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A Medical Mission to Little Tibet: Notes from a Pharmacy Editor's Diary
FEATURE
A Medical Mission to Little Tibet: Notes from a Pharmacy Editor's Diary Nestled in the Himalayas of northern India, the area of Ladakh provided a unique opportunity to experience firsthand the rewards of a medical mission. L. · Michael Posey
A few days before leaving the comforts of the United States for a medical mission to India, I heard a startling statistic on the radio: A majority of the homes in Atlanta now have a personal computer, fewer than one-half of the children in the world have ever made a telephone call. For me, that disparity reflected the immense gap that exists between the haves and the have-nots of our world as we enter the 21 st century. As I was to see frrsthand, perhaps nowhere are the disparities between the technology-savvy, prosperous West-where the daily papers debate the value of biotechnologically engineered foodstuffs and report on advances in treatment for another exotic cancer-and much of the rest of the world more evident than in the world's most populous country. As numerous pharmacists are now discovering, hundreds of organizations offer health care professionals unique opportunities to see other parts of the globe and meet, talk with, and care for the people who live there. At the same time, by reaching out with a caring touch to these friends, medical missions can provide pharmacists and other providers chances to help others and experiences that will not soon fade from their memories. In this article, I provide information and points to consider about medical missions. In addition, I describe some of the people and places I encountered on a 2-week mission through the Himalayas of northern India, ending at Dharamsala, exile home of the 14th Dalai Lama.
were already becoming acclimated to the constant hom blowing of the drivers and the cows wandering everywhere. Our team included four physicians: Robert DuBroff, a cardiologist from Albuquerque who would provide primary care on the trip; Chandra Modi, an internist-pathologist who practices in Chicago but was originally from Bombay and speaks Hindi, the most common of the many languages and dialects spoken in India; Jason Hitner, a pediatrician who had just completed his residency at Emory University Hospital in Atlanta; and Alan Rich, an ophthalmologist from Lakeland, Fla. , who had brought along an assortment of medications and surgical tools for eye care. Gary Rodger, a sociologist from southern California, served as an optician on the mission; as an avocation, he collects discarded eyeglasses, measures their corrective power and labels them with that information, and then matches glasses with patients' needs on medical missions. The two dentists, Gayle Cheatwood from southern California and Randall Poe from Oregon, were experienced in mission work. I was the pharmacist on the team. Several support members were also part of the team, including David Buxton, a college student considering medicine as a career;
Missions and Team Members: All Different Types The 14 members of the Flying Doctors of America mission team to Ladakh gathered at 4 am on Sunday, July 2,2000, at the Palam Airport, a few kilometers from the Indira Ghandi International Airport, where we had frrst arrived in Delhi, India. Most of us had landed just a few hours earlier, and we were dazed by jet lag, sleep deprivation, and the time difference from the United States (9.5 hours from New York, 12.5 hours from Los Angeles). But some team members had been in Delhi for a few days and
Vol. 41, No.2
MarchlApril2001
The Flying Doctors medical mission team to Little Tibet encountered snow in July, when its members passed through the Himalayas.
Journal of the American PhannaceuticaJ Association
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Medical Mission
Many organizations are connected to Christian denominations, and their missions have an overtly religious tone. Others, like the Flying Doctors, are based on Christian principles but are not directly tied to specific types of churches, and a few are nonsectarian. All mission members must be constantly aware of their personal safety. Food-borne, water-borne, and vector-borne diseases are all potential hazards, and pharmacists on the teams must keep these 'potential conditions in mind when deciding what medications to stock. In addition, special insurance is required for medical evacuation and transportation back to the United States in the event of a serious illness, an accident, or another emergency. Finally, and unfortunately, physical and sexual safety is a concern during missions to many parts of the world. l The view from the team's pharmacy at the hospital in Leh, the ancient capital of Ladakh.
Poe's sons Ryan and Chris; and DeBroffs son Nick. Two team leaders from the Flying Doctors organization in Atlanta, Allan M. Gathercoal and Hartmutt Willinsky, set the schedule and organized us into units at various points during the mission. They were assisted by an outfitter company, Himalayan Expeditions (www.himalayanspirit.com). that specializes in trips to this region. In all, as many as 20 people were on the team at various times during the trip. A wide variety of medical missions currently operates in the United States and around the world. (A list of medical mission groups is published periodically in the Journal of the American Medical Association, most recently in August 1999. l) Some missions, such as the one described here, are of limited duration, whereas others require a longer commitment by volunteer health care professionals who live in an area and provide care for several months. The organizations that require long-term commitments generally have permanent clinics operating in specific locations. Like volunteers in similar mission groups, members of the Flying Doctors typically travel to an area, provide care directly to people who have few or no other options, and focus primarily on acute diseases or those that can be handled with a single intervention (often surgery, but also using limited courses of medications such as antibiotics or cough and cold remedies). Other organizations teach new concepts and techniques to local providers, enabling them to sustain a higher level of care after the team leaves. SGme groups focus on catastrophic care, perhaps in areas affected by a natural disaster or war; these include the Nobel Prize-winning group Medecins Sans Frontieres (Doctors Without Borders). Medical missions may provide general care for a wide variety of diseases, or they may limit their care to specific medical or surgical specialties. For instance, Project HOPE emphasizes pediatrics in its worldwide missions. Surgical Eye Expeditions International provides eye care. MAP International, the organization that provided our medications for this mission, sends teams of medical students, interns, and residents to developing countries. Other groups travel only to specific countries or parts of the world. FOCUS, for example, provides ophthalmologic care only in Nigeria.
