Back to Basics in Borneo: Why Rheumatologists Are Meant for Medical Missions

Rheumatologic training provides a preparation for any physician who is interested in providing medical care in developing countries, according to Dr. Daniel Albert, who has been globetrotting on medical missions for decades, most recently in Borneo. "Rheumatologists have a broad training in internal medicine, and are great internists," Dr. Albert said. "Being a rheumatologist is very good background for the kind of work that I did [in Borneo], and a good background for clinic work in developing countries in general," he said.

Dr. Albert’s most recent adventure was a monthlong medical trip to Borneo in January 2012, via Health in Harmony, a nonprofit global health organization with an environmental slant. Health in Harmony is funded by individual donations and grants from a range of sources, including the Bill & Melinda Gates Foundation and the National Institutes of Health.

Courtesy Dr. Daniel Albert

Rheumatologists are well suited to clinic work in developing countries because they are trained to pursue patients’ problems in an analytic fashion that comes down to pattern recognition in a way. Rheumatologists deal with many abstract concepts, Dr. Albert noted. They are always forced to clarify: What are the objective features of the disease, and how do they relate to a possible diagnosis that you are considering?

"Working in a setting where medical resources are limited takes some flexibility in your approach to differential diagnosis, because you don’t have the facilities available that you do in developed countries. Serologic evaluation is nonexistent in most developing countries, so you are much more reliant on the physical exam and history skills," said Dr. Albert, who is a rheumatologist at the Audrey and Theodor Geisel School of Medicine at Dartmouth, Hanover, N.H.

No matter where rheumatologists practice, be it somewhere with high-tech equipment or in a rain forest, "we constantly have to sort through very vague complaints, and we have to do it by the use of our clinical skills," he said. "I think rheumatologists are in a particularly good analytic position to address many of the problems."

Before he set out for Borneo, Dr. Albert said that he prepared in the same way any attending physician would in the United States. "Before going overseas, I think it is useful to do some background homework about diseases that might be more prevalent where you’re going than in America. For example, you certainly want to know about tuberculosis, because that is a worldwide problem that we don’t see much in the United States. In tropical areas, one must recognize malaria and also dengue fever," he said.

Once he was in Borneo, Dr. Albert said that he served as a resource of knowledge and expertise in a teaching mode for the Indonesian doctors, as well as for students and medical residents from the United States (Dartmouth, Yale, and Stanford universities) who were at the clinic. The Indonesian doctors often shared insights with the visiting physicians from their experiences, because they see a different spectrum of diseases than do U.S. physicians.

Among the clinic staff in both Borneo and other developing countries where Dr. Albert has served, he said he was impressed by the depth of knowledge about the common local diseases among the physician and nonphysician medical staff alike. Thanks to their expertise, "it is more important for you to share your expertise in your specialty than for you to be an expert on indigenous conditions," he said.

The people in Borneo actually are quite well nourished, and diseases of malnutrition are rare in Indonesia, according to Dr. Albert. The Health and Harmony program where he cared for patients is located in a fishing village, so the local residents have a good diet, consisting mainly of rice and fish, and fruit, which grows plentifully in everyone’s yard, he said.

"I think volunteering at a remote medical clinic is a far better way to get to know a country than traveling there as a tourist."

However, there are waterborne epidemics because of diseases due to poor water sanitation, but otherwise people have pretty good baseline health.

The Health and Harmony program consists of a walk-in clinic in the village called Sukadana and outreach clinics in remote areas. The Klinik ASRI would look familiar to most internists because it is similar to any other walk-in clinic, with three or four exam rooms and an urgent care facility, half a dozen nurses, and three or so general practice trainees. The job of supervising the clinic and its staff falls to the visiting physician from overseas.

Health in Harmony is a very well organized volunteer organization in a very pleasant part of Borneo, so it is considered a very desirable residency that attracts the top students. When Dr. Albert was there, he worked with three trainees. They were in their first year out of medical school, which is certified by the government as a residency.

Most of the time, the patient comes to the clinic alone or with one member of the family. But very sick patients may arrive with several relatives. And if they are very, very sick, they may come in with a substantial portion of their village. "It can be pretty interesting in clinic when you have large numbers of people accompanying a patient in a relatively small space," Dr. Albert said.

