Title:Cross-Border Care

Alumni share lessons from the field

Despite an increasingly interconnected world, where culture, finances, and people spill over porous borders with relative ease, access to high-quality health care remains stubbornly inconsistent. In many countries, including the United States, the gap between the wealthiest and the poorest continues to widen, and medical challenges facing some of the neediest communities go unaddressed. The complexity and size of the global challenge makes it difficult to find solutions.

But for these five intrepid citizens of the world, merely watching from the sidelines is not an option. Whether at home or abroad, they are making their impact on some of the world’s most underserved patient populations.

In Oregon or Kenya, Care at the Margins

Today Gipson is a family medicine physician with the Peace Corps in Malawi, caring for volunteers who range in age from 21 to one woman in her 80s.

Teresa Gipson (M’94) did not originally plan on becoming a doctor, let alone an international physician. Hailing from a diverse community in Los Angeles, she was a registered nurse but wanted to provide a deeper level of care. Despite the significant cost, Gipson decided to attend medical school at Georgetown but continued to practice nursing at the university’s hospital to help fund her medical education.

Even before coming to Washington, D.C., she knew family medicine would be her specialty. “I was interested in that full spectrum of health care. At Georgetown, people often think anesthesiology, cardiology, surgery,” she says. But she notes that in rural environments, there’s much more demand for “cradle-to-grave” care from family medicine physicians.

A National Health Service Corps scholar, Gipson had long been interested in working with medically underserved communities. She recalls inspiring faculty members at Georgetown including the late Angelo D’Agostino, S.J., and Jon O’Brien, S.J. “They were dedicated as physicians and immersed in their faith and the spirit of their work. They transformed their faith into action.”

A 1993 medical school rotation took Gipson to Kenya and sparked 20 years of work organizing short-term medical relief there and running a clinic in the slums of Nairobi. From her home in Oregon, she coordinated a global health elective which brought medical students and nurses to Kenya on rotations. The program flourished until the 2014 Westgate Mall bombing in Kenya, when it was stopped due to safety concerns.

All the while, she continued to serve the marginalized at home. After a residency in family medicine at Oregon Health Sciences University (OHSU), Gipson worked primarily in community and migrant health clinics in Oregon. Even domestically, she says, resource management posed a significant challenge.

“In Oregon I worked with farm workers who didn’t have a lot of money or resources. Finding people the health care they needed and the resources to actually treat people in the way that they should be treated was one of the big challenges,” says Gipson. “That looks very different in Oregon than in Kenya, but there are ways it’s the same. You make difficult decisions about how you’re going to utilize your resources, and you do the best you can.”

She left Oregon briefly to pursue a fellowship in family planning and reproductive health at the University of Rochester and a Master’s in Public Health at Johns Hopkins University, but returned to serve on the OHSU faculty.

Today, Gipson is stationed as a Peace Corps Medical Officer in Malawi. She oversees care for all Peace Corps volunteers there, mitigating tropical disease risk, developing strategies for providing care in the context of local health services, and planning extrication procedures for emergency situations. Although she works with a relatively healthy population, Gipson sees a lot of environmental and mental health cases.

“Volunteers often have issues integrating into a new culture while living in villages with no electricity or running water, and trying to learn a new language and job,” she says. To reach distant patients, she practices telemedicine via What’s App and text messaging.

Despite the challenges of resource-constrained conditions, Gipson remains motivated by the impact she has. “You can pay me all the money in the world, but the ‘thank you’ for saving someone’s life is the reward in doing this work.”

Over several years, Speicher sponsored infrastructure improvements that brought clean drinking water, electricity, and a new bridge to his friend’s Honduran village.

A Life-Saving Friendship

Twenty years ago, San Antonio ophthalmologist Peter Spiecher (M’82) joined a group of surgeons for an annual medical mission trip in Honduras. While there, he met Isaias Arita-Bureso, a local tour guide, and they began a friendship that would change both lives forever.