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Pharmacists Important on Mission Teams We flew from Delhi directly to Leh, the ancient capital of the kingdom of Ladakh. Ladakh gets less rain than does the Sahara Desert, and most of the available water comes from melted snow and glaciers in the higher elevations of the Himalayas. The terrain there is often described as a "moonscape," and that is what we saw while circling to land: huge mountains, boulders strewn on their sides, and almost no vegetation anywhere. Although only an hour away by plane, Leh is a world away from Delhi in many respects. For starters, we were now in the Himalayas at 11,000 feet above sea level, and over the next 2 weeks it would take 5 long, hard days of riding in jeeps over twisting mountain roads to get us back to Delhi. At this altitude the entire team was at high risk for developing altitude sickness. Thanks to acetazolamide and other remedies, only one member became ill, but we all struggled for breath when walking up the three flights of stairs in our hotel or climbing the many steps to the Buddhist monasteries we visited. Unlike in Delhi, where Hinduism predominates, nearly everyone in Ladakh is Buddhist. Ladakh is, in fact, known as Little Tibet and, given the Chinese occupation of Tibet since 1959, many refugees from there have settled in Ladakh and in Leh. Ladakh lies in the Indian state of Jammu-Kashmir, a region that is disputed by the nuclear powers India, Pakistan, and China. As a result, the military presence is ubiquitous; an estimated 40% of the Indian army is based in Jammu-Kashmir. In Leh, the mission team provided 2 days of clinics at a local hospital. We worked alongside local physicians and dispensed medications to the many patients who could not otherwise afford them. Chris, a high school student, was to assist me in the pharmacy on the first clinic day, but he was ill from altitude sickness. Instead, Hartmutt helped, calling upon his prior experience in mission pharmacies as he showed me how things needed to work. Since nearly all of my career has been spent in editing and writing about pharmacy, Hartmutt was fond of pointing out that he had more experience in a pharmacy than I did.
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The pharmacy was stocked with medications obtained from MAP International, which obtains donations from pharmaceutical companies and provides medications to mission groups. We had ample supplies of a few types of medications, such as antibiotics; cough syrup; children's vitamins; fluoride supplements; calcium/vitamin D supplements; aspirin, acetaminophen, and ibuprofen; simethicone capsules; antidiarrheal medications; anthelmintics; and oral rehydration salts; and a few topical creams and ointments. In addition to the many drug classes and products missing from this list, the pharmacy had no medication vials, counting trays, or other supplies. To dispense medications, we folded them inside pieces of paper from a yellow writing pad. The other phannacy workers and I drew diagrams and wrote numbers on the outside of the paper to convey the dosing instructions. Patient counseling was translated into Hindi and local dialects. The moment I most remember from Leh was when Jason, the pediatrician, asked me to prepare something for stomach pain in a 15-day-old infant. The only stomach agent I had was simethicone. A liquid sealed in soft gelatin capsules, I figured the parents could pierce the capsules and squeeze the medication into the baby's formula. As I began to explain the process, demonstrating with my brand-new Swiss army knife how to puncture the capsule, I suddenly thought of a problem. Through the interpreter, I asked the mother whether the baby was breast-feeding. Of course, came the reply. I tasted the simethicone, and was relieved to find that it was not bitter. I was then able to continue with the demonstration, but with instructions to place the medication into the baby's mouth just before feeding three times each day. While this was not board-certified pharmacotherapy, I felt satisfied that I had solved one problem for one patient. The lack of medications to treat stomach problems was the biggest disappointment from a drug-availability standpoint. Nearly every internal medicine patient complained of stomach problems. The living conditions in Ladakh certainly put the population at high risk for Helicobacter pylori infection, but we were not sure whether that organism was causing the high incidence of stomach pain and complaints we encountered. Furthermore, although we had amoxicillin and clarithromycin in stock, we did not have the other agents needed for double or triple therapy aimed at H. pylori eradication. So we dispensed a lot of simethicone. People in Ladakh have a cultural taboo against surgery, so patients would not accept that treatment modality. Therefore, we saw adults with cleft palates that could have been easily repaired with little follow-up care, but they would just smile and shake their heads "no" when they understood what we were proposing. Nevertheless, we did see some patients who had traveled to Delhi for advanced therapies, including surgical interventions that were without question on the cutting edge of medicine. This was an encouraging aspect of the health care system we encountered in Leh. At that altitude, everyone had eye problems from the intense sun, high winds, and blowing dust. Rich, the ophthalmologist, stayed busy long after the internal medicine and pediatric physicians had seen all of their patients. The dentists, too, saw a steady
Vol. 41, No.2
March/April 2001
FEATURE
The author compounds a prescription for a scalp condition in an infant with a heart defect, using cardboard for a pill tile and a pocketknife for a spatula.
procession of patients of all ages, nearly all of whom had poor teeth. Despite virtually no processed sugar in the diet of Ladakhis, poor oral hygiene had eroded teeth and damaged gums in almost every patient we saw. During the trip, nearly everyone on the team came down with some type of illness. As the keeper of the medications, I was quite popular, doling out acetazolamide and analgesics for altitude sickness prophylaxis and treatment, antibiotics and antipyretics for a nasty lower respiratory infection that wasn' t helped by a day of inhaling diesel fumes in our convoy of five j eeps, and ciprofioxacin for travelers' diarrhea. Not all medical mission teams include pharmacists, but they should. Our expertise is needed for organizing the pharmacy quickly, determining which available products are appropriate for which conditions, and solving medication-related problems so that other team members can best use their own special skills and abilities. Without a phannacist, other team members-usually nonhealth care professionals or medical students-assume respon ibility for dispen sing medications. While th at process can go
Some of the people seeking care on the shores ofTso Morari walked for 6 hours to reach the village monastery.
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Used at night as an emergency department, this room at the hospital in Leh served as the pharmacy during the team's mission.
smoothly if a team member is experienced, the personnel still lack a pharmacist's understanding of what the drugs do, how the medication should or can be used, and what problems patients need to watch for. In addition, a pharmacist is in a better position to solve problems and provide creative solutions when necessity demands. Most short-term missions focus on acute care, because it is generally impossible to provide follow-up care or large supplies of medications. Furthermore, if medication-related problems occur, many people in developing countries have no access to health care providers who can recognize and treat the complications after the team leaves. Thus, the numbers and types of medications stocked in the pharmacy are appropriately limited.
