What this physician learned from medicine in developing countries [PODCAST]

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“On a recent call with a small health organization in rural Uganda, I asked the director about the C-section rate in the community. In some private maternity centers, this procedure is performed far more often than one might expect. I’ve learned that while this practice may be financially motivated, the extra fees also pay for staff and encourage doctors to maintain practices in these remote areas. This, in turn, keeps more pre- and post-natal care in those communities, including family planning and HIV care. For almost every ‘best practice’ cost in global health care, there is a benefit. One of the fascinating aspects of my work is to discern those rationales.”

Ann Messer is a family physician.

She shares her story and discusses her KevinMD article, “Don’t push harsh health care realities under the rug.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Ann Messer. She is a family physician, and she wrote the KevinMD article “Don’t push harsh health care realities under the rug.” Ann, welcome to the show.

Ann Messer: Thank you so much. I’m delighted to be here.

Kevin Pho: So we’ll get into your article a little bit, but first off, can you share your story and journey to where you are today?

Ann Messer: Sure. I’m a family practice doctor, and many years ago, I took a family vacation to rural Nicaragua, where we were supposed to build a clean water system. It was one of those voluntourism opportunities. When we got there, the organization we were working with recognized that my husband and I were both doctors, and they literally handed us a beat-up cardboard box full of old, expired medicines and said, “Don’t do the water. We can handle that. Please go take care of people.” We were so deep in the Nicaragua mountains, we were on donkeys and fording streams and that sort of thing, and saw hundreds and hundreds of people with really basic medical problems.

I came home from that trip a changed person, as did my family. But I would wake up in the middle of the night thinking to myself, “It’s gastritis. It’s so easy. It’s a sinus infection; we can handle that. It’s a little something in your eye.” But folks just don’t have the knowledge that we have here in America. We have this huge wealth of information coming at us. So from that genesis, it took a little while, but One Good Turn was born, with the idea of bringing very practical medical education to communities where they’re already taking care of people, and they just need a little bit more knowledge to do it in a best-practice type of way.

Kevin Pho: So tell me about some of the other places that you’ve been to over the years. What would you say are some of the most striking examples of those disparities of care that you’re talking about?

Ann Messer: Every example is striking, and typically it’s just by circumstance. One Good Turn only goes where we’re invited. One Good Turn is the name of my organization. So far, we’ve largely been invited to areas that are sort of in the equatorial belt and a little bit above and below. I’ve been to Nicaragua and Cambodia and Kenya and Uganda and Mexico, Dominican Republic, Costa Rica, Haiti, Haiti, Haiti, Haiti, really all over the place, Peru.

What’s interesting to me about that is two things. Thing number one is that in all of these environments, the basic medical issues that people deal with are the same. They’re very common, and things that are easy for us to care for here in America. And number two, what’s different from America is that there’s some level of academic medicine in all those places, but the drop-off between what you see in the high-level academic centers and what you see in rural communities is so profound, just like the economic drop-off and the educational drop-off. So there’s just an enormous opportunity to provide service in more rural and remote areas.

Kevin Pho: Is this something that you had specifically trained for? Is this something that your family physician background prepared you for? So tell me some of the skills that you have to learn in order to do what you do.

Ann Messer: Yes, certainly being a family doctor helps. It’s interesting, because so much of the training to do appropriate global health is actually ethical. It has to do with being a student of other people’s cultures, even when you think you know the answer already. And it has to do with doing an enormous amount of research from the perspective of the community, not from the perspective of a rich American, so that you can learn about what the health care problems are, as perceived from where I’m going, not what I think is going on, good or bad.

And then, of course, researching the culture. All of that is so important, because as a guest, I need to recognize that I’m very, very lucky to even be invited there, and it would be so presumptuous of me to suggest, for example, what we should have for dinner, because I don’t know; they know. And that’s true of all sorts of medical care and all sorts of traditions: to recognize that there’s always a good reason for what’s being done in another culture. It’s just that from my perspective, I may not understand it. So I need to be a student and learn about what that reason is.

Kevin Pho: Let’s transition into your KevinMD article that you wrote. It’s titled “Don’t push harsh health care realities under the rug.” Now, for those who didn’t get a chance to read that article, can you just walk my audience through it and share the story of why you decided to write it?

Ann Messer: I think one of the reasons that developing countries get labeled with that is that they’re so honest. They talk about female genital mutilation, or sex out of marriage, or leg ulcers that cause people to have to be amputated, and homelessness and poverty and lack of good nutrition, in such matter-of-fact terms that for us in a different culture, we’re just aghast by that. Because here in America, well, we’re so lucky to have so much, we tend to sort of sugarcoat some of those terms.

But I’ve found that when I’m working with a community that’s really honest about what’s going on, and you know that the average age of pregnancy for a young girl is 12, then that gives me an entree into really addressing the problem. And I find that that’s very different from here in America, where we really work hard, in our attempts not to offend people, to sort of gentlify what we’re talking about. I think in some ways that makes it harder for us to get at the truth.

Kevin Pho: Now, what do you think are some of the reasons why that is?

Ann Messer: It’s because of our own health care disparities. So when I’m talking about the homeless guy under the bridge nearby where I live, I’m going to call him “currently without a house,” instead of saying that the guy has no place to go and he’s living in the gutter, which is actually the reality. And why is that? Maybe a little bit of it is that I’m guilty. Because I have a beautiful home, it makes me feel kind of guilty.

