External Affairs

KP Providers Touch Hearts and Souls Around the World
By Ronnie Louis Chriss; Mari Edlin

	Medical Rescue Team following Taiwan earthquake.

Dr James Yu is one of those people who thinks quickly on his feet. As rescue helicopters, unable to land in the darkness, hovered over the devastation wrought by a 7.6 earthquake in Taiwan, the Woodland Hills (CA) Permanente anesthesiologist quickly conferred with his associates to rally everyone with a car to park around the field, their headlights glowing in the pitch dark.

Within hours of the deadly 1999 earthquake, Dr Yu, a native Taiwanese, organized five medical teams, including Permanente coworkers: Dr Chiu I Tan, an emergency services physician; Dr Kuan-Cheng Yeh, a family practitioner; and Dr Chun-Chick Chiu, an emergency services physician in West Los Angeles. In that instant, The Taiwan Earthquake Medical Mission was born. "It was like a war zone, pulling people out of the rubble," he recalls. "The hospital had collapsed and there wasn't enough equipment, so we had to constantly resterilize supplies."

Dr Yu is one of many Permanente physicians who have come to the rescue in remote parts of the world in recent years. Volunteering is not new to Kaiser Permanente (KP) clinicians, but traveling halfway around the world to do it takes a special commitment. It also takes flexibility, family support, empathy, and a love of airplanes and rustic conditions.

An informal survey conducted recently found that hundreds of Permanente physicians have traveled to more than 20 locations around the world to bring medical care and health services to populations in need. It's a virtual Permanente foreign legion.

"KP is fundamentally a community benefit organization structured to deliver high-quality health care," says Jay Crosson, MD, Executive Director, The Permanente Federation. "Permanente physicians believe strongly in benefiting the community and extend that same idea globally."

"As a leader in health care, KP attracts the best physicians--those that are interested in all aspects of medicine, such as education and research, but also in international humanitarian efforts. [The volunteer work being done] is a tribute to our organization and to all of the Permanente physicians," adds Robert Pearl, MD, Executive Director and CEO, The Permanente Medical Group, Inc, who has also worked with volunteer organizations.

This article profiles a representative sample of globetrotting volunteers from different regions and a variety of specialties. They have contributed time, energy, and medical expertise to those in need in countries from Romania to Kyrgyzstan to the highland villages of Guatemala.

Southern California Permanente Medical Group

James Yu, MD, Anesthesiology, Woodland Hills Medical Center
Dr Yu's lifesaving trip to Taiwan is just one of many overseas humanitarian efforts logged by the anesthesiologist, who started his global missions in 1986, a year before joining the Southern California Medical Group (SCPMG). Since then, under the auspices of Operation Smile (see Sidebar), he has been to Israel, the Gaza Strip, Romania, China, Thailand, Peru, Vietnam, and Brazil, where, in the last two years, he has reached out to children with facial deformities.

During the first week of Dr Yu's two-week missions, the medical team prepares the operating room, screens potential patients, and determines how many surgeries to perform. It's not unusual to hear singing and guitars allaying the patients' fears--often led by Dr Yu's wife, Mary, a social worker and musician.

With everything in place, the operating team--usually a reconstructive surgeon, an anesthesiologist, scrubbing and circulating nurses--arrives supported by speech therapists, oral surgeons, and nonmedical volunteers. Over a five-day period, six surgical teams operate on as many as 200 children. A postmedical team assures there are no complications and then passes the baton to a local medical team.

Training local physicians is a high priority for the team. "We modify what we do at home in one stage and, once we leave, we feel confident putting the children in the hands of a local surgeon and scrubbing nurse," Dr Yu explains. "They participate in the operation and by the third day can operate with our assistance." Dr Yu credits the Woodland Hills Research and Education Department for preparing handouts and slide shows used to train foreign doctors.

Dr Yu feels his experiences are "give and take". "When I return from each mission, I realize how much I have learned--how the local clinicians are able to create an operating room with the most primitive equipment and limited supplies," he says in awe. "Chinese nurses painstakingly soak surgical gloves in antiseptic, sprinkle them with powder, and rinse them out for reuse. It's so touching to see this." Operating arenas run the gamut from a MASH unit-like tent in Africa to primitive regional medical centers with rusty equipment and wobbly operating tables put to right with a brick under one leg.

