Anne Zimmerman:

Hi I’m Anne Zimmerman and this is the Voices in Bioethics Podcast. Today we welcome Marc-David Munk to the podcast. His book Urgent Calls From Distant Places chronicles his time as a doctor with AMREF Health Flying Doctor services in Nairobi with the organization Dr. Monk provided emergency medical services to people in need across the region traveling to Rwanda, Tanzania and the Democratic Republic of Congo among other East African countries. Welcome to the podcast.

Marc-David Munk:

Thanks, Anne. Nice to be here.

Anne Zimmerman: 

So what drew you into emergency care? And was that even before you went to medical school that you started to have that interest?

Marc-David Munk:

You know, I fell into it, as I say to some people, and it’s like a nice accident that happened. I was I was in upstate New York at college, studying the humanities like philosophy and religion, and didn’t have much of a sense of what I was going to do with myself momentarily entertained an idea of being a writer. But I fell fortunately into the local towns Volunteer Ambulance Service and Fire Department when I was just a freshman in college. And it was one of those things that I immediately loved, and recognized that this was the big break, and this was going to be destiny. The problem was, when I made the decision to go into medicine, it was pretty late in the game. And I had to go back and do all of my science, again, to get into medical school, which took a couple years, but it did become a passion, but a bit late.

Anne Zimmerman:

Right. It’s very interesting. And it’s nice to see that kind of passion. So do you also have some particular interest in flying and aviation? Or how did it come to be that you would end up in that field.

Marc-David Munk:

I’ve always loved it. I’ve loved flying, I’ve loved being on the road, I’d love traveling in faraway places, they’ve all been passions of mine, I gave some thought to being a pilot once and did actually take some private pilot classes. And I realized a couple of classes in that there was a good chance that I was going to kill myself, like small airplanes that doctors are notoriously bad pilots. And this was the surefire way for me to end my life sooner than I would have hoped. And so I stopped taking the lessons, I realized my boundaries, I didn’t have time to devote to it and stepped away. But I’ve always loved being in the air.

Anne Zimmerman: 

And what really inspired you to travel to Africa, and to provide emergency medical care there and to do it in that way, flying in planes and everything.

Marc-David Munk:

I’ve had a passion for international medicine for some time. So after I finished my training and emergency medicine at the University of Pittsburgh, I went back and did a one year fellowship and international medicine and spent a lot of time really studying infectious disease and tropical medicine and diseases that are endemic to the developing countries and really wanted to spend at least a portion of my career working in those places. Simultaneously, I kind of hit a wall early on in my career as an emergency doctor in the ers, I realized that I really wasn’t well suited to spend the rest of my career showing up and seeing patients in the ER, I was just, I think, maybe had too many competing interests, and was also a little dismayed honestly, by the way that emergency medicine was being practiced, it was really very much a victim of a broken healthcare system, where visits had been reduced to just a few minutes at a time and patients were cycling through quickly. And we just didn’t have the time to do the work that we wanted to do. So for me, Africa was an opportunity to get away and clear my head a bit and figure out what I wanted to do next with my career. And it was just one of those fortunate things. I had sent an email to Africa, there was an organization AMREF Flying Doctor Service, I’d heard about them tangentially there was somebody in our family who knew somebody who knew somebody who had been there a couple of years earlier. So I sent them an unsolicited email. And I said, Listen, I’m a doctor specializing in emergency medicine, would you be interested in having me come for a visit and they got back and it was like one of those break breaks that you got some times in your life? They wrote back and said, hey, it turns out that we have an opening next month, can you be here in like four weeks, and I brought them back? And I said, Absolutely, I can be there in four weeks and got my Kenyan medical license and packed my bags, and I was on the road.

Anne Zimmerman: 

That’s great. It’s so exciting. That’s a huge life change to make. And interesting that you would do it in the wake of noticing some of the problems with our healthcare system. I’m sure that that put you on extra notice of what might be broken in the health care systems throughout the world. And you were also mentioning your dedication to studying and learning about tropical disease. So how many of the cases that you saw in East Africa were kind of preventable diseases? And what types of preventable diseases Did you see there?