Speicher sponsored the young man to study in the United States in 2002. But the summer after he arrived, Arita-Bureso began to lose his appetite and he felt run down. Tests revealed he was in end-stage kidney failure, requiring long-term dialysis.

With just a few dialysis machines in the whole of Honduras, it was critical that Arita-Bureso remain in the U.S. for his care. To maintain his student visa status, he also needed to stay in school. They were soon informed that his insurance only covered any disease for one year, so that in a few months the dialysis treatment would no longer be paid—a cost of $1,200- $1,800 per week. A new kidney would be the best option, and miraculously, Speicher turned out to be a match for his friend.

Arita-Bureso had successful transplant surgery just days before the expiration of his insurance. He completed high school and enrolled in college in Houston, but returned to Honduras to visit family. Upon reentry to the U.S., he was told that his student visa needed renewal—an involved process that would take some time, but Arita-Bureso had only a month of extra medication with him.

“My congressman helped get him a rush visa interview,” recalls Speicher. “But when they asked Isaias what his plans were after college, he said he wasn’t sure, since his anti-rejection medicine was not available in Honduras. They then denied his student visa.”

Speicher flew to Honduras with a three-month supply of medication, and went with Arita-Bureso to his village for the first time. After a three-hour taxi ride to the base of a mountain, they waded through several rivers and climbed up mud roads. When they finally arrived, Speicher was surprised by the living conditions: “They had adobe houses, no electricity, no running water except for a dirty creek. I knew Isaias would not survive for long there with a kidney transplant and his immunosuppression.”

Every several months Speicher went to Honduras to deliver the medication. He also sponsored the building of a 50,000 gallon water tank to provide a clean drinking water and a spigot to each home plus three electricity projects completed entirely with local labor. Later, he funded a bridge for one of the river crossings.

“Going on a mission trip and doing surgery makes you feel good,” says Speicher, “but a lot of the work that needs to be done is building infrastructure. On medical missions with the Army Reserves, we’d pass out antibiotics, creams for skin rashes, deworming medicine. But if people keep drinking dirty water, they will get worms again the next month. In many cases, it would be better to send the Army Corps of Engineers down there to dig a well or put in electricity.”

Over the past decade, Arita-Bureso has continued to face health challenges due to shifting visa approval policies. When he reapplied in April 2018, his visa was denied, says Speicher, out of fear that he wouldn’t return to Honduras. Even with Speicher’s exceptional personal and professional support— immigration navigation, financial help for education and infrastructure, and even a kidney—crossing borders for better health continues to be a struggle.

During McCarty’s three years in Tanzania, the obstetrician and gynecologist learned to innovate in resource-poor settings.

The Art of Medicine

Before she had even decided on her specialty, obstetrician and gynecologist Siobhan McCarty (NHS’07, M’11) knew she wanted to work with underserved populations. She grew up near Princeton, New Jersey, and attended an all-girls Catholic school that emphasized community service. Doing advocacy work in Washington, D.C., during her time at the School of Nursing & Health Studies and immersing herself in the School of Medicine’s commitment to service and cura personalis only solidified her values.

In the summer following her first year of medical school, McCarty got her first taste of global medicine while shadowing a retired, U.S.-trained family medicine doctor in Johannesburg, South Africa. After that experience, she decided to work abroad.

“I knew the direction I wanted to go, so whenever I went for trainings I looked for ways to help underserved communities,” says McCarty. “Having OB/GYN skills allows me to be helpful in many different scenarios.”

After residency, she went to Tanzania through the Global Health Service Partnership, a program offered by Seed Global Health, the U.S. Peace Corps, and the President’s Emergency Plan for AIDS Relief (PEPFAR). Launched in 2013, the program builds institutional capacity in global health by placing nurses and physicians in faculty positions at medical and nursing universities, in collaboration with the ministries of health, to work, teach, and train alongside local health care professionals in five African countries.

Sustainability was a key factor in McCarty’s decision to join the program. “I knew that if I wanted my interventions to work, I had to be with a program that empowered local staff and students.”

