Training physicians in poor countries offers the best hope for them and their patients

Among movingly naïve paintings in vivid colors of Buddhist mythologies sits a small girl in a neatly pressed man’s shirt with sleeves far too long for her tiny frame.

“They call me ‘cripple,’” she, named Sythan, answers hesitatingly when asked for her nickname, and for just a fleeting moment, tears start to well up in her soulful almond eyes. Then she stares out into the humid and gloomy heat of the Cambodian monsoon season.

“That’s what your family calls you?”

She nods once and stares down at the dusty soil around her right foot. That’s the only one that can touch the ground. The other one hides permanently folded up against her thigh, toes glued to her shin, heel to her buttocks, in an unholy union. It has been this way for 13 of her 14 years.

“Driving along the lone country road, I saw this little person hopping along. ‘Perhaps another landmine victim,’ I thought, but then I found out the real reason,” explains Bill Simonsen, who took her into his home for disabled children. “Her homemade crutches hurt her so much that she learned to hop along on one foot for miles. When she was 2 months old, she got burned in a fire. That’s how it healed by itself.”

In this nation of 14 million people, health care is but a dream for most of them. The herbal healer rules supreme. The average Cambodians earns $300 per year. Therefore, the cost of traveling to the hospital, let alone receiving medical services, is prohibitive. And in most hospitals, primary physicians are the only choice.

Simonsen nearly died a while ago from a tropical infection, so his home is now closed. So Sythan returned to hopping along that same dusty road that once held promise for a better life.

What can we do for the myriad of burn scars and other reconstructive challenges? Shall we send in a team of plastic surgeons and free those limbs from their chains of gnarly scars? Shall we fly Sythan and others like her to rich countries and perform restoration miracles? Shall we pay for am­putations in the big city or poor country?

New Solution Needed

Perhaps education and training can provide a solution different from creating dependence. Unless the local surgeon learns how to release scars and graft skin, problems like Sythan’s will fester on. Unless patients in poor countries gain confidence in their physicians, they see hospitals as places to die. As long as professional isolation robs physicians of the chance to increase their skills to a level appropriate for the pathology presented, their self-confidence will languish as well.

Medical missions often impair the economic survival of local physicians, hospitals, and pharmacies, because patients will wait for the next handout. “Despite im­proved skills, we see less and less cleft lips in our practice,” says Mok Theavy, MD, a surgeon trained by Operation Smile. “Foreign teams take over. We are reduced to footing the bill for the hospital costs.”

In the end, these physicians will look for any way to get out of their country, even at the cost of retraining as nurses, as happens in the Philippines. The health gap widens.

Yet, there may be an alternative, sensible approach, as proposed by Medicorps, a Hawaii-based nongovernmental organization: Increase capacity by the unobtrusive transfer of specialty skills and technology. Here is how it works:

A plastic surgeon receives an e-mail in his office with some images attached. The message reads: “I am Dr X, a general surgeon from Cambodia. Could you kindly have a look at the attached case and give me your opinion?”

The physician in the United States sees pathology he likely will never see in his practice at home. Folded-up legs from burns, 40-year-old cleft lips, advanced tumors displacing entire faces, and giant scars of any shape and size—great material for grand rounds, and challenges for the best physicians. During a quiet moment in his office or at home, he hammers out an answer.

“With a click of the mouse, I can be in the middle of a distant country, like Cambodia, and help people who have no hope,” muses Honolulu plastic surgeon Fereydoun D. Parsa, MD. “It’s a miracle come true. I feel privileged to participate in this noble cause. That’s why I became a physician.”

He attaches the screened pages of textbook illustrations hoping that the faraway colleague can follow the instructions. One day, he thinks, he will donate a week or two of his time for hands-on training with Medicorps.

A Familiar Face

Gregory Borah, MD, has done just that. He sees a familiar face on the operating-room table in Siem Reap. “It’s a case that I had discussed earlier with a local surgeon over the Internet,” he says as he deftly places an incision he had planned back home. “It really helps greatly to know what one encounters before one sets out on a teaching visit.

“I wish I would have asked for pictures of the instruments and sutures in the hospital next door. I could have brought my own,” he continues as he watches the local surgeon complete his first plastic surgery repair.

Strategic planning, careful scheduling, and minimal intrusion are the trademarks of Medicorps’ approach. All emphasis is on teaching and training, and universities are starting to encourage their residents to spend elective time with programs like Medicorps. The ultimate goal is to create autonomous chapters of Medicorps in poor countries with a continuous connection to the industrialized world.

“One day, I would like to become an English teacher,” Sythan whispers among those Buddhist paintings, “but I cannot walk to school.” That goal is now farther off than ever for her and many other kids like her unless we support her physicians with our skills. PSP

Gunther Hintz, MD, was a plastic surgeon in Honolulu for 10 years before retiring in 1987. He is now president of Medicorps and is working on relief projects in several poor countries. He can be reached at [email protected]