In the middle of his third year of medical school, Eric Nagengast realized he wasn’t ready to graduate just yet.
“All of my classmates were talking about applying for residency, but I was not ready for all of that. I remember thinking, now is the time to get global health experience. If I don’t do it now I may never get a chance,” Nagengast said.
He had pursued a career in medicine because he was fascinated with people and programs that provided medical care for people in remote parts of the world. Before starting medical school, he volunteered with Mission of Healing Eyes, a charitable organization that provides eye care in Mexico.
“As I watched people who had been blind leave the clinic with perfect vision, I vowed that I’d continue to help people in this way,” he said.
Nagengast searched for international surgical programs and eventually gained acceptance into the Program in Global Surgery and Social Change (PGSSC) at Harvard Medical School as a Paul Farmer Global Surgery Research Associate, a position that has taken him to the far reaches of the world.
PGSSC addresses disparity by providing global surgical and anesthesia care to people in resource-limited settings. Nagengast started the year-long program last summer with classes at the Harvard School of Public Health and then was assigned three major projects – the Lancet Commission, cleft lip and palate surgery in India and Columbia, and ear, nose, and throat research and care in Rwanda.
The Lancet, one of the highest impact journals in medicine, recently formed commissions on important areas of medicine that need more direction or consensus. The goal is to increase foreign medical aid for surgical programs, which now stands at less than 1 percent of the total of medical outreach funding.
This year marked the beginning of the Lancet Commission on Global Surgery. PGSSC collaborates with King’s College in London and Lund University in Sweden to spearhead the commission. Nagengast served as research assistant for the information management group.
His group was tasked with advising global surgery metrics – basically, determine the type of data needed to be collected to monitor the status of surgery in low and middle income countries.
“This is not as easy as it sounds,” he said. “Medical records are quite poor in some areas. They are not using Epic (an electronic health record vendor) in Rwanda. The final paper will definitely be a landmark paper, but most importantly, it will get recognition in the field.”
In India, Nagengast worked in Operation Smile, Guwahati Comprehensive Cleft Care Center in Guwahati, the highest volume cleft center in the world. Surgeons performed more than 8,000 operations in the center’s first three years. He worked on several research projects, the largest of which was on the quality of life of patients, and families of patients, who have cleft lip or palate.
“Many people in India live their entire life with this birth defect without access to surgical care,” he said. He interviewed patients and family members regarding the impact the defect has on their quality of life and economic productivity.
He also studied the financial impact the center has on the region. “Before the center was built in Guwahati, cleft care was provided by international missions. The center provides training, salaries for local employees and increased productivity. Now, Guwahati has more qualified health care providers, more money flowing into the region and a lower number of untreated cleft patients.”
Nagengast saw patients pre- and postoperatively and participated in surgery. “I learned from some of the best cleft surgeons in the world and have seen more cleft operations this year than any plastic surgery resident in the United States.”
One of the most remarkable cases was a baby unable to breast feed because of a cleft lip and palate. “This child was skin and bones. To be honest, I couldn’t believe the baby was still alive. He was put on a nutrition program, brought back to a healthy weight and operated on. It was a second chance at life. In reality, that is what the center provides all of the patients… a second chance at life.”
In Rwanda, Nagengast worked at the University hospital in Kigali with the otorhinolaryngology team on ear, nose, and throat disease research projects. Part of his research demonstrated how the lack of care created a burden for the country. “We hope these projects will help establish education and training for primary caregivers to manage ENT disease before it becomes a surgical condition,” he said.
While there, he also volunteered with the Starkey Hearing Foundation to provide ear examinations, basic ear care and free hearing aids. In one day he examined 250 patients. He performed otoscopic examinations at several missions and follow-up clinics. At a school for deaf children, Nagengast tested children whose ear disease could not be helped by a hearing aid. He recalls one child who could hear and was fitted with a hearing aid. “Hopefully, this child can return to traditional school and live a normal life.”
Nagengast said he could write a book about what he’s learned this past year, but his two main lessons: Every student could benefit from spending time working with a marginalized population, and all students in medical school should take an extra year to pursue research, extra clinical experience or another degree.
“Most people in medical school chose this career path because they want to help people. It is easy to get caught up in the long hours and hard work and lose sight of this amazing side of medicine. But, spending time helping people who would not otherwise receive care reminds you of the incredible power we have as health care providers.
“I also have learned about providing care in low-resource settings. One of the most important things I have learned is that context is key. Every place you work is different. And, you need to understand your environment, the local health system, and the population you intend to treat before you can make any plans.
Having a big heart and good intentions is not enough,” he said. “This year has made me thankful for all I have and the opportunities I have. But, it also has made me much more aware of the injustices that exist in our world.”
The only downside to Nagengast’s year abroad: all his classmates graduated without him. “It would have been nice to be on stage with them. Now they all make me call them ‘doctor.’”