Earlier this month, I spoke with Diane Dakin, a family doctor based in Olympia, Washington who recently volunteered at ASRI, helping to train newly-graduated Indonesian doctors and organizing a training for local midwives.
She's been working as a family doctor for the past 28 years, including over 25 years doing low-risk obstetrics. She estimates she's delivered over 1,000 babies! I asked her how she heard of Health In Harmony, and she told me the story of chance connections that led her to volunteer. In her own words, "It was a coming together of all sorts of little connections, that made it seem like, 'I should look into this place!' … I was reading the Yale alumni magazine, and I saw an article about a woman – Kinari Webb, the founder of ASRI - who initially had been an orangutan researcher. Since my youngest son was studying chimps, I was interested, so I read it… Later, after medical school, it turned out that she had gone to the same family practice residency that I had gone to many years earlier. I thought, 'the ASRI program sounds really interesting,' and knowing that I had a sabbatical coming up, I wrote and asked if they needed a Family Medicine volunteer and they said 'sure!'"
After spending two weeks in language school in Yogjakarta, Diane arrived in Sukadana, ASRI's home base, and stayed for three months. She spent most of her time acting as the attending physician at the ASRI clinic, helping to teach the doctors who are recent medical school graduates, and preparing for a two-day conference of the area midwives at the end of her stay. In our conversation, Diane described the experience of working at ASRI:
Diane: It was really fun. We had a great time. I learned a lot, as well. Without the ability to do much lab work, utilize other technology, or consult with specialists, the doctors are forced to rely on history and physicals to make diagnoses. We would also look up information on-line, but half the time, the internet would be down, so we'd be looking through the books madly. The doctors, though, all had Blackberries, and they would be looking stuff up tons faster than I could do it [she mimes typing with thumbs on a tiny keyboard]… and it was fun! So, I learned a lot, as well as - hopefully - taught something. One of the nurses, Pak Wil, who ran the lab, had been taught by someone from the CDC and could diagnose malaria and TB as well as other parasitic diseases. The doctors were also learning to use a portable ultrasound.
Rosevan: And the idea behind that is, you teach doctors who are fairly new?
D: [nodding] We don't see patients on our own, at all. Even if you could speak the language, you wouldn't be doing that. We're there as consultants to the docs, most of whom are either right out of medical school or have spent one year doing their rural "payback" for going to medical school - they all have a one-year social service requirement, in Indonesia. Those clinics however are generally very basic, and they don't get any training or teaching. So, our goal is to help teach, to share our experience and help improve their skills and confidence. Doctor Nur, who's been there for two years now, knows quite a bit, and he can function almost completely on his own. And he was certainly teaching me about tetanus, leprosy, and tuberculosis… things that I never or rarely see! Dr. Ruth left while I was there - she had finished one year at ASRI, and I was totally impressed by how much she had learned from the different attending physicians. Of the other two docs - one was right out of med school and one was right out of his social service. They had good book knowledge but needed guidance with their clinical skills.
R: And whether or not they go to ASRI, are Indonesian doctors going to another residency where they get a similar year of training? Or is ASRI really providing a higher standard of education for them?
D: ASRI is providing a much higher standard of education. Most Indonesian doctors do not go on and do a residency, because they have to pay to do a residency. So if they do it, it's only after they've worked for a couple of years. Indonesia doesn't have a Family Medicine program, which is really too bad, because they really do need family doctors who can see adults, children and take care of women with GYN problems, especially out in these rural areas. Most obstetric practice is done by the midwives, and so obstetric patients don't come to the clinic unless there's a problem, or they need an ultrasound...
Doctor Willi started at ASRI about a month before I left. He'd love to become a family doctor, but since they don't have that specialty, he's going to try for a residency in Ob/Gyn, and his girlfriend is going to try to do a residency in Internal Medicine, and then they would like to settle in a rural area. I could see them wanting to settle and work at ASRI Clinic, which would be wonderful. I had a great time working with him. He translated my talks on different aspects of OB care, and during the two day sessions with the midwives, I would say something and then he would translate it. It would also be up on the projector in Indonesian.
R: Sounds like a good team.
D: It was really fun. He was very lively and knew how to work the audience.
R: What was your experience with the midwives?
