Making a World of Difference
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The first time Reza Jarrahy, MD, traveled to Guatemala with a team of plastic surgeons, in 1999, he was a surgical resident. He helped lug equipment over pitted roads to a military base near the border with Mexico and scrubbed dust off walls and sprayed Lysol everywhere to sanitize and convert an empty supply building into a four-room hospital.
The surgical team expected at least 100 mothers would come to them from the surrounding villages, seeking surgery to repair their children’s cleft lips and palates. But none came. It turned out the military base where they’d established their makeshift hospital was infamous. “The civil war had ended a few years earlier, but these were simple people who live with folklore and oral stories,” Dr. Jarrahy says. “All they knew is that in the few years before we arrived, their husbands and sons had been taken to this same base and never came back. No mother was going to bring her child there.”
Gradually, some mothers overcame their fears and trickled in. A few days later, word spread to the villages as women returned home and told how their children’s facial defects had been repaired. “It was like an early version of Twitter,” Dr. Jarrahy says. “Word got around.” Soon, hundreds of mothers and children descended on the base. “It was powerful to see how a simple operation can change the community’s idea of people and places they associate with evil-doing,” the UCLA plastic and reconstructive surgeon says.
Many physicians take their skills to remote areas to transform the lives of people who have limited access to medical care by performing surgeries and treating myriad ills. But Dr. Jarrahy realized he could be even more effective in his work if he better understood the cultures of the people he was treating. Today, he is at the forefront of an interdisciplinary movement at UCLA to establish permanent ties with overseas practitioners and populations. He initiated an innovative collaboration with UCLA Latin America-specialist and anthropologist Bonnie Taub, PhD ’92, adjunct assistant professor in the UCLA Jonathan and Karin Fielding School of Public Health, to study the intersection between Western and traditional medicine.
Since 2007, Dr. Jarrahy has spent three-to-four weeks a year helping children in Guatemala, Peru and Brazil. “In these less-developed regions, you have an indigenous population living in poverty with virtually no access to healthcare. It’s very pure medicine, what we do. There’s no issue of money, no administrative burden,” he says.
But three years ago, Dr. Jarrahy, who is also on the faculty of the newly established Blum Center on Poverty and Health in Latin America and on the advisory committee of the UCLA Center for World Health, took a more critical look at the outreach. “Many missions follow the parachute model,” Dr. Jarrahy says. “You parachute in. You set up a hospital. You operate on 50 patients, and then you disappear. A baby comes in with a cleft lip. A baby goes out with a lip repair. That child’s life is changed, no doubt about it. But what if that baby has a complication? What about the longitudinal care? Who will take care of that child after we leave?”
When a Guatemalan doctor emailed him that a patient’s lip repair had come undone – a rare complication – Dr. Jarrahy realized he needed more knowledge. “When we take patient histories in the states, we get their backgrounds, occupations, whether they drink or smoke. That wasn’t part of our routine assessment for patients overseas. There was certainly no cultural awareness in our interactions with patients in the setting of surgical missions,” he notes.
Rather than the parachute as a model, he envisioned a garden. “The ideal situation is to be working together with other gardeners – local physicians, nurses and hospital administrators. You’re educating them, training them and empowering them to develop systems whereby they can take care of these patients on their own,” he says.
Dr. Jarrahy was troubled that his patients were often filthy from head to toe. Even their teeth were black. He visited Lake Atitlan in Guatemala, guided by the non-profit Mayan Families. Visiting the homes of his patients – where eight-to-14 people may live in 10-by-20-foot shacks and the children are often malnourished – was an “aha! moment.” He came to understand how the living conditions of people in these remote areas might affect their surgical outcomes.
“Everything is covered in soot because there’s an open fire in the corner, which is the family’s only source of heat and fuel for cooking,” he says. “Smoke inhalation can easily contribute to wound complications, such as causing a lip repair to fall apart. From the day these kids are born, that’s what they’re breathing.”
