Year: 1994
Setting: Port Moresby General Hospital, Papua New Guinea
Position: Chief medical officer for Chevron Oil Co.

The wife of an expatriate employee has injured her arm and, suspecting that she has fractured her left elbow, I accompany her to the Port Moresby hospital for further evaluation. The building looks good and new. In fact, it was recently donated to Papua New Guinea by the Japanese government. While waiting for the X-rays, I stroll down the corridor peeking through various doors. I discover that the glass in many of the building’s windows is broken. I wonder if an earthquake may have been responsible, and inquire further with the janitor. He tells me the windows have been broken for months. A temporary road was built after the hospital completion and when heavy trucks pass by they spray gravel that hits the windows. The glass hasn’t been replaced because the panes are unique and must come from Japan.

Open windows create multiple hazards in hospitals: Risk of falls and cuts, noise, wind, dust, rain and germs. As I think about the bureaucracy entailed in trying to get Japanese windows shipped to Papua New Guinea, I am reminded of a scene a few years earlier when I visited a hospital in Saudi Arabia. A room was filled with unused, sophisticated equipment (such as a CT scanner), and I was told that insufficiently trained technicians had broken the machines but that spare parts from overseas were not readily available. Moreover, the hospital needed to hire consultants from the United States and Germany to fix the equipment.

These examples, and others, taught me that a lot of the money intended to improve the health sector of developing countries ends up being wasted. What has been, and is still, lacking in global health projects are consensual, societal visions that take into account the infrastructure differences of developed and developing countries. Without this kind of forethought, the money and effort spent with the best of intentions (such as building the hospital in PNG) is rendered nearly worthless because training, repairs and replacement parts aren’t available.

Lesson for the doctor: Foreign assistance can be a blessing to developing countries, but only if the receiving nations can effectively take advantage of the aid over the long term.

Yann Meunier, MD, is the health promotion manager for the Stanford Prevention Research Center. He formerly practiced medicine in developed and developing countries throughout Europe, Africa and Asia. Each week, he will share some of his experiences with patients in remote corners of the world.

Year: 1986
Place: Lome, Togo
Position: Consultant in tropical diseases, Pitie-Salpetriere Hospital in Paris

I have been sent to West Africa by a French multinational drug company to share information from recent clinical trials about a new anti-emetic compound. It is late November and I am in Togo, midway through a tour that includes Senegal, Ivory Coast, Cameroon, Gabon and Congo. The day I land in Lome, I take a much-needed break by hitting the tennis courts with a local physician. We have to settle an old score. He beat me the last time I was in town and it cannot be my last showing. Next to us, two French architects are intensely competing as well. They reached the Togolese capital that same morning for an international congress and are enjoying the summer-like weather at a time when it is freezing in France.

Suddenly, a shower breaks out, as it is customary in the evenings at this time of the year close to the equator. The games stop and everyone runs for cover. After half an hour or so, the clouds move on and crews dry the courts with sponge rollers. My partner and I wait for the surface to be fully playable, but the architects resume their battle. We see one of them running toward the back fence to retrieve a lob when he slides on a wet patch. We hear a snap that sounds like a gunshot. The player falls on the ground like a rabbit hit in full flight by a bullet. He lies there in acute pain. I rush toward him and, upon physical exam, the diagnosis is obvious: Achilles tendon rupture. He is transported to the hospital and flown back to Paris on the first plane available. He has not even spent one night in Africa!

Lesson for the doctor: People can often injure themselves when their competitive juices are flowing and they don’t pay full attention to their new surroundings.

Yann Meunier, MD, is the health promotion manager for the Stanford Prevention Research Center. He formerly practiced medicine in developed and developing countries throughout Europe, Africa and Asia. Each week, he will share some of his experiences with patients in remote corners of the world.

Year: 1987
Setting: Pitie-Salpetriere Hospital in Paris, France
Position: Specialist in tropical diseases

I am a consultant in tropical diseases at the Pitie-Salpetriere Hospital in Paris in professor Marc Gentilini’s department, which has been receiving HIV/AIDS patients from all parts of the world since the onset of the pandemic. Indeed, in the early days most patients came from Haiti and Africa and were seen primarily in tropical disease departments because of their geographical origin. Now famous international stars, such as Rock Hudson and Rudolph Nureyev, seek treatment on our premises and at the Pasteur Institute, which works closely with the hospital. In 1982, one of the patients of Dr. Willy Rozenbaum had a lymph node biopsied and sent to the Pasteur Institute where professor Luc Montagnier and his team identified the virus causing AIDS, which ultimately came to be known as the human immunodeficiency virus. In 2008, he and Francoise Barre-Sinoussi were awarded the Nobel Prize in Medicine for this breakthrough achievement.

