A Reciprocal Education: Leonard Y. Lee
For a Westerner, practicing medicine in the developing world can be revelatory. Certainly it was for Leonard Y. Lee, chief of cardiothoracic surgery at Robert Wood Johnson University Hospital, who in 2007 went on the first of what turned out to be an annual eight-day medical mission to Vietnam’s Ho Chi Minh City. He remembers leaving the luxuriously appointed Caravelle Hotel and taking a van to Cho Ray Hospital. The building’s relatively modern exterior didn’t prepare him for what he found inside the glass doors.
“I thought, Oh my God, what is going on?” he recalls. The hospital has 1,700 beds, roughly twice as many as Robert Wood Johnson, but those beds accommodate some 3,000 to 3,400 patients daily. That means that each bed has to hold two patients, who sleep head to foot. And because many of the patients travel from rural villages accompanied by multiple family members, the hospital’s population (not including medical staff) swells to about 10,000. “They sleep on the floors; they sleep in stairwells. There are bodies everywhere,” Lee says.
Lee, a cardiac surgeon, doesn’t go to Vietnam to operate. As part of the nonprofit organization Hearts Around the World, he’s there to teach the hospital’s surgeons what he knows so that they can provide improved care after he and his colleagues leave. In fact, he says, most of them are already excellent surgeons. What many lack is a sense of how to collaborate with other doctors to prevent a common occurrence— a patient who might be better served by a nonsurgical approach being operated on anyway. But sometimes what’s critical is choosing the right type of surgery. Lee remembers examining a 6-year-old girl with a huge thoracic aortic aneurysm—a bulge in the section of the aorta that runs through the chest. The Vietnamese surgeons wanted to operate immediately.
Lee was aghast. He knew the girl needed treatment at a specialty hospital by a pediatric cardiac surgeon. She was transferred on his orders. He later learned she’d done extremely well. Such outcomes, he says “are incredibly rewarding.”
The surgeons at Cho Ray make do with less, which is often a disadvantage. Because there aren’t enough ventilators, for instance, many patients have to be ventilated using a respirator bag operated by relatives. Lee remembers a 22-year-old patient who died when his brother, who was enlisted to bag him through the night, fell asleep.
In some cases, though, making do can be a good thing. Unlike their Western counterparts, Vietnamese surgeons don’t have access to the expensive heart monitors known as Swan-Ganz catheters, and Lee noticed that they did perfectly well without them. When he returned to New Jersey, he began using them sparingly. “It saves a lot of money and simplifies things,” he says. “There’s something to be said for simplifying.”
Never Forget: Lawrence Najarian
Sometimes a mission is about more than saving lives. For Dr. Lawrence Najarian, an ophthalmologist in Bedminster Township, it’s also about acknowledging lives lost. Najarian is president of the Armenian American Health Professionals Organization, whose mission to Armenia in June of this year was timed to coincide with the 100th anniversary of the Armenian Genocide, the Ottoman government’s systematic effort to wipe out the Armenian population in what is now Turkey. Between 800,000 and 1.5 million Armenians perished in the Genocide, and, says Najarian, “this mission was our way to recognize all that our forefathers went through.”
The goal of the mission was not to perform surgery, but to pass along knowledge to help elevate the quality of medical care in the former Soviet republic. To that end, Najarian taught basic ophthalmological skills to primary care physicians and instructed ophthalmologists in the latest surgical techniques. It was exhilarating but sometimes frustrating. At one point, Najarian was approached by a group of surgeons working in a modern hospital recently built with a $22 million donation. The hospital had a sparkling new ophthalmological surgical suite equipped with a $100,000 phacoemulsification machine, designed to help surgeons perform state-of-the-art cataract surgery. There was just one problem, the surgeons told Najarian with tears in their eyes: They had no idea how to perform surgery using the new machine.
At times, Najarian felt a similar frustration. He saw patients with the same diseases he saw at home, but so advanced that many of them were beyond treatment—because, he says, “they didn’t have access to medical care or they couldn’t afford to take the time off to be screened.” He and his colleagues are chipping away at that frustration one skill at a time. They’ve arranged to teach the surgeons phacoemulsification online and are planning a return trip. “The doctors there,” he says, “have such a passion to learn.”
Doing What They Can: Sanjeev Kaul and Evangeline Epper
You can’t help everyone. It’s a truism of medical mission work and one of the greatest challenges for the health care workers involved. When Sanjeev Kaul, chief of trauma and surgical critical care at HackensackUMC, met a man with thyroid cancer on a 2013 mission to Haiti, his first reaction was no. He had operated on similar cases in the States but not many of them, and to do so under suboptimal conditions—the lighting in the makeshift OR in the tiny town of Dajabon was so poor that the surgeons had to wear headlamps—would be incredibly risky.
“He was very calm, very elegant, and a very graceful man,” Kaul remembers, “and I asked him what his options were if I didn’t do the operation.” The answer—that because he didn’t have the money to pay for an operation, he’d go back to his village and prepare to die—changed Kaul’s mind. Kaul’s wife, Dr. Shubha Varma, a vascular surgeon, was with him on the mission, and by pooling their skills, they were able to pull off the surgery.
But then there was the woman he had to turn away. She had advanced breast cancer, and the mastectomy she needed would have left a gaping wound on her chest. At home, Kaul (or a breast specialist) would call in a plastic surgeon, but the team from Life Is Great Global (LIG), the sponsoring nonprofit, wasn’t traveling with one. With enormous regret, Kaul told the woman he couldn’t help her. “To this day,” he says, “I don’t know if it was a good decision or not.”
It was Kaul’s first mission, and the Indian-born surgeon was impelled to join it by the twin incentives of working with his wife and sharing the opportunities he’d received in the United States, his adopted country. Another incentive: to work in the field with the woman he calls his inspiration, HackensackUMC, nurse Evan Epper. She has been on dozens of missions, traveling two or three times a year to countries like Eritrea, Niger, Vietnam, Peru, the Dominican Republic and the Philippines, where she was born. She gives up vacation time to go on the missions and funds them largely with donations from the hospital and the families of patients she’s worked with. Her reason for going is simple. “Being from the Philippines, I’ve seen how it is not to receive medical treatment because you don’t have money,” she says.
In fact, she’s been on only one mission to her native country, largely because political corruption and the difficulty of accessing supplies can add to the challenge of working in the Philippines. She was able to go with LIG Global after the 2013 typhoon, and the widespread devastation she witnessed shocked her. “So many people had lost their houses, and there was so much death—you could smell the bodies,” she remembers. Damage to facilities made surgery impossible, but the team was able to offer general medical care, and supplies bought largely with money from their own pockets. They also bought small boats for some of the local fishermen so they could get back to work. One day they walked through rice paddies, giving out packages filled with rice, toiletries and clothing.
You can’t help everyone, but you do what you can.