Although the language barrier is often overcome by local translators or occasionally by American volunteers, such as a group of young, Portuguese-speaking Mormon missionaries who accompanied Dr Yu to Brazil, the cultural mores often present more of a problem--especially in Muslim countries. "You can't touch a female patient unless someone is there to explain what is going on--or a young girl without her parent's permission. It's just not appropriate," he explains.

Dr Yu has seen it all--embarrassed kids draping their faces with towels to hide their defects in public, others ridiculed by their classmates or passed over for adoption. "But they always have a smiling inner soul despite the defect," he says. "What really makes it all worthwhile
is when the kids wake up from the anesthesia and we hand them back to their mothers. The reaction is always tears of appreciation."

Stefanie Feldman, MD, Plastic Surgery, Woodland Hills Medical Center
Over the past 15 years, Stefanie Feldman, MD, a plastic surgeon with the SCPMG, has crisscrossed the globe numerous times, under the auspices of Operation Smile and Interplast, in order to give impoverished children the most precious gift imaginable--a new smile.

In Africa, Peru, the Philippines, Vietnam, China, Russian, Morocco, Thailand, and most recently Nepal, Dr Feldman has used her clinical skills to operate on infants, children and teenagers with cleft lip and palate abnormalities. She has also worked with severe burn victims.

	Dr Stefanie Feldman performs cleft palate surgery on a patient.

"After the first surgery done in one of these developing countries, I knew I'd made a difference and changed a life forever," said Dr Feldman. "It's a spiritual experience that crosses political and social boundaries and gives you a whole new outlook on life. These experiences give me the opportunity to practice basic medicine. It's appealing and refreshing."

Through Interplast in Mountain View, CA, for whom she also volunteers, Dr Feldman helps train physicians. She and a group of 10 to 15 people set up incubator sites where local physicians are taught how to care for their own people. "Our goal is to someday not be needed," says Dr Feldman. "Education of physicians worldwide is important." She adds that while most countries have more primitive hospitals than in the United States, the surgeons she has trained end up with skills similar to their American counterparts and with even greater experiences because of the higher volume of cases in their country.

Dr Feldman was moved on a recent trip to Morocco, where her team operated on a 17-year-old boy who almost didn't reach her in time. He and his father had walked for several days and took two buses to arrive at the hospital just as the screening process was ending. "When you see older children, it's a very emotional experience," she said. "This boy lived in a very remote area; his clothing was primitive, and who knows exactly how far he and his father had traveled. But somehow word reached them that the American doctors who could "fix" him were coming, and they found us. It was a miracle. Now he'll go and lead a more normal life."

Dr Feldman feels her work has been a rewarding experience personally. "I've seen each country and its people as an insider and have had a whole cultural, emotional, and medically fulfilling experience I otherwise would have never had."

Terry Mendelson, MD, Orthopedic Surgeon, Panorama City Medical Center; Robert Zane, MD, General Surgeon, Harbor City Medical Center; and Walfrido (Wally) Castelo, MD, Radiologist, Harbor City Medical Center
One person's medicine is another's poison. That axiom makes it possible for Drs Terry Mendelson, Robert Zane, and Wally Castelo to send medical supplies worth thousands of dollars to Third World countries.

The three physicians collect syringes, latex gloves, surgical gowns, sutures, drapes, and IV materials. Most of what they collect has been opened, so it is no longer sterile but is unused and clean; some has been discontinued or is outdated. These are deemed unsuitable by US hospital and manufacturers' standards.

"In other parts of the world, they will use these items 'as is'; nothing is unclean or unsafe," Dr Mendelson explains. "They will take what they can get. What are bread-and-butter items to us are luxuries to them."

"We think nothing of using gloves once and throwing them away," adds Dr Zane.

Four years ago, Dr Mendelson read about REMEDY, a medical donation project started at Yale University that sends treasured supplies to clinics and small hospitals in Macedonia, Bulgaria, and Albania. The volunteer program piqued his interest, allowing him to devote his time and energy on a flexible schedule without having to travel. "I could still help others while maintaining a balance between my professional life and my family," he says.

