Dr. Shom Dasgupta is a first year resident in the Department of Pediatrics. Since 2007, Dr. Dasgupta has served as a fieldworker and staff physician for the non-profit organization Wuqu' Kawoq, which focuses on healthcare, language revitalization, clean water, and the treatment of malnutrition in Guatemala, one of the poorest countries in the Western Hemisphere. Speaking both Spanish and the Mayan language Kaqchikel, Dr. Dasgupta works on Wuqu' Kawoq’s malnutrition interventions and trains local community health workers to provide basic primary care and health surveillance in rural communities.
In December, award-winning journalist Christiane Amanpour reported on Wuqu' Kawoq's efforts to treat severe malnutrition in Guatemala as part of a special broadcast of "20/20" that kicked off ABC's year-long global health care campaign called "Be the Change: Save a Life.” According to Dr. Dasgupta, ABC first expressed interest in their work over the summer, when Wuqu' Kawoq's was raising emergency funds to establish a food supplementation program for victims of Tropical Storm Agatha. The episode garnered so much attention for the organization that $53,000 was raised overnight by viewers around the world. A few days later, Christiane Amanpour featured the story on her show "This Week with Christiane Amanpour." Watch clips from the episodes here.
Dr. Dasgupta received his M.D. degree from Northwestern University. In addition, he studied medical anthropology as a graduate student at Harvard University. He has a background in public health and anthropology and he is interested in healthcare and social welfare in impoverished nations. Dr. Dasgupta plans to complete his residency and continue his work with Wuqu' Kawoq in Guatemala. For more information and to see how you can help, visit http://www.wuqukawoq.org
How did you first get involved in Wuqu’ Kawoq and the people of Guatemala?
During medical school, I had begun to realize that there were certain lacunae in the experiences, skills and competencies that clinical training in traditional hospital and ambulatory settings would not address. The most powerful determinants and modulators of the pathologies we diagnose and treat as physicians are social, historical, and economic, and yet I felt ill-equipped to understand and intervene effectively in those domains.
So, at the end of my third year of medical school, I decided to spend a year working with a group of community health workers that I had heard about during a previous two-week vacation in Guatemala. I calculated that I had saved enough money from my med school scholarship and loans to live frugally for at least a year in rural Guatemala. I hoped this would be enough time to begin to develop the skills that I felt would be necessary to mobilize my ongoing clinical training towards more comprehensive and sociologically robust approaches to disease.
During the first few months of living and working with community health workers in hamlets in the west Central Highlands, it became apparent to me that the idea of Guatemala as a Hispanic country was entirely false. The rural poor in Guatemala are almost entirely indigenous, and I found that Spanish was spoken as a second language — or often not at all — by many of my prospective collaborators and virtually all of my potential patients. The most commonly spoken language in the central highlands is Kaqchikel Maya, so I began to seek out resources to help me learn this under-documented but very vibrant language. Through a series of fortuitous introductions, I met Peter Rohloff, a physician, and Anne Kraemer, a social anthropologist, who had just founded what is perhaps the first international non-profit in Guatemala with an explicit mission to deliver healthcare and health education in the preferred language of its target population — in this case, Kaqchikel Maya.
As my Kaqchikel improved, and as my engagements in specific communities evolved, Wuqu’ Kawoq invited me to take an active role in the organization’s most ambitious pediatric effort — the design, implementation and evaluation of clinical protocols to combat chronic child malnutrition. Over the past three years, there have been a number of exciting accomplishments with regards to child malnutrition. For example, in the first 18 months of our pilot intervention in an extremely impoverished target community on the southern piedmont, we saw the rate of stunting in under-2-year-olds drop from more than 70% to just 35%, an unprecedented change in a country with one of the longest traditions of modern nutritional research in the world.
What is it like practicing medicine “in the field” versus in urban and suburban clinical settings?
