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Global Health

Curative medicine and public health

Year: 1993
Setting: Chevron hospital in Papua New Guinea
Position: Chief medical officer

I have been working in Papua New Guinea for one month and I will stay there for two years as chief medical officer for Chevron. I am in charge of the hospital and four clinics, but also for implementing the public health program that I created for about 10,000 villagers in the Kutubu area. At the hospital, I begin to see patterns emerge for diseases stemming from the villages in the Southern Highlands province under my responsibility.

As in similar situations that I have encountered in Africa and South America, the main reasons for consultation are, in decreasing order of frequency: infectious diseases, gastrointestinal disorders, skin diseases and trauma. In the last category, I am confronted for the first time with injuries resulting from bows and arrows (weapons that are sometimes used in tribal fights over land, money, etc.).

The demands on the medical staff are intense. There are frequent emergencies at night and they put a strain on health-care providers. I would like to know more about the origin of the diseases and injuries we treat, but no stats are readily available. Therefore, I decide to work with corporate software technicians to create an electronic medical record system that will give us objective data to help alleviate the workload at the hospital while also increasing the quality of care. There are snags along the way, but we overcome each of them and in a few months the system is operational.

At the end of the first month, we start analyzing the data that we gathered. Now we know the villages where malaria and gastrointestinal disorders are more prevalent, for example. This will be extremely useful for the public health program. My motto for its implementation is: timely, targeted and temporary (with transfer of leadership to local authorities). We determine the implementation priorities as follows: mosquito nets, clean water tanks, latrines, garbage disposal pits and mass treatment for worms. The time frame is a two-year period. Immediately, we observe dramatic results such as: lower morbidity and mortality rates; decreased number of emergencies and total volume of villager consultations; less stress on the medical staff and better quality of care. This is particularly interesting for costly chopper medevacs.

With the money saved, I create CME programs that train the clinical staff on emergencies related to trauma and obstetrics as well as performing lab tests, and another program that enhances the efficiency of the health extension officers and aid post officers who are stationed throughout the area. The courses are provided in different hospitals in PNG and overseas. I also supply the aid post officers with boards that can be used in evacuating patients with spine injuries, watches to measure pulse rates, thermometers, blood pressure cuffs, solar-battery-powered radios and protocols for emergencies. Our enhanced cooperation with provincial and central governments has ensured a regular and updated basic drug supply to local pharmacies.

Lesson for the doctor: In developing countries it becomes more obvious that curative medicine and public health are two faces of the same coin. Try to work at both levels for better results.

Yann Meunier, MD, is the health promotion manager for the Stanford Prevention Research Center. He formerly practiced medicine in developed and developing countries throughout Europe, Africa and Asia. Each week, he will share some of his experiences with patients in remote corners of the world.

Global Health

A pesky tropical rash

Year: 1980
Setting: Beach in Martinique
Position: Tropical diseases specialist, Pitie-Salpetriere Hospital, Paris

It is my first summer holiday after joining the tropical diseases department of professor Marc Gentilini at the Pitie-Salpetriere Hospital in Paris where I will stay for nine years. I am relaxing on the beach in Martinique admiring a rocky island called “Le Diamant” (“the diamond”), which used to be a refuge for pirates in the 18th century. By pure coincidence, the young people lying next to me are a group of medical students from different cities in France. After a few jokes and local drinks, I learn that they have been on the island for 10 days and are celebrating after passing an exam that will allow them to practice and study in the best French hospitals.

As the conversation evolves, a couple comes by my side and requests to talk to me privately (a doctor is always on call!). They then disclose that they have been experiencing some ferocious itching all over their bodies for two days. They proceed to show me their skin lesions. As I examine them, they add that the symptoms get significantly worse at night and they have to take sleeping pills to get some rest. They also say they have observed that the numerous snakelike red furrows on their skin move forward a few centimeters each day. The diagnosis of cutaneous larva migrans (creeping disease) is easy to make. However, what is highly unusual in this case is that the lesions are so profusely disseminated. Generally, they are limited in number and located on the feet. After probing deeper on their experiences during this holiday, they reveal that the first night they went skinny dipping in the Caribbean Sea and frolicked in the sand between swims. What the couple didn’t realize is that wild cats and dogs defecate on the beaches, and the waste contains the eggs of hookworms. When the eggs come into contact with animal or human skin, the larvae emerge. In humans, the larvae wander aimlessly under the skin for weeks and then die. This was why the couple’s skin lesions had spread so widely.