Marc-David Munk:

So very interesting epidemiology of disease. And they were different. I went on two trips to Africa. The first one is in 2008. And the second was in 2012. And actually, in the book, urgent calls from distant places, the first half of the book, or the 2008 calls, the second half of the book of the 2012 calls and I think they’re really profoundly different sections of the book. They have got a completely different vibe in the first half, I would say either there was a certain innocence to Africa. And it went, the types of patients that we saw were, for example, tourists who had contracted bad malaria. There were a number of people in severe motor vehicle accidents, both local children, Australians on motorbikes driving too quickly, a range of viral diseases, bacterial diseases, a number of heart attacks and strokes. And so what we didn’t see in 2008 was a lot of islands there was these are really diseases about trauma and medical, but were they preventable, of course, they were preventable. I mean, there was better road safety would have contributed prophylaxis against malaria, better malaria, insect control would have helped for sure. But what we saw in 2012, was dramatically different. This was actually after really a critical time, in Kenya, there had been an outbreak of severe violence that had flowed over the borders, from Somalia into Kenya. And if you remember, back then there were actually numerous instances of terrorism, there had been bombings in malls and people had been kidnapped and shot and there was really a cloud of fear that had descended in East Africa. And by the time 2012 came around, we were suddenly flying doing missions for the UN, for example, there were soldiers that we meant to go collect in Somalia who had been shot, there were servicemen who were their American servicemen who were there trying to keep the peace, who we had some medical evacuate out of East Africa as well. And so the vibe significantly changed. It’s an interesting question me how much of 2012 was preventable, I would say, a good amount, but preventable for different reasons, right? These were probably politically preventable, not medically preventable.

Anne Zimmerman:

Sure, very interesting, and great that you experienced the two different times I think the breadth of experience you got was really important as well. So a lot of the stories really focused on individual care, I remember reading the story of the two year old who had been in their mother’s lap rather than in a seatbelt and that kind of thing. But that focus on individual care also comes off as kind of difficult to reconcile with public health failures. So how did you reconcile the two or the thought between, you know, kind of flying around in a relatively expensive airplane, while there are diseases of poverty, and the people you’re going to help are sometimes people living in that impoverished world where they didn’t have access to some of the public health safety nets that we take for granted?

Marc-David Munk:

Yeah, I mean, such such a bunch to unpack here Anne. And I so let me start sort of by saying I had trained in public health just before I went into medicine, so I came with both the public health worker background and a physician background. And one of the interesting things about spending time in Africa was that really the first time in quite a while I had felt this profound tension between those two sides of my training, they were in conflict quite regularly. So I’ll give you a few examples. We had flown in to collect a patient who had some sort of an infection. And when we went to go find him on the runway in Ethiopia, we found a guy who was super sick, nothing was working in his body, his kidneys were shutting down, his liver was shutting down, I looked at my nurse and I said, you know, I’m really a little bit frightened that this may actually be a viral hemorrhagic fever, like highly contagious, like Ebola, there had been a similar episode, not long before in South Africa, where somebody with a hemorrhagic virus had gotten on a flight, and had gotten a bunch of people sick. And so this wasn’t an academic exercise. And I remember thinking to myself, I’m a little bit torn here, because of course, I have a significant doctor patient responsibility to the man in front of me, I’m his doctor, now I’ve taken responsibility for his care. But of course, we do run the risk of really disrupting public health in a big way if we fly this guy to Nairobi, because then we could potentially infect millions of people in Nairobi. So I had these two competing concerns. I mean, it’s I had this absolute responsibility and duty to the patient in front of me, I had this more theoretical responsibility to this larger group of people I haven’t met, but potentially many more of them than the patient front of me. And I honestly had never had to deal with that before. We had never sort of put an asterisk next to the Hippocratic Oath when we took it. And so that was something to work through at the scene, it was, you know, really a complex question for us. The other one more generally, is this question that you raise, is this the appropriate way to be using resources, so every time you launch an aircraft, and AMREF goes to collect the patients in the periphery of outlying 11 outlying East African countries, and bring them back to Nairobi that we burned 1000s of dollars in fuel, and we have the most advanced ICU and state of the art aircraft, and each of those missions is enormously expensive, especially when compared to the cost of say, providing a vaccine or providing basic preventive services to young children in Africa. I mean, you could do 1000s of vaccinations for the cost of one flight. And I really struggled with that question. When I finally decided at the end of the day was that I certainly wasn’t in a position to answer that question. I wasn’t entirely sure who was in a position to answer that question. And of course, it mattered a lot. You happen to be the patient who was sick on the edge of the runway. In those circumstances, getting evacuated by an ICU level air ambulance would probably be the most important thing in the world to you and your family. And so what I realized that the time was that we had a very high functioning air ambulance service, one of the best in the world. They regularly win awards for being best the international air ambulance and I really couldn’t imagine chopping them off at the knees in the name of some more abstract or theoretical concept of vaccinating children, because what I have come to realize is that, of course, there is an absolute scarcity of resources in Africa, it’s a common problem. But resources aren’t the only factor in Africa, a lot of it has to do with your organizational ability to execute it to cut programs done and those sorts of things. And so just simply shutting down a high functioning air ambulance, and diverting the money someplace else wasn’t a guarantee that anything was gonna happen from a public health perspective. And so these are the questions that came up again and again. And I, as I say, in the book, I didn’t necessarily have great answers. I mean, unlike you, I’m not an ethics expert, I really didn’t have a deep bioethics background, but I did struggle with them in a thoughtful way. And I think came to came to terms with the work that we were doing. 

