Aira dusk. Mile high fields of tef, coffee, barley, sorghum, and maize surrounding the hospital. Photographer: James Li, M.D.


The Field Course for Remote Medical Service

Medical service: a message from abroad

Nine years have gone by since I wrote ‘Africa’ and six since the founding of Remote Medicine. The practicalities of funding an organization that offers training in medical service to the poor are harsh in an age when our western society has turned inward rather than outward. But the need for us to responsibly mobilize our resources in service of the underserved has never been greater, as worldwide targets for development and poverty ‘eradication’ are hopelessly abandoned. Furthermore, much of our present western-style aid is inappropriate, gauged for the short term, as in famine relief and cholera treatment. We respond and thrive on disaster and drama, forgetting too frequently that the poor need tangible, incremental, and stable progress, continued long past famine and epidemic, to allow lasting health and the pursuit of happiness. Thus, simple systems for composting feces or for storing roof runoff rain as disease-free drinking water are so much more important than the helicopter bearing aid rice, but so little emphasized for their lack of drama.

We are also too proud of our wealth and its resultant technology, and wrongly believe that we are in a position, by virtue of resource-superiority, to be qualified in skills and attitudes for service to the developing world. I write this from a poor but stable corner of Ethiopia, where despite my experience and training in three prior remote African hospitals, not to mention tenure in American medicine, I am still well behind the generalist skills of my African colleagues. I know malaria and tetanus and typhoid and how to operate and how to use ketamine, but the intern here still is a much better hand at these things than am I. This is not a statement of humility, but of simple fact.

So what are we doing here? Of what usefulness is our desire to help, to work abroad in such locales, to forego our known havens? The answer is a complex but meaningful one. We represent resources, and with resources, hope. For the patients, doctors, and even families I pass along the dirt paths to work, the presence of a Westerner in some impoverished corner of the world means that the poor are not forgotten. This representation is the beginning of something with great potential, but bears with it an equally great responsibility, for the next step is practically insurmountable. Once we have seen and experienced for ourselves, we must also, somehow, bring the resources we represent to bear on those regions of have-nots.

So here is a lesson, simple-sounding but profound. Westerners in the field, working while embedded in the communities of the poor, are always (yes, always) the best bridges to resources appropriate for progress and lasting good. This is at distinct odds with the most common model of poverty eradication, where large centralized organizations that are successful in gathering useful funds and technologies are forced to distribute them via networks of managers with little or no field experience. Such distributions rarely reach the populations most needful of them. Even more disturbing are the many well-intentioned programs that due to sheer ignorance have thrown millions of dollars of unusable donations abroad. The bulk of Africa does not need advanced life support trainers, CT scanners, laparoscopic surgical techniques, or even HIV medications [note]. Ask any African doctor what the hospital needs most, and the answer will be something much more basic: a portable ultrasound machine with rechargeable batteries, surgical needles that can be threaded with fishing line, a good stock of injectable ceftriaxone, artesunate for resistant malaria, a solar panel to recharge the portable operating room light for use at night, a second doctor qualified to perform emergency caesarean sections and laparotomies.

The simple truth is that it takes someone on the ground to discover what is needed and what is appropriate. Take another example. Several groups have published guidelines disdaining donations of expired (but otherwise appropriate) medications for impoverished communities. The justification at first seems straightforward: ‘If it is not good enough for a western patient, then it should not be good enough for anyone.’ But this only works for those who have never themselves been caught short of essential drugs. Spend one night on call at Masanga, where typhoid has killed five children during the day for lack of chloramphenicol, and then tell yourself that the box of expired ciprofloxacin under your bed is morally suspect. On facing the next limp hot comatose child, the discussion becomes absurd: a real chance at cure versus a certain death, and expiration be damned. Unquestionably, our greatest service first necessitates intimate knowledge of conditions on the ground. Without this experience, our efforts will fail no matter how well-intentioned and well-funded we are.

The need, in sheer numbers, has never been more. Yet, the opportunities today are equally enormous. We now have a rich history of resourcefulness derived from living with and caring for the poor that can be drawn upon to aid future efforts. Modern ‘single-use’ instruments are now able to survive hundreds of sterilization and use cycles. Patents have expired on many effective long-acting antibiotics which are now available at low price from countries such as India, Malaysia, and China. We have developed simple methods to make suture materials, intravenous fluids, and even dialysis fluid within the setting of a poor rural district hospital. We have enough experience and science to be confident that patients can be effectively operated upon without sterile fields, suction, cautery, oxygen, or sophisticated monitoring devices.

Hidden among the many wasteful technologies of the West are a few wonderful and useful ones, inexpensive and totally applicable to service efforts in the developing world. Non-flushing composting toilets have emerged as not only the least expensive, but the most effective means of managing human waste. Low cost clean water systems using rainwater, solar power, or gravity rams are much better than they were a decade ago. High frequency radios have become inexpensive, portable, and nicely functional: one can now be carried in a backpack and still, with a car battery and simple wire dipole antenna strung in a mango tree, communicate eight thousand miles. And we have ketamine, indestructible foot-powered suction, micro amperage LED lights, and solid state solar panels that can produce 185 watts at 48 volts.

Recognizing our responsibility to appropriately bridge the resources of the West to the needs of the poor, we are set with two tasks. First, we must be willing to work, on the ground, in a community where there happens to be great need, and for a duration sufficient to be of useful service. This means that we must be willing to get dirty. It also means that we must adjust and improve our medical skills to match the broad needs of the kind of place foreign to any experience we may have had in the West. We must become generalists in the truest sense of the word. Second, we must become familiar with nonmedical technologies appropriate and applicable to poverty. Such technologies are inexpensive, use renewable resources, create little waste, and are useful over a long-term.

As doctors and nurses, we have a unique opportunity to become powerful ambassadors for the underserved, a population with great need but few advocates, for few other Westerners are willing to give up their comforts and live with the poor. As such advocates, we must be reminded that our responsibilities include but also transcend medical care, for true health results from a broader perspective and a great deal of hard work. Poverty, which now encompasses half our world, will never be much improved without a good many of us committing our best efforts to creating permanent systems for food, sanitation, health, and industry.

Encouragingly, we live in a time when there are indeed many practical and attainable solutions to the seemingly immense problems of poverty. The implementation of these solutions is not difficult, but requires stubborn persistence, and as important, experience on the ground. Such admonitions – to become true generalists, technology experts, advocates of the poor – may seem arduous, and at first read they are indeed. In reality and from firsthand experience, I tell you they are not. Given any period of time, a life dedicated to service of the underserved is intensely rewarded with a sense of true purpose, usefulness, and well being.

Writing from this house and hospital above the river Birbir Wenz, I urge you to take the next great step forward, to leave your homes for a while and work next to the poor, recognizing your role as representatives of hope. This is the kind of work that will set us apart from our own inevitable advance, through consumption at all costs, toward self-extinction. We must not forget that technological progress and material wealth are not most meaningful when applied to ourselves, but when used to make others happy. For all of this, health care is a front line of hope, bearing with it the responsibility of bringing long lasting progress in the midst of scarcity.

James Li, M.D.