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.