D: The talks were, I think, well-received, but they really liked the practical sessions. An OB/GYN at the University of Washington had given me a pair of what she called "parto-pants" - like scrub pants that had a large hole where a baby could be delivered, and little pockets where you could have fake blood come out… I brought a baby doll, and we delivered the baby doll. And, it really was true, when you had a real person putting these pants on, moving and squirming, with their legs in the way- it was much more realistic. And they loved it when the (fake) blood started flowing for the postpartum hemorrhage.
R: [laughing] That's why they're midwives, I guess, because they think that's "fun." What else did you do?
D: We had prizes - we'd ask them different questions on what the presentations had been about, and then they could pick a prize, as a little bit of game-show-y type stuff. It was entertaining as well as educational. They're really looking forward to Karen Brown, a midwife from the University of San Diego, and a repeat volunteer, coming so hopefully that training will continue on.
R: And did you attend any births while you were there or help treat any babies?
D: The only birth I attended was one of the ASRI nurses - she lived across the street from the clinic. The midwife did the delivery, but I was there. She went really fast, and it was a nice normal, healthy birth, so that was good. I was a little perturbed because I knew that they didn't usually use any lidocaine (local anesthetic) for sewing tears, but I had some and brought it in case she had any tears. She did have a tear, and I offered the lidocaine to the midwife and she said "nah, nah, she doesn't need it." So I turned to the new mom and said, "Are you sure you don't want anything? I've got it right here!" and she said "Nah, nah, I'm okay." And so she just sewed her right up without any local anesthetic! I was thinking "I can't believe it!" People were really, really stoic, all the time - I was pretty amazed.
D: And then, we did see a number of babies in the clinic, including a baby that had been rushed in - a midwife who had done a home delivery had sent the baby in when it developed a fever at four hours of age, and then another couple of babies that developed fevers a couple of days after birth. And the nurses went right to work - they got the vital signs, they got the antibiotics that were required in really fast, they started IVs… they knew what to do. It was really good teamwork.
I've worked a lot in Latin America at different clinics, and I thought this was the best-organized in terms of how the nurses did the pre-work before the docs saw the patients, the follow-up, the fact that they're keeping track of all the diagnoses… It is a bit of a hassle for the staff to put diagnostic codes into the computer but it means they're really going to know what they're doing, what meds they used, what the clinic needs more of… It's not just going to be your "feel" for things - they're going to have the data. And I think that's great.
R: Would you say that there are any lessons to be learned from the status of maternal and child health in Indonesia? Especially in comparison to other places you've worked, Latin America, and even in Olympia?
D: Well, the biggest difference is that they have a really high level of infant and maternal mortality, much much higher than we have here. The government's encouraging more training for the midwives and better prenatal care, but I think there are things that public health could do in terms of postpartum hemorrhage that they're not doing, like giving the midwives access to certain drugs that they could carry with them - they have access to some, but not others that I think would be really useful.
A lot of patients from small villages came to us by motorcycle from 2-5 hours away, and the hospital that performed C-sections was 2 hours from us. Especially out in these smaller villages, if a woman was having a hemorrhage, and the midwife was unable to stop it or if the baby is not doing well then there wasn't time to get to a larger clinic.
R: And are there things that people who haven't been to ASRI should know?
D: That their funds are really well-utilized. I was really impressed with how the clinic ran, with the dedication of the staff… It was interesting that a lot of the local people think that the docs and nurses work a lot harder at ASRI. Staff who don't want to work hard tend to move on. The docs love it because even though they're working harder than they would somewhere else, they're also learning a lot. And these people do really good care. Everybody in the clinic really worked well together, there was a lot of camaraderie, and I was really impressed by that.
R: That's wonderful. And would you go back?
D: I would definitely go back, but it might have to wait until I retire.
R: Anything else you'd like to share with our future readers?
D: I would just say if anybody - especially anybody with medical training - has any interest in working in a new culture it's a fabulous experience. The docs all spoke great English, so you don't have to worry about not having language skills, that was not a problem at all. And the folks at ASRI take good care of you. It was just a wonderful experience and I encourage anybody to try it! People who have other skills, not only medical, such as forestry backgrounds, water quality backgrounds, animal husbandry backgrounds for the Goats for Widows program, or computer skills – are also in great demand. ASRI offers a great medical facility - and its impact in the community is much wider.
For volunteer opportunities, contact Volunteer Coordinator Kari Malen. Don't have the time to travel across the world? Give online or ask about other ways to contribute to Health In Harmony. We'd love to hear from you.