The journey to the outreach clinics is made via a van that carries a doctor, nurse, and driver to the remote location. This team usually stays in the home of a local chief there. Traditional healers are part of the culture in Borneo, and "the interface between traditional healers and Western doctors" occurred without tension or distrust, he said. "I hope to participate in the outreach clinics on a future trip, but did not do so on this visit. Traveling to the remote clinic, caring for patients, and returning takes 3 days, which was not possible for me on this trip," Dr. Albert said.

Clinic care runs smoothly. Staff collect demographic information from each patient at intake and enter it into donated Apple computers, along with short patient notes and the patient’s picture. Most of the medication at the clinic is donated, largely by the humanitarian association AmeriCares and volunteers who often bring medications with them to stock the pharmacy. The Indonesian government also provides some medicine.

Patients are charged on a sliding scale for the clinic visits and the medications. A unique element of the Health and Harmony program is the availability of barter options; patients can offer to work in place of payment, usually on the forest preserve or the organic farm, or they can pay in a variety of different crops.

As in America, a good 20% of people presenting to a clinic have musculoskeletal complaints. These are just the kinds of ailments that rheumatologists hope to diagnose and treat.

"It is more important for you to share your expertise in your specialty than for you to be an expert on indigenous conditions."

"I saw patients with rheumatoid arthritis whom we treated with methotrexate. We had a difficult time getting some lab tests, but not others. We were given a machine for blood counts, but we couldn’t do liver function tests. We were able to give patients folic acid supplements, and hydroxychloroquine was available. Of course, we didn’t have any biologics, but we had sulfasalazine," Dr. Albert said.

"We had some cases of septic arthritis. We had both intravenous and oral antibiotics to give them, so that wasn’t a problem," he said.

"Of course there were some patients that we weren’t able to help. We had people show up who were sick with a fatal disease like cancer, and we would have to say that we couldn’t do anything for them. We sent only a very few people elsewhere for treatment, largely because making such a trip with a very sick patient is such a difficult proposition. While I was there, the closest x-ray machine was about 2 hours away, and cost a lot of money, so we tried to work without much imaging. If we needed to send anyone for surgery, they had to go to a town that was 4 hours away by boat. Fortunately, there weren’t many surgical cases," he said.

Medical trips such as Dr. Albert’s to Borneo are for the adventurous. "We didn’t have running water, but we had water available in pots that felt great to pour over your head a few times a day, given the hot temperatures and high humidity. And it was perfectly fine. We also had bottled drinking water. I think volunteering at a remote medical clinic is a far better way to get to know a country than traveling there as a tourist. You come away with a deeper understanding of the culture and people, and I think you get a new perspective on happiness, seeing how people can be so happy with so little, compared to what we have in the United States."

"Not everyone can take a full month for this type of trip, but I have some flexibility in my work schedule that allows me to make up time before and after the trip. I advise anyone considering this type of trip to look for a well-run organization, such as Health in Harmony," Dr. Albert said.

Rheumatologic training provides a preparation for any physician who is interested in providing medical care in developing countries, according to Dr. Daniel Albert, who has been globetrotting on medical missions for decades, most recently in Borneo. "Rheumatologists have a broad training in internal medicine, and are great internists," Dr. Albert said. "Being a rheumatologist is very good background for the kind of work that I did [in Borneo], and a good background for clinic work in developing countries in general," he said.

Dr. Albert’s most recent adventure was a monthlong medical trip to Borneo in January 2012, via Health in Harmony, a nonprofit global health organization with an environmental slant. Health in Harmony is funded by individual donations and grants from a range of sources, including the Bill & Melinda Gates Foundation and the National Institutes of Health.

Courtesy Dr. Daniel Albert

Rheumatologists are well suited to clinic work in developing countries because they are trained to pursue patients’ problems in an analytic fashion that comes down to pattern recognition in a way. Rheumatologists deal with many abstract concepts, Dr. Albert noted. They are always forced to clarify: What are the objective features of the disease, and how do they relate to a possible diagnosis that you are considering?

"Working in a setting where medical resources are limited takes some flexibility in your approach to differential diagnosis, because you don’t have the facilities available that you do in developed countries. Serologic evaluation is nonexistent in most developing countries, so you are much more reliant on the physical exam and history skills," said Dr. Albert, who is a rheumatologist at the Audrey and Theodor Geisel School of Medicine at Dartmouth, Hanover, N.H.