Death and Dying, Ladakhi Style After 4 days in Leh, the team began an all-day journey through the Himalayas to Tso Morari, a lake at 15,000 feet. Along the way, we stopped at two Buddhist monasteries, including one where a birthday celebration was in full swing. It was July 6, 2000, the 65th birthday of the 14th Dalai Lama, who is revered by the Tibetan Buddhists just as the Pope is by Catholics. We also passed many roadside stupas, where the ashes of departed family members are placed. As believers in reincarnation, Buddhists view their current life as one of many they will experience as either animals or humans, and that belief allows them to be more accepting of whatever station in this life they find themselves occupying. Serious problems are viewed as the consequences of misdeeds in a past life; by accepting one' s status and state and enduring one's punishment now, one can have a better next life. Whatever the spiritual traditions of team members, thoughts of this life and the next were on our minds as we rode in jeeps over narrow, twisting Himalayan roads. Little more than paths strewn with rocks and small boulders, the roads snaked through mountain passes, around sharp peaks, past valley farms, and, at times literally, through shallow, glacier-fed streams. At curves, rather
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than slowing down to see whether anyone is coming from the other side, Indian drivers use an elaborate system of signaling with their horns. Constantly honking at oncoming traffic, pedestrians, dogs, cows, and anything else along the way, the drivers sped through the passes. Despite the speed, the roads' primitive conditions ensured that every day spent traveling was a long one---often more than 12 or 14 hours. On the day we traveled to Tso Morari, the team stopped to eat sack lunches on the bank of the Indus River, which winds for nearly 2,000 miles through Tibet and Ladakh on its way to Pakistan and the Arabian Sea. While eating, I noticed a 5- or 6-yearold boy squatting a few feet behind me, studying me. He had followed us from the quaint house we'd passed on our way down to the river. I gave him my chicken and a candy bar, and then some of the other team members came over and shared their meals. He had quite a feast that day! As we returned to the vehicles, we noticed that the boy's grandmother was lying on blankets outside the house, surrounded by her daughter and other members of her family. Modi talked with them in Hindi and relayed to the team that the grandmother was very ill. He and DuBroff examined the woman briefly, finding a disoriented patient with extensive swelling of the ankles who was obviously in the terminal stages of some disease process. Some members of the team wanted to further examine the woman and treat whatever was wrong, or take her back to the hospital in Leh. But Modi prevailed, convincing us how beautiful it would be to die in peace, surrounded by one's children and grandchildren, instead of lying in a Western-style hospital with tubes, machines, and strangers as your final guests. Also, some team members observed, as Buddhists, the family would not want the grandmother sedated when she died, as this would delay her journey to the next life. Their culture would not allow them to accept the types of extensive medical care we tend to provide at the end of life in developed countries. As this experience helped bring home to me, the recognition of the beliefs, culture, customs, and experiences that one encounters in a given region is an essential element of a successful medical mission. Here are some tips for mission volunteers from recent articles 2- 5 : • In areas such as Kosovo and Bosnia, bear in mind the great trauma the people have been through. Displacement from homes, combat, murders, relocation to concentration camps, and rape are but a few of the human rights violations they or close family members may have experienced. • Listen to patients and work with interpreters to overcome language differences. Traumatic experiences will lead people to complain about nonspecific aches and pains, but what they may really need is therapy and counseling. Cultural differences often prevent people from talking about matters considered private. Jason, the pediatrician on our team, encountered one 20-year-old patient with a severely swollen right knee. Jason had to practically scream at the young man before he
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would admit to having had a lesion indicative of gonorrhea a year earlier. Since it had not been treated, he now had disseminated infection, in this case localizing in his knee. • Respect people's values and beliefs. While you may not agree with or understand a particular point, remember that your patients may not understand or agree with American and Western ideas and ideals, either. • Do not usurp the existing health care system, limited though it may be. When physicians and other providers are present, mission teams should either teach new techniques to the local professionals or work alongside them in providing care. • Be aware of the work done by other mission groups. For instance, an American civic organization recently conducted a national immunization campaign across India. As a result, and because of the lack of poliovirus vaccines, which require refrigeration, o~ mission team did not attempt to provide any preventive interventions for this disease, even though it continues to affect several thousand Indians each year.
Care for Hundreds of Ladakhis
FEATURE
Web Sites Offering Information on Medical Missions Healthcare Opportunities Clearinghouse U.K. Christian Web Interserve Conservative Baptists International BMS Missions
http://library .umassmed.edulihoc/ http://www.ukcc.jireh.org http://www.interserve.org http://www.cbi.org http://www.rpc.ox.ac.uklbms/
In all, we provided care to 930 Ladakhis during 4 days of clinics in Leh and at Tso Morari: • 350 patients in ophthalmology • 360 patients in internal medicine • 135 patients in pediatrics • 74 patients in dentistry, with 105 extractions (including one tooth from the boy lama) and 80 restorations More than $12,500 in medications and more than $9,000 worth of eyeglasses and equipment were distributed or donated to local health providers. But in a country whose population recently surpassed 1 billion, replacing China as the world's most populous land, I wondered whether we made any real difference. Were we just a drop in the ocean, or did we really do some good? After traveling through the majestic Himalayas and arriving at Dharamsala, I put that question to Allan M. Gathercoal, team leader and executive director of the Flying Doctors of America. As we ate our last dinner together as a team the following Thursday, in a restaurant just down the mountain from the Dalai Lama's complex, Allan answered in humanitarian terms: "Someone once asked me, 'Why do we do this at all?' The reason, really, is because we can. We have the education. We have the financial ability, and we have the wherewithal. And I believe we have the humanitarian intention to bring hope and healing into the world,
The mission team arrived on the shores of Tso Morari at dark on Thursday night. This scenic lake lies 10 kilometers from the Chinese border and is the summer home to a wide variety of splendidly hued migratory birds. There we camped-in tents-for 3 nights in an area where nighttime temperatures could drop below freezing. Luckily, during the nights the temperature only dipped into the 40s, so we were pleasantly overprepared in that respect. On Friday and Saturday we conducted clinics at the Buddhist monastery in the small village, Karzok, near the lake. This setting was more typical of a Flying Doctors mission: a remote location where few or no health care services are available. Snow falls 9 months of the year, and 16 families live there through the winter. Nomadic families in the area follow herds of sheep and goat to fresh pastures all year long. In winter, they move to higher elevations in the mountains where vegetation is available in areas above the clouds and snow. At our clinic, we treated both townspeople and nomads who walked 6 hours-one way-to reach the monastery. To my Western eyes, the poverty was striking-the village lacked electricity and running water-yet the people there were the happiest I think I have ever seen. We were introduced to a 12year-old boy who is the lama, or spiritual head, of this and four other monasteries and was staying there at the time; his rinpoche, or teacher, was expected to arrive on Saturday afternoon. In the rinpoche's honor, the townspeople had cleaned everything, swept the dirt from the few concrete patches that served as plazas , dressed in their Ladakhi finest, and tuned their musical instruments. With the dust blowing into my eyes as I stood near the monastery overlooking the village, I came to appreciate the joy of a life without the pressures we place on ourselves in Western cul- A visit to the team's pediatrician leaves the parentjeeling better than the patient. tures.
