During my fellowship at Yale University my wife came to visit me with our four-month old son. It was winter and everything was new for the family. One week into her visit she got a fever and was rushed to the emergency room. I was immediately called in, not to attend to her, but to our son as the doctors took care of my wife. A myriad of tests were performed including a CT scan. In the end a diagnosis of malaria was made and the team wanted to take her to a high dependency unit. I later joined the discussion and convinced them that she would be fine if we treated her with Coartem (Artemether/lumefantrine), an antimalarial.
Because the hospital did not have this kind of drug, the doctors wanted to contact the CDC in Atlanta to get it. Otherwise, Quinidine, a drug sometimes used to treat heart rhythm problems but with antimalarial properties, would have been used! Luckily, I had travelled with a few doses of Coartem which I offered to treat my wife. A week after her discharge, I received a bill of $8,000 in my mailbox which kept increasing every week thereafter. This bill totaled more than a quarter of my year’s fellowship funds. I was so confused and felt so vulnerable to the point of wanting to quit my fellowship prematurely. How could this have happened? Why is it so expensive to treat malaria in the USA? From where am I going to get all this money to pay the bills? These and many more terrifying questions ran through my mind. I realized my experience in the United States was not unlike that of the medical students and foreign physicians I have hosted in Uganda.
Every year, we receive hundreds of medical students, residents and faculty from the USA and Europe to Uganda. It is often their first time to Africa. Though they receive countless briefings before they arrive, nothing seems to prepare them for the realities that they face on the medical wards and in their daily routine. Seeing young patients very sick on the wards with HIV-AIDs and sepsis is a common scene on the wards. Often the beds are scarce, to the extent that some patients have to be nursed on the floor and most times by a close relative because the nurses are equally limited. Privacy, which is at the core of medicine in students’ home countries, is a luxury saved for those able to afford private room costs. The litany of stark comparisons between host and home institution often exceeds what they ever imagined before leaving their home country.
The visitors are thus very vulnerable, and a single extreme event such as the death of a young patient could tip them over and irreparably scar them. These life events have the potential to limit future possibilities of becoming the compassionate, empathetic and passionate doctors that we often want them to be. How can this situation be handled? How does a good global health program turn this vulnerability into a life changing experience that could have a lasting impact? This is indeed a difficult question which needs to be answered by every global health program. I don’t pretend to have all the answers but allow me to share a few lessons I have learned over the years.
Each of us has a point of vulnerability that is often heightened by an unfamiliar environment. What differs from one person to another is the level of resilience. Participant resiliencies vary and are often hard to predict before they face real life experiences. It is very important to be aware of, and appreciate, vulnerability when it surfaces. When the clinicians come to a foreign country for the first time they need to be patient and not too hard on themselves. They need to take time and be willing to learn not only the medicine but also the culture and environment where they have gone to work or study. They should be willing to be silent but curious observers who may not be able to contribute much at the outset. However, every lesson should be used to learn and be prepared to give back when the right moment comes. For the medical student, it may be going back to finish their residency so that they can gain more skills in order to return and treat the patients who enabled them to learn so much.
Great global health participants look at every patient as an opportunity to learn something new, not only in medicine but also in culture. They use their experiences as a platform for building empathy which is the essence of medical practice. Vulnerability of patients and students should stimulate us to look deep in ourselves and draw from the inner strength to make ourselves and, more importantly, our patients better.
Global health programs should establish a feedback mechanism as well as a learning environment in which the incidences of vulnerability, contention, tension and struggles from within and without can be discussed within a free and non-judgmental environment. Once this process is handled well, it can lead to an infinite spring of energy that can transform participants not only into global health champions but also into doctors who serve the minority and needy people in their home countries.
To end the story of the piling bills, mentors at Yale University found a way of settling the bill and I never heard from the hospital again. I returned home after my course to become one of four nephrologists serving a country of close to 36 million people. We have also been able to set up a community program called ACCESS which serves people from rural communities.