As a fourth-year medical student, Mali Schneiter delivered twins — by herself — in a hospital in Uganda. Classmate Nicole Cook counted potentially dengue-carrying mosquitoes in Peru, conscientious of her exposed body parts. Nisha Fahey, D.O.’16, and an undergraduate classmate expanded a research project in a poverty-struck region of India into a foundation that continues to tackle health care disparities faced by local residents.
Amid those experiences, Schneiter learned from “wicked smart” doctors and nurses who, given their minimal resources, possessed razor-sharp diagnostic skills. Cook learned from naval researchers and physicians she accompanied who provided patient care in remote Peruvian villages and urban Lima. Fahey has engaged in partnerships with other students, researchers and health professionals both in India and the United States.
These are the rewards of stepping out of one’s comfort zone, testing limits and boundaries, taking chances and embracing the unknown. Many DMU students seek and embrace these experiences, which change their lives and those of the people they will encounter going forward.
“It is amazing what you can do when you are truly pushed to the brink of your capabilities, even when you are really, really sweaty,” Schneiter wrote about her time in Uganda and Tanzania. “I learned so much about myself, my stamina and my breaking points along the way, and some of the lessons I learned I hope to carry with me for the rest of my life.”
“Uganda love this”
Before she took that much-anticipated walk across the Commencement stage in May, Mali Schneiter trekked to Africa’s highest point, 19,341 feet, on the world’s highest freestanding mountain, Kilimanjaro; rappelled down the cliffs of Uganda’s Sipi Falls; visited a rhinoceros sanctuary; and survived extreme kayaking down the Nile River.
She also delivered twins by herself, assisted with breech vaginal deliveries and saw a number of rare-in-the-U.S. obstetrical surgeries, including on patients with an emergent ruptured ectopic pregnancy and molar pregnancies. She unexpectedly served as a surgical resident’s first assist on the removal of the necrotic uterus of a septic patient.
“It is amazing what you can do when you are truly pushed to the brink of your capabilities, even when you are really, really, sweaty,” she wrote in her blog about her experience, titled “Uganda love this”.
Schneiter spent six weeks on adventure-filled rotations at Makerere University and Mulago Hospital in Kampala, Uganda, and Gonja Lutheran Hospital, nestled on the side of a mountain in Tanzania. The contrast of caring clinicians with very few resources was striking. In Mulago Hospital’s gynecology department, for example, women bring their own bed sheets; retrieve their own water, food and prescriptions; often crowd in rooms with several other women, sometimes on the floor; and experience births, episiotomies and vaginal laceration repairs without any anesthesia, including local. Patients, whose medical conditions would get them rushed to the operating room in the U.S., may wait for days to be operated upon.
In the gynecology operating room, she observed that “sterile technique is merely a suggestion…people come in and out without masks or proper attire and the surgeon serves as his or her own scrub tech. Needless to say, this part has been the most shocking part of my journey thus far.
“However, the doctors, nurses and staff I have met are wicked smart, they are amazing diagnosticians and have skills that most physicians in developed countries have never even thought of having,” she wrote. “The acuity and the amount of patients these physicians deal with are incredible. Oftentimes when I am on the ward for merely two hours, I feel as if I have worked a 12-hour shift in the States.”
Schneiter experienced many joys, too: babies born to mothers who “always end up saying, ‘Thank you so much, musawo,’” which means “doctor.” She “felt like a guest of honor” at a Tanzanian wedding and bridal “send-off” party. She noted the great hospitality and resourcefulness of people as well as the deep appreciation of hospital staff for the contributed supplies she’d brought. The charge nurse in Mulago Hospital’s emergency department, for example, “literally jumped for joy.”
“She could not believe that she had not one but two new glucometers for her department, and she had suture supplies and TB protective masks for her residents,” Schneiter wrote in a blog post. “Somehow, even after donating all these supplies, I still felt that I was gaining more from the experience than they were.”
That’s in part because she had patient care opportunities that honed her manual diagnostic skills and her confidence. The fetal heart monitoring system at both hospitals, for example, was a wooden “fetoscope,” not the ultrasound version found in U.S. hospitals.
