The patient was feeling more miserable than she ever had before.  Fevers racked her body into uncontrollable rigors, and every joint hurt.  An unforgiving headache had settled behind her eyes, and refused to leave. After performing her initial evaluation and making sure she was stable, we left her in the observation room and crossed the hallway to the medical laboratory in the Health Unit inside the U.S. Embassy in Namibia. 

Our astute lab technician, a Namibian himself, gestured to the microscope to show us the rings and trophozoite forms inside her red blood cells he had easily identified.  This patient had previously declined our recommendation to take malaria prophylaxis throughout her tour in a malaria-endemic region. This is not uncommon; there are a variety of reasons people choose not to take malaria prophylaxis, ranging from not believing our recommendations to fear of side effects to just not being able to remember.

It’s important to initiate treatment for malaria as soon as possible.  We administered the medication immediately.  Most U.S. Embassy health unit pharmacies stock emergency medications like Coartum, a treatment for malaria, so that we don’t have to delay treatment. Fortunately, our patient did well and made a full recovery. Not all cases end this well.

US Embassy, Kigali, Rwanda

My name is Becky Stafford, and I’m an American internal medicine physician living and working abroad in the Foreign Service.  Currently, I serve in the health unit inside the U.S. Embassy in Kigali, Rwanda.  My husband is a foreign service officer, and he is actually the reason we’re here.  We have two elementary-aged children, a dog we left behind with family in California, and, hot off the presses, a kitten. 

I don’t see “tropical” diseases as often as one might guess. My patient population consists only of the U.S. Embassy-affiliated Americans and their families.  We are a very privileged population.  We have access to clean drinking water, sanitary food practices, the appropriate travel immunizations, and anti-malarial medication if they choose to take it.  Still, illness can and will happen.  Infectious gastroenteritis, commonly known as “traveler’s diarrhea”, is more common here but rarely serious.  You are much more likely to receive antibiotics for diarrhea here than if you present to a U.S. emergency room.  We even have a cool machine in our lab where we can run a PCR of common GI infectious organisms and tell people exactly how many “bugs” they have.  Sometimes it’s several.  It’s a good reminder for folks to bleach their produce and scrub their eggs.  

One infectious disease I see more often here than in the U.S. is latent TB.  For people who have lived or worked in TB-endemic countries, we offer PPD or IGRA testing at the end of every tour.  It’s not uncommon for someone to convert.  Another test we offer at the end of someone’s tour is schistosomiasis antibodies.  Schistosomiasis, sometimes called Bilharzia, is commonly present in African freshwater lakes.  Its life cycle involves snails. Lifelong chronic exposure to them can have dire health consequences. However, our population’s exposure tends to be much more limited, and I have fortunately never seen a case of acute schisto or sequela of chronic exposure.  Occasionally, we identify antibodies, and the treatment is an easy one-day anti-parasite regimen.  Speaking of parasites, we also sometimes see roundworms (ascaris) or entamoeba histolytica.  

Challenges of Working in a Resource Limited Setting

A more common challenge I face at work is managing a routine issue in a resource-limited setting.  For example, imagine a woman is 28 weeks pregnant and begins spotting.  We live at least 1000 miles from a Level 3 NICU.  How much do I, an internist, trust the local OB/GYN to assess the situation correctly?  To no fault of the local physicians and surgeons, in many cases, their medical education and practice standards are not on par with the U.S.  Should I “medevac” (send the patient back) to the U.S. on a commercial flight that will take more than 24 hours?  Or would I consider sending her on a shorter flight to a nearby country with better medical care but still not as good as the U.S.?  Or am I facing an air-ambulance situation?  Maybe it’s not safe for her to get on a plane at all, and I have to deal with the cards I am dealt utilizing local resources and digging deep from my own clinical experience. 

In my years abroad, I have had a case of an acute abdomen that couldn’t wait, and I had to go to the OR that night at our local hospital.  Some of my colleagues have had to urgently med-evac a decompensated case of malaria or ongoing acute stroke symptoms.  While we do have air-ambulance capabilities, there are no planes parked on a given U.S. Embassy compound.  In conjunction with local medical care, when available, we still have to keep the patient stable until the plane arrives from wherever they are staged.  