In her first year McCarty was the only OB/GYN specialist in rural Sengerema, Tanzania. Her labor and delivery unit saw over 10,000 deliveries annually, and she quickly learned to be innovative in a resource-poor environment. In Sengerema, patients purchased everything from surgical gloves to IV bags out of pocket and brought them to McCarty. Small, private pharmacies nearby supplemented her work; only a few supplies and essential medications were available at her district hospital’s pharmacy.

Practicing in this environment forced her to confront difficult questions: “What do you do in these situations when you’re faced with a patient and a diagnosis that you know how to treat, but you don’t have the medication or maybe even the resources to treat it? How do you balance the art of medicine with the science of medicine?”

In her second year, McCarty moved to the city of Mwanza to work in an academic capacity at Bugando Medical Center, a referral hospital for the entire Lake Victoria region in Tanzania, and her team handled large caseloads of gynecological and fistula surgeries. Bugando had a 900-bed capacity, but she still operated with resource constraints.

“Because I was still in the public sector, not much was different,” says McCarty. “There were more resources in terms of lab tests, diagnostics, and imaging than we had in Sengerema, but we were still using 1990s cooler packs to keep oxytocin and other medications cool.”

In her last year with the program, she moved to Hubert Kairuki Memorial University Hospital in Dar es Salaam, Tanzania’s largest city of approximately 5 million. Although they had over 1,000 Tanzanian medical students, McCarty’s OB/GYN department consisted of only three part-time and three full-time faculty, including herself and the dean of the medical school.

“That meant large pre-clinical class sizes of 200 and a serious shortage of clinical supervision,” she notes.

Despite these challenges and a large caseload of rare procedures and complications like cesarean hysterectomies, McCarty affirms that teaching was one of the most rewarding aspects of her time in Tanzania. “It’s incredibly motivating to be involved with students who are so inquisitive and eager to learn.”

Epstein founded the conflict-zone medical relief and training group in his first year of medical school at Georgetown.

Cura Personalis in Conflict Zones

Flying from Miami to Boston to begin his freshman year of high school, Aaron Epstein (MA’12, M’18) was on a plane headed towards New York City as the events of September 11, 2001, unfolded. This led him to pursue national security, studying international policy and economics in college, and working in the defense industry for a few years before completing Georgetown’s security studies master’s program. But he wanted to be more than “just a small cog in the machine.”

Working in Lebanon, he saw victims of bombings and shootings. “You would put a tourniquet on someone and that would be a direct, tangible way of helping people. A simple medical intervention seemed more effective at changing hearts and minds than policy work.” So he completed his prerequisites and applied to the School of Medicine.

In his first year of medical school, Epstein founded the Global Surgical and Medical Support Group (GSMSG) to provide high-quality medical personnel for humanitarian relief near front-line conflict areas. GSMSG teams offer the full spectrum of care, says Epstein, plus training for local medical professionals to respond to the brain drain often seen in conflict zones. Epstein cites the Jesuit value of cura personalis as a guiding principle for the group.

“Georgetown emphasizes that you need to consider the whole patient and their environment,” he says. “So we think about social and cultural factors.” For example, part of the group’s work involves training local women in health care to increase women’s access to care, particularly in areas where cultural norms limit contact between men and women.

GSMSG, which is almost entirely self-funded, has conducted 11 major trips and trained 900 health care providers, including 750 EMT-level medics and 150 physicians and surgeons. The group includes 800 military veterans—former army physician assistants, nurses, or other medical personnel. Although some humanitarian organizations have restrictions around volunteers who are former military members, GSMSG takes the opposite approach.

