Karen Snyder Asher, DO, and her husband, Thomas E. Asher, DO, have been practicing in Sierra Leone since 2008 and have found that working in a developing country occasionally has health consequences. Both physicians have gotten malaria more than once. Dr. Thomas Asher broke his leg when he fell off of a metal roof he was trying to secure during a storm. And the Ashers have been exposed to Lassa fever, a hemorrhagic fever, though they didn’t get sick.
Then an Ebola outbreak hit the country.
The Ashers are currently in the U.S. because they typically spend the summers stateside and travel restrictions within Sierra Leone are preventing their return to Africa. The physicians work with an association that supports the country’s Christian hospitals and clinics. They travel to health care facilities across the nation, providing education, interim labor and supplies. But the current roadblocks imposed to help contain Ebola mean that the Ashers are unable to resume their work.
While in the U.S., the Ashers are raising funds for Sierra Leone hospitals and collecting and sending supplies. But the couple plans to return to Sierra Leone as soon as they can.
“When we’re able to do the job that we normally do, we see a big improvement in the quality of the care and the survival rate of patients,” Dr. Karen Asher says. “We feel it’s worth what risk might be there.”
Other DOs practicing in Africa’s developing countries share similar insights: They are aware of the elevated threat of disease but say their mission to help patients in an area with tremendous need trumps personal dangers. The DO spoke with Dr. Karen Asher and DOs in Kenya and Malawi about their work, the hazards they face and the reasons they’re planning to stay the course.
Six years ago, the Ashers moved to Sierra Leone to work at a hospital in Kamakwie, a town of roughly 8,000 that sits amid the forests, savannas and grasslands dominating the country’s north. They were the only physicians in a 120-bed hospital. Four years later, they joined the Christian Health Association of Sierra Leone and started bringing their medical skills and other forms of assistance, including fundraising, to Christian hospitals throughout the country.
“We bring medical supplies to the hospitals, and we staff them when their doctors are on vacation,” Dr. Asher says. “We also run scholarship programs for people who are going into the medical field.”
Sierra Leone’s rudimentary health care system has posed significant challenges to the country’s fight against Ebola, Dr. Asher notes. Many hospitals in Sierra Leone don’t have running water or electricity. The hospitals use well water and may operate a diesel fuel generator for a few hours during the day when physicians are doing surgery. Sierra Leone also doesn’t have a residency program, so the 20 or so physicians who graduate from medical school each year in this country of 6 million usually leave for residency and don’t return. And during the rainy season, many roads become impassable, stopping necessary transport of supplies, physicians and patients.
Ebola entered the country this spring and has since sickened or killed more than 2,000 people there, according to the Centers for Disease Control and Prevention. The virus has disproportionately hit health care workers, who take care of patients in hot and humid conditions, and it has killed the country’s chief virologist, Sheik Umar Khan, and several nurses Dr. Asher knew.
Even before Ebola hit Sierra Leone, the Ashers faced considerable health hazards by working there for extended periods. The country’s other common infectious diseases include malaria, HIV, tuberculosis, typhoid and Lassa fever. When the Ashers return, as they plan to, Ebola will be an added hazard to watch for. But right now, the physicians are more concerned about the country’s pressing health care needs, many of which are falling by the wayside as the Ebola crisis worsens.
“Ebola may be a focal point right now, but the country is still in need of physicians to treat malaria and deliver babies and treat small children with illnesses,” Dr. Asher says.
The Ashers have focused on educating health care workers and midwives on safe home delivery and how to tell when an expectant mother needs emergency medical attention. The maternal mortality rate in Sierra Leone dropped 45% between 2005 and 2013, according to the World Bank. Dr. Asher attributes the decrease in part to her group’s education efforts. The Ashers have also helped install a solar power grid on two of Sierra Leone’s hospitals, and plan to install grids at eight more hospitals. The solar grid allows administrators to power the hospital without using diesel fuel.
“Most doctors want to feel that what they’re doing is making a difference,” Dr. Asher says. “We see a lot of lives saved. We feel we’re making a big difference there.”