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Ladakh is a Buddhist land that contrasts in this and many other ways from the rest of India. Here, a shrine displays photographs of revered lamas, including the small boy in the second frame from the left. He is the Panchen Lama, second in importance only to the Dalai Lama in Tibetan Buddhism. He and his family have not been seen since they were taken into custody by Chinese authorities when in 1995 he was declared the 11th reincarnation by the Dalai Lama.
regardless of what our religious persuasion is. We can do it. And so, if you have the ability to help and you do nothing, then I think you have a dilemma. Whereas if you have the ability to help and you do something--regardless of the significance of it-I believe you've fulfilled what you rightfully owe back to the world you live in. "But a lot of it is not the 1,000 people we've helped here in India-there are still 999,999,000 more we didn't reach. Rather, look at the growth in our team-in ourselves. Two weeks ago we were all strangers-literally, all strangers. Now we're a cohesive team, functioning, moving forward. And we've also challenged ourselves, we've pushed boundaries within ourselves. Look at yourself. As you told the team when we began in Leh, you said you had never been on a medical mission, hadn't camped out since Boy Scouts, and had never really practiced pharmacy. You've pushed boundaries. We all have." Gathercoal estimates that nearly 100 organizations conduct some type of medical or dental missions, and these can be found at several places on the Web (see box) or in the recent lAMA article.! B·ut only a few, less than six, he estimates, provide the Flying Doctors type of mission: short-term, specially managed, affordable missions to distant locations and with a broad range of medical specialties. Since pharmacy is such a key component of these missions, Gathercoal encourages pharmacists who might be interested in serving on a medical mission to contact him (www.fdoamerica.org;[email protected]; 770-209-9277; or 770-446-9634 fax). He sends monthly updates about upcoming missions to interested health professionals by either e-mail or fax.
much too small to be several months old. Hitner quickly determined the reason for the boy's failure to thrive: a congenital heart defect whose gurgling could be heard through the stethoscope. As interpreters struggled to convey the gravity of the situation to the mother, I could see the tension building in her face. She looked as though she would break into tears, but she never did. Perhaps that is another cultural aspect of Ladakh that no one explained to me. Hitner asked me what I had for a strange, unidentifiable black goo that covered the baby's scalp. The only topicals I had were antibiotic ointment and hydrocortisone cream, and Hitner asked me to mix them together. As with the simethicone in Leh, it took me a couple of minutes to identify the resources I had available: the cardboard backing of the pad of yellow paper we were using, my trusty pocketknife (still clean), and two empty film canisters. Soon my fIrst compounded prescription in years was ready for dispensing. Then came the really hard request: Hitner wanted to provide the mother with a supply of antibiotic suspension for use when her baby had colds or fever. He explained to her when she should use the medication. Through two interpreters, I went through a stepby-step description of how to reconstitute amoxicillin suspension. In her eyes, the anguish grew, and I could not imagine that the complicated information we were conveying could possibly stick. As I watched the mother struggling with our instructions, I thought of a passage from the teachings of Buddha: "There are three occasions when it is impossible for a mother to save her son or a son to save his mother. These three occasions are the time of sickness, the period of growing old, and the moment of death. How can a son take his mother's place when she is growing old? How can a mother take her son's place when he is sick? How can either help the other when the moment of death approaches? No matter how much they may love each other or how intimate they may have been, neither can help the other on such occasions."6 If I were to return to Ladakh, it would be to find this mother and this baby, to see how they're doing, and to ask them if there is anything more I can do to help. L. Michael Posey is pharmacy editor, Journal of the American Pharmaceutical Association, and executive editor, Pharmacy Today ([email protected]).
References 1. Mitka M. Advice for aspiring volunteer physicians. JAMA. 1999;281 :413-8. 2. Mitka M. Fixing femurs in a rain forest. JAMA. 1999;281 :41~20. Friedrich MJ. Volunteers help Kosovar refugees in camps. JAMA. 1999;281 :420--1. 4. Friedrich MJ. Addressing mental health needs of Balkan refugees. JAMA. 1999;281 :422-3. 3.
5.
Beller GA, Ryden L. Joint efforts across national boundaries between professional organizations in cardiovascular medicine: one way into the future. J Am Coli Cardial. 2000;36:957-8.
6.
The Teaching of Buddha. Tokyo, Japan: Bukkyo Dendo Kyokai (Buddhist Promoting Foundation); 1992:184.
