February 20, 2014

Rites of Passage: Docs and Nurses in the Developing World

  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 ...


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.


  • 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.

Podcast • October 1, 2009

Tracy Kidder: "…faith that looks through death"

Click to listen to Chris’s conversation with Tracy Kidder. (51 minutes, 23 mb mp3) Tracy Kidder actually finds a needle in the haystack — a kernel of inspiration in a continent of bad news — ...

Click to listen to Chris’s conversation with Tracy Kidder. (51 minutes, 23 mb mp3)

Tracy Kidder actually finds a needle in the haystack — a kernel of inspiration in a continent of bad news — in his virtually irresistible new saga (with a Wordsworth title) Strength in What Remains.

The bad news is the ongoing massacres and underlying misery in East Central Africa – in the neighborhood of Rwanda, hard by the killing fields in the Congo today.

The inspiration in Tracy Kidder’s sudden best-seller is a young man named Deo – short for the Latin “Deogratias,” meaning “thanks be to God” – who goes back to his blighted roots in Burundi to found Village Health Works, putting his medical education at the service of war’s survivors.

How we long — writers, book-buyers, interviewers, too — for bulletins from abroad without US Marines or drones in the picture. I like the moment in our conversation when I refer to one of Deo’s signature stories, about the need to build a six-kilometer road to his new health clinic in Kayanza. Tracy Kidder leaps up. “Can I read this?” he asks, reaching for his own book. In the anecdote, Deo, in Africa, was saying that a Belgian construction company would want US$50,000 to build the road, when a Burundian woman with a baby crying on her back interrupted him.

She said: “You will not pay a penny for this road. We become so much sick because we are poor, but we are not poor because we are lazy. We will work on this road with our own hands.”

The next day a hundred sixty-six people showed up with pickaxes, hoes, machetes, and other tools. The road was finished before the Belgian road builders got to bid on the job.

“Who did it?” the professionals asked. “We are the only road construction company in the entire region!”

“Not anymore,” Deo responded.

From Tracy Kidder’s Strength in What Remains, pages 255-6.

What I am asking Tracy Kidder here is how to generalize that Deo story to the scale of Africa’s problem and the policies from Washington, the West, and now China, that have been anything but a solution:

It’s not tremendously complicated but it is difficult work. And it’s not the kind of work that some people like to do [because] you can’t do it in Washington D.C.

Too often what happens is that people start out with good intentions and raise substantial sums of money to do their work. Then things start to go wrong: they buy fleets of SUVs for their own use in that country, they call for big huge conferences with experts who don’t speak the language, and then they realize that it is really hard to work in a place like Haiti or Burundi and pretty quickly declare defeat. Before they leave they blame the people they had come to help …

I don’t think the conclusion should be that we give up because it is impossible. I consider effective foreign aid as a debt that is owed by the West to many of these countries, such as Haiti, which has been a virtual colony of the United States. Certainly Europe owes some big debts to many countries in Africa …

The fact is that to have a Burundian leading this effort in Burundi is a really important aspect … I mean you’ve really got to speak the language. You have got to understand connotation and so on. You’ve got to be able to cultivate a local base: people you can trust. I think the effective projects are the ones that, while they have big goals, start with the individual. Let the individual patient teach you how to treat their family, and let that family teach you how to treat a village, and let that village teach you how to treat a province and the province: the nation. You can be working from both ends but you can’t forget the essential part: the local. I mean it’s where we all live.

Tracy Kidder with Chris Lydon in Cambridge, September 22, 2009.