Internists Leaving the Comfort of Their Practices to Join Doctors Without Borders

By Rosemary Frei, MSc

Doctors Without Borders (known internationally as Médecins Sans Frontières) is in the news frequently these days, with its volunteers and staff on the front lines of natural disasters and war zones from the Sudan to Sri Lanka. The television images portray physicians steadfastly making difficult decisions about how to triage and treat hundreds or even thousands of seriously injured or sick people under extreme conditions, sometimes with only minimal access to medical resources.

Despite these difficulties, Doctors Without Borders continues to attract enthusiastic volunteers from the United States and countries all over the world, including many internists. Why do these well-trained physicians choose to leave the comfort of their practices and homes for 6 months to a year to work in conditions that are a far cry from those they enjoy at home?

Internist Cynthia Gay, MD, readily supplies the answer. Dr Gay was in rural Uganda for 8 months during 2002 and 2003, expanding the antiretroviral (ARV) treatment program at the town of Arua's HIV clinic. She said the rewards for physicians from this kind of overseas work are “huge.”

“I believed in this kind of project before I went [to Uganda],”she said. “I wanted to make changes in the lives of individual patients, and I believed I would do that. And I left with hope—collectively for HIV/AIDS patients in Uganda, and for Doctors Without Borders’ ability to treat people with HIV/AIDS in a resource-poor environment.”

The Rewards of Fighting AIDS in Uganda

While in medical school, Dr Gay decided she would pursue work in HIV/AIDS in developing countries because of the enormity of the global AIDS crisis and the lack of resources available. She chose Doctors Without Borders because of its reputation, its lack of association with any religious or political groups, as well as its financial prudence with donors’ money.

Her 8-month mission in Arua involved working with an established ARV program that was set up to provide AIDS treatment to residents in the town of Arua and its surrounding areas. Dr Gay was the only physician, but was assisted by several physician assistants, a laboratory technician, a field coordinator, a logistician, and 2 Ugandan nurses who worked as adherence counsellors. These nurses were a critical part of the team, helping people understand the importance of trusting the non-Ugandans in their midst who were asking them to take anti-HIV medications. Doctors Without Borders provided the ARV agents free—lamivudine/zidovudine (Combivir) and efavirenz (Sustiva)—as well as for use of prophylactic trimethoprimand sulfamethoxazole(Bactrim) for pneumonia. The World Health Organization supplied food to patients in the ARV program.

By the time Dr Gay left last spring, the number of people receiving ARVs had expanded from 29 to 250.

“Uganda surprised everyone, because the program really took off,” Dr Gay told Internal Medicine World Report. “We got a system in place where we could get more patients on ARVs each month, so the number of patients started on ARVs went up faster than we expected, and the number of patients that came to the clinic also increased more rapidly than we’d anticipated.”

Many patients rapidly gained more than 20 pounds once they started taking ARVs, and others, such as patients diagnosed with comorbid cryptococcal meningitis, also rebounded from their condition. Dr Gay said another unique aspect of this experience was the way in which people living with AIDS supported each other and pitched in to help educate other Ugandans about the disease and about available treatment.

“They were just a phenomenal group of people that I was lucky enough to get to know as individuals, not just as patients,” she observed. “It was an amazing experience for me. I still miss the patients and the staff every day.”

Dr Gay's team demonstrated a successful model of treating HIV in rural Africa, and their example will now be emulated by other Doctors Without Borders teams in other areas, as well as by other groups and health care professionals battling the AIDS epidemic in Africa.

Presently in Malawi doing an infectious disease fellowship with the University of North Carolina, Dr Gay intends to continue splitting her time between Africa and the United States for the rest of her medical career, as a way of sharing her medical skills and knowledge with people in disadvantaged countries, to enrich her practice and relationships with patients at home, and to cultivate something personal that, she noted, is hard to describe.

“First, it’s not like here in the United States—while you’re on an international assignment, if you don’t show up for work, there is no other person to replace you. You are really providing a service that is needed,” said Dr Gay. “And then when you’re back in the United States, you can bring to your patients the more finely-honed bedside diagnostic skills and interpersonal skills that you gained overseas, where you have a lot less to lean on.”

Physicians Are Needed for Overseas Aid

Doctors Without Borders is one of the largest independent international medical relief organizations in the world. Established in 1971, it sends more than 2500 volunteers annually to provide emergency medical care in more than 70 countries. In 1999, it was awarded the Nobel Peace Prize. It has offices in 18 countries, including North America, western and northern Europe, Australia, Hong Kong, and Japan.

Doctors Without Borders is particularly interested in recruiting internists, family medicine and emergency medicine physicians, pediatricians, obstetricians/gynecologists and infectious disease specialists. Also needed are nurses, laboratory scientists and technicians, midwives, logisticians, and administrators with a financial background.

The organization collaborates with the local Ministry of Health in each region and works with about 15,000 local staff to rehabilitate hospitals, carry out in-patient and outpatient consultations, set up surgical programs, and conduct massive vaccination campaigns. Application forms, field positions, and the entire process are described on their Web site, at www.doctorswithoutborders.org.

One Third of the World Infected with TB

Myles Spar, MD, MPH, an internist from Los Angeles, joined Doctors Without Borders in 2001 and was sent to Nagorno-Karabakh in Azerbaijan to set up a multidrug resistant tuberculosis (TB) pilot project. “The TB global crisis is quite disturbing,” said Dr Spar. “One third of the world’s population currently is infected. Two million people die every year, with 8 million people becoming sick with TB yearly. What was significant in our pilot project was we were treating drug-resistant TB, which very few organizations were doing. It is time-consuming, long-term, and complicated work. It requires a lot of logistics, funds, and expertise,” he explained.

Dr Spar and his support team worked with the country’s Ministry of Health to obtain the necessary medication, renovate the hospital, and begin a direct observed therapy program for TB patients in the area.

Upon his return home, Dr Spar has redoubled his efforts to help those infected with AIDS and TB, both overseas and in the United States. He works in the largest free clinic in the United States, the Venice Family Clinic, based in Los Angeles, and helps Doctors Without Borders recruit other physicians and raise awareness about the medical and humanitarian issues in the media and speaking events. Dr Spar, who is also a clinical instructor of internal medicine at the University of California Los Angeles, is now serving a 3-year term on the organization’s Board of Directors and is the resource consultant for their HIV/AIDS program in Guatemala.