IIBecause VVe Can" We encountered our most touching situation in the village at Tso Morari. A young mother brought in an infant who looked
A Medical Mission to Little Tibet: Notes from a Pharmacy Editor's Diary Nestled in the Himalayas of northern India, the area of Ladakh provided a unique opportunity to experience firsthand the rewards of a medical mission. L. · Michael Posey
A few days before leaving the comforts of the United States for a medical mission to India, I heard a startling statistic on the radio: A majority of the homes in Atlanta now have a personal computer, fewer than one-half of the children in the world have ever made a telephone call. For me, that disparity reflected the immense gap that exists between the haves and the have-nots of our world as we enter the 21 st century. As I was to see frrsthand, perhaps nowhere are the disparities between the technology-savvy, prosperous West-where the daily papers debate the value of biotechnologically engineered foodstuffs and report on advances in treatment for another exotic cancer-and much of the rest of the world more evident than in the world's most populous country. As numerous pharmacists are now discovering, hundreds of organizations offer health care professionals unique opportunities to see other parts of the globe and meet, talk with, and care for the people who live there. At the same time, by reaching out with a caring touch to these friends, medical missions can provide pharmacists and other providers chances to help others and experiences that will not soon fade from their memories. In this article, I provide information and points to consider about medical missions. In addition, I describe some of the people and places I encountered on a 2-week mission through the Himalayas of northern India, ending at Dharamsala, exile home of the 14th Dalai Lama.
were already becoming acclimated to the constant hom blowing of the drivers and the cows wandering everywhere. Our team included four physicians: Robert DuBroff, a cardiologist from Albuquerque who would provide primary care on the trip; Chandra Modi, an internist-pathologist who practices in Chicago but was originally from Bombay and speaks Hindi, the most common of the many languages and dialects spoken in India; Jason Hitner, a pediatrician who had just completed his residency at Emory University Hospital in Atlanta; and Alan Rich, an ophthalmologist from Lakeland, Fla. , who had brought along an assortment of medications and surgical tools for eye care. Gary Rodger, a sociologist from southern California, served as an optician on the mission; as an avocation, he collects discarded eyeglasses, measures their corrective power and labels them with that information, and then matches glasses with patients' needs on medical missions. The two dentists, Gayle Cheatwood from southern California and Randall Poe from Oregon, were experienced in mission work. I was the pharmacist on the team. Several support members were also part of the team, including David Buxton, a college student considering medicine as a career;
Missions and Team Members: All Different Types The 14 members of the Flying Doctors of America mission team to Ladakh gathered at 4 am on Sunday, July 2,2000, at the Palam Airport, a few kilometers from the Indira Ghandi International Airport, where we had frrst arrived in Delhi, India. Most of us had landed just a few hours earlier, and we were dazed by jet lag, sleep deprivation, and the time difference from the United States (9.5 hours from New York, 12.5 hours from Los Angeles). But some team members had been in Delhi for a few days and
Vol. 41, No.2
MarchlApril2001
The Flying Doctors medical mission team to Little Tibet encountered snow in July, when its members passed through the Himalayas.
Journal of the American PhannaceuticaJ Association
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FEATURE
Medical Mission
Many organizations are connected to Christian denominations, and their missions have an overtly religious tone. Others, like the Flying Doctors, are based on Christian principles but are not directly tied to specific types of churches, and a few are nonsectarian. All mission members must be constantly aware of their personal safety. Food-borne, water-borne, and vector-borne diseases are all potential hazards, and pharmacists on the teams must keep these 'potential conditions in mind when deciding what medications to stock. In addition, special insurance is required for medical evacuation and transportation back to the United States in the event of a serious illness, an accident, or another emergency. Finally, and unfortunately, physical and sexual safety is a concern during missions to many parts of the world. l The view from the team's pharmacy at the hospital in Leh, the ancient capital of Ladakh.
Poe's sons Ryan and Chris; and DeBroffs son Nick. Two team leaders from the Flying Doctors organization in Atlanta, Allan M. Gathercoal and Hartmutt Willinsky, set the schedule and organized us into units at various points during the mission. They were assisted by an outfitter company, Himalayan Expeditions (www.himalayanspirit.com). that specializes in trips to this region. In all, as many as 20 people were on the team at various times during the trip. A wide variety of medical missions currently operates in the United States and around the world. (A list of medical mission groups is published periodically in the Journal of the American Medical Association, most recently in August 1999. l) Some missions, such as the one described here, are of limited duration, whereas others require a longer commitment by volunteer health care professionals who live in an area and provide care for several months. The organizations that require long-term commitments generally have permanent clinics operating in specific locations. Like volunteers in similar mission groups, members of the Flying Doctors typically travel to an area, provide care directly to people who have few or no other options, and focus primarily on acute diseases or those that can be handled with a single intervention (often surgery, but also using limited courses of medications such as antibiotics or cough and cold remedies). Other organizations teach new concepts and techniques to local providers, enabling them to sustain a higher level of care after the team leaves. SGme groups focus on catastrophic care, perhaps in areas affected by a natural disaster or war; these include the Nobel Prize-winning group Medecins Sans Frontieres (Doctors Without Borders). Medical missions may provide general care for a wide variety of diseases, or they may limit their care to specific medical or surgical specialties. For instance, Project HOPE emphasizes pediatrics in its worldwide missions. Surgical Eye Expeditions International provides eye care. MAP International, the organization that provided our medications for this mission, sends teams of medical students, interns, and residents to developing countries. Other groups travel only to specific countries or parts of the world. FOCUS, for example, provides ophthalmologic care only in Nigeria.
