November 01, 2008

By: Heidi Splete

Dr. Howard Homler, an internist in solo practice in Carmichael, Calif., knows firsthand that short-term services can have long-term benefits when it comes to practicing medicine overseas in underserved areas.

“I have volunteered at a medical clinic in Mexico,” he said. “I was talking to a cardiologist friend who told me about going to Fiji to volunteer as part of an organization called Fiji Aid International. I thought it sounded like an interesting adventure and a chance to see what I could do to help.”

A 10-day time frame worked well for Dr. Homler. An avid scuba diver, he was able to combine his passion for patient care with a chance to enjoy the beauty of Fiji. Although 10 days may not sound like much, a dedicated, energetic physician can have a lasting impact, especially in terms of patient education.

Dr. Homler earned his medical degree at the University of California, Irvine, and completed his residency at the University of California, Davis, where he was chief resident. In addition to his clinical practice in internal medicine, he served for several years on the volunteer teaching faculty at University of California, Davis.

Fiji Aid International is a nondenominational, nongovernmental relief organization that was established by a retired nurse administrator, Damyenti Chandra, in Sacramento in 2000 (www.fijiaidinternational.com

What was the nature of your work in Fiji?

The nurse who established Fiji Aid International had an interesting program that included both working in the clinic and participating in an outreach program. The outreach program consisted of driving into a small village and working out of someone's house. I saw 47 patients there that day.

The problems I saw included peripheral neuropathy, thyroid nodules, abdominal masses, coronary disease, hypertension, back pain, stomach pain, migraine, bronchitis, and diabetes.

I also spent some time at the hospital in Lautoka [the second largest city in Fiji]. I was able to make ward rounds after sitting in for the morning report. I saw the medical inpatients they were caring for, and I also gave the medical staff a lecture on type 2 diabetes. Most of the Fijians spoke English, but for those patients who didn't, there were medical staff who could translate. The patients in the hospital had conditions including autoimmune hemolytic anemia, meningitis, myocardial infarction, rheumatic heart disease, osteomyelitis, and endocarditis.

What are some of the challenges of practicing medicine in Fiji?

There is a lack of resources and a lack of personnel. The doctors and nurses with whom I worked are wonderful, skillful, and dedicated. However, many health care professionals choose to leave Fiji to practice elsewhere, where they can make more money.

Right now the economy in Fiji is very poor and the doctors have very few supplies. I think there is a lot of potential there; it is a beautiful country, and people are very friendly. But the government needs to address some serious health care issues.

Fiji Aid International tries to buy medicines and supplies locally to help the local economy, but it is tough to get certain basic items, such as syringes for insulin injections.

And people who want good care have to fly to Australia or India. They don't have MRI on the island, and the only CT scanner is in the city of Suka, which is a 3- to 4-hour drive from Lautoka. I saw one young woman who presented with lower abdominal pain and distention accompanied by weight loss. I identified a localized, tender pelvic mass. Local doctors had told her that she was just “fat.” Reassured that there was indeed something wrong, she was able to go to India for further treatment.

How has your experience in Fiji inspired you to stay involved after your return to the United States?

Since I have been back in the United States, I have been working to get some assistance for a 16-year-old Fijian girl with leukemia. They don't use chemotherapy for acute leukemia there, so she was just going to get some blood transfusions, and probably die. It was tragic to see that kind of waste of life. I'm also trying to see whether I can get some assistance from pharmaceutical companies with a special interest in diabetes treatment to get some more supplies for patients in Fiji.

Would you elaborate on the problem of type 2 diabetes in Fiji?

When I went to Fiji, I was expecting to see a lot of unusual tropical diseases, but the biggest problems they were having were high blood pressure and diabetes. When I went to the local supermarket, I understood why. The grocery stores stocked lots of junk food and unhealthy quick-fix foods. The diet there is not as healthy as one would think it could be, or as it should be. The typical diet includes coconut milk and foods high in sugar and fat.

Diabetes is extremely undertreated in Fiji, and it was routine to see people with their blood sugars in the upper 200s and 300s [mg/dL]. I was surprised by the extent of the lack of diabetic control. I was treating adults, so I didn't see pediatric cases or many adults with type 1 diabetes. But the doctors in Fiji rarely use insulin, even for type 2 diabetics who clearly need it. I think there is some resistance on the part of both the patients and physicians to put in the necessary effort. Patients find it difficult to afford insulin syringes, and they didn't like the idea of giving themselves shots. It would probably involve more time and teaching than some of the doctors could put in, or that the patients would want.

I don't know the clear reason, but I was very surprised by the lack of insulin use overall.

Even during a short visit, what stood out to you about practicing medicine in Fiji?

The things that we take for granted. There are some good support services, and there are some people who work for a small stipend, such as one woman who had been trained to check blood pressure and blood sugars. And some companies have donated materials. But, for example, one nurse had a stethoscope that was so old that on one side she just had a bare metal tube that she was putting in her ear. I was also impressed by the numbers of patients who came to the clinic because they wanted to know what their blood sugar and blood pressure were.

What should be done to improve health care in Fiji?

I think if patients had the diabetes supplies, they would use them. If people get poorly controlled diabetes under control, they feel so much better that they are more motivated to maintain control.

Also, I wrote a few articles on diabetes for the Fiji Times, the biggest newspaper in Fiji, and I hope that will help to educate people about the disease and how to manage it.

What did you enjoy most about your experience in Fiji?

One of the nurses had a 9-year-old in school there, and they invited me to speak to the class. They were doing a project about international health, and I got questioned on health issues by about 30 kids, decked out in their school uniforms. That was a nice change of pace.

I enjoyed working with the people there, and having the opportunity to educate patients, especially children, because that will make a difference for future generations. It's nice to be able to go and help out and feel like you are doing something more than just handing out pills. You are trying to educate and bring awareness to a society.

Any other anecdotes from the trip?

On the flight home I had to help two people who had medical problems. One person had acute diverticulitis, and the other had either food poisoning or acute gastroenteritis. The only other doctor on the flight was a gynecologist, so she deferred to me on those issues. The flight crew was very grateful and gave me a bottle of champagne for my efforts!

One of the challenges for a private practice physician with a passion for volunteer work is finding the time to get away. What are some benefits of a program like Fiji Aid International as a way for U.S.-based physicians to get involved overseas?

I felt that this experience was more fulfilling than when I went to Mexico. There the patients viewed us simply as dispensers of medicine, and there was little interest in lifestyle advice or education.

I'm in my own full-time, solo practice, so it's hard for me to be away for a long time. I paid for my flight, but the organization paid for transportation on the island, as well as room and board. I felt very well cared for, and I would do it again. Volunteering short-term in Fiji would be something where a doctor could go with his or her family; it's a great vacation destination.

I spent 10 days there, but the schedule is very flexible. Dr. Gopal Nemana, the cardiologist who told me about the program, had spent a month there.

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