Through Mayan Families, Dr. Jarrahy joined a stove-building project, installing cinder-block ovens in homes to eliminate the need for sooty indoor fires. “These are people who live a simple lifestyle, but the impact of that lifestyle for their families is not lost upon them,” Dr. Jarrahy says.
Dr. Taub accompanied Dr. Jarrahy to assess that impact. While he performed surgeries, she interviewed family members about their understanding of the procedures. Such interdisciplinary alliances are becoming more common. As coprincipal investigators, Dr. Taub and Dr. Jarrahy expect their effort, funded by a transdisciplinary seed grant from the UCLA Office of the Vice Chancellor for Research and the Clinical and Translational Science Institute, will result in the development of anthropological-assessment tools to guide physicians in providing culturally appropriate care. Dr. Taub and Dr. Jarrahy also coordinated three “At the Crossroads” symposia at UCLA, funded by a working grant they were awarded through the Latin American Institute. The first, in March 2013, focused on medicine and culture, followed by gatherings in April on surgery and culture and in May on community well-being.
Many surgeons, like Dr. Jarrahy, will take vacation time and pay their own way to provide indigenous people with medical care, and their efforts often can make a dramatic difference in the lives of their patients – giving them potential to get married, to attend school without being bullied, to become accepted members of their communities. “The surgeons are extraordinary people who think beyond their own community,” says Dr. Taub. “Without their expertise, there wouldn’t be any intercultural exchange. But the additional awareness that someone like Dr. Jarrahy has developed about cultural beliefs and practices benefits local people. If they are asked about their beliefs and tell a story about their lives, it makes them feel more comfortable and trusting.”
Most surgeons don’t tend to have that holistic perspective, however. They are “laser focused,” Dr. Jarrahy says. “We think about the width of the cleft and how good the repair is, what the shape of the nose is afterward. But the questions Dr. Taub is asking of our patients and their families – how do they feel about receiving surgical care from visiting foreigners? Is the care consistent with their traditional beliefs about health and healing? – are to some degree as important as our technical efforts. Ultimately, the answers to her questions will determine to what extent our surgical interventions are successful. It’s unrealistic to expect that our patients will be compliant just because we come from the U.S. and we’re good surgeons. We can’t expect that. Cultural sensitivity is all the more important in that context.”
UCLA Pediatric Neurosurgeon Jorge Lazareff, MD, has been working to establish “gardens” overseas since 1990. Born and trained in Argentina, Dr. Lazareff was director of neurosurgery at Mexico City’s Hospital Infantil de Mexico Federico Gomez when Guatemala’s Jorge Von Ahn Hospital invited him to demonstrate surgical procedures. “I was pleasantly surprised at how knowledgeable the doctors from Guatemala were,” he says. “Pleasantly and shamefully surprised. Why should I have thought they would not be good?”
It was an epiphany. But in 2002, during his first medical mission, he saw Guatemalan doctors in one corner speaking Spanish and American-based doctors in another corner speaking English. “There was a divide and a separation,” he recalls. Dr. Lazareff no longer joins large missions. Instead, he goes with teams of two or three and matches up with local counterparts. In 2012, for example, Mending Kids International, a Burbank, California-based non-profit that organizes and sends medical missions abroad, dispatched Dr. Lazareff to Guatemala with a neurophysiologist and an anesthesiologist and matched them with Guatemalan neurosurgeon Graciella Manucci, MD, and her team. They did one cerebral-palsy surgery together. Afterward, Dr. Lazareff asked Mending Kids to fund the Guatemalan team rather than paying to bring him back to the country. Similarly, Dr. Lazareff worked for three months at UCLA with Nicaraguan neurosurgeon Juan Bosco Gonzalez Torres, MD. After promising signs from the Guatemala program, Dr. Gonzalez Torres submitted a budget for a neurosurgery clinic in Nicaragua, and Mending Kids agreed to fund it. “The concept was the same all along,” Dr. Lazareff says. “Don’t fund American doctors to do the work that can be done by local doctors.”