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Pharmacists Important on Mission Teams We flew from Delhi directly to Leh, the ancient capital of the kingdom of Ladakh. Ladakh gets less rain than does the Sahara Desert, and most of the available water comes from melted snow and glaciers in the higher elevations of the Himalayas. The terrain there is often described as a "moonscape," and that is what we saw while circling to land: huge mountains, boulders strewn on their sides, and almost no vegetation anywhere. Although only an hour away by plane, Leh is a world away from Delhi in many respects. For starters, we were now in the Himalayas at 11,000 feet above sea level, and over the next 2 weeks it would take 5 long, hard days of riding in jeeps over twisting mountain roads to get us back to Delhi. At this altitude the entire team was at high risk for developing altitude sickness. Thanks to acetazolamide and other remedies, only one member became ill, but we all struggled for breath when walking up the three flights of stairs in our hotel or climbing the many steps to the Buddhist monasteries we visited. Unlike in Delhi, where Hinduism predominates, nearly everyone in Ladakh is Buddhist. Ladakh is, in fact, known as Little Tibet and, given the Chinese occupation of Tibet since 1959, many refugees from there have settled in Ladakh and in Leh. Ladakh lies in the Indian state of Jammu-Kashmir, a region that is disputed by the nuclear powers India, Pakistan, and China. As a result, the military presence is ubiquitous; an estimated 40% of the Indian army is based in Jammu-Kashmir. In Leh, the mission team provided 2 days of clinics at a local hospital. We worked alongside local physicians and dispensed medications to the many patients who could not otherwise afford them. Chris, a high school student, was to assist me in the pharmacy on the first clinic day, but he was ill from altitude sickness. Instead, Hartmutt helped, calling upon his prior experience in mission pharmacies as he showed me how things needed to work. Since nearly all of my career has been spent in editing and writing about pharmacy, Hartmutt was fond of pointing out that he had more experience in a pharmacy than I did.
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The pharmacy was stocked with medications obtained from MAP International, which obtains donations from pharmaceutical companies and provides medications to mission groups. We had ample supplies of a few types of medications, such as antibiotics; cough syrup; children's vitamins; fluoride supplements; calcium/vitamin D supplements; aspirin, acetaminophen, and ibuprofen; simethicone capsules; antidiarrheal medications; anthelmintics; and oral rehydration salts; and a few topical creams and ointments. In addition to the many drug classes and products missing from this list, the pharmacy had no medication vials, counting trays, or other supplies. To dispense medications, we folded them inside pieces of paper from a yellow writing pad. The other phannacy workers and I drew diagrams and wrote numbers on the outside of the paper to convey the dosing instructions. Patient counseling was translated into Hindi and local dialects. The moment I most remember from Leh was when Jason, the pediatrician, asked me to prepare something for stomach pain in a 15-day-old infant. The only stomach agent I had was simethicone. A liquid sealed in soft gelatin capsules, I figured the parents could pierce the capsules and squeeze the medication into the baby's formula. As I began to explain the process, demonstrating with my brand-new Swiss army knife how to puncture the capsule, I suddenly thought of a problem. Through the interpreter, I asked the mother whether the baby was breast-feeding. Of course, came the reply. I tasted the simethicone, and was relieved to find that it was not bitter. I was then able to continue with the demonstration, but with instructions to place the medication into the baby's mouth just before feeding three times each day. While this was not board-certified pharmacotherapy, I felt satisfied that I had solved one problem for one patient. The lack of medications to treat stomach problems was the biggest disappointment from a drug-availability standpoint. Nearly every internal medicine patient complained of stomach problems. The living conditions in Ladakh certainly put the population at high risk for Helicobacter pylori infection, but we were not sure whether that organism was causing the high incidence of stomach pain and complaints we encountered. Furthermore, although we had amoxicillin and clarithromycin in stock, we did not have the other agents needed for double or triple therapy aimed at H. pylori eradication. So we dispensed a lot of simethicone. People in Ladakh have a cultural taboo against surgery, so patients would not accept that treatment modality. Therefore, we saw adults with cleft palates that could have been easily repaired with little follow-up care, but they would just smile and shake their heads "no" when they understood what we were proposing. Nevertheless, we did see some patients who had traveled to Delhi for advanced therapies, including surgical interventions that were without question on the cutting edge of medicine. This was an encouraging aspect of the health care system we encountered in Leh. At that altitude, everyone had eye problems from the intense sun, high winds, and blowing dust. Rich, the ophthalmologist, stayed busy long after the internal medicine and pediatric physicians had seen all of their patients. The dentists, too, saw a steady
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The author compounds a prescription for a scalp condition in an infant with a heart defect, using cardboard for a pill tile and a pocketknife for a spatula.
procession of patients of all ages, nearly all of whom had poor teeth. Despite virtually no processed sugar in the diet of Ladakhis, poor oral hygiene had eroded teeth and damaged gums in almost every patient we saw. During the trip, nearly everyone on the team came down with some type of illness. As the keeper of the medications, I was quite popular, doling out acetazolamide and analgesics for altitude sickness prophylaxis and treatment, antibiotics and antipyretics for a nasty lower respiratory infection that wasn' t helped by a day of inhaling diesel fumes in our convoy of five j eeps, and ciprofioxacin for travelers' diarrhea. Not all medical mission teams include pharmacists, but they should. Our expertise is needed for organizing the pharmacy quickly, determining which available products are appropriate for which conditions, and solving medication-related problems so that other team members can best use their own special skills and abilities. Without a phannacist, other team members-usually nonhealth care professionals or medical students-assume respon ibility for dispen sing medications. While th at process can go
Some of the people seeking care on the shores ofTso Morari walked for 6 hours to reach the village monastery.
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Used at night as an emergency department, this room at the hospital in Leh served as the pharmacy during the team's mission.
smoothly if a team member is experienced, the personnel still lack a pharmacist's understanding of what the drugs do, how the medication should or can be used, and what problems patients need to watch for. In addition, a pharmacist is in a better position to solve problems and provide creative solutions when necessity demands. Most short-term missions focus on acute care, because it is generally impossible to provide follow-up care or large supplies of medications. Furthermore, if medication-related problems occur, many people in developing countries have no access to health care providers who can recognize and treat the complications after the team leaves. Thus, the numbers and types of medications stocked in the pharmacy are appropriately limited.