Lesson for the doctor: Before traveling to a tropical country, brush up on your knowledge of tropical diseases.

Yann Meunier, MD, is the health promotion manager for the Stanford Prevention Research Center. He formerly practiced medicine in developed and developing countries throughout Europe, Africa and Asia. Each week, he will share some of his experiences with patients in remote corners of the world.

Global Health

A new lifestyle

Year: 1988
Setting: Lifou Island, New Caledonia
Position: Private general practitioner

It is the wedding season and almost every weekend I am invited by a tribe to participate in their festivities. Each is a big production that lasts three or four days with local gourmet food, such as grilled lobster, fresh fish, coconut crabs and the signature dish called “bounia.” It is basically a piglet cooked atop sizzling stones and stuffed with coconut milk, yams, taro and sweet potatoes wrapped in banana leaves and covered with dirt. It takes hours to be ready. Wine and liquor flow freely day and night. By the end of the first day, a few people are drunk (mainly young folks). Most guests sleep in the village huts and try to cure their hangovers by drinking more the next day!

My presence on the island had created a dilemma for the local social structure: How can an alien be integrated without disrupting traditional rules? All foreigners have the same status, but they appear to want to create an exception for me because of my medical contributions. A solution has been found, and now at ceremonies I am seated to the right of the big chief (there are three on the island).

It is Sunday and one of these happy days. I am enjoying the company, the food and the ceremony. Suddenly, a car pulls up on the lawn and the driver makes a beeline toward me. His son is experiencing acute abdominal pain and needs urgent medical attention. I go to his place and examine him. Diagnosis: Suspicion of acute appendicitis. I spend hours organizing a medevac to the hospital on the main island. Phone calls take place between me, the airline, the hospital, the airports, the hospital and the surgeon. I also have to find an accommodation for the mother, who will stay in Noumea until her child is discharged. Moreover, on a Sunday everything is slower and more complicated. Ultimately, it equates to another Sunday spent at the office. For some reason, many emergencies wait for the weekend or evening to emerge! Everyone knows where I live (which is also where I work) and because I am the first and only private practitioner for about 10,000 people, the demands are high for medical services. It takes me a while to adjust to this fact. I remember my intern days at GWU hospital when I was on call every third night and was envious of my counterparts on the West Coast on call only every fourth night. Little did I know that one day my on-call schedule would be 24/7!

Lesson for the doctor: Before accepting an assignment/position on an island, always consider the special working conditions created by the physical environment.

Yann Meunier, MD, is the health promotion manager for the Stanford Prevention Research Center. He formerly practiced medicine in developed and developing countries throughout Europe, Africa and Asia. Each week, he will share some of his experiences with patients in remote corners of the world.

Global Health

No respite for the weary

Year: 1998
Setting: Yi villages, Yunnan province, China
Position: Medical mission leader

It is about one week before Christmas and we have been working in various villages examining patients, providing treatments and delivering public health messages ranging from using clean water to building latrines to washing hands before meals to dental hygiene. The days are long and cold, the food unsavory and sleep scarce because of the coldness of our housing. A couple of us catch a virus and become sick. But now I am on the plane back to the lion city with all my Singaporean Chinese colleagues. On this trip, I learned as much from them about the social life in the city-state as from observing the living conditions of the Yi people.

The plane takes off and reaches cruising altitude. I relax and begin to have a good time in a warm, dry and familiar environment. Alas, a few minutes later the pilot’s voice resonates throughout the cabin: “Is there a doctor on the plane?” If I had the intention of waiting, in the hope that someone else would raise a hand, my strategy would have been shattered in a nanosecond. As soon as the announcement ends, every single head of the delegation turns toward me with the same expression: “Why don’t you go?”

Within a minute I find myself examining an overweight, middle-aged German lady who has been vomiting in the toilets. I administer a dose of an anti-emetic medication. As she begins feeling better, I am able to rule out gall bladder stones and other serious conditions. I also discover that she is a Christian and has been celebrating the holiday with her family and friends, eating two large pieces of dark chocolate before boarding. As I return to my seat, I reflect on another example of the big divide in this world. Within a few hours I have been confronted with two extremes: Food deprivation and misery on one side, and food excess and indulgence on the other.

Lesson for the doctor: A doctor is always on call.