Introducing students to Kenya
On the other side of the continent in Kenya, David K. MacIntosh, DO, spends six weeks each year in Chogoria, a mountainside village in the country’s center. He downplays the risks to practicing in Kenya, noting that the rewards, which include introducing U.S. medical students to health care in a developing country, outweigh them.
Dr. MacIntosh’s journey to Africa began in 1977, when he had just finished his internship. A bout of wanderlust led him to Kenya, where he volunteered in a Chogoria hospital for a year before finishing his residency in the U.S. He then spent several decades dreaming up ways to return to Kenya.
“Once you’ve spent time in Kenya, you meet the people and learn the culture and kind of fall in love,” he says.
In 2009, a colleague inspired Dr. MacIntosh to develop a clinical rotation for fourth-year medical students from the Michigan State University College of Osteopathic Medicine in East Lansing, where Dr. MacIntosh is a clinical associate professor. Dr. MacIntosh arranged for students to rotate at the very same place he worked back in ’77, a 300-bed hospital surrounded by mountainside coffee and tea plantations.
“The students are young, and they’re all very enthusiastic,” says Dr. MacIntosh, who is also a cardiologist in Traverse City, Mich. “Working in Kenya is often totally different from anything they’ve done so far, and it’s just so exciting to watch them and see how much they grow in a six-week period.”
Each year, Dr. MacIntosh brings four to six fourth-years to the hospital, where they can focus on internal medicine, surgery, obstetrics-gynecology or pediatrics. They learn how resourceful and hands-on physicians need to be when they don’t have MRIs and other imaging technology available.
“Students get to experience medicine without doing a CT scan for every diagnosis, and they get to see a new culture,” he says. “The people in the area are gracious and kind.”
Some students rotating with Dr. MacIntosh also perform surgery. For instance, those with backgrounds in ob-gyn have performed Cesarean sections after just a few weeks of rotating at the hospital. While an attending physician is present during the surgeries, the student serves as the principal surgeon.
Because roughly a third of the hospital’s patients have HIV, students performing these surgeries could be exposed to the virus if they get a cut or laceration on their skin. So far, this hasn’t happened, Dr. MacIntosh notes.
“We have anti-viral medicines we take with us in case a student is exposed, but we’ve been very fortunate so far,” he says.
Dr. MacIntosh goes over these risks with his students and tells them the percentage of patients who have HIV and TB. When they work with TB patients, students often wear face masks, he notes.
The students and Dr. MacIntosh also must be wary of other infectious diseases common across the continent, such as malaria. To prevent malaria, they take prophylactic medication and sleep under mosquito nets. TB is harder to ward off. So far, Dr. MacIntosh and one of his students have acquired inactive TB, which requires a nine-month course of isoniazid, a harsh antibacterial medication that reduces one’s chance of developing active TB.
But Dr. MacIntosh says the knowledge the students gain during the rotation supersedes the dangers.
“All young people should have an experience in a place like this because it will give them a better appreciation for the resources we have in the U.S.,” he says. “It also gives students a better appreciation for a different style of medicine.”
A lifelong mission
A few hundred miles southwest of Chogoria, Tonya K. Hawthorne, DO, is the sole physician serving a population of 10,000 in Ngoswani, a small village in the Maji Moto region of southwestern Kenya. Dr. Hawthorne, who has spent her career taking medical missions in developing countries and war zones, opened Ngoswani’s clinic, which she helped build, in 2009.
Like Dr. Asher, Dr. Hawthorne has gotten malaria and faces possible exposure to other tropical infectious diseases while caring for her patients. She additionally must be mindful of wild animals and Islamic militants.
“Some days, it’s very hard,” she says. “I have days when I’m faced with challenges. I don’t have resources such as MRIs and CT scans. I have to rely on what I learned as an osteopathic physician. While it’s challenging, I know that mission work is my calling. It’s what I’m supposed to do. On a daily basis, I don’t think about typhoid or malaria or the other tropical diseases that I’m exposed to. I think most physicians doing mission work don’t think about those things.