One of my patients is a bisexual fashion designer in his mid-30s. He tells me about his past pleasures, attending colorful and extravagant parties on yachts belonging to billionaires in the Greek islands. He is happy to share the best moments of his life with me, and enjoys reminiscing. As he recounts with great details these experiences, I sometimes contrast the excitement in his voice with the poorness of his diagnosis, and I face my own conflicting feelings of joy and sadness on his behalf. Nevertheless, I try to live in the moment with him and I pay close attention to the descriptions that he provides. His current girlfriend sometimes comes with him and also tells me how she is doing. Over time, we witness the progressive physical and psychological downward spiral that leads her boyfriend to his death.

In the aftermath of the burial, she is despondent and keeps in touch with me at the hospital. One day she asks for my personal phone number, which I give to her. In the ensuing weeks her morale goes further down and she frequently calls me at night because she cannot sleep. This taxing relationship continues until she finally heeds my advice and begins seeing a psychiatrist when she starts to have suicidal thoughts. He treats her successfully. Though I am pleased with her outcome, I wonder whether I should have given her my home phone number in the first place.

Lesson for the doctor: Maintaining a private space can be difficult when patients share trying times with you. Hard choices must be made, but the patient’s best interests should always prevail.

Yann Meunier, MD, is the health promotion manager for the Stanford Prevention Research Center. He formerly practiced medicine in developed and developing countries throughout Europe, Africa and Asia. Each week, he will share some of his experiences with patients in remote corners of the world.

Year: 1988
Setting: Electricite de France clinic at Daya Bay, China
Position: Resident physician

A Japanese encephalitis epidemic has struck southern China and I am in its midst at Daya Bay where Electricite de France is building a nuclear plant for the Chinese government. As the resident physician for the company, I see the local employees and their families. They all get immunized against the disease with the inactivated virus Biken vaccine, which comes from Japan and is expensive. By contrast, the Chinese government has not yet started an immunization campaign. However, I know from employees living in the area that people are dying from the disease in local health facilities. The extent of the epidemic in terms of morbidity and mortality remains unknown. The regime does not communicate statistics to health-care providers, much less to the domestic media. The international community also is left in the dark. This concerns me a great deal, particularly because one of the camp nurses is from Hong Kong and her family is worried about a possible extension of the epidemic into the British territory.

There are political, social and psychological tensions at various levels: between expatriate management and local workers, who would like their friends not working for EDF to be immunized; between EDF executives and local Chinese authorities about the lack of communication; and between people working on-site and outsiders. Providing medical care in this environment has been an eye-opener.

Despite official recommendations discouraging off-site travel, I manage to visit villages in the plant vicinity with a few Chinese friends. We witness first-hand the level of poverty in the countryside. Conditions are typical of developing countries: poor hygiene, children walking barefoot among farm animal excrement, ragged clothes, etc. I do not observe any sign of malnutrition, but I wonder how the children fare in the winter when the temperature drops below freezing level. With the help of my co-travelers, I inquire about the vaccination status of these children. No parents recall any recent shots. I compare this with the statistics the Chinese government has provided to the World Health Organization indicating that most of its citizens have been immunized. Something is not right!

After leaving the camp a few weeks later, I hear that the Chinese authorities have started a vaccination drive, which helps bring an end to the encephalitis epidemic.

Lesson for the doctor: Frustration and despair can reach an apex when a government does not provide the necessary health care to its population in times of crisis. Getting a true assessment of the situation may involve doing your own investigation among the people who live there.

Yann Meunier, MD, is the health promotion manager for the Stanford Prevention Research Center. He formerly practiced medicine in developed and developing countries throughout Europe, Africa and Asia. Each week, he will share some of his experiences with patients in remote corners of the world.