Yann Meunier, MD, is the health promotion manager for the Stanford Prevention Research Center. He formerly practiced medicine in developed and developing countries throughout Europe, Africa and Asia. Each week, he will share some of his experiences with patients in remote corners of the world.

Global Health

When your worst wish comes true and it makes you better

Year: 1983
Setting: Ikoyi branch of the St. Francis Hospital in Lagos, Nigeria
Position: Private general practitioner

About 70 percent of my patients are locals, and the rest are expatriates living overwhelmingly in Lagos. They rarely come from other cities in Nigeria. The main motives for consultation are (in decreasing order of frequency): Fever, gastrointestinal disturbances, skin lesions and trauma. Pediatrics is an important segment of daily practice, as well as obstetrics and psychological disorders in women.

Pregnancy monitoring can be challenging. Although the city has more than 6 million people, ultrasound exams are only available at the general hospital and in a single clinic. Serologies can solely be performed at hospitals where quality control and availability of results are serious issues. It creates a feeling of insecurity; for these and other reasons, many expatriate women decide to fly back home to deliver their babies. Nevertheless, some choose to give birth in the city where they live, like the wife of my neighbor, who is a French news correspondent in Nigeria. From him, I learn tremendously about the country’s social structure and political mores.

I have never witnessed any adverse outcome from delivering a baby locally, an option that is much less costly than flying to Europe. At any rate, a highly educated British lady one day shares her feelings about her life in Nigeria, her interactions with nationals (mainly domestic help) and the state of Nigerian health care, as well as her racial views. She declares that under no circumstances she will allow her first child to be delivered by a black doctor. I tell her my professional experience in this respect. Predictably however, and as she wishes, one month prior to the expected date of delivery she takes a plane to London. About three months later she is back in my office and I am curious about her whole obstetrical experience in England. Everything went fine, she says, including the physician’s care. As I ask for his references to request a copy of her file and test results, I cannot stifle a chuckle. He has a Yoruba name! She sees my reaction and in a typical understated English humor lets out: I might have my second child here after all.

Lesson for the doctor: It often takes a strong dose of reality to dislodge a patient’s preconceptions.

Yann Meunier, MD, is the health promotion manager for the Stanford Prevention Research Center. He formerly practiced medicine in developed and developing countries throughout Europe, Africa and Asia. Each week, he will share some of his experiences with patients in remote corners of the world.

Global Health

When your best is not enough

Year: 1994
Setting: Chevron Hospital in Papua New Guinea
Position: Chief medical officer

There are a few villagers living near the hospital, and often kids play on the dirt track leading to the main gate of the prefab compound. After a few trips out of the camp, I notice one boy in particular who is often near that gate. He cannot run, and walks only short distances. His chest is protruding and he pants a lot. I ask a nurse to talk to his parents to see if we could help him. First, she reports that the parents have taken the boy to a witchdoctor who has given them some local medication and assured them that their son would get better. I send her back with the following message: “If his condition does not improve, please come to the hospital.”

Weeks go by, and one day I see them in the waiting room. The child is now constantly short of breath when he moves around. I examine him and the diagnosis is a defect in the wall between the two ventricles in his heart. The bad news is that there is no pediatric cardiac surgeon in Papua New Guinea. The somewhat good news is that in two weeks one is coming from Australia and will be in Medang, which is a 20-hour car trip from the village. I make an appointment with him and arrange for transportation for the boy and his parents.

I see the boy each day in the hospital until his departure. As it is often the case with the sickest children, he is the sweetest patient. These are stressful consultations because, despite my best efforts, his condition is gradually deteriorating. On the day he leaves, he is breathing heavily even at rest. I wonder if he will make it through the 20 hours of travel in the back of a truck on bumpy tracks in a rugged, mountainous terrain. We say a poignant good-bye. To this day, his penetrating, grateful, anxious and pleading look is printed in my brain. A few weeks later, I learn that he had made it across the ridges to the seashore (what a fighter!) only to hear the surgeon say that the boy’s status was so severe that surgery was impossible. He died just a few days later.

Lesson for the doctor: In undeveloped countries, doctors must face the fact that their efforts won’t enable them to save all of their patients. It is useful to learn how to cope with frustration and guilt beforehand.

