November 25, 2011

Doctor Brings Expertise and Gains Insights in Ethiopia

Dr. Gordon, BCM-Osher-JDC Medical Fellow
in Ethiopia, hosts a teaching session with
medical students from University Hospital, Gondar.
 In an effort to improve medical education, clinical care, and research in Ethiopian pediatrics, JDC has teamed up with the Baylor International Pediatric AIDS Initiative (BIPAI) and Gondar University Hospital (GUH). Over the past two years, BIPAI pediatricians placed as fellows have been formally integrated into every aspect of medical education at GUH, contributing invaluably to both the education of the local medical professionals and the care of the hospital’s patients.

David Gordon, M.D., M.P.H., is the current BCM-Osher-JDC Medical Fellow in Ethiopia. He trained in pediatrics at the University of California in San Francisco, holds a Masters in Public Health from Boston University, and has worked in India, Lesotho, Kenya, and Turkmenistan. David shares his insights on medical miracles, mind-bending local challenges, and the importance of cardboard toys for malnourished children.

JDC: Can you share some details about your personal background? When and how did you initially decide to go into medicine?

DG: I was born in Walnut Creek, California. I wanted to be an aerospace engineer until 1992, when on a whim I joined a program called Amigos de las Americas, run out of Texas. I raised money by selling grapefruit door to door, and paid for a ticket to Ecuador as a "community sanitation" volunteer. I was placed in a small village high in the Andes, where I worked with the local health department to construct latrines, give health-related presentations to villagers, and do what I could to develop the local infrastructure. It was my first time seeing poverty like that, and as a kid coming from suburban California it made a big impression on me.

I went to college, where I studied international development through the geography department, to figure out why people in Ecuador were so poor. At some point, I recognized how integral a population's health was to its economic productivity: people become sick because they're poor, and they become poor because they're sick. I became interested in public health, and in medicine by proxy. The rest of my education fell into place from there.

JDC: You've worked in such a wide variety of places, including India, Lesotho, Kenya and Turkmenistan. In what ways is Ethiopia a unique place for you to be working? What issues do you see transcending national boundaries?

DG: Ethiopia is like nothing I've ever seen. Its landscape, with green plateaus and rocky outcroppings, is stunning. Its culture, practically untouched by colonial hands, seems pure in a way I can't fully describe. And its people are friendly and respectful of me in a way I've rarely seen in my travels. As wonderful as Ethiopia is, it presents many challenges to providing medical care. First, there are local customs that threaten the health of children, and as a physician it's difficult to understand why these customs still exist. Holy water is used for everything from ear infections to the treatment of HIV, a practice which considerably delays a patient's presentation to allopathic care.

Second, the pathology that I see here is unlike any I've seen elsewhere. Ethiopia aspires to become a middle-income country, but it is still extremely poor. It has the world's 7th highest incidence of tuberculosis; it is one of just three places on earth endemic for a parasitic disease called visceral leishmaniasis (or kala-azar), which hits children here quite frequently; seasonal food security continues to be a problem, and severe acute malnutrition accounts for the bulk of our admissions; and countless rare diseases, including endemic typhus (the last place in the world this condition can still be found), abound. The wards are as much a classroom for me as they are for our medical students and interns.

Third—and this has more to do with me than with Ethiopia—this is the first time I've worked as a fully-credentialed pediatrician in another country. My status as a physician affords considerable legitimacy, and I have been able to connect with colleagues faster and accomplish much more than I was as a Peace Corps volunteer, a medical student, or a resident. The willingness of my Ethiopian colleagues to collaborate with me in this way has made my experience here more gratifying than any I've ever had.

Many of the same problems that weaken medical care in the US can be found in Ethiopia, too. Interns are severely overworked, and everyone (including me, sometimes) expects them to be miracle workers. Systems of delivering care break down constantly, as they do in the US, and fixing broken systems takes time and energy above and beyond what we're already putting into the job. And in a busy ward, with everyone dealing with the same problems, it happens too often that providers fail to relate to patients as human beings: we know what needs to be done, we need to do it quickly, and the human side of delivering care is undermined by the machines we have to become. Fighting all this is just as difficult here as it was in San Francisco!

JDC: Can you describe your typical day, if there is such a thing?

DG: I wake up at 5:45 and go for a run along the main road, usually getting warm greetings from passersby who yell "Gobez (well done)!" One child runs out to me, pumps his arm up and down several times, and yells "YES!" The latter happens just before a large hill that brings me home, and always recharges my energy. I drink a cup of buna—or coffee—at a cafe across from the hospital, where the owner often brings his 4-year-old son for me to evaluate for one ailment or another.

At eight, I join the department for morning conference, where we hear from interns about patients that were recently admitted and help them learn the essentials of pediatrics. Truthfully, I probably learn as much as I teach, since the pathology in Ethiopia is so different from that in the US!

After conference, two days a week, I teach medical students at the patient bedside. One student presents information about the patient, and I spend two hours making corrections, expanding the list of possible diagnoses, and reviewing the basics of physical examination and therapy. On the remaining three days, I work on "quality improvement" and research.

At noon, I walk across the street to a restaurant, where I fill my stomach with local cuisine for the equivalent of 50-75 cents. From two to four, I do rounds with interns on actual patients, hearing about details and making corrections to their management. I usually spend an hour at the end of the day reading about conditions I've seen on the ward and making sure my team's management is in agreement with international standards of care.