No matter where rheumatologists practice, be it somewhere with high-tech equipment or in a rain forest, "we constantly have to sort through very vague complaints, and we have to do it by the use of our clinical skills," he said. "I think rheumatologists are in a particularly good analytic position to address many of the problems."

Before he set out for Borneo, Dr. Albert said that he prepared in the same way any attending physician would in the United States. "Before going overseas, I think it is useful to do some background homework about diseases that might be more prevalent where you’re going than in America. For example, you certainly want to know about tuberculosis, because that is a worldwide problem that we don’t see much in the United States. In tropical areas, one must recognize malaria and also dengue fever," he said.

Once he was in Borneo, Dr. Albert said that he served as a resource of knowledge and expertise in a teaching mode for the Indonesian doctors, as well as for students and medical residents from the United States (Dartmouth, Yale, and Stanford universities) who were at the clinic. The Indonesian doctors often shared insights with the visiting physicians from their experiences, because they see a different spectrum of diseases than do U.S. physicians.

Among the clinic staff in both Borneo and other developing countries where Dr. Albert has served, he said he was impressed by the depth of knowledge about the common local diseases among the physician and nonphysician medical staff alike. Thanks to their expertise, "it is more important for you to share your expertise in your specialty than for you to be an expert on indigenous conditions," he said.

The people in Borneo actually are quite well nourished, and diseases of malnutrition are rare in Indonesia, according to Dr. Albert. The Health and Harmony program where he cared for patients is located in a fishing village, so the local residents have a good diet, consisting mainly of rice and fish, and fruit, which grows plentifully in everyone’s yard, he said.

"I think volunteering at a remote medical clinic is a far better way to get to know a country than traveling there as a tourist."

However, there are waterborne epidemics because of diseases due to poor water sanitation, but otherwise people have pretty good baseline health.

The Health and Harmony program consists of a walk-in clinic in the village called Sukadana and outreach clinics in remote areas. The Klinik ASRI would look familiar to most internists because it is similar to any other walk-in clinic, with three or four exam rooms and an urgent care facility, half a dozen nurses, and three or so general practice trainees. The job of supervising the clinic and its staff falls to the visiting physician from overseas.

Health in Harmony is a very well organized volunteer organization in a very pleasant part of Borneo, so it is considered a very desirable residency that attracts the top students. When Dr. Albert was there, he worked with three trainees. They were in their first year out of medical school, which is certified by the government as a residency.

Most of the time, the patient comes to the clinic alone or with one member of the family. But very sick patients may arrive with several relatives. And if they are very, very sick, they may come in with a substantial portion of their village. "It can be pretty interesting in clinic when you have large numbers of people accompanying a patient in a relatively small space," Dr. Albert said.

The journey to the outreach clinics is made via a van that carries a doctor, nurse, and driver to the remote location. This team usually stays in the home of a local chief there. Traditional healers are part of the culture in Borneo, and "the interface between traditional healers and Western doctors" occurred without tension or distrust, he said. "I hope to participate in the outreach clinics on a future trip, but did not do so on this visit. Traveling to the remote clinic, caring for patients, and returning takes 3 days, which was not possible for me on this trip," Dr. Albert said.

Clinic care runs smoothly. Staff collect demographic information from each patient at intake and enter it into donated Apple computers, along with short patient notes and the patient’s picture. Most of the medication at the clinic is donated, largely by the humanitarian association AmeriCares and volunteers who often bring medications with them to stock the pharmacy. The Indonesian government also provides some medicine.

Patients are charged on a sliding scale for the clinic visits and the medications. A unique element of the Health and Harmony program is the availability of barter options; patients can offer to work in place of payment, usually on the forest preserve or the organic farm, or they can pay in a variety of different crops.

As in America, a good 20% of people presenting to a clinic have musculoskeletal complaints. These are just the kinds of ailments that rheumatologists hope to diagnose and treat.

"It is more important for you to share your expertise in your specialty than for you to be an expert on indigenous conditions."

"I saw patients with rheumatoid arthritis whom we treated with methotrexate. We had a difficult time getting some lab tests, but not others. We were given a machine for blood counts, but we couldn’t do liver function tests. We were able to give patients folic acid supplements, and hydroxychloroquine was available. Of course, we didn’t have any biologics, but we had sulfasalazine," Dr. Albert said.