Death and Dying, Ladakhi Style After 4 days in Leh, the team began an all-day journey through the Himalayas to Tso Morari, a lake at 15,000 feet. Along the way, we stopped at two Buddhist monasteries, including one where a birthday celebration was in full swing. It was July 6, 2000, the 65th birthday of the 14th Dalai Lama, who is revered by the Tibetan Buddhists just as the Pope is by Catholics. We also passed many roadside stupas, where the ashes of departed family members are placed. As believers in reincarnation, Buddhists view their current life as one of many they will experience as either animals or humans, and that belief allows them to be more accepting of whatever station in this life they find themselves occupying. Serious problems are viewed as the consequences of misdeeds in a past life; by accepting one' s status and state and enduring one's punishment now, one can have a better next life. Whatever the spiritual traditions of team members, thoughts of this life and the next were on our minds as we rode in jeeps over narrow, twisting Himalayan roads. Little more than paths strewn with rocks and small boulders, the roads snaked through mountain passes, around sharp peaks, past valley farms, and, at times literally, through shallow, glacier-fed streams. At curves, rather
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than slowing down to see whether anyone is coming from the other side, Indian drivers use an elaborate system of signaling with their horns. Constantly honking at oncoming traffic, pedestrians, dogs, cows, and anything else along the way, the drivers sped through the passes. Despite the speed, the roads' primitive conditions ensured that every day spent traveling was a long one---often more than 12 or 14 hours. On the day we traveled to Tso Morari, the team stopped to eat sack lunches on the bank of the Indus River, which winds for nearly 2,000 miles through Tibet and Ladakh on its way to Pakistan and the Arabian Sea. While eating, I noticed a 5- or 6-yearold boy squatting a few feet behind me, studying me. He had followed us from the quaint house we'd passed on our way down to the river. I gave him my chicken and a candy bar, and then some of the other team members came over and shared their meals. He had quite a feast that day! As we returned to the vehicles, we noticed that the boy's grandmother was lying on blankets outside the house, surrounded by her daughter and other members of her family. Modi talked with them in Hindi and relayed to the team that the grandmother was very ill. He and DuBroff examined the woman briefly, finding a disoriented patient with extensive swelling of the ankles who was obviously in the terminal stages of some disease process. Some members of the team wanted to further examine the woman and treat whatever was wrong, or take her back to the hospital in Leh. But Modi prevailed, convincing us how beautiful it would be to die in peace, surrounded by one's children and grandchildren, instead of lying in a Western-style hospital with tubes, machines, and strangers as your final guests. Also, some team members observed, as Buddhists, the family would not want the grandmother sedated when she died, as this would delay her journey to the next life. Their culture would not allow them to accept the types of extensive medical care we tend to provide at the end of life in developed countries. As this experience helped bring home to me, the recognition of the beliefs, culture, customs, and experiences that one encounters in a given region is an essential element of a successful medical mission. Here are some tips for mission volunteers from recent articles 2- 5 : • In areas such as Kosovo and Bosnia, bear in mind the great trauma the people have been through. Displacement from homes, combat, murders, relocation to concentration camps, and rape are but a few of the human rights violations they or close family members may have experienced. • Listen to patients and work with interpreters to overcome language differences. Traumatic experiences will lead people to complain about nonspecific aches and pains, but what they may really need is therapy and counseling. Cultural differences often prevent people from talking about matters considered private. Jason, the pediatrician on our team, encountered one 20-year-old patient with a severely swollen right knee. Jason had to practically scream at the young man before he
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would admit to having had a lesion indicative of gonorrhea a year earlier. Since it had not been treated, he now had disseminated infection, in this case localizing in his knee. • Respect people's values and beliefs. While you may not agree with or understand a particular point, remember that your patients may not understand or agree with American and Western ideas and ideals, either. • Do not usurp the existing health care system, limited though it may be. When physicians and other providers are present, mission teams should either teach new techniques to the local professionals or work alongside them in providing care. • Be aware of the work done by other mission groups. For instance, an American civic organization recently conducted a national immunization campaign across India. As a result, and because of the lack of poliovirus vaccines, which require refrigeration, o~ mission team did not attempt to provide any preventive interventions for this disease, even though it continues to affect several thousand Indians each year.
Care for Hundreds of Ladakhis
FEATURE
Web Sites Offering Information on Medical Missions Healthcare Opportunities Clearinghouse U.K. Christian Web Interserve Conservative Baptists International BMS Missions
http://library .umassmed.edulihoc/ http://www.ukcc.jireh.org http://www.interserve.org http://www.cbi.org http://www.rpc.ox.ac.uklbms/
In all, we provided care to 930 Ladakhis during 4 days of clinics in Leh and at Tso Morari: • 350 patients in ophthalmology • 360 patients in internal medicine • 135 patients in pediatrics • 74 patients in dentistry, with 105 extractions (including one tooth from the boy lama) and 80 restorations More than $12,500 in medications and more than $9,000 worth of eyeglasses and equipment were distributed or donated to local health providers. But in a country whose population recently surpassed 1 billion, replacing China as the world's most populous land, I wondered whether we made any real difference. Were we just a drop in the ocean, or did we really do some good? After traveling through the majestic Himalayas and arriving at Dharamsala, I put that question to Allan M. Gathercoal, team leader and executive director of the Flying Doctors of America. As we ate our last dinner together as a team the following Thursday, in a restaurant just down the mountain from the Dalai Lama's complex, Allan answered in humanitarian terms: "Someone once asked me, 'Why do we do this at all?' The reason, really, is because we can. We have the education. We have the financial ability, and we have the wherewithal. And I believe we have the humanitarian intention to bring hope and healing into the world,
The mission team arrived on the shores of Tso Morari at dark on Thursday night. This scenic lake lies 10 kilometers from the Chinese border and is the summer home to a wide variety of splendidly hued migratory birds. There we camped-in tents-for 3 nights in an area where nighttime temperatures could drop below freezing. Luckily, during the nights the temperature only dipped into the 40s, so we were pleasantly overprepared in that respect. On Friday and Saturday we conducted clinics at the Buddhist monastery in the small village, Karzok, near the lake. This setting was more typical of a Flying Doctors mission: a remote location where few or no health care services are available. Snow falls 9 months of the year, and 16 families live there through the winter. Nomadic families in the area follow herds of sheep and goat to fresh pastures all year long. In winter, they move to higher elevations in the mountains where vegetation is available in areas above the clouds and snow. At our clinic, we treated both townspeople and nomads who walked 6 hours-one way-to reach the monastery. To my Western eyes, the poverty was striking-the village lacked electricity and running water-yet the people there were the happiest I think I have ever seen. We were introduced to a 12year-old boy who is the lama, or spiritual head, of this and four other monasteries and was staying there at the time; his rinpoche, or teacher, was expected to arrive on Saturday afternoon. In the rinpoche's honor, the townspeople had cleaned everything, swept the dirt from the few concrete patches that served as plazas , dressed in their Ladakhi finest, and tuned their musical instruments. With the dust blowing into my eyes as I stood near the monastery overlooking the village, I came to appreciate the joy of a life without the pressures we place on ourselves in Western cul- A visit to the team's pediatrician leaves the parentjeeling better than the patient. tures.
