A world of difference

Ramona Farid, M.D., knew she wasn’t in New Haven anymore the night she found herself on a hospital patio pouring a patient’s urine on an anthill. She was testing for glucose.

If she’d been at Yale, Farid wouldn’t have had to think twice about how to follow the progress of a 16-year-old girl in diabetic ketoacidosis, or DKA; she would simply have ordered finger sticks at two-hour intervals and checked the patient’s blood for glucose using a glucose monitor. But this was rural Haiti, where the second-year resident was working for a month with Yale’s International Health Program (IHP). It was 2 a.m., and there wasn’t a test strip to be found at Hôpital Albert Schweitzer.

“I said, ‘How the heck am I supposed to manage DKA without Chemstrips?’” recalled Farid.

Finding low-tech (or no-tech) strategies for diagnosing and treating patients is one of the challenges for residents like Farid who take part in the Yale IHP. Since 1981, the popular program has sent residents in internal and emergency medicine to serve more than 300 rotations overseas or in Indian Health Service hospitals in the United States. This year, 40 of the 100 residents in internal medicine will spend four to eight weeks in locales ranging from Alaska to Zimbabwe. They will be the first to be sponsored by a grant from Johnson & Johnson that will fund the 20-year-old program and allow it to expand.

That night in Haiti, Farid realized she understood enough about diabetes to monitor her patient’s ketoacidosis without Chemstrips. Talking on the phone with the Haitian attending, she saw the logic behind the anthill approach. In a patient in DKA, glucose levels would be high not only in blood, but also in urine. By observing how many ants were attracted by the sugar in the girl’s urine compared to urine from someone without diabetes, Farid could track the decline in the patient’s glucose levels. And so, for the rest of the night, she went out to the anthill with urine samples every two hours. At 8 a.m., the ants stopped coming. Farid took the girl off the insulin drip and sent her home with injectable insulin.

The insight that Farid gained in Haiti—recognizing that she had useful knowledge of a disease independent of expensive technology—is one of the goals of the IHP, according to Frank J. Bia, M.D., its co-founder with Michele Barry, M.D., HS ’77. With the extensive use of diagnostic radiology and laboratory testing, said Bia, young doctors today “often are not allowed to think through a diagnosis. The diagnosis might be handed to them on a silver platter, or an MRI scan.” Overseas, residents “have to go back to actually listening and touching. We feel these are very important skills to bring back to the art of being a doctor.”

In a retrospective study of the program, residents reported that by practicing back-to-basics medicine they gained confidence in their ability to do physical examinations and came to value them more. The study by Robert Wood Johnson Clinical Scholar Anu J. Gupta, M.D.’94, HS ’00, was published recently in The American Journal of Tropical Medicine and Hygiene.

Residents in the program also have the chance to try procedures they rarely get to practice at home. At the Alaska Native Medical Center in Anchorage, second-year resident Walter Lin, M.D., helped with a bone marrow biopsy and saw internists take on other tasks usually reserved for specialists. In South Africa and in Cuba, resident Delia Radovich, M.D., HS ’01, found that practicing medicine where care is free and resources are limited was liberating. She did not have to document every move she made, haggle with insurers or track myriad confirmatory tests. Working in a medically underserved area, she said, “makes you a better doctor just by realizing the whole world doesn’t work the same way the United States works. It makes you more human. It pulls you out of your daily grind, and it brings you back to the real reason you chose medicine, or should have chosen medicine: taking care of patients.”

The physician’s obligation to care for patients provides the motive for the International Health Program, said Bia. “It’s a professional ethic that guides the program. You have a social contract that extends beyond the walls of the hospital, and which others do not have. You have taken the Hippocratic Oath.”

Barry, who is president-elect this year of the American Society of Tropical Medicine and Hygiene, said the goal of the program is “not to train tropical disease doctors but to instill a sense of global responsibility. Our philosophy is opening people’s minds to underserved areas around the world, not only overseas but also in New Haven.”

Alumni of the program have chosen careers reflecting this vision. Gupta’s study found that the 130 Yale residents who went abroad between 1982 and 1996 were more likely than their counterparts to practice in public health settings and more likely to care for indigent patients, immigrants, substance abusers and patients with HIV. For instance, among the doctors in the study who now practice in public health settings, 10 had participated in the International Health Program, while two had not. Among those in the study with a substantial number of HIV-positive patients (more than 20 percent), 30 had gone abroad, while 13 had not.

Joel E. Gallant, M.D., M.P.H., HS ’89, fits this profile. Having elected a rotation in Haiti in 1987 and one in Tanzania and Zimbabwe in 1988, he now serves as associate director of the Johns Hopkins AIDS Service. “It was always my goal to be working with underserved populations in developing countries,” said Gallant. “However, my training at Yale and at Hopkins showed me that there were underserved populations on our doorstep, and that was especially true with AIDS.”

The fact that many participants in the program go on to care for marginalized patients appealed to the contributions committee at Johnson & Johnson, according to Conrad Person, its director of international programs. The New Jersey company’s credo calls for community and global responsibility. “This program fit,” said Person. “Yale was able to demonstrate that people who participated in this program were more likely to develop compassion in the practices they developed years later. This is an exciting program that expands the perspectives of people who are very likely to be leaders in the world of health care in the years to come.”

This year’s grant from Johnson & Johnson will send 40 residents to Indian Health Service hospitals in Arizona, New Mexico and Alaska and to 12 countries including Fiji, India, Russia, Israel, Brazil, China and Nepal. Next year, the gift will allow the program to expand to include residents from other medical schools as well as physicians with established practices. Bia estimates that the grant will come to about $350,000 annually, covering expenses formerly paid for by the Department of Medicine and income from a travelers’ clinic run by Barry and Bia. Yale-New Haven Hospital will continue to pay residents’ salaries while they are away.

For Radovich, now a fellow in hematology/oncology at Memorial Sloan-Kettering Cancer Center, the experience of working abroad was invaluable. “I chose Yale for Yale, not even knowing that this program was in place. But I think people should come to Yale in droves, knowing this is an option.”

September 11 hasn’t diminished the program’s ambitions; if anything, it has set the bar higher, Barry told a group of students attending the poster session for the Downs International Health Student Travel Fellowship Program in October. “There is a whole world out there that is going to need you even more,” she said to the students, who had conducted research abroad. “As America becomes more xenophobic, and as more health care workers hunker down and stay in the United States, I just hope you keep your global vision.” YM