By Lorna Brass, MD
As a retired surgeon, I spend some of my time on medical missions. A typical mission was two surgeons, an operating room staff, and 80 cases (mostly cleft lip and palate with an occasional head and neck infection or issue) over one week. When you came home you felt like you made a difference. You could ‘humbly report your trip to friends and family and your halo would definitely get “bigger.” After one mission though, I felt that something didn’t feel right. Yes, I made an impact on a few people’s lives but what have I done to move the dial? How will my patients get follow-up care, how would the next doctor know what to do for the patient?
Although medical records were produced, the availability was severely limited, and the issue of episodic care versus continuity of care was clearly troublesome.
I began investigating medical mission work, this is an almost 3.7-billion-dollar industry (Caldron, 2016). Much of it is unregulated and unsanctioned by either the sending or receiving government. Many of these missions are often ill-conceived and counterproductive to the issue of medical care in these developing countries (Sykes, 2014). As I contemplated my next mission, COVID-19 spread worldwide.
I trained as a FEMA doctor and helped with various issues including vaccination clinics up and down the front range (Denver metroplex), working closely with Public Health officials. It was during this experience that I determined that I could possibly be of more use as a Public Health practitioner.
My graduate experience has given me a new perspective on medicine in general. I always knew that American medicine was fractured but the depth and scale of the issues in how that practice impacts the health of our country was laid out in every class. This perspective changed my view to some degree as to what work I might be able to accomplish to be of use. Following a course in international Public Health I once again began to think about those medical missions. Although I had originally thought I would work in a local public health capacity I began to form a notion of how I might make an impact.
The Bill and Melinda Gates Foundation (2022) has stated that if 100,000 community health workers were trained with 30 basic skills, 30 million lives could be saved by 2030. The notion of developing training programs to teach people where they live, and work was a revelation and a spark for me.
Project C.U.R.E. with a long history (37 years) of contact in many countries (137) (Project C.U.R.E., n.d.). While their original mission was centered around the delivery of medical materials, supplies, and equipment to resource-limited counties, in recent years they have utilized those relationships in various countries to provide short-term medical missions of various types. This program called Project C.U.R.E clinics had had success with two training programs for mother and baby health. My project was to help develop a training program to screen and treat patients for cervical cancer. The beginnings of a program had already been started but because of the pandemic the mission was canceled and some of the personnel had changed in the interim. Our new program would follow the World Health Organization’s (WHO) protocol for screening and treating cervical cancer in resource-limited countries, we would develop our own training and trial it with a small group of physicians in Paraguay (WHO, 2021).
I was very enthusiastic about this project. I had a pretty good idea of how I would approach it from an academic point of view as well. Having studied the recommendation of WHO and others, the initial evaluation and program seemed to be fairly straightforward. Then I made the cardinal mistake (a definite rooky error). The number of times this issue has been discussed and reiterated in the course of the program would imply that the professors were trying to make a point. “Meet the people where they are, not where you want them to be. Ask what the strengths are that we can build on; do not tell people what they ‘need’.” From the beginning of the project, I was confounded by 2 issues. The first was the complete lack of interest on the part of the Ministry of Health or any actual official to give us any information about the existing status of their efforts on the subject of cervical cancer ( or any other health statistics for that matter), and the issue that we would likely not be able to do HPV testing as part of our protocol as recommended as the most ideal program according to the WHO. I was frustrated enough to think that this was not a worthwhile program.
Stepping back, I began to understand that the people we were working with in Paraguay were very enthusiastic about this project (an area where Project C.U.R.E had worked in the past). What we could accomplish is significant, not only for the people who come to our clinic that week but by leaving our knowledge and experience with their physicians as well as some of our equipment will make a real impact on the region. These trained physicians will see the advantage of training others and ultimately, they may be able to convince the more central authorities of the advantages of the program we have started. Planting these seeds in fertile soil is more productive than trying to pry into the ‘hardened rock of bureaucracy’ of the central government.
While working on this project I always felt I had plenty of time but I found that my time management was not as good as I thought. There was a bit of a time crunch near the end before the trip left that I had not anticipated.
This experience has shown what you can do on a real-world level. I began to think more incrementally. This program could improve cervical cancer outcomes as it is but has the potential to grow, use available resources and improve care in more areas of the country as time goes on.
Working with other medical professionals is nothing new in my experience, having been in clinical medicine in hospitals and surgeries my whole life. But I was cognizant of the potential to be intimidating or authoritative with my colleagues and from my perspective I made a point of being deferential to their ideas and suggestions. The team of midwives and one physician were wonderful to work with (and for), and their level of enthusiasm was contagious.
My professional growth throughout this project has been to learn new skills for interaction, compromise, and creative thinking (especially around funding!) I understand so much more about the inner working of a nonprofit organization. I was able to apply some of my newfound skills effectively, developing a logic model, and process and outcome evaluations plans, along with developing a flushed-out curriculum and ancillary training tools. I think I could continue this sort of work; I love the idea of ‘teaching a person to fish’. Training doctors, nurses and community health workers with skills that can save lives is my big idea for leaving a legacy.
Bill and Melinda Gates Foundation, Goalkeepers (2022) Scaling Community Health Worker Program accessed from https://www.gatesfoundation.org/goalkeepers/the-work/accelerators/community-health/
Caldron, P. H., Impens, A., Pavlova, M., & Groot, W. (2016). Economic assessment of U.S. physician participation in short-term medical missions. Globalization and health, 12(1), 45. https://doi.org/10.1186/s12992-016-0183-7
Project C.U.R.E.( n.d.) Touching Lives of Children and Families in over 135 counties. Accessed from https://projectcure.org/our-work/
Sykes K. J. (2014). Short-term medical service trips: a systematic review of the evidence. American Journal of Public Health, 104(7), e38–e48. https://doi.org/10.2105/AJPH.2014.301983
World Health Organization. (2021). WHO guideline for screening and treatment of cervical pre-cancer lesions for cervical cancer prevention. World Health Organization.