Anne Zimmerman: 

It’s interesting work, and it’s definitely saving lives and has that importance. I think another question is sort of about the financing. I mean, if you didn’t have this service, there’s no reason to think that that bucket of money was going to go help others anyway.

Marc-David Munk:

Yeah, the way Flying Doctors works is that they get money from a couple different places. Mainly, they get it from travelers who have health insurance, or travel coverage. And so they can build the insurance companies and they get reimbursed for services. They also have a subscription program where if you are a Kenyan, for example, you can pay the small amount of money every month and have a card as the almost like a triple A card where you can you can call the air ambulance when you need it. And then of course, there was a charity fund as well, that provided services to people who didn’t have access to it otherwise. But it’s not like AMREF was being funded by governments. In fact, that was completely separate buckets of money. There was obviously some philanthropy that that came through AMREF they well known NGO. But yes, you’re right. I mean, these were different buckets of money. And there was no guarantee that shutting down, one of these sources of care was going to have any effect on the other.

Anne Zimmerman:

And then just to compare, not exactly public health initiatives, but just different versions of ways to deliver individual care. You know, a lot of times in the book, you mentioned the stories of people who were kind of left behind. So you know that the families and other people or even in some cases, other sick people are there, but you are on your mission to pick up the person you’re sent to pick up. And I concluded that you find it especially satisfying, to truly care for the individuals that you’re caring for which is understandable and the role of the doctor. But did you do feel like resources really should go to changing the individual clinical delivery of care in those areas? I mean, are some places too rural to need sophisticated hospitals? Or do you think that that’s a need that they need their own medical infrastructure?

Marc-David Munk:

You know, I think you’ll always need medivac, no matter where you are, I mean, certainly in the US, there are medivacs that happen every day, from outlying hospitals, bringing patients back to to university medical centers, and so that need would never go away. But there was a bit of an absurdity to these cases, there was one in particular at the beginning of the book, where we were called to Western Kenya to pick up a fellow who had a severe infection and wasn’t able to breathe on his own. And so we have the scene in the book where we go into a dark hospital in the middle of the night, and you maybe you read this particular story, but it’s this scene where we finally make it to the bedside, we’re in a long dormitory with 15 or 20 patients, all of them very sick and not receiving much service, because we’re just there wasn’t ready access to intensive care level service in Africa, extremely resource constrained. And we have this almost absurd situation where my nurse partner and I put a breathing tube into a patient to put them on a ventilator and get the drips going and give him antibiotics and do all of these things and get them onto the air ambulance. And we leave behind 14 other patients who were similarly ill. Now he you know, this is kind of tough, you throw your hands up and say, I’m not going to take care of the one. And because there should be some sort of egalitarianism, I don’t know. But what I do know is we were there to save this one fellow. And we did, and it was what we could do with the resources and circumstances that we had. And so I never second guessed the work that we were doing.

Anne Zimmerman:

So why in that scenario, why don’t the other people have access to you? Or to a version of you? Or another brand of you? Why don’t they get that kind of care as well? 

Marc-David Munk:

Yeah, you know, I never fully understood who, who got flown out from those places. And who didn’t, I think a lot of it had to do with certainly insurance coverage. A lot of it had to do with the availability of charity resources, a lot of it some of it had to do with I think, who was able to make connections at the University Hospital and arrange for an open bed on the other side. This is always kind of the funny thing when you’re in a foreign country is that you never fully understand how decisions are made or how things work. And I do say this in the introduction to the book, which is that I was I was a short term visitor to Africa, and I did what I could as a doctor, if you were to make the claim that I knew deeply how things worked, I would say you’re exaggerating, and I didn’t really have much of an idea how things worked at all, but my suspicion was that’s kind of how it happened.