Many of the differences will be obvious to any clinician who has had the opportunity to take care of patients in the “Third World,” whether on another continent or closer to home, i.e. on Indian Reservations, the US-Mexico border, or even parts of LA County! Given the relative inaccessibility of the most basic labs and imaging, physical exams must be performed carefully and interpreted with precision. When, for example, is an echocardiogram indispensable to diagnosis of a murmur, and how quickly do you need it to be done? Given meager formularies and frequent stock-outs, how do you treat an infection when your first and second-line choices are both unavailable?
In rural Guatemala, however, longitudinal clinical engagements give rise to an additional layer of questions: why is there so much undiagnosed and untreated congenital heart disease in a country that boasts Central America’s most advanced pediatric heart institute, UNICAR? Why are antimicrobial choices so limited, and certain vaccines altogether absent, in places where infectious diseases are the proximal cause of so many childhood deaths?
Moreover, if we hope to accomplish more than just muddle along one patient at a time, we must begin to accept real responsibility for the development of effective community health systems and tackle still further questions: how do we improve the rates of detection, accurate diagnosis and timely referral of suspected cases of congenital heart disease in impoverished rural areas with low physician-to-population ratios? How can we ensure sufficient and reliable supplies of a broader range of antimicrobials — and free, universal access to vaccines deemed essential for the non-poor — even when the drugs and vaccine preparations in question are "protected" by the pernicious synergies of international free trade agreements and patent drug law?
In moving back and forth between the “Third World” and the “First,” global health practitioners are uniquely positioned to trace the mechanisms by which global structural inequalities cause preventable suffering and premature mortality among the poor. Ironically, then, practicing medicine "in the field," under a sometimes quite compelling illusion of isolation, can bring into sharper focus the broader social phenomena that make “the field” such a hard place to live and work.
Nonetheless, I have to admit that the illusion of isolation — and it is an illusion, and nothing more — does have powerful experiential and moral consequences for me. Taking care of patients in “isolated” rural hamlets means many house calls, and even “reverse house calls,” when patients come to find the physician in the latter’s home! In fact, the space that we call a “clinic” at one of Wuqu’ Kawoq’s child malnutrition sites is really the front room of a family’s home. Practicing medicine “in the field,” thus, is intensely immersive, permitting a closeness with communities, families and other US collaborators that is at once the best and worst part of working in rural Guatemala. Losing a patient is always difficult, but it can be devastating when the patient was the newborn daughter of a close friend and collaborator. Among the US staff members of Wuqu’ Kawoq, there is a shared sense of guilt, sorrow and indignation that accumulates from such traumatic experiences, making it very difficult, if not impossible, to walk away from “the field” and the people who live there.
What are the most challenging aspects of working with indigenous peoples? Do cultural values about health and the body impact treatment protocols?
I’ve had to learn to identify medicinal plants used for common ailments in indigenous communities, but this is really no different from the situation in the US, where the widespread use of “dietary supplements” is very well documented. And paying attention to ethnomedical nosologies — instead of simply dismissing them as bogus because they differ from my understanding — is necessary if we hope to provide high quality clinical services to any of our patients, whether they are Mexican-Americans in LA or Maya Kaqchikel in rural Guatemala.
I would even say that there is a lot that we can learn from these cultural differences, and even more that we can accomplish if we attend respectfully to them. For example, Wuqu’ Kawoq has integrated a variety of medicinal plants into treatment protocols for its community diabetes management programs in the central highlands, and the outcomes — both in terms of adherence and HbA1c’s — have been astoundingly good.
Indeed, I imagine that my experience as a US physician working in Guatemala is much less challenging than the experience of an indigenous person in rural Guatemala seeking to collaborate with or receive care from a US physician. I would not trust someone who did not acknowledge and affirm my illness experience and essentially refused to communicate with me in my preferred language, via a translator or otherwise.
And yet, indigenous people in rural Guatemala are routinely told, in Spanish, that their understandings of their illnesses are mere superstition. In in-depth interviews with mothers in one community, Wuqu’ Kawoq fieldworkers discovered that many patients experienced their therapeutic relationships with local clinicians as, in their own words, “abusive.” If medical care is to be a vehicle for social justice, clinicians must be wary of facile explanations that discount poor outcomes by labeling the indigent sick as “challenging.”