“If you’re going to provide care in a war zone, it makes sense to bring the person who was deployed there for eight years and is comfortable with that operating environment,” Epstein says. And the group is efficient: “For every $50,000 we get in donations, we can do $3 million worth of surgery and training,”

Epstein notes, citing minimal overhead. “Our people are volunteering, they have full-time jobs, and every dime goes directly towards the medical effort. Our ultimate aim is self-programmed obsolescence through training locals to become self-sufficient.” Epstein continues to run GSMSG during his surgery residency at the University of Buffalo. The group’s next trip will be to Iraqi Kurdistan, planned for November 2018, and will focus on building up local nurses and staff whose critical work is undervalued, says Epstein.

“In the Middle East, many view doctors and surgeons with prestige but equate nursing and therapy with janitorial work,” he says. “We’ve seen the lack of nurses and staff be a huge driver of mortality and morbidity in conflict regions. All the surgery in the world does no good without post-operative or nursing care. The doctors may be good navigators, but if you don’t have people in the engine room, the ship isn’t moving.”

Family medicine physician Aleinikoff (left) facilitates a pregnancy care group for newly-arrived Afghan refugees.

Welcoming the Stranger

For newly arrived refugees in America, taking the entire family to the doctor’s office can be an overwhelming experience. Seattle-based family medicine physician Shoshana Aleinikoff (M’12) is working to make it easier.

During her residency in family medicine at Seattle Swedish Cherry Hill Medical Center, Aleinikoff crafted an elective to work on resettlement cases in the Seattle area. Afterwards, she joined the family medicine team at a community health center, HealthPoint Midway, to work with resettled immigrants. Today, her panel consists mostly of newly arrived refugees and asylum seekers, and most are uninsured or rely on Medicaid.

As a medical student, Aleinikoff pursued her interest in global health by working on asylum evaluations and affidavits for refugees through Physicians for Human Rights, with Family Medicine Professor Ranit Mishori (M’02). She also completed an elective in Nyarugusu, a refugee camp on the Tanzanian border of the Democratic Republic of the Congo. Meanwhile, her work at Georgetown’s student-run HOYA Clinic allowed her to explore her interest in the longitudinal effects of poverty on health outcomes.

“HOYA Clinic was one of the most valuable experiences of medical school for me,” Aleinikoff says. “Early clinical involvement— and thinking about the relationships between poverty and health—helped me pursue a residency focused on underserved medicine and helped me develop the tools needed for my current practice.”

Originally, she saw people from a wide variety of countries including the Congo, Somalia, Iraq, Afghanistan, Burma, Sudan, and Iran. But recent policy changes on immigration have changed that patient mix, with fewer refugees being admitted and resettled. Today, most of her incoming patients are Afghan immigrants.

Aleinikoff strives to build rapport with new families before delving deeper into their medical histories on subsequent visits. “I try to establish myself as the primary care physician for the entire family,” she says. “My only goal for that first visit is to build a welcoming environment that fights the sentiment that refugees and immigrants are not welcomed. If I can build a relationship and get the family to come back, then I think of it as a win. Over time, we can address all of their medical needs.” Otherwise, for many immigrants, the health system may only be accessed in times of acute emergency.

With that challenge in mind, Aleinikoff is experimenting with models of primary care for newly arrived refugee families. She hopes that her work adds to growing literature and resources around this type of care. She recently presented to a packed audience at the annual North American Refugee Health Conference and co-published an article with Mishori in American Family Physician.

In her refugee care, Aleinikoff sees entire families together, and can capitalize on HealthPoint’s integrated health services: lab work, specialists, dental care, behavioral health support, and nutrition. She partners with resettlement organizations to maximize patient access to care.

Often, Aleinikoff must temper recommendations to fit her patients’ circumstances. “Does this make sense culturally, and is it something that can be easily implemented?” she asks. “If a child is anemic, and you make a recommendation to eat iron rich foods, does the family have access to those foods? Is your recommendation consistent with something they would eat based on where they came from or based on their religious allowances?”

As the global refugee crisis presses against both the American borders and the American conscience, opportunities to help present themselves in local communities across the country. Global health practitioners are welcoming the stranger and caring for the most vulnerable right here at home, and Aleinikoff believes serving this population’s need for accessible, holistic care can be uniquely met by family physicians.