Careers in Medicine: Clinical Service in Developing Countries
A NextGen Pathways in Medicine Article
From an Interview with Louise Ivers, M.D., Partners in Health
Louise Ivers, M.D. (second from right) in Haiti with Partners in Health
Though one of the most personally challenging paths a physician can pursue, clinical service and policy development in developing countries can also be one of the most satisfying. According to Dr. Louise Ivers, a member of the Boston-based organization Partners in Health (PIH), "It is incredibly rewarding to see the dramatic influence you can have in the developing country. People get sick with the most basic diseases, things they would otherwise die from pretty easily [without medical care]. We are working with patients who are very sick, and with standard care, they are now walking and talking. It is rewarding to see what your impact can be—it is magnified from [patient care in] the U.S."
Characteristic of many other career settings and roles available to physicians, work in developing countries can be pursued through a variety of routes. Dr. Ivers first became interested during lectures and classes in medical school that discussed "diseases of poverty" in tropical regions: she was shocked to discover that people were still dying of measles, diarrhea, and other diseases that are managed with ease in developed countries. She had the opportunity to do an international elective during her fifth year when she worked in a rural health center in Ghana, her first ground exposure to international medicine. Despite constraints in scheduling, she also pursued international medical opportunities during residency whenever possible. She later joined PIH, an organization that is unique in its approach of combining clinical care of patients overseas combined with ties to the academic medical community in Boston. While Dr. Ivers spends half of her time in one of PIH's clinics in Haiti and half in Boston at the Brigham and Women's hospital, commitment to international medicine varies substantially between physicians: some participate in medical missions over a couple of weeks each year, some participate in policy research or fundraising and are only overseas for short amounts of time, and some spend most or all of their time overseas.
At the heart of medicine in developing countries are the fundamental differences in infrastructure and resource availability that require physicians to adapt to these unfamiliar situations. Many aspects of medicine that are taken for granted in developed countries (i.e. running water, sturdy and climate-controlled buildings, water to wash hands between patients, and readily available medications and tests) are often unavailable or scarce in these clinics. "As a physician, you need to draw on your clinical experience and expertise—the clinical acumen. What is the best thing to do? You must choose from a limited array of tests and deal with the consequences of managing patients [with few resources available]." Because many causes of disease among poor people are related to their socioeconomic situation, some organizations such as PIH try to address the socioeconomic circumstances as much as possible. "You must visit patients in homes and try to treat the entire situation. You can't treat TB (tuberculosis) with medications alone when [the patient is] living in a one-room house with ten other people."
Besides the need to adapt to the limited infrastructure and resources, physicians also need to adapt to the local cultural setting. In some cases, the local people have never experienced medical care before. Physicians must be adaptable and practice with cultural competency in order to provide the best care possible. However, in most circumstances, there is much common ground on which to found a clinical service: "They know they live in terrible housing and have poor water sources. When they come to the clinic to be seen, they've already overcome many of the barriers to health care. They want to see what physicians can offer." In many cases, these clinics and physicians engage in other efforts in the community besides clinical service to build a reputation and a lasting medical system, from community education in churches and schools to volunteer work in building houses and cleaning up water sources.
Dr. Ivers notes that despite the rewards, clinical service in developing countries is also very challenging. "It's frustrating to see how widespread and fundamental disparities are, especially when going from the poorest of the poor in the countryside to the wealthiest country in the world." Some of the hardest trials for physicians are when they have to deal with malnutrition, children dying, and people arriving at the clinic too late: all of which could be prevented to some degree if the socioeconomic status of the people and their home regions were improved. In order to persevere against difficult odds, Dr. Ivers asserts that one must have the care of the underprivileged and the improvement of care for the poor as personal motivations. "You can't do this work for your career advancement, or for the justification of some principle. Patients must be the primary interest—the primary goal." Physicians aiming to do clinical service overseas have to be very flexible and adaptable: "You might be stuck on the road overnight, there might be a tarantula in the room, the food might be inedible, patients might be dying despite your efforts, and the medicine might run out. Also, you must be careful in how you approach medicine—you can't be the 'big foreigner' coming in thinking that you can solve all of the problems." Dr. Ivers strongly recommends doing international electives during medical school and taking any opportunity available to work in the field. "It doesn't have to be with a famous researcher or at the WHO—just go work in a clinic, even if you don't have clinical skills yet (i.e. take blood pressure, fix water sources). Just see what it's like, and see if it's right for you and if you're right for it." 
Lester Leung is the founder of the Next Generation and a member of the Harvard College Class of 2006.
Louise Ivers, M.D. is an Associate Physician at the Division of Social Medicine & Health Inequalities and an Instructor in Medicine at Harvard Medical School. Dr. Ivers spends half her time at Partners In Health sites in Haiti, treating HIV/AIDS and TB, as well as providing care in the general medicine, pediatrics and malnutrition clinics there.