Year: 2002
Setting: Gleneagles Hospital, Singapore
Position: Private general practitioner

I am the first and only non-Anglo-Saxon, foreign, private general practitioner in the city-state and the physician of reference for 14 embassies, consulates and a high commission from Europe, Asia, South America and Africa. One afternoon, a nurse comes into my consulting room saying that an ambassador from a European country has had an accident and that he insists on being seen immediately.

I greet him and learn that he has slipped on a wet marble floor and badly twisted his right ankle. I get an X-ray to make sure there is no fracture. Then, because of the severity of the sprain and the intensity of the pain, I recommend a walking cast. He retorts that he will make an appointment with an orthopedic surgeon for this procedure, against my advice. I tried to argue that the longer he waits for the cast to be placed, the longer the recovery time will be, but the patient insists on his own course of action. We bid each other farewell by sharing the latest ex-pat joke. I do not see him in the subsequent weeks and assume, by default, that all is well.

However, about two months later I am attending a function with representatives from the diplomatic corps and I spot him in the crowd, hobbling about with a cane. As I approach, his group, his wife comes to me and makes the following request: “Please don’t be too hard on him. He did not follow your recommendations because he does not want to be seen in a cast.” I have witnessed this kind of behavior before. Some people, when they have reached a prominent social status, refuse to adopt behaviors they think will damage their image. I cannot help but think that, had he allowed me to put his ankle in a cast, he would be happily walking by now, even running if he wanted to. I call the waiter for a cocktail and forget about it by mingling with the crowd.

Lesson for the doctor: You cannot treat a patient against his/her will.

Yann Meunier, MD, is the health promotion manager for the Stanford Prevention Research Center. He formerly practiced medicine in developed and developing countries throughout Europe, Africa and Asia. Each week, he will share some of his experiences with patients in remote corners of the world.

Year: 1979
Setting: George Washington University Hospital
Position: Intern

In sharing my global health background, I would be remiss if I did not talk about some of my American experience. After all, Washington, D.C., is remote from Palo Alto and Paris! I am in my late 20s and an intern at George Washington University as an exchange student from Brazil. My mentor, Stanley Talpers, MD, has organized a rotating program for the interns, and this month I am working in the ICU.

One of my patients is Mr. C. The first time I see him is the day after his surgery. He is obese, diabetic and has just undergone amputation of both legs and both arms. I cannot communicate with him because he is intubated. The medical challenges surrounding his care are myriad: controlling his diabetes, his hypertension, his electrolytes, avoiding bed sores, etc. I have read his chart but, as I start my round this morning, I do not know what to expect. The minute I walk into the room he stares at me with piercing eyes. His look reflects sheer horror. His eyes seem to be asking: What happened to me? How could they do that? How am I going to live like this? He is also very frustrated and angry because he can neither verbalize his feelings nor point at anything.

I am taken aback and absolutely do not know what to do. This is no longer a medical issue. It is a human tragedy. I walk out of the room and try to figure out what to do next. Should I ask for help? If not, what should I say to my patient? I decide to go back into the room, sit next to Mr. C. and talk to him. I look into his eyes and try to explain his medical condition and why the surgeons had to remove his four limbs, which had gangrene. It was to save his life. I feel better for a while as I delve into the different sides of the problems, but suddenly he starts to cry and it is like I have fallen into an emotional abyss. Witnessing this 350-pound man break down like a baby is very hard to take. How can I console him? I decide to I call for assistance, and a nurse is paged. She takes over and I move on to my next patient. The following days, however, I am much stressed each time I need to attend to Mr. C. and my anxiety heightens when his condition deteriorates. At the site of his IV, he develops an infection that is resistant to multiple antibiotics, and he dies in a few days. After his death, his terrorized expression at my first visit stays with me for months. For the first time, I am confronted with the limits of my profession and it is a sobering experience.

Lesson for the doctor: Sometimes, no matter how well-prepared you are, you will face circumstances that you are not ready for. But you should always treat your patient with compassion.

Yann Meunier, MD, is the health promotion manager for the Stanford Prevention Research Center. He formerly practiced medicine in developed and developing countries throughout Europe, Africa and Asia. Each week, he will share some of his experiences with patients in remote corners of the world.