“The first few days I couldn’t hear anything, but after a few dozen tries I finally am able to find most heartbeats with the fetoscope. Just getting used to using this rudimentary tool developed my diagnostic sense and awareness within a few days,” she wrote. Later she noted, “I even was able to tell a mom that she was carrying twins — just by feeling her stomach!”
Schneiter concluded her rotation with a deeper understanding of the challenges many people in the world face in getting even minimal health care as well as a commitment to continued global health service.
“What it comes down to is that we just come from such different worlds, backgrounds, resources and cultures. However, I do not think this is an excuse to allow one world to suffer so incredibly, while another has ample resources that could easily be shared,” she wrote. “The only answer I’ve really been able to come up with is that learning from each other and working with each other can hopefully bring our two worlds closer together.”
Schneiter also gained heartfelt gratitude to her Ugandan and Tanzanian colleagues. “I would not have felt like family had they not extended their open arms to me, and I would not have been able to participate as much as I did had they not given me so much room to grow,” she said. “I am forever indebted to their kindness.”
The best of all worlds in Peru
Nicole Cook, D.O.’15, wanted a global health rotation during which she could use her Spanish language skills and gain clinical and research experience. She also hoped to get insights into the Navy, which she will join after her residency with Mercy St. Vincent Medical Center in Toledo, OH.
She got the best of all worlds, with a bonus trek to the ancient Incan citadel of Machu Picchu, during a seven-week stay in Peru this spring.
“The experience reinforced what I want to do,” she says. “I think I’ll be able to help patients more, teach my peers and have the ability to adapt to other cultures.”
Her rotation came about after Yogesh Shah, M.D., M.P.H.’14, traveled to Peru to meet with Capt. Kyle Petersen, D.O.’94, FACP, FIDSA, and Capt. Adam Armstrong, D.O.’96, FACP, the commanding officer and executive officer, respectively, of the Naval Medical Research Unit No. 6. Headquartered in Lima, NAMRU-6 is the Navy’s busiest overseas research lab.
“When Dr. Shah mentioned he was going, I said, ‘Sign me up,’” recalls Cook, who spent six months in Chile as an undergraduate and a month in Ecuador, working with the nongovernmental organization Child Family Health International, after her first year at DMU.
She spent her first three weeks working in various naval clinics around Lima and villages around Iquitos, in the Peruvian Amazon. She was there during its wet season, when the Amazon River is eight to 10 feet higher than in its dry season, forcing many jungle residents to abandon their homes for government tents elsewhere. She participated in research on dengue and malaria, using “mosquito vacuums” to collect the insects from homes and then dissecting them in a Navy lab.
“One of the studies I was involved with has the end goal of developing a dengue vaccine. There are four types of the disease, which is why that’s a challenge,” she says. “We collected about 200 mosquitoes in a single home. I did get bit a lot. If you live in the jungle, you’re bound to get dengue at least once.”
Cook also accompanied a doctor who provided services to malaria patients in remote areas. Given local beliefs in ancient healing traditions, many patients didn’t seek help “until they were really sick,” she observed.
She experienced more western-style medicine and medical education in a large hospital and clinics of the Universidad Peruana de Ciencias Aplicadas, or UPC, in Lima. She made that connection through Teresa Aoki, M.D., FCCP, associate professor of internal medicine at DMU who grew up in Peru. Cook participated in pediatric care, emergency medicine and some surgeries, including getting to serve as first assist on a neurological surgery, all in Spanish. She describes the hospital as “beautiful — like a college campus,” but notes the staff “did so much with a lot less” than in the U.S.
“You really have to conserve and use your clinical diagnosis skills a lot more,” she adds.
Cook provided public health education, too, to young Peruvians in the military on safe sex behaviors and sexually transmitted diseases. Her face reddens only slightly when she recalls giving a session, in Spanish and using a banana, on how to properly apply a condom. She also seized opportunities to experience Peru’s rich culture and history. She joined a three-day trek from Cusco through Andean villages to the famed ruins of Machu Picchu, which was built at the height of the Inca Empire in the 15th century. As her group climbed to an elevation of 17,000 feet, Cook marveled at the local Quechua people who accompanied them.
“They were hiking with 15-foot steel beams, because they were building a church up there,” she says. “Our tour guide was great, too — you could tell he loved the culture and teaching us about it.”
