6 May 2019

Physician, clone thyself

global health

The thought must have gone through your mind at least once: shouldn’t I go and work overseas where more people truly need my help?

It’s a widespread, well-intentioned, perhaps slightly romantic ideal that doctors from developed countries should offer their skills and time in poorer parts of the world where health infrastructure and staff are lacking.

But there is a growing body of literature suggesting that, while a short stint in Africa or Central America it may look good on your Instagram and resume, it may actually do more harm than good.

Medical voluntourism, to use its derogatory name, can discourage investment by local authorities in health infrastructure and increase dependence on foreign aid, rather than building capacity.

Volunteers arrive not understanding the local language, culture or disease presentation, and don’t spend long enough to build trust with communities. They can be a burden on host communities, requiring transport, accommodation, food and translators, and often get sick themselves.

Whether specialists or generalists, they may not have the most appropriate skill set. The medical services they offer come without accountability or continuity of care, with follow-ups left to local doctors. Free services may deprive local doctors of paying patients.

And many have noted the inherent paternalism of such missions and tendency to entrench imperialist stereotypes.

That’s before considering your travel costs – often paid to operators in rich countries – and the time spent away from your family and your own patients.

Five years ago Gosford, NSW-based rheumatologist Dr Rob Baume was contemplating a volunteering trip, but not long into his research he realised the negatives outweighed the positives.

Besides the reasons above, Medecins Sans Frontières, the premier organisation for doctors abroad and probably the most scrupulous operator, takes volunteers for a minimum of nine months. (Anaesthetists and obstetricians can go for shorter stints.) This is an appropriate time frame if you want to make any real impact, but hard to do mid-career, especially for a parent.

This didn’t cure his desire to help, and revealed a philanthropic gap he thought should be filled. So Dr Baume and colleagues founded Twice the Doctor, a charity that encourages doctors to donate one day’s pay a year to health programs in African countries.

By directing those donations in a laser-focused way, and saving on administration costs by donating in bulk, Twice the Doctor can make every dollar go orders of magnitude further.

It could be any day, of course, but the organisation suggests making “One Day in May”, May 25, the day doctors dedicate to funding their avatars.

Twice the Doctor works with programs that address areas of real medical need and involve training and capacity-building. The result is a local health professional doing the work for you, without any of the inefficiencies or unintended consequences of voluntourism.

“What I came up with was the concept of working here in your usual practice and donating a certain amount – not an ordinary donation, but to programs that train doctors and high-level nursing staff to essentially do the work you would have done had you gone there,” Dr Baume tells Rheumatology Republic.

“It’s almost an avatar concept. While you’re working here they can be working there, and the logistics of that are far superior.

“You can make an enormous difference for peanuts.

“Unless you have the skill that no one else has, [going overseas] doesn’t make much sense. If you’re teaching a skill that no one else can, or you’re inspiring others, it’s worthwhile – but for the vast majority of us this is a better way, I think.”

In sub-Saharan Africa, he says, a nurse might earn in a year what a specialist makes here in a single day.

“So why would you go over there, spending a lot of money to do so, not see your family or your patients, risk getting a lot of infections, not speak the language, not know culturally what’s required, not have the skills – just to get the picture of you treating the happy natives? This would be more about you than about making a difference.

“Not only that, but they really need the wages over there and they need the skills that you’re helping to provide. A nurse there does a hell of a lot more than a nurse here – they’re given a lot more responsibility because of the lack of staff. In the Central Republic of Congo there’s no medical services for 70% of the population.”

Twice the Doctor has so far raised $600,000 for UNICEF, the Barbara May Foundation, the Fred Hollows Foundation and SurgicaLife. It is now working with a mentoring program in Zimbabwe that flies obstetricians and gynaecologists to remote areas to train health workers to do deliveries and caesareans.

The Barbara May Foundation is dedicated to maternal health. It has established two maternity hospitals in Ethiopia and one in Tanzania, is about to set up one in South Sudan and expects to build one in Uganda after that. Co-founder Dr Andrew Browning AM has also helped establish fistula repair units in 10 countries.

Dr Browning is an Australian gynaecologist/obstetrician and a fistula surgeon who worked in Ethiopia for 10 years and Tanzania for seven before returning to Australia a year ago. He still travels back regularly to work.

“I think it’s a fantastic initiative,” he says of Twice the Doctor. “I just wish that more doctors would take it up.

“The beauty of it is that the local guys, they know the language, they get what’s appropriate, whereas a volunteer coming in often doesn’t know all these nuances.”

Last year his organisation delivered 16,000 babies, while over the years he has treated about 7000 fistula patients.