"We had some cases of septic arthritis. We had both intravenous and oral antibiotics to give them, so that wasn’t a problem," he said.

"Of course there were some patients that we weren’t able to help. We had people show up who were sick with a fatal disease like cancer, and we would have to say that we couldn’t do anything for them. We sent only a very few people elsewhere for treatment, largely because making such a trip with a very sick patient is such a difficult proposition. While I was there, the closest x-ray machine was about 2 hours away, and cost a lot of money, so we tried to work without much imaging. If we needed to send anyone for surgery, they had to go to a town that was 4 hours away by boat. Fortunately, there weren’t many surgical cases," he said.

Medical trips such as Dr. Albert’s to Borneo are for the adventurous. "We didn’t have running water, but we had water available in pots that felt great to pour over your head a few times a day, given the hot temperatures and high humidity. And it was perfectly fine. We also had bottled drinking water. I think volunteering at a remote medical clinic is a far better way to get to know a country than traveling there as a tourist. You come away with a deeper understanding of the culture and people, and I think you get a new perspective on happiness, seeing how people can be so happy with so little, compared to what we have in the United States."

"Not everyone can take a full month for this type of trip, but I have some flexibility in my work schedule that allows me to make up time before and after the trip. I advise anyone considering this type of trip to look for a well-run organization, such as Health in Harmony," Dr. Albert said.

Rheumatologic training provides a preparation for any physician who is interested in providing medical care in developing countries, according to Dr. Daniel Albert, who has been globetrotting on medical missions for decades, most recently in Borneo. "Rheumatologists have a broad training in internal medicine, and are great internists," Dr. Albert said. "Being a rheumatologist is very good background for the kind of work that I did [in Borneo], and a good background for clinic work in developing countries in general," he said.

Dr. Albert’s most recent adventure was a monthlong medical trip to Borneo in January 2012, via Health in Harmony, a nonprofit global health organization with an environmental slant. Health in Harmony is funded by individual donations and grants from a range of sources, including the Bill & Melinda Gates Foundation and the National Institutes of Health.

Courtesy Dr. Daniel Albert

Rheumatologists are well suited to clinic work in developing countries because they are trained to pursue patients’ problems in an analytic fashion that comes down to pattern recognition in a way. Rheumatologists deal with many abstract concepts, Dr. Albert noted. They are always forced to clarify: What are the objective features of the disease, and how do they relate to a possible diagnosis that you are considering?

"Working in a setting where medical resources are limited takes some flexibility in your approach to differential diagnosis, because you don’t have the facilities available that you do in developed countries. Serologic evaluation is nonexistent in most developing countries, so you are much more reliant on the physical exam and history skills," said Dr. Albert, who is a rheumatologist at the Audrey and Theodor Geisel School of Medicine at Dartmouth, Hanover, N.H.

No matter where rheumatologists practice, be it somewhere with high-tech equipment or in a rain forest, "we constantly have to sort through very vague complaints, and we have to do it by the use of our clinical skills," he said. "I think rheumatologists are in a particularly good analytic position to address many of the problems."

Before he set out for Borneo, Dr. Albert said that he prepared in the same way any attending physician would in the United States. "Before going overseas, I think it is useful to do some background homework about diseases that might be more prevalent where you’re going than in America. For example, you certainly want to know about tuberculosis, because that is a worldwide problem that we don’t see much in the United States. In tropical areas, one must recognize malaria and also dengue fever," he said.

Once he was in Borneo, Dr. Albert said that he served as a resource of knowledge and expertise in a teaching mode for the Indonesian doctors, as well as for students and medical residents from the United States (Dartmouth, Yale, and Stanford universities) who were at the clinic. The Indonesian doctors often shared insights with the visiting physicians from their experiences, because they see a different spectrum of diseases than do U.S. physicians.

Among the clinic staff in both Borneo and other developing countries where Dr. Albert has served, he said he was impressed by the depth of knowledge about the common local diseases among the physician and nonphysician medical staff alike. Thanks to their expertise, "it is more important for you to share your expertise in your specialty than for you to be an expert on indigenous conditions," he said.