Kaiser Permanente Shares Overseas (KPSOS), dedicated to sending supplies to underdeveloped countries, has evolved out of Dr Mendelson's efforts. The supplies are sorely needed in the Third World, where patients bring their own food, bedding, and dressings to the hospital and their families serve as nurses.

Dr Mendelson wasted little time marshalling the efforts of his wife Lindy, his children Lauren and Brian, now 19 and 17, and many of his coworkers, who devote as much as 16 hours a month gathering supplies and storing them in a dedicated room at the medical center. Once word about KPSOS trickled down through the clinic, supplies began miraculously appearing from the operating room, day surgery, ob/gyn, the pain clinic, infusion therapy, and pharmacy as did walkers, wheelchairs, and crutches no longer needed by patients.

The makeshift collection team sorts and labels supplies every six to eight weeks and sends them a few times a year. REMEDY, in conjunction with the Albert Schweitzer Institute for the Humanities in Wallingford, CT, arranges for the shipping, funded by private and corporate donations. Orbis, an international eye relief organization, and Operation Smile (see Sidebar) are also recipients of the Panorama City's efforts.

Dr Mendelson shared his experiences with other Southern California KP physicians and rallied the support of Drs Zane and Castelo in 1998. "You need a physician champion to get this kind of program going," he says.

"Terry got me excited," says Dr Zane. "I always wanted to go overseas and help, and this is the next best thing." He collects about 20 pallets two or three times a year with the help of colleagues.

Dr Castelo readily jumped on board when he realized he could help physicians and patients in his hometown of Cabanatuan in the Philippines. Besides collecting supplies for KPSOS, he sends boxes of goods at his own expense to the governor of the province to ensure the items are directed where needed. Taking his humanitarian efforts one step further, for the past three years, Dr Castelo has joined a four-day medical mission to Ilagan, also in his native country, where he uses his skills as a radiologist, interpreting x-rays. "The situation there is so sad it makes you want to cry," he relates.

For these three doctors and their helpers, volunteering is all in a day's work. Dr Mendelson puts it simply: "When my wife, kids, and I finish a hard day of sorting, we feel great; and when we send the supplies off, we feel like we have accomplished something worthwhile.

Colorado Permanente Medical Group

Ted Palen, MD, Preventive Medicine
When Ted Palen, MD, an internist in the department of preventive medicine, first went to Guatemala last year, he thought he was outside his element--not just because he was in a foreign country but because he knew little about tropical medicine. "I thought I'd be alone out there, but I felt right at home after the first day. There were fewer diagnostic dilemmas than I expected. Problems were similar to here but in a different setting," he says. And quite a different setting it is--the highlands at 9000-foot altitude.

Dr Palen attributes much of his instant comfort level to Hugo Gomez, MD, Area Administrator for Central America for Medical Ambassadors International (MAI). MAI is a missionary group with which Dr Palen's church, Mission Hills in Littleton, CO, has been affiliated for ten years. Living in Quezaltenango, a town in the northwest highlands, Dr Gomez became an integral part of Dr Palen's small medical team, along with a physician's assistant and a registered nurse.

With the word out, hundreds from four villages lined up for hours--long before Dr Palen's arrival--in front of a multipurpose building and patiently awaited treatment for diarrhea, dysentery, eye infections, musculoskeletal aches, and postpartum uterine infections. Over a four-day period, Dr Palen and his team treated 300 villagers, some in the glow of a flashlight when the skittish electricity went out.

Although the Guatemalan government has established prevention programs and clinics, they are usually in large cities--a far trek for residents of isolated highland villages without access to a four-wheel-drive vehicle.

Dr Palen did not arrive empty-handed. Raising $12,000 from friends, he brought packs of medical supplies and medications--Tums, Prilosec, vitamins, pain relievers, antibiotics, and antiparasitic drugs--that were provided by the Medical Assistance Program (MAP), based in Atlanta. And working in the remote highlands of Guatemala did not stop him from bringing along modern medical technology--a handheld computer to generate dosage information for antibiotics for children and to access medical references for treating tropical diseases.