Most of our medevacs, however, are a much slower roll.  For example, myself or a local dermatologist may do a punch biopsy of a suspicious mole, but if it turns out to be something that needs a Mohs surgery or a wide excision, we will send them out on a commercial flight.  Fractures and broken bones can be similar, depending on the location and severity.  We or the local orthopedist can obtain the initial imaging and put on the initial splint or cast, but anything that might need surgery usually gets sent out as well.

Running the Health Unit

Those are the more exciting moments in the health unit, but most of my days are uneventful, sometimes even mundane.  Our patient population is a fraction of a typical U.S. practice, so it’s not the 20-40 patients a day you would see in a stateside family practice.  Also, families who are posted abroad to resource-limited settings are generally healthy and don’t tend to have complex chronic conditions. There is no way that someone who is on dialysis or undergoing active chemotherapy could be safely managed in some of these austere environments.   

A lot of our work is administrative and has to do with the actual running of a health unit itself. At my current post, we have a full lab complete with a lot of equipment (better than some of our local hospitals) and an excellent laboratory technician.  The lab machines need calibration tools, solutions, and maintenance.  We have a system to dispose of hazardous waste.  Our lab technician monitors cafeteria food safety.  We also run a small pharmacy, so ordering, tracking, and inventory are constant challenges.  A medication you need a large supply of in one month may be obsolete several weeks later, and all of them may end up expiring.  We stock and maintain emergency equipment throughout the Embassy, such as trauma bags and AEDs.  We write “cables” (think of this as an email template) to organize medevacs and the funding for them depending on the patient’s host agency.  

From Wellness Programs to Mass Casualty Training

We run wellness programs ranging from health information sessions upon arrival to post or on a given topic (such as women’s health, my personal favorite).  We provide first aid training and mass casualty training.  We spend time preparing for a number of emergency scenarios we hope will never happen (i.e., death or sexual assaults at post).  We meet and vet local physicians, clinics, and hospitals and see who we might use as a local referral base for our patients.  Sometimes, we accompany patients to appointments if necessary.  We liaise with other government agencies such as DoD, CDC or USAID when need be, especially when there are outbreaks of diseases like Ebola or Zika and the like.  And there are a lot… a LOT… of emails, paperwork, and meetings.  What is a Government without bureaucracy? 

A Family or Urgent Care Practice on Steroids

We provide primary care, from well-child visits to vaccine programs to prenatal care to adult preventative care.  We do intake and outtake visits to review vaccines.  We help people coordinate needed medical appointments back in the States on occasion.  We also address many common non-urgent health concerns, running the gauntlet from headaches to birth control.  And sometimes, there are more urgent ones, like a laceration or a panic attack.  It’s like a family practice and urgent care practice on steroids. Your clinic is located in the same building where all of your patients work, and your patients are also your neighbors, colleagues, and sometimes family members.  It can sometimes get a little… claustrophobic.  

Luckily, I do not do all of this on my own.  Most of the work described above is done by the whole team.  How a given health unit is staffed depends on the size of the Embassy, the location of the Embassy, who is available, and how acceptable local care is.  At my current post, we have an American MD, an American PA, two local RNs, a local administrative assistant and a local lab tech.  Some places are so small there is only a local RN.  On the other hand, the Embassies that are also our med-evac centers are much larger.

It Wasn’t What I Expected…

To sum it all up, working in an Embassy Health Unit was not what I would have expected it to be.  Having previously been a hospitalist, working in a family-practice type of setting has really broadened my horizons from just getting better at primary care to having to manage clinical situations far outside of my comfort zone.  All of my patients are also my friends and colleagues, so this is a unique dynamic.  

Finally, I have really enjoyed working in a close team environment ( (rounding on the floors tends to be a fairly solo activity).  This has pushed me to grow professionally in the realms of teamwork, leadership, and management.  The work-life balance is generally great.  The hard part is being on call 24/7, but with such a small patient population, this is not often that disruptive.  I otherwise never have to take work home with me.  I have time to be involved in my children’s school and pursue personal interests, and that is not something I take for granted. 

This isn’t a long-term career for me since I am the “trailing spouse” in our family, but it is possible to make this your long-term career if your specialty is IM, ER, or FP. More on that in the next blog!  

If you’re interested in joining the Foreign Medical Service, learn more and browse the available jobs here. 

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(Names, dates and places have been altered to protect patient privacy, but the stories are true. These are the personal observations and experiences of Dr. Becky Stafford, and do not represent those of the U.S. Government.).