Yann Meunier, MD, is the health promotion manager for the Stanford Prevention Research Center. He formerly practiced medicine in developed and developing countries throughout Europe, Africa and Asia. Each week, he will share some of his experiences with patients in remote corners of the world.

Global Health

Political no man’s land

Year: 1988
Setting: We, Lifou, New Caledonia
Position: Private general practitioner

On Nov. 18, six months after the killing of 19 Kanaks (the indiginous Melanesian inhabitants of New Caledonia) by the French special forces on the island of Ouvea, I open the first and only private medical practice of the Loyalty islands in We, capital of the island of Lifou. The total population is about 10,000 people, 99 percent of whom are Melanesians. In the first weeks, my life is threatened a few times by drunken pro-independence backers at various social events including a wedding. They accuse me of exploiting the islanders and resort to violence when I challenge their statements, pointing out that my medical services and all the medications are delivered for free to all of them. On the other hand, some anti-independence islanders criticize me for, in their view, helping the pro-independence movement by taking care of and treating its supporters.

My waiting room is like a scene from the American Civil War. Pro-independence patients sit on one side and anti-independence supporters stay as far as possible from them on the other side. Some know each other very well and even live in bordering houses and huts. The atmosphere can become quite heavy at times and I cannot help but wonder what would ensue if anyone broached a political topic. Fortunately as the weeks go by, the patients start talking to one another. Maybe my tireless reiteration that all patients are equal to me (exemplified by the care I provide) contributes to a more relaxed atmosphere under my roof. At any rate, the phenomenon is spilling over into other areas of the town and the people who started a dialogue while waiting for a consultation carry it on later in public places, such as the grocery store or the gas station (people usually come to the capital for a sweep of errands). In months of this snowballing effect, relationships are back to normal.

Lesson for the doctor: In some circumstances, the doctor’s office can become a forum for long-reaching societal changes, and his/her attitude can be the catalyst for reconciling enemies.

Yann Meunier, MD, is the health promotion manager for the Stanford Prevention Research Center. He formerly practiced medicine in developed and developing countries throughout Europe, Africa and Asia. Each week, he will share some of his experiences with patients in remote corners of the world.

Global Health

Communicating with the patient

In settings where no lab tests, X-rays or other diagnostic help is available, the diagnostic process relies on taking an accurate history of the disease and performing thorough, pertinent physical exams. This makes communicating efficiently with the patient and his or her representatives of paramount importance.

I remember one of my first patients at the Moncorvo Filho Hospital in Rio de Janeiro. She was a middle-aged lady, slightly overweight, who lived in a city slum after migrating from the northern part of the country with her family. Her main complaint was: “Estou sentindo dor nas cadeiras,” which literally meant, “I am feeling some pain in the chairs”. I had absolutely no clue what she was referring to, so I had to ask the people who were with her and learned that she was suffering from low back pain.

On the island of Lifou in the Pacific Ocean, some of my some Melanesian patients used the moon cycles as time reference when I asked about the onset of their symptoms, saying that they began feeling ill so many days before or after the last full moon. I quickly bought a calendar with the moon phases on my first trip to the main island.

In Cameroon, some patients would focus on what they believed to be the cause of their symptoms rather than describing the nature of their symptoms, as I had requested. For example, they would tell me how walking by a cemetery had angered some spirits that retaliated by invading their bodies and inflicting various kinds of ailments. Guiding the discussion back on track without offending them required great delicacy and tact.

In Papua New Guinea, a patient who was happy with the result of an antibiotic therapy once told me, “We used to go to the traditional healer, but now we trust you.” Curious, I asked him how I gained his confidence. I expected an answer based on the efficacy of modern medicine, and so I was startled when he replied, “Because your power is stronger.” I tried to explain that my perceived power was the result of the active ingredients in the tablets. His reply was: “We do not understand how this is possible. What we know is that you put your power inside the pills that cure us.” It was a perfect example of the reconciliation of modern science and traditional culture!

Lesson for the doctor: To be efficient in an environment with limited resources and a high level of demand, it is imperative to relate quickly to patients. Knowing the local culture and its idioms goes a long way toward achieving this.

Yann Meunier, MD, is the health promotion manager for the Stanford Prevention Research Center. He formerly practiced medicine in developed and developing countries throughout Europe, Africa and Asia. Each week, he will share some of his experiences with patients in remote corners of the world.

