One Brain at a Time, part 2: Are medical missions doing more harm than good?
The flight lands in Oregon, 9,500 miles from Tanzania. Dilan Ellegala fills his lungs. No smell of wood smoke here. He just spent the past six months volunteering in a small hospital deep in the sun-baked African bush. Now, in the summer of 2006, it's back to work in the lush green city of Portland, to a new job as director of neurotrauma at Oregon Health and Science University.
Read the first story of the series
A Doctor's Quest: Teaching brain surgery in the bush, published 7/25/10
A challenge? That's a sure bet to fire the neurons of a brain surgeon, and Ellegala is eager to start this plum job. He'll disarm those deadly aneurysms, treat those emergency head wounds and share his skills with medical students at a top research university. He's in his mid-30s, on the star track, riding an elevator toward higher positions, higher pay, grants, recognition.
Not so fast; a rift formed inside his mind during those six months in Tanzania. On one side: dreams of becoming a distinguished neurosurgeon, dreams that fueled him through five years of medical school, eight years of residency, a prestigious but brutal fellowship in cerebrovascular medicine at Harvard.
On the other: memories of the Tanzanian village of Haydom, high on a plateau overlooking fields of maize and sunflowers and acacia trees, the taste of fried potatoes and eggs at wood clapboard stands along the village's red-dirt road, a medical technician named Emmanuel Mayegga, the man he trained to do brain surgery.
Yes, even in Oregon, he can almost smell the cook fires, the metallic scent of blood mingling with sweat in the hospital's wards; he can see the children with grotesquely large heads suffering with hydrocephalus, glazed eyes gazing downward from the pain and pressure, the men and women with tumors and head wounds, people who are alive because he taught Mayegga the skills to heal them.
Neuroscience is all about movement and connections, left hemisphere to right, brain to nervous system. Yes, now that he's back in the United States, he's convinced that his work with Mayegga should move forward, that he should find others to train and train them to share their skills with even more people, generating a critical mass of expertise that transforms the troubled country he just left behind.
Medical mission side effects
No, the paradigm isn't working for Tanzania and many other developing countries, he thinks. More than $2 billion in foreign aid, nearly $400 million from the United States, pours into Tanzania every year, much of it for public health programs. Despite this aid, average life expectancy hovers at 52 years, and one in 10 children dies by age 5. Even with this foreign infusion, Tanzania has just 20 doctors for every million inhabitants, one of the worst doctor-patient ratios in Africa. (The United States has 2,600 physicians for every million residents.) Ellegala could fill a page with numbing statistics about malaria, tuberculosis, diarrhea -- numbers that make you throw up your hands. What can one person do?
Go on vacation, that's one answer. That's what Ellegala did in Haydom for six months -- take a break after a grueling fellowship to test his skills in a place of infinite need. That's what a lot of doctors and nurses do; every year, thousands of health care workers from the United States and Europe fly to Africa, treating everything from cleft palates to tuberculosis. Many go for just a few weeks during their vacations and fit in a safari or beach trip. All told, more than 500 groups around the world run upward of 6,000 short-term medical missions a year. These missions have saved countless lives.
But Ellegala kept thinking of a question as he walked through the wards in Haydom's hospital, rooms filled with patients suffering from head wounds, tumors, water on the brain -- easily treatable injuries and diseases if you have the skills: What happens to these people when we leave? And this question led to a diagnosis: Sure, short-term medical missions save lives and make doctors who do them feel good, but they don't cure the real disease, the country's ailing health care system. No, they ultimately make things worse by perpetuating a culture of dependence, a tumor that crowds out the growth of a more sustainable and effective system.
Leave it to a surgeon to come up with a radical treatment. Ellegala decides it's better to focus on training locals, even if it means teaching procedures to non-physicians. Yes, he can already hear the old guard howling: You can't teach brain surgery to amateurs! There's a reason we train brain surgeons for more than a decade! But it's easy to say those things from your comfortable offices in the United States, a nation with 3,500 neurosurgeons. Tanzania has only three brain surgeons, and thousands of people are dying because they don't have access to these specialists. So, back in Oregon, Ellegala forms a nonprofit, Physicians Training Partnerships, to teach Tanzanians brain surgery. He'll start with neurosurgery, because that's what he knows, then move to other specialties. He'll train Tanzanian doctors when possible, but also people like Mayegga, ambitious health care workers who have a few years of medical training under their belts.
He's not exactly breaking new ground here. You can go back a couple of thousand years to ancient China for the proverb: Give a man a fish, and you feed him for a day; teach him to fish, feed him for a lifetime. Or you can follow Brian Mullaney to Vietnam in the 1990s. Mullaney is a board member of Operation Smile on a mission to fix cleft deformities, pondering whether this send-in-the-cavalry model makes sense. His teams, flown in from America along with 10,000 pounds of gear, can do 100 surgeries in a few weeks, but 400 children typically show up. So he returns to the United States with an idea, cue the Chinese proverb: train local doctors instead of flying doctors in from across the ocean. His fellow board members shake their heads; the kids need help now; there's no time to teach; The group's head surgeon shakes his head. Let the locals do these procedures, and children probably will end up dying.