Anne Zimmerman:

So switching gears, then you know that Nairobi had a lot of economic improvement and there was sort of a rise of affluence and In the region, did you find some downsides to that affluence? Or is there more inequality in the region? And how did that impact your work?

Marc-David Munk:

There was a really interesting phenomenon that when countries become more affluent, they start developing a lot more what we call time sensitive illnesses. So if you think back to the way medicine is practiced, maybe 20, 30, 40 years ago, in Africa, as an example, you tended to have a lot of people with the same malaria, infectious diseases, they tended to be quite young people didn’t live a long time. And so when people got sick, typically, it wasn’t an extremely time sensitive illness. They were the types of illnesses that a doctor could come by in a couple hours or a couple of days and give you treatments. And they were more indolent in their presentation. And what happens as you become more affluent is people get fancier cars, and the roads get bigger, and people drive faster, and the crashes get worse. And at the same time, these are people who suddenly are eating Western diets and putting on a lot of weight and developing diabetes and having heart disease. And there are really three conditions that are extremely time sensitive. One is trauma, we have this concept of what’s called the golden hour in emergency medicine, which means that you really want to be from the scene of a crash into a trauma center within an hour to maximize your your outcomes. And the two other time sensitive illnesses are things like heart attacks and strokes where you need to do an intervention really quickly in order to save heart function or brain function on the other side. So paradoxically, as these places got more affluence, these types of diseases began presenting themselves. And they require things like air, ambulances, and much more effective trauma centers and grab mace, the ambulances and things that would respond quickly. And the challenge to the country, of course, is that it’s one thing to provide basic clinics with rudimentary primary care services. And it’s a whole other thing to provide 24/7 trauma centers and cardiac centers and cath labs and air ambulances, the costs are exponential dealing with those things. And so these were the consequences of affluence. And you know, paradoxically, although money was going up, and government revenues were going up, I think the aggregate health care costs and expectations went up even faster than the money coming in.

Anne Zimmerman:

That sounds really similar to our country. It’s the similarity of the increase in chronic disease and swapping out chronic disease for more viral infections and that kind of thing that are quick to come and go. That’s put a lot of pressure on our health system as well. And then I think another added circumstance in Africa would be that you also have the continuing prevalence of some tropical diseases and things like that at the same time. Did you feel as the affluence increased that you had to shift and miss out on some of the cases of helping the impoverished and the people suffering from those tropical diseases?

Marc-David Munk:

We had a nice mix at the Air Ambulance AMREF itself is an interesting organization. It was founded back in 1953. By three physicians, there was an American plastic surgeon actually, with an interesting story. I won’t bore you with the details, but a fascinating guy called Sloan Reese, and then two Englishmen, one of whom had been the chief surgeon for the Royal Air Force in World War II. And they had set up this ambulance basically, it’s three doctors flying around and setting up clinics. And it had evolved over the years into this larger organization called AMREF, which had as one of its wings Flying Doctor Service, which was the organization I was working with this, this medivac service. But MF also does a bunch of things such as surgical outreach, and public health and hand washing and maternal health and health health worker training. They have a healthcare University in Nairobi. And so the the broader organization is very involved in all aspects of the health care journey, everything from primary care, which has been their real focus, actually, for the past five or 10 years, establishing a much better primary care network for Kenya in particular, but really much of much of East Africa, but also, you know, hand washing clinics, surgical outreach, and then the ambulances, the smaller parts. So I didn’t deal with the day to day but you know, as a flying emergency doctor, I didn’t deal with things like hand washing and malaria prophylaxis, but other people in the organization did.

Anne Zimmerman:

Interesting. So I do you have a last question that kind of brings things more to the US in the United States, public health and safety are really pervasive. And while they’re clear public health failures, we do have a system in place to try to prevent accidents, seatbelt laws, things like that, and to prevent preventable diseases and foodborne illnesses. How do countries in East Africa differ from the US in that? Do they have a different approach to public health and safety? 

Marc-David Munk:

Yeah, I was really struck. I was really struck by this because at the time that I was going there was kind of a rise I would say, in the US of libertarianism where everybody you know, wouldn’t be commenting in the press. We you know, we don’t want government intervention. We don’t want government telling us what to do. You know, you can’t tell me to wear helmets. There were helmet you know, motorcycle helmet laws that people were pushing back on. There was just generally this really big tea party type push libertarian push against governments intrusion in day to day life. And I thought after the fact that in a lot of cases, libertarians are like house cats, right. They’re profoundly convinced of their own independence, but absolutely dependent upon others to feed them and take care of them and not really appreciative of that fact. And so when you go to Africa, you realize that we take so much of this for granted. A bottle of water on the side of the road is pretty easily contaminated and gets you sick. The roads are not designed to any particular standard or specification. Nobody wears seatbelts and they speed. So there is this whole safety net that I realized we took for granted in the United States that surrounds us. And we’re not, we’re not even aware of it. I mean, the fact that you can open a package of food or open a bottle of water here, or go to a restaurant, and this this invisible public safety system is supporting our wellness is so profound, because it’s not there in Africa. And you’re so aware of it when you see bad accidents, for example. 