“You don’t look at the risk to yourself. You look at what you are doing with your talents, and you look at what you’re doing with what gifts you have. The risk to you becomes very little when you it compare it to the good you’re doing.”
Dr. Hawthorne’s clinic is the only place her patients can receive medical attention. The nearest public hospital is an hour and a half away on dirt roads, and two bigger hospitals are four to five hours away depending on the weather and road conditions. This means that Dr. Hawthorne, too, has scant options for medical care when she gets sick.
The clinic doesn’t have running water or electricity, though Dr. Hawthorne has access to well water and a generator and solar power. Her patients are predominantly shepherds in the Masai tribe who make their living selling and trading sheep and cattle.
“We live in a mountainous area, and people still live in what are called manyattas, which are mud-and-dung houses,” she says. “They bring their cattle in at night, they bring their sheep in at night. Everything is closed up into their houses because we live backed up against a nature conservancy. So we have elephants, buffalo, lions and leopards. Last night the elephants were right behind our house by the river and you could hear them drinking.”
In this remote corner of Kenya, Dr. Hawthorne is painfully aware of the dearth of physicians. She recalls a recent patient she treated at a nearby safari camp. A man in his 20s, he was having an anaphylactic reaction to a bee sting.
“When I walked in the room, he literally took his last breath, and then he had no respiration,” she says. “The owner of the camp had an EpiPen, but nobody there knew how to use it. I plunged that EpiPen into his leg and seconds later, he was breathing again.”
For the chance to save lives, Dr. Hawthorne is willing to accept the hazards of infectious diseases, rogue lions and even militants.
About 1,300 miles south of Dr. Hawthorne’s clinic, Terrie E. Taylor, DO, spends half of every year in Blantyre, Malawi, where she has been researching pediatric malaria since 1986. The country’s biggest city, Blantyre is a densely populated metropolis with tree-lined streets, wide boulevards and a comfortable climate, which it owes to its 3,400-foot altitude.
Despite Blantyre’s cosmopolitan vibe, physicians and health care workers spending long periods of time there face the threat of malaria and other infectious diseases such as TB, HIV, rabies, cholera and bacterial meningitis. Dr. Taylor got malaria the year she didn’t take prophylactic medication against it. She also got hepatitis back in 1987, when she first came to Blantyre, because she forgot to obtain a vaccine booster.
But Dr. Taylor says she’s far too intrigued by her research to worry much about the repercussions of working in Malawi.
“Our topic of study, which is how the malaria parasite wreaks its havoc, is so interesting,” she says. “The level of interest completely eclipses the risks. And the risks are manageable.”
In 2010, malaria killed 675,000 African children younger than 6 years old, the World Health Organization reported. Dr. Taylor and her team have examined why some children with cerebral malaria, a form of the disease that causes neurological complications, succumb to the disease while others survive. Her colleagues at Michigan State University, where she is a distinguished professor in the school’s college of osteopathic medicine, persuaded GE Healthcare to donate an MRI machine to the hospital. The machine is the country’s first, and Dr. Taylor has used MRIs to discern what happens to the brains of children with cerebral malaria.
“The MRI has shown us that the major cause of death is massive brain swelling,” she says. “Eventually the brain exceeds the capacity of the skull, and it gets extruded through the bottom of the skull, and it presses on the brain stem and causes respiratory arrest, and the children stop breathing.
“We’d like to figure out what’s causing the brain swelling and nip that in the bud. Another useful finding of the MRI is that in two-thirds of the patients, the swelling goes away on its own and the kids wake up and they live happily ever after. It only takes a day or two for that to happen. So we might be able to put the children on ventilators and keep them breathing until the brain swelling resolves on its own.”
She also notes that the more progress her team makes, the more she’s motivated to stay.
“Now we’re very close to figuring it out, so it’s kind of tantalizing,” she says. “I don’t want to stop now. I want to keep going until we finish the story.”
Like Dr. Taylor, the Ashers and Drs. MacIntosh and Hawthorne are also propelled forward by their own progress: the reduction in maternal mortality, the medical students’ joy of discovering a new health care system, the saved life of a young man with a bright future. They stay because their patients need them.