would home visits even be important in the United States?). We also come from a country of intense privacy and freedom, which makes the accompaniment model harder to implement.

    You move away from the Columbia Point topic so quickly without explaining what it is or why it didn’t work. I wish you had asked a follow up question or two. Later you asked “why don’t we have a community health center here?” which none of your guests properly answered. I think you should have pressed them more, but I’ll leave that to your expert judgment.

    Instead of diving deeper into the CHW model, you talk about your experience in Cuba and then religion and faith and your meeting at the church with Paul Farmer.. what did this have to do with improving healthcare at home? The “spiritual connection” may be interesting to you, but I did not see how it was relevant. Instead of using up precious time with that (rambling) anecdote, I wish you had stayed on topic.

    I hope this post doesn’t come across as disrespectful, and I want you to know that I appreciate all the work you do. I simply wanted to share my thoughts.

    NJ

  • NJ

    I was also disappointed that I felt an underlying hostility towards American doctors throughout the program, particularly from both you and your guest Pat Daoust (more on that to come). I wonder whether you had some terrible experience with a doctor in Boston that has tarnished your view of the entire medical profession?

    Here are some things said in this program that made me feel that way:
    “Imagine that… doctors having to listen to their patients, and have to do a physical exam.”

    “We trust nurses.. doctors sometimes”

    And from Pat Daoust:
    “nurses have always been in the community.. we’ve been there”

    “I think nurses have ALWAYS provided hands on care, we never moved too far away from that”

    “Nurses are the backbone of our healthcare system,” implying (largely with the tone of her voice) that they are somehow more important than everyone else.

    As a physician in Boston, I felt insulted by those statements, and felt that the smug Ms. Daoust was immediately defensive and disparaging of doctors. She spent most of the program bragging about how important nurses are and how much more they understand the holistic nature of medicine compared to doctors. I wish she would understand that doctors understand this too, just as much as she does, and that healthcare delivery is a team effort.

    Every resident I teach understands that healthcare is a holistic process. Doctors do not, as Ms. Daoust smugly implies, view patients as just “a disease in front of them.” Home-life, stress, nutrition, mental health, family – we obviously understand this! And to say that doctors don’t “lay their hands” on their patients and consult personal histories is wrong, Mr. Lydon. You live in a city with the best doctors and most advanced medicine in history, where the most amazing procedures and treatments are developed every year, and I wish you would understand that and appreciate it. Instead, you long for the “good old days” and an idealized version of rural healthcare that would never work in a country of 300 million people who expect first class care.

    If you lived in England, you wouldn’t be able to have a hip replacement if you’re over 65. In India, where I have visited hospitals and had residents come train with me in the U.S, doctors will schedule 50 patients to arrive at 7 in the morning, and then spend 2-3 minutes with each patient, writing prescriptions and sending them on their way. You really think medicine is better in the developing world, and that doctors are more likely to sit at the patients bedside? I wish you could visit a third world hospital and witness the quality of medicine practiced. Dr. Palazuelos describes an extremely idealized version of medicine practiced by a select group of NGO’s and foreign doctors abroad. It is by no means the norm!

    You say “If you were to pick your doctor, one who spent 5 years in a robotics clinic and one who worked in East Africa. Which one would you go to?”

    Mr. Lydon, there is nothing wrong with using an MRI or robotic surgery machine (in fact, exactly the opposite). I am willing to bet when you need a knee replacement, you would rather have it done by a surgeon trained with those minimally invasive machines in Boston hospitals than doctor trained to make a 6 inch incision in Cuba. I simply cannot understand your disgust with technology, when it has allowed us to dramatically shorten recovery times and reduce complications.

    I admit that doctors have much less time to spend with their patients now than when I started practicing back in the mid 1980s. At the Brigham, my patients are scheduled every 20 minutes, which I think is a shame. However, your attacks on doctors seem misguided in this case as well. There are of course bad doctors at MGH, but I do the best I can for every single one of my patients, and I am insulted that you think doctors view patients as merely “diseases” to be treated.

    On a more positive note, I hope to hear Ophelia on your program in the future. She sounds like a wonderful human being, and I’d love to hear more of her thoughts on the changing nature of international aid over the past 30 years.

