By Dennis Gates, MD
I have been taking part in medical missions for more than 50 years. My first trip was as a medical student at Loyola University, when I worked as a laboratory technician for a couple of doctors in Brazil. That experience enlightened me to the far greater need for orthopedic and medical care in Brazil than in the U.S. A child in America with a club foot is going to get treatment somehow, whereas in Brazil, that’s not the case. There aren’t adequate medical facilities, and patients can’t afford treatment or simply don’t have access to care. Then, two years in the Peace Corps as a family doctor in Nigeria and Ghana reinforced to me the incredible medical needs of developing countries.
Once in orthopedic practice, some colleagues and I started making regular mission trips to Brazil. We’d go down to a little clinic on the Amazon River, called Esperanca, to perform many surgeries and train orthopedic residents. When we started in the mid-1970s, there was only one local orthopedist; by the time we stopped making the trips 30 years later, there were seven well-trained orthopedic surgeons in town. That was pretty satisfying.
In the 1980s, the IM rod (a metal rod inserted into a cavity in a broken bone to support it and hold it straight while healing) became commonplace in the U.S., and continued improvements in technology and technique made this the gold standard of care. Today of course, IM rodding is done with minimal incisions and within 24 hours of injury. But this great care is not available worldwide, because the rods themselves are not available to the average poor patient; or, if they are available, surgeons cannot insert them. The reasons for nonavailability are mainly cost — the patient must buy the implant before surgery — lack of imaging, poor hospital conditions, and surgical delays ad nauseam.
In the 1990s, Lew Zirkle — a dynamic orthopedic surgeon from Spokane, Washington, and one of my heroes — developed and self-manufactured an inexpensive IM rod that could be inserted without X-ray, and he started a foundation to go with it called SIGN Fracture Care. Their motto is, “Equality of fracture care around the world.” He gives the implants, with instruments, to hundreds of hospitals around the world, which has helped thousands of patients.
Reframing the problem
Even with Lew’s admirable efforts, however, two problems persisted. Some hospitals don’t have any type of fixation. And for many, many patients, surgery is delayed by days, weeks or months. After a few weeks, the fractures begin to heal themselves, leading to malunions, malformations, and other complications. That’s why most people in developing countries with untreated fractures end up with some degree of disability. Patients are admitted to the public hospital, but then they lie in bed and wait and wait while their fractures consolidate in poor positions.
It was clear we needed a basic traction frame that could be built inexpensively, with local parts, and required very little training. So we modified a very old British frame — the Böhler-Braun frame — that keeps the leg out to length and aligned, and fashioned a new model out of PVC pipe, of all things. We discovered that PVC is a universal construction material, available worldwide.
It took a year to make dozens of models that would fit a variety of patients, but now the Gates frame is being used routinely in the Dominican Republic and Haiti. The frame is applied immediately when the patient comes in, while they lie in bed waiting for surgery. If they lie there long enough in the frame, they may end up not even needing surgery, just like decades ago when all fractured femurs were treated with traction.
These days, I make regular trips to both the Dominican Republic and Haiti. Since the Haitian earthquake in 2010, I have traveled to Haiti, the Dominican Republic and other countries three to four times a year. Medically, things are so difficult in all these countries it can be discouraging, but it’s still it’s imperative to go and try to help as much as possible, because there’s such a tremendous need.
Some of these trips have been with the Rush Global Health Program and the Department of Orthopedic Surgery. Stephanie Crane, MD, an internist, runs a wonderful program both in Haiti and the Dominican Republic, and works closely with our department.
A tale of two countries
In January 2017, I traveled to the Dominican Republic with a group from Creighton University for 10 days. It’s strange and sad, because so many tourists go there for the beautiful beaches and hotels. But the hidden poverty is just staggering. There is no health insurance, and there is no money.
We performed a lot of surgery on that trip. When we walked into the emergency ward our first day there, we counted 35 patients with fractures lying either on carts or on the floor. because there were no available beds. It was mind-boggling. We had five of the PVC traction frames on hand for patients who needed traction until receiving surgery, but there were far more patients than frames.
All in the family
My entire family has been going on these mission trips with me. My wife, Lois, is a nurse and the assistant executive director of Misericordia Home for the disabled in Chicago. She first accompanied me to Zaire and cared for young children in a leprosorium while I did orthopedics. On many trips to Brazil she assisted in surgery and the recovery room, and took care of disabled young people in a local facility. My children have also accompanied me on missions. It’s been a good experience for them to see their parents helping others, as well as to help out themselves. And they went right to work. My eldest son is quite handy, so one time in Brazil when I needed a set of hinges for a cast brace, I said, “John, get these made.” He was 18 years old, and he figured it out, finding a local shop to make the hinges.
David, our youngest, started traveling when he was 6 years old and recently worked as a translator on a Loyola Medical School trip to Guatemala. After the Haiti earthquake in 2010, my adult daughters, Ginne and Alba, along with my wife and David, came with and worked in an orphanage in Port-au-Prince. Son Peter, living in Spain, has twice joined me in Haiti.
The mission trips have been part of our family’s culture, something meaningful that we could do together. It is a way of giving back, and, of course, it is in giving that we receive.
The gift of giving
Providing care in developing countries has always given me feeling of peaceful satisfaction. As an orthopedic surgeon in the United States, you frequently do get that feeling in your regular practice, but it’s not the same, because you know that if you don’t take care of a patient in the U.S., someone else will. Patients are always going to get care here.
In places like Brazil, Haiti or the Dominican Republic, if you aren’t able to do a case, that patient may not receive treatment at all. It’s also gratifying to have a family say thank you for enabling them to work again, and give you a chicken or a bag of fruit. Or to walk through town and everybody knows who we are and calls out to us, “Doctor, doctor, muchas gracias!”
I think it’s important for every physician to go on at least one medical mission early in their career. Then, as you get older, you may be able to do it more often because you have more time. I’m a seasoned doctor now, but every time I make one of these trips, I am inspired, invigorated and grateful.
Dennis Gates, MD, is an emeritus professor of orthopedic surgery at Rush University Medical Center.