One of the Barbara May hospitals delivers 2500 babies a year and trains midwives in cohorts of 100, while supporting up to nine government health clinics. It’s all free for the women, and there has never been a maternal death – in a region where, without access to a hospital, one in 12 women will die in childbirth.

All this is done on a budget of about A$400,000 a year.

“That’s all salaries, all bills, everything,” Dr Browning says. “So it averages out about $155 per woman looked after, for four clinic visits beforehand, the delivery, with a 15% chance of a caesarean, and the postnatal visit as well.”

A doctor in Tanzania might earn $1000 a month, he says, a midwife $600.

Dr Baume estimates that a hospital offering the same level of service in Australia would have a budget of $40 million to $100 million a year.

The Barbara May Foundation takes volunteers for month-long stints, because that’s the longest business visa you can get in Ethiopia. This is unfortunate, Dr Browning says, as it takes years to build trust and implement changes that won’t lapse as soon as you leave.

“We’d much rather have long-term volunteers. You know, one, two, three, five, 20 years. Then they get to know the language, to know the people. In these situations it takes a long time for you to get the trust of the local people and to be able to instigate change.

“When you come in and out, the local staff will just tolerate you for a while and tolerate your demands, and then as soon as you go they’ll go back to the way they do things. And you can imagine that’d be the same if people came here from abroad somewhere and started telling us what to do in a hospital.

“In Ethiopia it took me four years of living in the fistula hospital before I could actually instigate my first change towards more modern practices. It took that long for me to gain their respect and trust. Short-term people can come and do the job and impact the people that they treat, but the impact of the short-term volunteer is limited.”

Dr Browning said he had seen bad behaviour from visiting doctors, ranging from arrogant attitudes and inappropriate treatments all the way to using patients as experimental or practice surgical subjects.

“I have seen groups, especially American groups, come in with a much more imperialistic attitude, saying, ‘We have to do these things the American way, because it’s the only way’. And they come over with their journalists and have their photos on the TV back at home after they’ve just volunteered for two weeks and really made a mess of things.

“They’ve done operations that are completely inappropriate for the context. For example, you might do a diversion operation on a fistula patient, which means that the urine’s collected on a bag on the skin. They’ll come along and do that on a patient who’s entirely operable, who could be cured normally. And then they leave, and there’s no bags to collect the urine. So they’re even more depressed because now they’re leaking urine through this opening on their abdomen.

“And there are stories of people coming in, very inexperienced, and just more or less experimenting with their operative skills and trying to gain operative experience while in Africa. It’s just dreadful.

“And so the governments are rightly clamping down on that and being much more rigorous in giving the medical accreditation in their countries. To get your medical accreditation in places like Tanzania or Uganda’s so cumbersome and laborious, it puts people off – but maybe that’s a good thing.”

He says volunteers can help raise awareness and lift enthusiasm in their colleagues when they return home.

“All our hospitals are reliant on overseas donations, because the health budget in these countries is something like $1.80 per person in the country. So it needs external help. And the volunteer coming over usually drums up interest back in their own hospital.

“So there’s still a need for volunteers, but they should be in a locally established program that’s got the buy-in by the government and the local health bureaux.”

Another program that also makes a huge impact “for peanuts” is treating trachoma, which Twice the Doctor supports through the Fred Hollows Foundation.

Dr Baume puts it in terms of QALYs, or quality-adjusted life years: in Australia, where a QALY is priced at $100,000, the average doctor might notch up 10-15 QALYs per year, or the equivalent of half a life saved. Through trachoma surgery, you can buy a QALY for just $17 –  so for just $350 you can double your QALYs for the year.

The world’s leading infectious cause of blindness, caused by the Chlamydia trachomatisbacteria, trachoma disproportionately affects women, who catch it from their children and have to cook over eye-drying smoky fires.

The disease causes eyelashes to invert, scratching the corneas and causing pain and ultimately blindness that can only be reversed with a corneal transplant – an impossibility in the areas where it is endemic. (Its prevalence in some Aboriginal and Torres Strait Islander communities makes Australia the only developed country with trachoma.)

Timely surgery on the tarsal conjunctiva can prevent the disease’s advance and preserve sight. Fred Hollows trains nurses in Ethiopia to do this at a cost of $US2000 ($2800) each, who then perform it at $US1 per procedure.

“They do 10 or 15 a week,” Dr Baume. “If you did one week like that and saved all that vision, you’d be crowing about it for the rest of your life.”

Dr Baume last year started a spin-off initiative called Twice the Patient, which gives people waiting in a doctor’s rooms a very low-pressure prompt to donate a small amount to the same cause. In his practice alone this has raised $5000 in five months.

To donate or to request Twice the Patient materials for your practice, go to twicethedoctor.org.au.