Dr. Lazareff, who along with Dr. Jarrahy is on the advisory committee of the UCLA Center for World Health, emphasizes cultural sensitivity to local practitioners, who might otherwise wonder, “What are you doing here, gringo?”
He has developed friendships in South Africa, Mexico, Guatemala, China, Iraq, Chile, Kenya, Romania, the Dominican Republic and Panama. “The way to respect people is by asking them what they need instead of saying to them, ‘I will tell you what the problems are,’” Dr. Lazareff says.
Dr. Lazareff becomes animated at the notion that doctors in the developing world need to be told what to do. “All participants have to stand at the same level, on the same platform,” he says.
But while there are many qualified physicians in these countries, poor infrastructure often prevents them from helping the neediest children.
Practicality is at the core of the approach of pediatric cardiologist Juan Carlos Alejos, MD (RES ’90, FEL ’93). “We can do all the surgeries we want, but if the kids can’t get any care after we leave, it’s all for naught,” he says. “They’re going to die.”
Dr. Alejos has been leading surgical missions to Peru, where his father trained as a pediatrician, since the mid-1990s, and he has developed close professional and personal ties with physicians and surgeons there. “Our counterparts in Lima and Arequipa follow these children after we leave, and when they need anything, we are here to communicate with them via Skype or email or Dropbox,” he says.
In 2006, Dr. Alejos created the non-profit Hearts with Hope, which sends four missions to Peru and El Salvador each year and is branching out to other countries. His organization has screened thousands of children, performed 113 cardiac surgeries and conducted thousands of dental evaluations, fillings and extractions. The organization sent a team of 72 people to Peru in April 2013, including surgeons, cardiologists, pediatricians, dentists, nurses and humanitarian volunteers. They do outreach in the villages and conduct surgeries, electrophysiology and cardiac catheterization at hospitals in Lima and Arequipa, the second-largest city in Peru, and San Salvador.
Dr. Alejos has heard stories about teams of doctors who would charge the government fees for their services. “They would go into part of the hospital, close off the wing and operate,” Dr. Alejos says. “Kids would be operated upon, but nobody was learning from them. Nobody was monitoring them. They just did their stuff and left. Wherever we go, we’re going to take care of the kids who need it most, while working side-by-side with that hospital’s medical team. We’re not there to take over. We want the physicians and their staff to learn from us and to want us to come back.”
In Peru, Dr. Alejos has observed that indigenous people are coming down from the mountains for work. Greater urbanization means they have one foot in the village, one in the city. “Certain herbs and teas to them are keys in treating diarrhea or all kinds of illnesses. We have to respect that. I’ve seen it in Los Angeles. If you disrespect their medical culture, they’re never going to listen to you,” he says. And he’s seen it in his own family; although Dr. Alejos’ father was a doctor, his grandmother used traditional remedies. “If you got a stomach ache, she would give you some kind of herb,” he says.
Indeed, many indigenous people seek treatment from both Western doctors and traditional healers. Dr. Taub’s research with Oaxaca’s Zapotec people showed they can simultaneously accept Western and traditional diagnoses. “It’s not that they have a brain tumor and they don’t also have soul loss,” Dr. Taub says.
“They believe that they have both. As a result, they can benefit from seeing the traditional healer to address soul loss and the doctor to address the brain tumor.”Dr. Alejos holds seminars to educate Western participants about what to expect during missions. Pediatric cardiothoracic surgeon Brian Reemtsen, MD (RES ’02), traveled to Lima with Hearts with Hope in May 2011 and found it easy to work with his counterparts there because Dr. Alejos had established such close bonds.
Every day, Dr. Reemtsen was bused along rutted roads to the Hospital Nacionale Dos de Mayo in Lima, which was like a gated city with armed guards, surrounded by shantytowns. “There were children running around, feral dogs and no order,” Dr. Reemtsen recalls.