Anne Zimmerman:

Interesting, I can see how it’s really controversial here that some people would say it’s almost this paternalistic baby setting. But at the end of the day, we take advantage of it all the time. And we do have a lot of trust, especially in things like food safety and highway safety here. The one thing I did not ask you about the question of whether the doctor patient relationship was different, and whether the respect for a doctor and the respect for a Western doctor in particular is sort of a different thing from the doctor patient relationship you have here?

Marc-David Munk:

Oh, I love that question. It’s such a good one. So this was a very interesting thing. There was one particular case that I’m thinking of where we were flown to the north of Kenya to pick up a little boy who had been hit by a car. This was the Daasanach tribe. They were a small tribe in the northern part of Kenya, they didn’t speak Swahili, which was the local language in Kenya, and they were really, really rural pastoralists. And we got a call to evacuate this little boy, because the surgeon who normally covered that county in Kenya was for some reason at a conference or had left town and there was nobody to do surgery. So we flew up into the north. And I remember meeting this little boy in his family, for the first time very simple people, it had been the boy’s first trip in a car, they had flagged down somebody who knew somebody who had a car, and they put the family into this car, and they drove three hours to make it to the airstrip. And certainly when we met them, this would be the first time that this family was going on an airplane, they had never set foot in the plane before. And so my nurse and I, we stabilized the little boy, we met the family, none of us could communicate, they didn’t speak English, they didn’t speak Swahili, we did certainly didn’t speak the local dialects of this tribal language. And so we communicated through hand gestures, and it just kind of pointing to one another and indicating what we wanted to have happened. And I remember being so struck by this experience, because here was this family who are carrying in a plastic bag, probably all of their worldly possessions. And here was the stranger who showed up in their lives. And I remember being so struck by the fact that these people had this absolute confidence that I would do what was in their best interest in the best interest of their boy. And I distinctly remember this, this young woman, she was veiled. She was shy, and she handed over her little boy into my arms, and let me carry him onto the airplane. And I remember thinking, what an enormous amount of trust you must have when you’ve had so few experiences in the big world. And this person shows up and takes your child, I mean, what an enormous trust that you must have. I remember being so touched by the experience and how much of an affirmation it was that I had picked the right profession, and that I was doing the work I was supposed to do as a doctor really, really touched by it and struck by it. And I came to realize, I think there’s something if we’re doing it right universal about the doctor patient relationship, where it transcends culture, transcends language, it transcends experience, it transcends religion. There’s just something very basic about this. And this is a phenomenon that has gone back thousands of years. And I worry today, frankly, in American medicine, that we’ve really lost sight in some ways of the importance of that caregiver patient relationship, we’ve become really all about widgets and our views and seeing a certain number of patients in a certain amount of time and generating surpluses and those sorts of things. And caregiving has become commoditized. And it’s ruining, I think the experience for both patients and for caregivers, and I think is in large part driving much of the burnout that we see in western medicine today. And so for me, the experience in Africa, very much reaffirmed medicine is the decision I should have made and did make. And it pushed me to try to get back to the US and improve the system in any way that I could. And so for me, when I got back from Africa, it was a pivot out of the emergency room, paradoxically and into more startup innovation type environments where I could help create better systems of care for patients. And that’s really guided me for the past decade of my career.

Anne Zimmerman: 

That’s really interesting. It sounds like you learned a lot about common humanity. And without even having the same language, you can communicate in that doctor patient relationship, which really does remain special. And if our systems here are respected, it will continue to remain special, especially in light of how much patients really need doctors and scientists. So thank you for joining us today. It’s been a pleasure to have you.

Marc-David Munk:

Thanks so much. It’s been it’s been fun. I’ve had as I saying it’s really nice to have a discussion about the bioethical implications of the work that we were doing. 

Thank you. Yes. So this has been the voices in bioethics podcast with Dr. Marc-David Munk, author of Urgent Call From Distant Places Thank you.