In the evening, after five or six, I like to walk around my neighborhood. Some children near my house teach me Ethiopian games; some families ask me to come inside to see a sick child and then sit me down for coffee or tea; and beyond my community, in the lush farmland, I like to walk and clear my mind for the night. Then I cook dinner, work on small projects or watch a TV show, and go to bed around 9:30; most of my friends call me an old man, but I can't function without a good night of sleep.

JDC: Do you work in tandem with the other Fellows in the program? What about local medical professionals?

DG: Currently, I'm the only BIPAI representative in Gondar. Usually, there are three of us, and two more will be joining me soon. We all work on our own projects, but lean against each other heavily: we consult each other on clinical cases, discuss good approaches to getting projects accomplished, and point out resources when we find them.

More commonly, to make our work sustainable, we partner with other physicians in our department. Six general practitioners, two residents, and three Ethiopian "senior consultant" doctors contribute significantly to our work, and without their involvement nothing would get done. We hope that when BIPAI leaves some day, we can leave behind a team of providers that can keep our interventions going into the future.

JDC: How do you cope with the difficult things you encounter so regularly? Have you seen any "miracles"?

DG: I wish there was a secret to making the sight of a suffering or dying child easy, but it never is, and I hope it never will be. I've seen students and residents visit this hospital for a one-month attachment and give up after two weeks, practically in tears; it makes me wonder if I've lost some element of sensitivity somewhere along the way.

I do two things when something bothers me. First, I run. Sometimes I run really far. And I always feel better when I come back. Second, I do something about the problem, even if it's small. Of all the cases I've seen in the past year, the malnourished kids have been the most heart-wrenching for me. They lie there, and they don't even have enough energy to complain. After my first week on that ward, I came home and made five toys out of cardboard, plastic bottles, and old magazines. Kids that I thought were lost forever smiled for the first time, mothers started playing with their children, and for a while the quietest ward in the hospital became the loudest.

Surviving here, I think, depends on feeling like you're moving forward, and on believing that your presence means something. A realist would probably die here, but as an idealist I'm thriving.

Honestly, every healthy discharge feels like a miracle, since kids come to us really sick and we care for them with so little! But other miracles happen, too. Interns who seem too busy to improve their practice sometimes take my advice to heart and surprise me with improvement. Medical students who I think aren't paying attention in lecture approach me afterward and ask appropriate questions, even asking for more reading material to augment their learning. If I look for miracles, I find them.

JDC: How does your Public Health background play into the work you are doing in Ethiopia?

DG: As a physician in general, moreover, I think it's important to think like a public health practitioner. One sees disease in a broader context if one is trained to think at the population level. It's easier to recognize clusters of disease and ask why they're occurring; it's easier to include environmental adjustment in a child's discharge plan; and it's more likely that a patient's family members will be recruited for testing when an infectious diagnosis is made. I've heard some people say public health (which focuses on communities) and medicine (which focuses on individuals) are mutually exclusive. On the contrary, I think public health and medicine can and should work very well together.

JDC: What are some of the biggest challenges you've faced in your time in Ethiopia so far? What are some of the most unexpected surprises?

DG: I always find technology frustrating, and technology in Ethiopia is no exception. So much of what I do requires 1) a source of electricity, 2) a source of internet, 3) a computer that works, 4) a cord that connects a computer to the internet and another that connects it to electricity, and 5) a printer that works, has electricity, has a cord that connects the computer to the printer, and accepts my flash drive. This may sound logical to you, but in Ethiopia you would be AMAZED by how rarely all these components actually co-exist.

The same is true for lectures in powerpoint—at least one of these components is almost always missing, no matter how prepared you are. Ethiopians deal with this by shrugging their shoulders; admittedly, I deal with it by getting really angry. I want to do good work, but I feel like the universe is working against me. I'm becoming more patient with time here, and I think I'm becoming a better person.

I've been surprised by how far we get with such few resources. A child with a newly-diagnosed neurologic disease in the US would get an MRI and blood work very quickly. Here, I have to re-learn how to interpret physical findings in context, knowing that the only data I'm going to get will come from my ears, hands, eyes, and nose. It's validating to know we can do so much with so little, especially having trained at a US tertiary care hospital where any question was answered with a sophisticated test. I'm also surprised by both the heroism and the greed of providers here. My fellow pediatricians and internists voluntarily stay long hours to care for their patients and are meticulous when educating medical students. In other departments, however, senior physicians often shunt the poorest patients into private clinics to earn more money from their care; equipment is stolen from the public hospital for use at private facilities; and, incentivized by more competitive salaries, many leave practices serving the poor to work abroad or for international NGOs that may or may not provide comparable services. I really do feel like I see the best and worst in people here.

JDC: What do you think you'll do once you complete your current service?

DG: I have absolutely no idea what I'll do after this. I've wanted this job, more or less, since I was sixteen years old, and it frightens me to think that I have to set new goals now. I have an interest in policy, and may pursue a career with the WHO or one of the US-based health development organizations. Alternately, I could continue practicing pediatrics for an underserved community in the US and focus on community development. After this experience, it will be difficult to ever let my interest in international health go. I'm open to ideas.

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