During her seven weeks in Peru, Cook befriended many people and relished the country’s flavorful cuisine, even sampling “cuy,” prepared guinea pig (“sort of like duck,” she says). She observed wild llamas, alpacas and monkeys as well as children wielding “giant machetes” while working in fields. She toured the tiny oasis where the 1982 Werner Herzog movie “Fitzcarraldo” was filmed and walked through markets where everything from traditional textiles and turtle meat to fresh produce and illicit drugs were available for purchase. She left with a Navy “challenge” coin for work well done — a gift from Capt. Petersen — and even stronger resolve to provide culturally competent, compassionate medical care.
“It really opened my eyes on how hard it is to get health care, especially in the jungle. In some areas, there’s up to 85 percent unemployment,” she says. “It’s an experience I’ll never forget and that will make me a better doctor.”
In pursuit of sustainable change
The state of Gujarat, India, is the birthplace of Mahatma Gandhi, who led an ascetic lifestyle while promoting economic development to lift up the nation’s poor. Both dimensions are strikingly obvious today in the state, where shacks made of cast-off materials sit cheek-to-jowl with new corporate developments.
“Despite the extreme socioeconomic and health inequity, I was struck by the sense of hope and optimism cultivated by India’s complex culture,” says Nisha Fahey, D.O.’16. She first traveled to Gujarat as an undergraduate molecular biology major at Boston University, where lessons from her anthropology classes already had expanded her perspectives.
“I had an appreciation for how a person’s health is affected by many factors that exist outside a doctor’s office, but I realized that a two-week-long visit was not enough to understand the underlying drivers,” she says.
That trip became a stepping-stone for a relationship with Charutar Arogya Mandal, or CAM, a charitable trust that operates a hospital, medical school and nursing school in rural Gujarat. Fahey and her classmate, Apurv Soni — who grew up in the Indian state before moving to the United States in high school — connected with Somashekhar Nimbalkar, M.D., professor of pediatrics and head of central research services at CAM.
“Our partnership with a local institution is critical for ensuring that our research is culturally sensitive,” says Fahey. Together, they developed a questionnaire for females of the region about their health and determinants that shape it. With a small grant from Boston University, she led the implementation of the study in India, including training staff to collect responses from 700 women. The team used the data to explore health care expenditures and factors that influence women’s choices on where to get health care for themselves and their children; results from the study were published in the International Public Health Journal.
This experience only fueled her desire to learn and do more. In 2013, she and Soni, who is pursuing his medical degree and Ph.D. at the University of Massachusetts Medical School (UMMS), cofounded Research and Advocacy for Health in India (RAHI) as a collaboration between CAM and UMMS. Funded by a $50,000 grant from the UMMS Office of Global Health, RAHI – which is the Hindi word for “pathfinder” – is investigating predictors of maternal and child health among CAM patients. Since the initiation of that study, RAHI has expanded to include research projects about ways to improve trauma outcomes and the use of mobile-based technology to screen for undiagnosed atrial fibrillation in rural India. These projects now involve numerous UMMS and CAM students, researchers and health care professionals as well as periodic trips by Fahey and Soni to Gujarat.
“A very significant reason why our work over the past five years has been successful is due to the engagement and partnership of experts in the U.S. and India,” she says. “Their cultural insight, clinical and research knowledge, and mentorship have been invaluable.”
Fahey says her DMU experiences have further reinforced her understanding of social justice and health disparities, including the Kaiser Permanente Diversity Health Series, the DMU Global Health Learning Collaborative, guest speakers and elective courses. “The opportunity to attend and participate in these events and electives greatly enhanced my medical education. They served as a reminder of the bigger picture and shaped the way I hope to practice medicine,” she says. “I feel very fortunate to be in a medical school environment that encourages students to understand social and cultural aspects of health.”
Through RAHI, Fahey’s current focus is a study of 220 women in Gujarat from their first trimester of pregnancy to six months postpartum. The study participants receive free health care while researchers are collecting data on their health status, ultrasound results and other factors that affect pregnancy, including depression, discrimination and domestic violence. She’ll soon dig into analysis of the data while completing her fourth-year rotations. Long-term, she plans to continue her leadership role in RAHI and other efforts to counter health disparities.
“We hope to better understand the barriers faced in the community and build connections to overcome them,” Fahey says. “Local institutions play a central role because they can most effectively champion social change to reduce inequities.”