Year: 1989
Setting: We, island of Lifou, New Caledonia
Position: Private general practitioner

An epidemic of hemorrhagic dengue fever has struck the New Caledonia archipelago. People are dying at the Gaston Bourret Hospital in Noumea from the bleeding complications of the disease. Drastic measures are taking place to control the epidemiological situation. At the collective level, swamps are being dried up by public works companies; at the individual level, small reservoirs of stagnant water (old tires, saucers, etc.) are eliminated by the islanders to get rid of the mosquito larvae and break the vector reproduction cycle.

As far as dealing with adult mosquitoes, one morning I am confronted with the effects of an action plan designed by health authorities. It is a rather slow day at the office, but there are many people gathered next door for a children party. We hear the rumbling of a propeller plane fast approaching the villa where I work and live. The vehicle is clearly off-path to land at the airport and I, with all the people around me, wonder what is happening. Indeed, nobody has ever seen any plane flying over this part of the island. As soon as we spot it, we can see the smoke-like insecticide pouring down from its belly. In a few minutes, this unannounced, large-scale public health measure is causing physical distress. Some of the islanders have burning red eyes, some are crying, others are sneezing and/or coughing and a few can hardly breeze because they are having an asthma attack. In a snap, my ”slow” day has become quasi-frantic. All of the residents complain about the lack of warning for this rather dramatic spraying action.

Looking at the positive side, I am thankful to the civil servants on the main island. Their planning failure has, unknowingly to them, filled my waiting room on a sluggish day! This later becomes a favorite joke in meeting places: The public sector working for the private sector. Everything is possible under the sun!

Lesson for the doctor: In public-health crises, information is the cornerstone of any successful, large-scale initiative.

Yann Meunier, MD, is the health promotion manager for the Stanford Prevention Research Center. He formerly practiced medicine in developed and developing countries throughout Europe, Africa and Asia. Each week, he will share some of his experiences with patients in remote corners of the world.

Year: 1986
Setting: Pierre and Marie Curie University, Paris, France
Position: Assistant professor in tropical diseases

It is my sixth year of teaching tropical diseases to post-grads at Pierre and Marie Curie University in Paris. After lectures, students often stick around to chat with me. Over the weeks I have gotten to know them better. Some are older than I am. One is a medical doctor from Cameroon who just received her specialty degree in ophthalmology in France. I ask about her career plan. She says she was sent by her government, from which she received a grant, and was poised to be the first eye doctor in her country. Only one for more than 10 million people! Unfortunately, she has decided that she will not return to her native country and will work in France instead, purely for professional reasons. For example, she has learned that for some diseases, the treatment of choice is laser therapy. Currently, there is no laser device in Cameroon and she does not have the financial resources to buy one. Her government has told her that it cannot make a commitment for such an investment because, after the financial aid she was given, it would look like she is receiving preferential treatment.

I inquire among other students. The majority plan to remain in France, and their motivations vary. One works at a hospital and is involved in an exciting study that will take at least five years to be completed. He will then follow a research track. Another cannot share his political opinions publicly in his country or he would go to jail. Another earns much more in France and has to support his extended family. Another has met a French student and they want to marry and raise kids in Bordeaux. Another has allergies that have completely disappeared in the temperate and dry climate of southeastern France. Another says the crime rate is high in her country and she fears for her life if she shows any signs of wealth.

In my view, it is a tragedy that the financial investments of France and the students’ home countries will not be put to best use, and that the students will not provide their medical services where they are needed the most. Twenty-four years later, I look at the situation of students from developing countries who are being trained in France and the United States. Sadly, not much has changed. The brain drain continues unabated. Although much has been written and promised to address the issue, a great deal more remains to be done.

Lesson for the doctor: Remember the words of John F. Kennedy: “Ask not what your country can do for you — ask what you can do for your country.”

Yann Meunier, MD, is the health promotion manager for the Stanford Prevention Research Center. He formerly practiced medicine in developed and developing countries throughout Europe, Africa and Asia. Each week, he will share some of his experiences with patients in remote corners of the world.

Year: 2001
Setting: Mauvezin, France
Position: Private general practitioner

I have been living in Singapore for six years, but this year I have spent my summer differently. I received a call from a friend looking for substitute doctor in a small town near Toulouse. July is coming to an end and so is my assignment. It has been a demanding and rewarding experience. On the rewarding side, it is the first time that I work in a single-payer health-care system in a rural setting and I learn a few things about its modus operandi. On the demanding side, I have to deal with some unique professional challenges.