The people in Borneo actually are quite well nourished, and diseases of malnutrition are rare in Indonesia, according to Dr. Albert. The Health and Harmony program where he cared for patients is located in a fishing village, so the local residents have a good diet, consisting mainly of rice and fish, and fruit, which grows plentifully in everyone’s yard, he said.

"I think volunteering at a remote medical clinic is a far better way to get to know a country than traveling there as a tourist."

However, there are waterborne epidemics because of diseases due to poor water sanitation, but otherwise people have pretty good baseline health.

The Health and Harmony program consists of a walk-in clinic in the village called Sukadana and outreach clinics in remote areas. The Klinik ASRI would look familiar to most internists because it is similar to any other walk-in clinic, with three or four exam rooms and an urgent care facility, half a dozen nurses, and three or so general practice trainees. The job of supervising the clinic and its staff falls to the visiting physician from overseas.

Health in Harmony is a very well organized volunteer organization in a very pleasant part of Borneo, so it is considered a very desirable residency that attracts the top students. When Dr. Albert was there, he worked with three trainees. They were in their first year out of medical school, which is certified by the government as a residency.

Most of the time, the patient comes to the clinic alone or with one member of the family. But very sick patients may arrive with several relatives. And if they are very, very sick, they may come in with a substantial portion of their village. "It can be pretty interesting in clinic when you have large numbers of people accompanying a patient in a relatively small space," Dr. Albert said.

The journey to the outreach clinics is made via a van that carries a doctor, nurse, and driver to the remote location. This team usually stays in the home of a local chief there. Traditional healers are part of the culture in Borneo, and "the interface between traditional healers and Western doctors" occurred without tension or distrust, he said. "I hope to participate in the outreach clinics on a future trip, but did not do so on this visit. Traveling to the remote clinic, caring for patients, and returning takes 3 days, which was not possible for me on this trip," Dr. Albert said.

Clinic care runs smoothly. Staff collect demographic information from each patient at intake and enter it into donated Apple computers, along with short patient notes and the patient’s picture. Most of the medication at the clinic is donated, largely by the humanitarian association AmeriCares and volunteers who often bring medications with them to stock the pharmacy. The Indonesian government also provides some medicine.

Patients are charged on a sliding scale for the clinic visits and the medications. A unique element of the Health and Harmony program is the availability of barter options; patients can offer to work in place of payment, usually on the forest preserve or the organic farm, or they can pay in a variety of different crops.

As in America, a good 20% of people presenting to a clinic have musculoskeletal complaints. These are just the kinds of ailments that rheumatologists hope to diagnose and treat.

"It is more important for you to share your expertise in your specialty than for you to be an expert on indigenous conditions."

"I saw patients with rheumatoid arthritis whom we treated with methotrexate. We had a difficult time getting some lab tests, but not others. We were given a machine for blood counts, but we couldn’t do liver function tests. We were able to give patients folic acid supplements, and hydroxychloroquine was available. Of course, we didn’t have any biologics, but we had sulfasalazine," Dr. Albert said.

"We had some cases of septic arthritis. We had both intravenous and oral antibiotics to give them, so that wasn’t a problem," he said.

"Of course there were some patients that we weren’t able to help. We had people show up who were sick with a fatal disease like cancer, and we would have to say that we couldn’t do anything for them. We sent only a very few people elsewhere for treatment, largely because making such a trip with a very sick patient is such a difficult proposition. While I was there, the closest x-ray machine was about 2 hours away, and cost a lot of money, so we tried to work without much imaging. If we needed to send anyone for surgery, they had to go to a town that was 4 hours away by boat. Fortunately, there weren’t many surgical cases," he said.

Medical trips such as Dr. Albert’s to Borneo are for the adventurous. "We didn’t have running water, but we had water available in pots that felt great to pour over your head a few times a day, given the hot temperatures and high humidity. And it was perfectly fine. We also had bottled drinking water. I think volunteering at a remote medical clinic is a far better way to get to know a country than traveling there as a tourist. You come away with a deeper understanding of the culture and people, and I think you get a new perspective on happiness, seeing how people can be so happy with so little, compared to what we have in the United States."

"Not everyone can take a full month for this type of trip, but I have some flexibility in my work schedule that allows me to make up time before and after the trip. I advise anyone considering this type of trip to look for a well-run organization, such as Health in Harmony," Dr. Albert said.