Part of it is, I think, we try hard in America not to separate ourselves from other people. So we try to find wording that makes it so that I’m maybe not so different from the homeless guy under the bridge down the street. But the reality is I’m incredibly different from him, and if I don’t acknowledge that, then I can’t provide him with appropriate service. And so I think that that’s a little bit of it: our desire to both empathize, but we’re doing it in a funny way, because we’re softening things for people, and also still just trying to be together with people. That’s well-meaning. And then I think there’s a lot of guilt around the true disparities of life here.

Kevin Pho: What are some of the things that we here in America can do to address this issue? What are some of the other lessons that you’ve taken from abroad that some of the physicians here in the United States can learn from?

Ann Messer: Probably one of the biggest ones is that when I encounter something abroad that is horrifying to me in some way, or that I instantly judge as being bad, I’ve learned to become a student of that thing and start asking the question “Why?” And if you keep asking that question now, like, “Why’d you do that? That’s mental,” but, “Why? Tell me more. I want to learn more. Explain that more to me,” in an open-voiced way, then you’re inviting the person to describe their experience a little bit more accurately. That allows us to get into understanding the cause of what might be going on.

And when we can understand that, then the symptom that we’re kind of trying to cover up, the person’s fat, or the person’s poor, or the person’s had six abortions, we’re trying to cover that stuff up. But if we find out why, then I think we can address those issues in a way that’s appropriate to the individual with whom we’re discussing those issues.

Kevin Pho: So I’m interested in hearing more about your experiences abroad. You’re a family physician from America, and you’re going to these places where people may not have seen a physician in a while. Tell me about some of the reactions that you get from seeing these patients.

Ann Messer: Well, first of all, I work with providers. So I do see lots of patients, but my job is to teach the care providers. I don’t do clinics where there’s a big white tent that somebody had to rent and a thousand people sitting underneath it that we run through. I work with clinics, sitting next to the person who’s providing the care, and it’s wide-ranging.

I worked with some midwives in Cambodia a couple years ago, right before COVID, and they were not interested in what this white lady had to say about birthing babies, and they were right. I’ve never given birth to a child on a picnic table. They deserve that disdain, and I had to work a long time to gain their respect, which I’m willing to do, because I understand that perspective.

But some people are so glad for two things. The biggest one is they’re so glad to be seen. They’re so grateful that somebody from over here went all the way over there and sat down with them, just like every patient is glad to be seen and every student is glad that somebody knows that they know things. So that has been profound. And I think when I can get to the place where people are glad to be seen and recognize that I’m not there as the big bad boss who knows everything, but just as somebody who’s trying to help figure out what the best resources are, that sort of changes the equation a little bit more.

Kevin Pho: Now, one of the things you mentioned earlier was learning the culture of the place that you are going to be in. So what are some of the ways that you do that in preparation for your trips abroad?

Ann Messer: Yeah, great question. The needs assessment is one of the most important parts of what we do. So we spend a lot of time talking with the people that we’ll be working with before we ever get there, and we ask questions and do some questionnaires, like surveys, to the community or to the care providers. Also, my team does a lot of just internet research and anthropological research about traditional health care in the community and that sort of thing. None of it really replaces going in person first, which I love to do, and I’m looking forward to getting back to it. But it’s a ton of research, recognizing that even with all our research, we’re not going to get it right. We’re going to be learning so much when we get there, and just be really willing to not make any kind of permanent judgment.

Kevin Pho: We’re talking to Ann Messer. She is a family physician, and she wrote the KevinMD article “Don’t push harsh health care realities under the rug.” For those physicians who may be interested in pursuing global health, what kind of advice, what kind of skills, what kind of characteristics should they have in order to pursue that goal?

Ann Messer: Be a student. Be a student leader. Be a student. I think that’s number one. It’s such an incredible privilege to be able to go into another world and offer some knowledge and expertise, but also learn so much yourself. So I think that’s absolutely thing one.

And thing two is you don’t have to know it all. We have the internet; we’ve got so much knowledge here in America. So we can say we don’t know the answer to that, or not be fully prepared to go into a community. You can’t be unprepared; that’s rude; then you’re taking people’s time. But you can’t think that you have to know every single thing. I don’t have any advanced-level global medical certification. I’m too old for that. I’m still a doctor, but I practiced regular medicine for 30 years before I started this. So I just went out there and started doing it.

And I think that’s true for any passion within medicine. We’re all so used to thinking we have to be experts at something before we proffer an opinion toward anybody, but that’s not true. We can just get out there and start doing it, and just be aware that you can make mistakes, and be aware to change them if you do.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Ann Messer: Be a community. Learn from each other. This is a great opportunity to do that. Always seek the good in medicine. There’s so much. It’s amazing that we have the opportunity to have this window into people’s lives. And I think ultimately, although I know we’re all trying to take care of people, at the very, very end of the day, what we’ll be thinking about is how remarkable it was that we had this chance to see how other people really live.

Kevin Pho: Thank you so much for sharing your time and insight, and thanks again for being on the show.

Ann Messer: All right, thank you, Kevin. It was a delight, and I’m so glad to have this chance.

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