Five years on

Five years ago, I packed my bag for an adventure that was longer than I had initially expected. I loaded up a taxi with boxes of spectacles, my giant Kathmandu travel sac and plenty of messages from family and friends to be safe. I was off for a month in Ghana.

So much of that trip remains crystal clear in my head. Arriving in Accra, the humid, burning heat off the plane. The fellow travellers who, awaiting their luggage at the baggage carousel, found their newly purchased electricals had been stolen from their boxes. The difficult conversations we had trying to convince the customs officials that the thousands of glasses we had brought with us were donated, and were to be donated onwards, rather than for our own financial gain. The attempts to find a taxi with a meter, as we had been told to do, but the distinct lack of any taxis with anything resembling a meter. The way that "taxi" was a loosely applied term to cars that had drivers willing to make money out of tourists needing to make it to the safety of their accommodation. We arrived just before New Years, which that year was spent celebrating by talking to a local working at the hostel where we were staying while listening to a pastor in the nearby church speak the tongue of God, which I had initially thought was a local dialect.

Kellie, my companion, and I spent several weeks travelling around Ghana with a charity organisation called Unite For Sight. We had done weeks of global health instruction prior to arrival but nothing could have prepared us for the reality we faced. From the simple, surprising and over time extremely frustrating calls from men all over Ghana, "white lady, will you marry me?" to the distinct lack of hot showers, drinkable tap water or public toilets. I remember, one day, unable to do my usual 12-hour bladder hold, I went in search of a restroom. The children pointed me to a nearby structure and I was baffled to find a tiled floor. Just a floor. I stood there wondering what people did when they needed to poo. And I didn't touch the soles of my shoes for days.

I remember our attempts at speaking the local language, and how much better at picking it up Kellie was than me. I remember her enthusiasm for communicating, however simply, in words familiar to the locals, and my own fear of slipping up and saying something completely incorrect. I remember meeting people whose lives and health shocked me to the core. Young people, blinded by disease or drugs, blind since birth, unable to seek any education or strive for the success that their intellect so deserved. I remember the elderly being lead by younger family members, blind or nearly so, by cataracts that had grown so opaque they could barely see a light right in front of their eyes. I remember the impoverished communities and the local kings in the comparative palaces. I remember driving into communities where groups of enthusiastic women and children would chant about how poor quality items were that were bought from China. Amongst all of this, I met so many educated, talented individuals who struggled to make an impact in their own world, or who sought to reach professional goals that were not possible in their local environment. I saw talent pushing against oppression and systems that did not support them. But above it all, there rang a sense of hope.

Change was coming.

Homesick, emotionally exhausted but intellectually stimulated, my course changed from a homeward bound journey to a mind-altering trip to Silicon Valley. I stopped off in Dubai, my original port for a trip home, and spent a solid forty minutes washing off what I thought had been a tan developed from all our work in the heat and humidity. It was, much to my surprise, three weeks of solidly ingrained dirt. And for those long minutes, I watched the aches and struggles wash away, and revelled in the simple pleasure of a hot shower.

After a short sojourn in San Franscico, I spent a week living on campus at NASA in Mountain View. Here I was, only days separated from a place where I had occasionally struggled to find a familiar type of toilet, in a land where space craft were designed and built. The enormity of it was like a slap in the face. From a place where the most basic of healthcare needs was a struggle on week, to a forum where I was learning about three-dimensional printing of organs, electronic applications sourcing and computing big data, visiting the land of robotic surgery and touring the prototype of Kaiser Permanante's healthcare system the next. It was perhaps this overwhelming juxtaposition that grew in me a passion for exponential technologies, which provide a platform for low-cost healthcare interventions. Where, using simple technologies available on mobile phones, we can work with communities to build systems that engage primary prevention strategies. Where communities themselves can be empowered to build, fund and design innovations that make life better. Because, though it is quite obvious it is often forgotten, communities that are under-resourced are more creative and determined to make change when given the opportunity.

Before too long, it was time to return to Australia and the seemingly mundane details of medical school life. My mind ached for the challenge of solving problems bigger than learning histology. My focus was more often on systems thinking and innovation that the fundamentals of biochemistry. My day job felt like innovation; medical school felt like a hobby.