During that week, Dr. Reemtsen performed 10 surgeries on children in dire need, some with only one pumping chamber of their heart. “They were so blue, it was unbelievable, like a squid,” he recalls. But one in particular stood out. A mother who knew her infant son had a heart defect had slipped past security to see the team of American doctors. Moved by her “willingness to sacrifice anything for her child,” Dr. Reemsten successfully operated on the baby.
Even when a sick child is able to reach the hospital, the odds of being treated successfully are long. Equipment often is decades old and outdated. Certain medications and blood thinners are non-existent. Even temperature control can be a challenge. “For cardiac surgery, you need to cool the patients,” Dr. Reemtsen says. “That’s one of the biggest hurdles down there, ice and air conditioning.”
When a devastating earthquake struck Haiti in 2010, David M. Cutler, MD, assistant clinical professor in the Department of Family Medicine, felt compelled to help. He went with his wife, Mary Bugbee, PhD, a psychologist, and son Nathan and has returned each year since, working with the Henri Gerard Desgranges Foundation. Initially, he saw patients and helped rebuild a clinic in Petit Goave, 42 miles southwest of Port-au-Prince. “You’re going from the wealth-iest country to the poorest country in the Western hemisphere,” Dr. Cutler says.
“You’re going to the country with the highest infant and maternal mortality rate in the Western hemisphere. To ask what role cultural awareness has in working in an environment like that is like asking how gravity affects your life. It’s so profound.”
Voodoo, for example, is pervasive. When Dr. Cutler first arrived, his son came down with an infection. Dr. Cutler treated him with penicillin and prednisone, but a high-level minister they stayed with suggested a special voodoo oil that he rubbed on Nathan’s back. Nathan soon recovered. Which one of the treatments had worked? “We’ll never know for sure,” Dr. Cutler says.
When taking patient histories, Dr. Cutler had to be sensitive when asking about sexual activities, important in diagnosing the spread of sexually transmitted diseases. But male sexual prowess is part of voodoo culture. “They won’t always be revealing because that information has special meaning that we don’t really understand,” he says.
Dr. Cutler realized that spending four weeks in Haiti in no way gives him cultural understanding or knowledge of what the people need. Instead, he asked local practitioners how he could help. “I take my lead from them,” he says.
Most women coming to the clinic had vaginal infections, so Dr. Cutler initiated a female-infections survey in March. Moreover, nearly 99 percent of births take place in the home. Dr. Cutler’s team began a GPS-aided mapping study of births to estimate how many women would use a new birthing center, an effort to reduce mortality rates.
Dr. Cutler was honored when the Haitian doctor at the clinic, Pierre Andre Tessier, MD, called him “Quatre by Quatre,” the Creole term for four-wheel-drive vehicles. “He’s willing to go anywhere to get the job done,” Dr. Tessier says.
“When I recall those words, I feel humbled by the strength, courage and endurance displayed by the Haitian people in the face of overwhelming adversity,” Dr. Cutler says. “They are the real heroes.”
Even if they leave exhausted, the doctors leave gratified. For their patients, the surgeons themselves may seem like modern-day shamans. In Brazil, Dr. Jarrahy remembered a 12-year-old girl and a 14-year-old boy who made the arduous trek from the Amazon to Sao Paolo to see him. “It’s like they heard this rumor in their villages, and they went on this pilgrimage,” he says.
In turn, Dr. Jarrahy and the others return with stories to share at symposia and around the water cooler. One shelf in Dr. Jarrahy’s office is lined with hand-crafted figurines presented to him by the families of his overseas patients. “What going overseas has reinforced for me is to continue to focus on children and their families,” Dr. Jarrahy says. “Children are universally beautiful, no matter where they are. They don’t care about insurance. They don’t care about Obamacare. They just want to live normal lives.”
Lyndon Stambler is a freelance writer and teaches journalism at Santa Monica College.