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Ladakh is a Buddhist land that contrasts in this and many other ways from the rest of India. Here, a shrine displays photographs of revered lamas, including the small boy in the second frame from the left. He is the Panchen Lama, second in importance only to the Dalai Lama in Tibetan Buddhism. He and his family have not been seen since they were taken into custody by Chinese authorities when in 1995 he was declared the 11th reincarnation by the Dalai Lama.
regardless of what our religious persuasion is. We can do it. And so, if you have the ability to help and you do nothing, then I think you have a dilemma. Whereas if you have the ability to help and you do something--regardless of the significance of it-I believe you've fulfilled what you rightfully owe back to the world you live in. "But a lot of it is not the 1,000 people we've helped here in India-there are still 999,999,000 more we didn't reach. Rather, look at the growth in our team-in ourselves. Two weeks ago we were all strangers-literally, all strangers. Now we're a cohesive team, functioning, moving forward. And we've also challenged ourselves, we've pushed boundaries within ourselves. Look at yourself. As you told the team when we began in Leh, you said you had never been on a medical mission, hadn't camped out since Boy Scouts, and had never really practiced pharmacy. You've pushed boundaries. We all have." Gathercoal estimates that nearly 100 organizations conduct some type of medical or dental missions, and these can be found at several places on the Web (see box) or in the recent lAMA article.! B·ut only a few, less than six, he estimates, provide the Flying Doctors type of mission: short-term, specially managed, affordable missions to distant locations and with a broad range of medical specialties. Since pharmacy is such a key component of these missions, Gathercoal encourages pharmacists who might be interested in serving on a medical mission to contact him (www.fdoamerica.org;[email protected]; 770-209-9277; or 770-446-9634 fax). He sends monthly updates about upcoming missions to interested health professionals by either e-mail or fax.
much too small to be several months old. Hitner quickly determined the reason for the boy's failure to thrive: a congenital heart defect whose gurgling could be heard through the stethoscope. As interpreters struggled to convey the gravity of the situation to the mother, I could see the tension building in her face. She looked as though she would break into tears, but she never did. Perhaps that is another cultural aspect of Ladakh that no one explained to me. Hitner asked me what I had for a strange, unidentifiable black goo that covered the baby's scalp. The only topicals I had were antibiotic ointment and hydrocortisone cream, and Hitner asked me to mix them together. As with the simethicone in Leh, it took me a couple of minutes to identify the resources I had available: the cardboard backing of the pad of yellow paper we were using, my trusty pocketknife (still clean), and two empty film canisters. Soon my fIrst compounded prescription in years was ready for dispensing. Then came the really hard request: Hitner wanted to provide the mother with a supply of antibiotic suspension for use when her baby had colds or fever. He explained to her when she should use the medication. Through two interpreters, I went through a stepby-step description of how to reconstitute amoxicillin suspension. In her eyes, the anguish grew, and I could not imagine that the complicated information we were conveying could possibly stick. As I watched the mother struggling with our instructions, I thought of a passage from the teachings of Buddha: "There are three occasions when it is impossible for a mother to save her son or a son to save his mother. These three occasions are the time of sickness, the period of growing old, and the moment of death. How can a son take his mother's place when she is growing old? How can a mother take her son's place when he is sick? How can either help the other when the moment of death approaches? No matter how much they may love each other or how intimate they may have been, neither can help the other on such occasions."6 If I were to return to Ladakh, it would be to find this mother and this baby, to see how they're doing, and to ask them if there is anything more I can do to help. L. Michael Posey is pharmacy editor, Journal of the American Pharmaceutical Association, and executive editor, Pharmacy Today ([email protected]).
References 1. Mitka M. Advice for aspiring volunteer physicians. JAMA. 1999;281 :413-8. 2. Mitka M. Fixing femurs in a rain forest. JAMA. 1999;281 :41~20. Friedrich MJ. Volunteers help Kosovar refugees in camps. JAMA. 1999;281 :420--1. 4. Friedrich MJ. Addressing mental health needs of Balkan refugees. JAMA. 1999;281 :422-3. 3.
5.
Beller GA, Ryden L. Joint efforts across national boundaries between professional organizations in cardiovascular medicine: one way into the future. J Am Coli Cardial. 2000;36:957-8.
6.
The Teaching of Buddha. Tokyo, Japan: Bukkyo Dendo Kyokai (Buddhist Promoting Foundation); 1992:184.
IIBecause VVe Can" We encountered our most touching situation in the village at Tso Morari. A young mother brought in an infant who looked