At the end of the year, I was privileged to spend a month of my life working in Papua New Guinea. Those hot, humid weeks were some of the hardest of my life. Every day presented its own emotional and intellectual challenges. I still remember, so vividly, our first tour of Port Moresby Hospital. I remember the cracked and missing tiles in the halls, the oddly poignant "hospital suggestion box" sitting proudly on the wall, the Emergency department with so many patients scattered on the floor and on benches, IV poles perching precariously between them, patients coughing persistently with what was most likely tuberculosis, and one person in the corner over-ventilating his brother, who could not be transferred to the ICU as there were no mechanical ventilators available. I remember turning to Sam, my buddy for this particular elective, and giving him a look of "what on earth did we think we were doing?" that was, as far as I could tell, exactly what his eyes were saying to me. We found the textbooks we had packed, knowing internet access would be scarce, entirely unhelpful. What was the use in knowing the laboratory tests or imaging investigations of worth when there were no re-agents for pathology in the lab and a CT scanner that was permanently on the fritz. What was the point in knowing appropriate antibiotic therapy for a particular condition where there was one, and only one, antibiotic available, and that antibiotic wasn't something we had ever used in Australia. There was no dream of exponential healthcare here; the dream was to have the basic and fundamental resources required for running a healthcare facility.

Our time in PNG was life-changing. It was mind altering. It was the hardest thing I think I've ever done and yet one of the most formative things I've ever experienced. There was a day when, much to our concern, Sam and I were left in charge of the Emergency Department in Goroka. The Emergency doctors had failed to turn up for the day. We had stood outside the door, unwilling to enter because we could see a patient with a spear through his abdomen and we had no idea what to do. But the doctors didn't come and we knew we couldn't wait forever. The nurses, many of whom had been working for years, asked us (us! second year medical students!) what we wanted to do, and we asked them "what would the doctors normally do in this instance?" We gave everyone an IV line and fluids, we did pleural taps and neurological exams and spent a good deal of time running up to theatres or down to the medical wards with calls for help (because, of course, the phone didn't work). "There's a man with a spear in his abdomen!" I said, desperate for someone to solve the problem. Was he unstable? Well, no. Uncomfortable yes, but stable. And so we waited for the surgeons to see him. "There's a man who can't breathe for himself and appears to have something neurological and it doesn't look like a stroke and..." and so they came, and that was the first time in my life I saw Guillain Barre Syndrome. Eventually the Emergency doctors turned up and though we were glad for their arrival, we were also overwhelmed by how the morning had treated us. And how little we really knew.

Around about this time, and strange as it may seem reading the previous paragraphs, I was struggling to maintain interest in the clinical and theoretical teachings of medicine. I was doing so much to make the world a better place outside of my studies and felt incredibly restricted by the slow progression of medical school. I wanted to change the world and improve medicine and give people less fortunate than myself opportunities to improve their own communities. I wanted to empower young people in rural communities and provide platforms for innovators to collaborate across the globe. I wanted to revolutionise medicine, not wait for slow evolution. And yet, I was stuck each day reading dense textbooks.

At the time, I was selected in the top 10 applicants for the Australian Youth Representative to the United Nations and was eagerly awaiting the outcome. I had also been selected to the national body for representing young people to the Australian federal government. I was ready, in my own way, to step away from medicine and into the land of public policy. And I know, had I have been successful in getting that Youth Representative position, my life would be entirely different today. But for what it's worth, I didn't advance to a seat in the UN or to a tour of Australia seeking the opinions of young people in both rural and urban communities with regards to local and international policy.

Instead, I fell in love with surgery. I fell in love with the honour and beauty of having a patient's future bodily function in my (well-supervised) hands. I fell in love with the healing application of anatomy and the peaceful, controlled environment of theatres. I fell in love with seeing patients pre- and post-operatively and seeing how our interventions initially hurt, then healed them. And though I terribly missed the skittish enthusiasm for problem solving, consulting on friends' innovations and discussing policy, I felt like I'd found a place where I fit in the medical world. For the years that have followed, I've knuckled down studying, filling my mind with facts and figures and internal diagrams of the human body. I've spent my days at work or at home learning, and for a while I stepped away from the passion for the bigger picture. While health policy matters, the big picture is often only an imposition to the care of the individual patient. When there is someone before me needing my help, there can be no other distraction in my mind.

Life turned a corner a few weeks back. I finished my studies for international accreditation. I finished my masters. I finished my first job as a resident doctor. I moved on. And with that, there has been space to reflect on the last five years. I could be disappointed that I didn't follow that dream into policy. Instead, I choose to recognise that these last five years have involved growth and achievement. I could have done more. I could have done less. But I have progressed. I am a different person now. And it's time again to seek out how I can have a broader impact on the health community than my individual interactions with patients. But I'm not ready to give up on those one-to-one interactions either.

It's time to work towards integrating this knowledge and these many experiences to bridge the gap between policy and individual healthcare. It's time to work with those improving individual and collective outcomes in the developing world. I made a promise to my registrar in Goroka that I'd be back one day. I don't plan on breaking that promise.

the long road

Comments

Lance Abel said…
Great post (as always!). If I can ask you to go back to your thoughts of 5 years ago but now with the benefit of all that clinical experience..What do you think are the main areas where hospitals in Australia or the developing world can benefit from "systems thinking"?

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