Nonsense, Mullaney thinks, and forms a new nonprofit, Smile Train, to "teach a man to fish … empower local doctors in developing countries." In the next 10 years, Smile Train provides free training to 60,000 medical professionals in more than 140 countries, reduces the cost-per-surgery by 90 percent, serves dollar-per-dollar 10 times as many children as traditional mission groups. Mullaney's dream: Teach so many doctors that it puts Smile Train out of business.
What's this, an organization with an exit strategy? Yes, that's the way to do it, Ellegala thinks. But he knows this is a challenge to the status quo, to the missionary industrial complex that has deep roots in Africa and reasons to stay put. "Medical services provided are merely a means to share the gospel with the patients and their families," one group says on its Web site. Another says it plans to "take the gospel through medical care to every rural area in Africa." But is it ethical to provide care in exchange for opportunities to convert, especially in a place where people have few alternatives for health care? A New Zealand researcher, Sharon McLennan, studies missions in Honduras and learns how one group bluntly defines its medical work as "bait."
A tough decision
No, better to teach people how to fish, not use them as bait, Ellegala thinks. With his nonprofit up and running, he spends the early part of 2007 recruiting doctors and medical students from across the country for another training mission to Haydom. Meantime, he follows Mayegga's progress, documenting how he repairs skull fractures, inserts shunts to reduce pressure inside the brain, removes brain lesions and does biopsies.
Here's where Ellegala's Brain Train could fly off the tracks: How are Mayegga's patients faring? If they die or have high complication rates, Ellegala's experiment fails. No, worse, it means people may have suffered needlessly, all because of an American doctor's well-meaning but flawed desire to help.
Ellegala knows he needs hard data, information good enough to present to medical journals. As his return trip to Tanzania nears, two graduate students track Mayegga's patients and compare them to ones Ellegala treated during his first stay in Haydom. They tally how many have died and e-mail a summary to Ellegala.
He looks at the totals. Not good: Mayegga's patients are dying at a slightly higher rate than he expected. Maybe you can't properly teach brain surgery to clinicians? He makes a mental note to find out why the patients are dying.
About the same time, his department chair in Oregon asks to see him.
"You can't go to Tanzania," he tells Ellegala. "I need you making money for the department."
Ellegala says he is using his vacation time.
"No, you can't do that."
They talk a few more minutes; Ellegala fumes, the left side of his brain, the logical side, says that maybe his boss is right, that he needs to stay on his steady and lucrative career path in the United States. But don't bet against the right side, the creative side, the side that processes the big picture, especially when it belongs to a guy who's comfortable enough with risk to open skulls for a living.
"It usually takes three dates before a couple finds out if they're compatible," Ellegala tells his boss, who looks a little confused. "I think this is our third date."
Score one for the right side. Ellegala resigns on the spot, the department chairman staring at him in stunned disbelief.
With no job lined up in the United States, a career he worked so hard to build in limbo, and a feeling that, yes, passion is better fuel than security, Ellegala leaves Oregon and flies back to Tanzania.
Every year, Smile Train does more than 120,000 surgeries to fix cleft palates. Brian Mullaney is the group's co-founder.
Q: How did you form Smile Train?
A: I was on the board of directors with Operation Smile in Vietnam when I had this epiphany. You know when we showed up, we would do 100 to 125 operations, but we'd have to turn away 300.
Q: That must have been tough.
A: It was heartbreaking. The hardest part wasn't seeing the kids getting their surgeries; it was turning kids away. You'd have a mother walk for a week with her kid on her back, and then you'd have to tell her you wouldn't be back for a year.
Q: You split from Operation Smile, and formed Smile Train?
A: Yeah, it was just such an obvious idea -- teach a man to fish -- but it was controversial at first. The head surgeon with Operation Smile said all these children were going to die. A lot of people look at the world in the old Colonial way. But training local surgeons is the only way to solve the problem.
Q: Your website says that you do surgeries at a tenth of the cost of traditional missions and do 10 times as many surgeries.
A: I remember the first surgeon we trained in China. He did 2,000 surgeries, and it would have taken us years to do that many the old way. We'll do 120,000 surgeries this year, and Operation Smile will do 9,000. It's very expensive to fly in 10,000 pounds of equipment, set up an operating room and fly in cosmetic surgeons from Cleveland and Georgia. We do our surgeries for about $250, and have done them for as little as $140. Others do it for $800 to $1,000 or much more.
Q: How do you keep track of quality?
A: We have digital charts for every patient. We've operated on 600,000 children, so we can look at photos, see how long the operation took. With the Internet and digital patient charts, we can run a business that we couldn't run 10 years ago.
Q: Think your model could work for brain surgery?
A: Brain surgery is a helluva lot more difficult than clefts, but the basic concept is brilliant, and the same principles apply, namely empowering people by training them. There are brilliant surgeons out there in these developing countries, and with a little bit of help, they can do great work.
Q: You've said that someday you'd like to put yourself out of business. You don't typically hear that from people who run organizations.
A: That's what we said when we started this 11 years ago. Look, I'm a business guy, not a charity guy. We picked clefts because we wanted to have an impact and they're easy to fix. We need a whole new approach to Africa and places like Haiti, where the World Bank and charities are giving out fish and building up a dependency.
Q: So when will you go out of business?
A: Last year, we did more cleft surgeries in China and India than the number of babies born with it. So we're beginning to reduce the backlog. In four or five years, I think we'll take care of the backlog and then it's a matter of keeping up with newborns, which is a fraction of the number of the backlogs. So, yes, I'd love to have a going out of business party.