Notes from the Field: The Need to Start Small
Marc Callender, MD, is the current Global Health fellow living and working in the Dominican Republic with his family. He will begin the second year of his fellowship this July. Dr. Callender splits his clinical time between NPS and Clinica La Familia, an HIV clinic in La Romana, D.R.
Marc Callender, MD, with children in the barrios of the Dominican Republic.
Fresh out of pediatrics residency and eager to embark on my Global Health fellowship, I remember counseling myself last summer to “always keep the big picture in mind.” Having been trained to prioritize individualized family-centered care, I consciously attempted to reset my approach to encompass a more comprehensive, systems-based approach to medicine in order to implement changes to improve the lives of many.
As I reflect on the past 10 months, however, I am struck most by how much the lives of just a few individuals have deeply impacted my experience and perspective. While acknowledging the importance of maintaining a global perspective, I’ve come to realize that such an approach must not dominate my daily experience. By far the most fulfilling part of my work here in the Dominican Republic is allowing myself to get intimately involved in the lives of my patients and their families. Paradoxically, through this process of personal and emotional investment, I’m gaining deeper insight into some broader global health issues.
The following vignettes briefly describe two patient cases that have challenged me and have been formative in my development as a pediatrician and global health practitioner.
Juan Marcos is a 1-year-old from Consuelo whom I’ve been following closely for moderate to severe malnutrition since I arrived. His home is a regular stop on our twice-weekly journeys into the community after clinic. We are typically greeted warmly by at least three of his nine siblings, who often eat the supplemental foods we bring for Juan even before he can benefit from them. His dad will only occasionally bring him in for acute visits or for his monthly weigh-ins, and his mother is typically out of the house working. Rarely fortunate enough to find either parent at home to offer counsel and support for Juan’s condition, we remain fearful that he might succumb to an episode of pneumonia or diarrhea that may take his life.
Yonaily was a 4-month-old whose mother was diagnosed with HIV when Yonaily was 3 months old. While counseling the family through the stages of acceptance, we worked with
several colleagues to orchestrate HIV diagnostic testing through a U.S. lab, since the Dominican National Lab, the only lab in the entire nation capable of processing the test,
lacked the necessary agents to run the test. Sadly, Yonaily died one week after getting her diagnosis confirmed and beginning therapy. The last days of her life consisted of an intense series of difficult conversations and moments of prayer with Yonaily’s father and multiple home and hospital visits, culminating in a funeral service at home led by Juan Marcos’ father.
Because of the relationships I’ve established and the experience I’ve gained working with these and other families, I’ve been inspired to address some larger themes during my
second year of fellowship, such as research focusing on the character and quality of father engagement in Dominican families, in addition to my work advocating for better screening and education to reduce vertical transmission of HIV. As I engage in these “big-picture” projects, I am reminded to embrace compassion for the individual in my work as a global health pediatrician.
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