What inspired you to become a doctor and pediatrician?
Like many of my co-residents, I knew I wanted to be a doctor fairly early on. The decision to pursue post-graduate training in pediatrics, however, evolved over the past few years as a result of experiences in Guatemala. The intense fear that I felt as a fourth year medical student in rural Guatemala, trying to take care of very sick children and infants with very little resources, taught me that I needed more in-depth training and experience to care for children effectively. Given the demographics of rural indigenous communities, the majority of my patients in rural Guatemala are sick children. Given the epidemiology of rural indigenous communities, the majority of pediatric mortalities occur in young infants and newborns. In some of the communities where I work in Guatemala, my colleagues and I have conducted health surveys that reveal infant mortality rates of up to 120 per 1,000 live-births over the last 10-15 years. The signs and symptoms of life-threatening illness, for example sepsis and meningitis, can be so non-specific and protean in children that I could not imagine continuing to work in rural Guatemala without the breadth and depth of experience that programs like Harbor-UCLA Pediatrics has to offer its trainees.
In a broader, systems-based perspective, global pediatrics until recently has been a field dominated by public health experts. While much has been accomplished through their efforts, there is a dearth of clinical expertise in pediatric disease in much of the Third World. As the AIDS epidemic has evolved in sub-Saharan Africa, specific efforts have met some of the need for pediatric clinicians on that continent. In rural Guatemala, however, children with acute illness are often treated as if there were just little adults, and, moreover, coordinated care for children with chronic disease is either inaccessible or entirely nonexistent. As such, I felt that I needed to pursue specialized training in the health of children, not only to provide competent clinical care to my patients, but also eventually to influence the culture of Guatemala’s medical establishment and bring attention to the need for scientific rigor in the formulation of child health policy in the country.
Has your experience in Wuqu’ Kawoq helped you train to become a pediatrician in the U.S.?
Working in rural Guatemala has probably given me some clinical experience that is relevant to my training as a pediatrician in the US. In general, however, I don’t agree with the idea that “elective” experiences in the Third World automatically enhance the clinical competence of trainees, for two main reasons. First, with the growing popularity of “global health,” the quantity of international elective offerings for US-based trainees have multiplied at the expense of quality — to the point that such opportunities more often resemble “medical tourism” than “medical service.” Second, this idea is ethically troubling, as it converts the sick and poor in places like rural Guatemala into “teaching cases” for US-based trainees, thereby obscuring the moral significance of differential suffering and its structural causes.
Nonetheless, my ongoing engagements in rural Guatemala help me to keep in mind the competencies I need to master during my training so that I will be able to respond better to the needs of communities there.
How would you advise future pediatricians interested in helping disadvantaged communities overseas?
I can offer two important suggestions from my mentors that have served me well thus far and that I think might be useful to all prospective pediatricians-in-training who want to work in the Third World.
Pursue a residency program where you will come out an excellent clinician. Harbor’s pediatrics program provides its residents a high volume of pathology, autonomy in decision-making, procedural experience and close interaction with leading specialists in general and subspecialty pediatrics. As a result, the third-year residents at Harbor seem like they are capable of handling anything.
Think strategically and seek mentorship. To take on the powerful forces that assault the lives of the indigent sick, we must learn to establish and mobilize a whole range of strategic alliances between academic institutions, governmental entities and non-profit organizations. At Harbor, I have benefited greatly from my interactions with a number of faculty members — from recommendations on how to manage specific patients I take care of in Guatemala, to guidance on how to begin tackling pressing public health needs that have not been addressed by PAHO (The Pan American Health Organization) or Guatemala’s Ministry of Health. If my colleagues in Wuqu’ Kawoq and I are able to continue doing good things in rural Guatemala, it is because we have benefited from the support and guidance of many people, including several of the amazing faculty members at Harbor-UCLA Pediatrics.