My work is organized as follows: In the morning, I see patients in the office. Most of them have made an appointment, but others just pop up any time and I have to squeeze them into my schedule. This is because French law mandates that a doctor cannot refuse to see a patient under any circumstances. It is disruptive, but I get used to it. Three times a week, I spend the afternoons making house calls in the countryside. The itinerary is organized by the secretary and she tries to create a logical flow from one patient to another. At first, I do not know what to expect but patterns begin to emerge. I deal mainly with renewal of prescriptions for chronic diseases such as hypertension, diabetes, arthritis, cardiac diseases, thyroid hormone replacement, etc., and conditions of people who are not totally autonomous for age-related or medical reasons. I am amazed by the ground I cover and the mileage I accumulate over a one-week period.

However, the most difficult part is finding the patients. I am equipped with a mobile phone but the landscape is hilly and, at the bottom of the valleys, communication is often interrupted. It means going to a hilltop before calling when you are lost! And getting lost is not a rare occurrence. There are no names for small roads and there are no house numbers. Consequently, GPS is no help. So, typically the directions I receive on my agenda go like this: “After a haystack bigger than usual (?), you will see a meadow with cows on the right-hand side. Make a left at the next crossing.” Sure enough, the haystack is gone or the cows have been moved to another meadow, or I am on the wrong road altogether. In those cases, I call the secretary who asks me: “What do you see around you?” I have to describe whatever I think would be landmarks in the vicinity. This can be difficult if you are a city person and do not know botany or agriculture very well! In the end, it all makes for a good laugh, but in the moment a feeling of frustration can build up rapidly. All in all, my stay in Mauvezin proves to be an enriching time personally, professionally and financially.

Lesson for the doctor: The practice of medicine comes in different colors and shades. Finding the one you like the most may be a long process.

Yann Meunier, MD, is the health promotion manager for the Stanford Prevention Research Center. He formerly practiced medicine in developed and developing countries throughout Europe, Africa and Asia. Each week, he will share some of his experiences with patients in remote corners of the world.

Year: 1993
Setting: Ambulance in the Southern Highlands province of Papua New Guinea
Position: Chief medical officer for Chevron

I am in an ambulance on my way to pick up a patient who needs to be evacuated for surgery in the general hospital of Port Moresby. As I drive up a hill to the helipad, the nurse sitting next to me learns by radio from the base camp that the chopper carrying the patient is on its way and will meet us in five minutes. We transfer the patient into the ambulance and proceed in haste to the airstrip at Moro. After about 40 minutes on the winding dirt road, I can see the Citation plane on the tarmac waiting for us. We reach the makeshift air-control tower and I run up the stairs and say hello to the controllers, who seem to be in a bad mood. I am glad to see that the pilot is in the room, although he, too, looks angry and starts a tirade. “I have been waiting for you guys for more than 15 minutes. Where have you been?” he says. I know that he is worried about his daily flight schedule. He also asks me, “Do you know the hourly rental rate of this plane?” I cut the discussion short, which is easy to do because everyone is focusing primarily on the task at hand.

As soon as the plane takes off, I start an investigation into the confusion over the timing of the helicopter and plane flights. The patient would have been at the airport sooner if the chopper had flown directly there. I discover that the source of the problem is the absence of a radio link between fixed-wing aircraft and helicopters in Papua New Guinea. Further discussions reveal that about two years earlier the helicopter company was unsuccessful in trying to set up a bilateral working scheme. I restart the process immediately, but this time including the PNG government (with national security and political advisors), helicopter and airline companies, radio technicians and Chevron medical department representatives. A few weeks later, we have worked out an agreement that establishes the first national radio network for emergency medical services in Papua New Guinea. Chevron is allocated three frequencies. The agreement will raise safety levels nationally as well as locally. Moreover, it carries minimal costs because the specialized network does not require the creation of new frequencies and no additional equipment will be needed for its implementation.

Lessons for the doctor: An efficient and reliable communication network is crucial for saving life and limbs, so do not accept the status quo when it falls short of best practices, particularly for emergency situations. Also, including all the partners at the table increases the likelihood of reaching an agreement.

Yann Meunier, MD, is the health promotion manager for the Stanford Prevention Research Center. He formerly practiced medicine in developed and developing countries throughout Europe, Africa and Asia. Each week, he will share some of his experiences with patients in remote corners of the world.