    Respectfully,

    NJ

  • chris

    For NJ in particular: May I ask you to accept an unreserved apology for the tone of those questions and flip observations that you gracefully protested — and accept, too, my thanks for bringing me up short. I was playing loose with stereotypes and caricatures, I know not why, in front of two doctors and a nurse I respect and admire absolutely — to be provocative, I suppose, when in fact I sounded like a wiseass, which I try not to be. I know lots of people who have a hard time reaching their doctors or making a rounded and satisfying connection with them. But I have to say with thanks that my direct experience with medical men over many years has been with professionals and human beings of a high order. This morning, as chance would have it, I made “outdoor rounds” with Dr. Jim O’Connell of MGH, as he checked in with his homeless patients on the streets of downtown Boston. I was keeping a date we’d made on the air a week earlier when Jim called into our “Boston Noir” show to speak with our guest Nick Flynn, the memoirist of Another Bullshit Night in Suck City. Jim noted on the radio that he had treated Nick Flynn’s father, Jonathan, at the Pine Street Inn in years past. And this morning again he was ministering as usual with a keen eye and heartening enthusiasm to the sort of people most of us don’t even see. And he was touching them, too — handling them! — with affection as well as expert care. So I read your comment with some dismay, wondering: Chris, where was that radio voice coming from? May I take it back, please? Seriously sorry, Chris Lydon.

    • Father Bruce

      Thanks for bringing in Dr. Jim O’Connell !
      Love your Boston stories and Book of Ruth!

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  • FC

    I just listened to this program, as a re-broadcast. I’m delighted that Christopher Lydon is back on the air. However, this program was unfortunately a “bomb.” Healthcare is, no question, a hot topic, but to take on an hour-long show that I thought was going to focus on global healthcare lessons and how lessons from that arena can be shared here at home, should have be done so with a LOT more preparation.

    The discussion was all over the map: mention of some work being done abroad, moral and spiritual focus and objectives, the role of the CHW, and others. This was a lost opportunity to focus on one key point and to discuss it more fully.

    With regard to the use of a CHW, quite simply, we here in the US, and particularly in the Northeast, do not live in community. We are not a people-focused society. People who live in third world countries live in community. This is their culture, this is their way of live. It isn’t ours here in the US, and especially in the Northeast region of the country.

    Time does not equate to money in the developing world as it does here in the US. Rather, relationships are critical there. This is why when a patient goes to the doctor or to the hospital, a large number of family or community members accompany them unlike here in the US, we need to depend on hired CHWs – if they exist – from the hospital to help us even get to a doctor appointment.

    The major differing issues between the developing world and the US specific to medical/health care are structural, i.e., their culture is community-based and ours is individual-based. We rely on technology, they rely on others in all aspects of live, not just healthcare.

    Of course there’s so much more to say on the subject, but in reference to the show I just heard, it was unfortunate that the discussion wasn’t focused.

  • http://ConstanzaMedicalMission David Rudolph MB BCh Rand FACS

    Dear Mr Lydon, Great program: So thoughtful : so much to say and do!!Thank you. Every this that was said was so interesting and useful and I endorse all the great ideas put forward. (except the nursing part. Without doubt critical… maybe the right arm of the doctor but not a second spine. Team work is absolutely essential both there and here in Boston to provide the very best care available. Over stressing one or other branch of the services is disruptive and definitely not helpful when trying to deliver the best medical care to all patients. .
    In a seven year program in the beautiful high mountains of the Dominican republic we have learnt so much beyond simple medical care e.g. a. clean water. in fact we delayed our surgical program to work with Rotary international to introduce clean water through biofilters. Poluted water is a major problem in the mountains with sewage polluting the multiple streams in the area.
    Caring, and so much more. Partnerships with the local people and the health care system,_ crucial time consuming and so slow,
    What can we bring back here? Every single person who has traveled with us has come back changed for the better. Our most recent foray into this realm was to bring premed students from Haravrd with us.We provided a short program for them learning preventive care and most important “carin”g medicine. Great inadvertent discussion and example was also provided bu a racist physician who works here. We could not have learnt better lessons tah hear from this bombastic unpleasant person but what great lessons and discussion was generated by his outburst!! What a wonderful and great success so far. Their letter are simply amazing. Their experience was simply beyond our greatest dreams.We will follow these young people through med school and hopefully provide them with an example and basis for once again providing “caring” medicine linked to our high technological training. The result will be superior care delivered to our patients back here in Boston.
    So sorry that I could not get onto your radio program and receive criticism or feed back for our program. There is simply so much to say.
    Enjoy our simple website and we are happy to answer any questions you may have.

  • Annie

    Dear Mr. Lydon,
    While I enjoyed the program, I was disappointed that social work was not represented or even mentioned in the discussion. Social workers are a vital, yet virtually invisible, force in the health care world. Nurses, doctors, patients, families, all rely on social workers throughout the healthcare world to foster communication between health care providers and patients/families about symptoms, diagnosis, treatment options, goals of care etc. We help solve problems, create safe and meaningful discharge plans, keep patients healthy and safe in the community and so much more.

    • Father Bruce

      Right on Annie!