Although superstition and local customs were somewhat bewildering, they did not get in the way of Dr Palen's ministrations. He said that one patient taught him the meaning of loyalty: He treated a recently widowed elderly woman for bursitis, a condition prompted by sleeping on her late husband's side of the bed--a set of boards--in the same position for four months in deference to him.

Neck and back strains were as common as colds--no surprise since women balance heavy loads on their heads, often while transporting babies in a wrapped shawl slung from front to back. "You wonder why they don't use carts or wheelbarrows, but those are only for men. It's a learned behavior," he says.

Dr Palen's mission also challenged his creative instincts. He devised a corn stalk splint for a woman with classic carpal tunnel syndrome, acquired from grinding stones. Wrapping it around her wrist with rags before going to bed greatly relieved her discomfort.

As for the language, it became almost a game of telephone tag--translations going from English to Spanish to Quiche, a native Indian dialect. Nevertheless, important information finally hit its mark.

Dr Palen had thought about volunteering since entering medical school in the late 1980s. "MAI offered the perfect opportunity through a church mission, and I had the capabilities to do it," he says. Although he brought his expertise in primary care to Guatemala, he took home much more. He still holds a picture clearly in his mind--one of a woman with a child on each knee and sitting in the courtyard of her house--what he calls "the classic view of someone devoted to giving care." He will make the trip again this November.

"My son Eric's analogy sums up our experience," Dr Palen says. "Certain times during the year, the tides bring starfish ashore who are floundering on the sands, and a boy throws one back in the ocean to save its life. A bystander asks, 'Why bother?' 'It matters to that one,' the boys responds." Eric, 16, his sister Nicole, 13, and their mother Karen accompanied Dr Palen and helped build a church in one of the highland villages.

"And that's just the point. We look at everyone who is in need and deliver care one patient at a time because it matters to that person," Dr Palen concludes.

The Southeast Permanente Medical Group

Lee Jacobs, MD, Infectious Disease; Associate Medical Director
When Lee Jacobs, MD, first visited Kyrgyzstan, a former member of the Soviet Union located on the western border of China, he wasn't exactly received with open arms. "The Soviets had spent many years convincing its people that Americans were evil and wanted to take over their country. But after they got to know us, it wasn't uncommon to hear, 'You are just like us,'" says Dr Jacobs, an infectious disease specialist and The Southeast Permanente Medical Group (TSPMG) Associate Medical Director.

He got his first taste of global volunteer work when he and his wife, Deb, joined members of their church, Johnson Ferry Baptist Church in Marietta, GA, on a sojourn to the Dominican Republic in 1988. They treated 500 people a day, primarily for malnutrition and ear infections.

Under the auspices of Central Asian Partners (CAP), a group of American medical and business volunteers he organized, Dr Jacobs has made many trips since then to offer medical attention, train local clinicians, and strategize with the government of Kyrgyzstan. His timing could not have been better--he met with the country's president and minister of
health during what would be Kyrgyzstan's formative years, the period following its declaration of independence in 1991.

	Dr Lee Jacobs examines a Kyrgyz child.

Dr Jacobs and his fellow volunteers butted heads with the tradition of institutionalized thinking ingrained by the Communist regime. "The country had no idea how to think and plan," he says. "We were shocked." With perseverance, however, Dr Jacobs was instrumental in shifting the medical school curricula toward family practice training and away from nuclear war medicine--quite a change in mindset.

Government officials were impressed by Dr Jacobs' broad experience with KP and its eight million members, more than double the total population of their country. The fall of the Soviet Union had brought the health care system to its knees.

Although the somewhat reserved, hospitable Kyrgyz people warmed up to the Americans--the first they had ever met--that did not instantly open the door of acceptance for American ways of doing things. The US clinicians had to tread softly when turning certain superstitions on their head for the benefit of patients--myths such as not eating fruit during pregnancy or wrapping oneself in clothing during the hot summer to avoid viruses and colds. "Despite differences, people are people; they just want to be listened to and respected," Dr Jacobs says. "As Americans, we have to make sure that we give them an opportunity to see themselves as smart."