Global Health

Knowing when to bend the rules

Year: 1990
Setting: Hut in We, Lifou
Position: Private general practitioner in New Caledonia

A small familial delegation comes to my office one morning asking me to pay a house call to a relative who is unable to come and see me. He has been diagnosed with end-stage liver cancer at the Gaston Bourret Hospital in Noumea, the capital of New Caledonia. He was sent back to Lifou, the biggest and most populated of the Loyalty Islands (99 percent of the islanders are Melanesians) with painkillers and recommendations that included a complete ban on alcohol, stating, “It has caused the disease that is killing you.” So much for psychology and the patient’s emotional state!

To my way of thinking, the physician’s recommendation made complete scientific sense, but didn’t consider the patient as a whole. Alcoholism is a major public health issue for the Melanesian population in New Caledonia. The situation is similar to that of the Aborigines in Australia. I knew that the patient’s physical condition was so poor that he had only a few days to live. Because of that, banning alcohol would have no impact on the patient’s prognosis whatsoever.

The patient is lying at the center of the hut and I have to wait a few seconds while my eyes adjust to the faint light coming through the door, which is the only opening in the whole structure. I listen to the patient’s medical history and give him a morphine shot. He knows that his condition is terminal and that he has only a few days left to live. When he feels more comfortable, we talk about his life. Then he asks me, “Could I have a beer?” People around him look at me with some guilt on their faces and say, “Please ignore what he said. We know it is not good for him.” But to their great disbelief and the patient’s utmost delight, I tell them that it OK as long as he does not get drunk. I want to show compassion to a this man who knew he was at the very end of his life and who wanted one last bit of pleasure.

As I walk on my way to the car, his wife asks me one more time, “Are you sure he can drink his beer?” When I remind her of her husband’s prognosis, reality sinks in and she becomes suddenly grateful. “I love this man in spite of everything. He is the father of my children and I want him to be happy at the end of life.”

Lesson for the doctor: Sometimes in medical practice, compassion is needed more than science. It is an art to know when.

Yann Meunier, MD, is the health promotion manager for the Stanford Prevention Research Center. He formerly practiced medicine in developed and developing countries throughout Europe, Africa and Asia. Each week, he will share some of his experiences with patients in remote corners of the world.

Global Health

Individual vs. public health

Year: 1993
Setting: Mendi Hospital, Southern Highlands province, Papua New Guinea
Position: Chief medical officer for Chevron

Chevron is contributing to the budget of Mendi Hospital in the capital city of the Southern Highlands province. Each year, the hospital director sends a financial request to the company’s medical department, and this is my first time to review and approve it. Curious about how the money will be used, I phone the director to request a list of the equipment and medical supplies most needed. I can hear some irritation in his voice. Several weeks later, I receive the document, and I go through it with great interest to find out priorities I may have overlooked. To my astonishment, the items at the top of the list are TVs, VCRs and wheelchairs. There is no correlation between the list and the main causes of mortality and morbidity in the area. I set up an appointment to meet with the director.

A few days later, after a short helicopter flight and car ride, I am at the hospital. It is dilapidated. The paint peels off the walls, there are cobwebs in the corners of the ceiling, the floor is covered with dust, some windows are broken and faucets leak in the bathroom. These sights do not put me in a good mood. After a short wait, I face the director. We engage in small talk, but soon turn to hard topics and I ask a few provocative questions: How many doses of polio vaccine could one buy with the money for a new wheelchair? How many mosquito nets could one buy for the cost of a TV? How many needles could one buy for the cost of a VCR?

My colleague seems to be recalibrating his approach but does not give up. He has one more weapon to use on me. He takes me to the wards and shows me a few diabetic patients with bilaterally amputated legs. These men and women have no means of getting around on their own and people have to carry them. One of them (I found out later) is an influential local politician. I am stirred but not shaken and regroup quickly when I see two kids with polio atrophic legs playing in the yard. I suggest a new list that better reflects the urgent medical needs of the local patients. I receive it a few days later, and it is the beginning of a positive and productive relationship with the hospital based on a sound foundation.

Lesson for the doctor: When working in developing countries, choices can be hard to make. Conflicts may arise between individual and collective benefits. Avoiding waste must be a priority.

Yann Meunier, MD, is the health promotion manager for the Stanford Prevention Research Center. He formerly practiced medicine in developed and developing countries throughout Europe, Africa and Asia. Each week, he will share some of his experiences with patients in remote corners of the world.

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