Despite the culture gap, Dr Jacobs organized teams of clinicians in the remote mountain villages of Kyrgyzstan, where most of the population resides, to focus on a few diseases using only a small number of drugs--blood sugar, blood pressure, and prenatal medications.

Prenatal and baby care has become a priority for Dr Jacobs in his training efforts. CAP has developed and piloted an intense, two-day emergency obstetric teaching program, which he feels could have a major impact on the country's infant mortality rate, now one of the highest in Central Asia. There is, however, a challenge in continuing this program because it requires a large number of volunteer obstetric personnel.

In addition, with assistance from the US State Department, he helped equip a maternity hospital built and abandoned by the Japanese. "There is a lot of humanitarian care that is hit-and-miss, but we are trying to create a focused approach," he explains.

Dr Jacobs has made some of his trips into a family affair. His youngest daughter, Julie, has accompanied him to Kyrgyzstan, working closely with KP nurse, Marian Sweeney. His wife, Deb, a pilot working on her commercial license, has met with the minister of aviation to devise a process for air transport of medical equipment and supplies. "She blew his mind because she is a woman, but he still offered her old Russian fighter planes to accomplish her mission," said Dr Jacobs.

And finally, thanks to CAP and a member of the organization who played matchmaker, his eldest daughter Beth married this summer.

Dr Jacobs only wishes that Kyrgyzstan were a bit closer. From Georgia, it's a 22-hour flight and then a long and grueling drive to reach the mountain villages. "That only leaves a small window of opportunity to share our skills, not to mention the fatigue from such a long trip," he says.

To Dr Jacobs, volunteering is a spiritual mission, a sense of calling. "If you have the urge to volunteer, step forward and do it," he says.

Northwest Permanente Medical Group

	Judy Wick teaching the village children how to play "crazy eights."

Judy Wick, RN, Health Research Interventionist; Center For Health Research
The only thing that Judy Wick, RN, Health Behavior Research Interventionist with the Kaiser Center for Health Research, could see as her team's four-wheel-drive vehicle approached the home of the Mixtec people in Oaxaca, Mexico, was what appeared to be small clusters of one-room adobe houses dotting a craggy, almost vertical hillside. For Wick and the other five members of the "Mountain Water Team," it was an awakening, because they only had one more chance to rest before beginning to work. Over the course of the next week, they dug trenches, laid water lines, and worked alongside the native people to help supply the 250 villagers with a fundamental necessity for both physical and mental health--"clean" water.

"Our project mission," explained Wick, "was to figure out a way to get the water flowing out of a small spring at the top of the mountain into a pipeline that pours into a sanitary retaining tank." In its natural state, the water trickles down from house to house picking up water-borne diseases along the way and threatening the health of the men, women, and children that must use the spring for their wash and daily meals.

"The people in the villages are economically very, very poor," says Wick. "They want more for their children, but it's difficult to move in that direction. That's where we can act as catalysts to make change happen. We also let them know that others care about their well-being."

Sponsored by Northwest Medical Teams International, a nonprofit humanitarian group in Portland, OR, Wick and her team began their efforts in 1992 and have traveled to three different regions in Oaxaca to provide similar services.

"We work right alongside the village men, digging trenches and carrying pipe beneath the hot sun," says Wick. "None of us really speak Mixtec or fluent Spanish, so during breaks we had a good time pantomiming conversation back and forth with the villagers to get to know each other."

For Wick, the personal connections are one of the greatest rewards--the cultural barriers are only there if you allow them. She is quick to tell stories of teaching the village school children to play games, grinding corn with the village women for the next day's meal, and rocking a child to sleep by firelight. "It's all so incredibly humbling," says Wick. "During the last trip, we were lucky enough to be able to sleep on the schoolroom floor. Previously, we slept on the dirt floor of a toolshed or outside on the ground."

At the end of the trip, something as simple as water housed in a clean environment and a community water faucet installed at the village school are the rewards for Wick, her team, and the villagers. "Seeing the pride, daily hard work, warmth, and generosity of people who have so very little is so inspiring," she says. "When I look back, I feel that we've made the world better in our own small way."

Wick and her team plan to expand their efforts to Romania next spring.

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