On December 26, 2003, the Iranian city of Bam suffered an earthquake that left more than 30,000 people dead, 80,000 homeless, 2,500 children orphaned, and more than 85% of the city's buildings in shambles.1 Volunteers from more than 44 countries arrived to help a city that, despite its 2,500 years of history, lost its infrastructure - electricity, water, and sewage system - in just 12 seconds. The ancient citadel at Bam, a source of pride, identity, and income for its people, had finally fallen.
In February, I joined the international group of volunteers in Bam; the experience was truly life changing. As a physician in training, I came to understand the courage, creativity, and humanity required to be a doctor. The relationships I made there exposed me to the role physicians play in creating an exchange between people and communities, despite political conflicts their countries may have. How this all came about demonstrates that some of the most rewarding resident experiences abroad are unexpected.
I worked in the International Federation of Red Cross and Red Crescent Societies' field hospital, financed mainly by the Finnish and Norwegian Red Cross organizations and staffed by workers from 16 different countries. Constructed of tents, it could accommodate 250 inpatients, had an operating room, emergency department, intensive care unit, and wards. It was conceived within hours of the earthquake and started a week later; it had treated 23,000 people by February 28, 2004.2
Both general practitioners and specialists staffed the hospital. I worked with a resident from Tehran and a Finnish attending physician to care for children. Pediatric admissions to the hospital ranged from common respiratory infections, to neglected trauma from the earthquake, to cases that revealed the psychological effects of the earthquake. These cases included failure to thrive in a child whose mother was depressed, children with toxicities from motor oil, nortriptyline, and opium, and young adults attempting suicide. The toxicities reflected the fact that many people lived shared each tent, many adults suffered from depression, and, paralleling the increase in depression, opium use was on the rise. The suicides were related to the fact that, for many people, just being alive was too depressing to tolerate because their entire extended families had died.
One night, I was called because a woman who had lost everyone in her family, including her husband, had recently given birth to a baby that she was convinced was "broken." During the middle of the night in a hot tent with many tired mothers trying to sleep with their newborns, one baby wailed continuously. Without the back-up of labs and imaging, without social workers and discharge planners to hide behind, I knew that I might not be able to affect her life circumstances at all. Left with my hands and time as my only tools, I held the baby and rocked him to sleep while the mother snatched a few moments of rest. With her quiet "thank you" the next morning, I realized the importance of a physician's hands and heart in healing.
A video grab image shows grieving people amid wreckage following an earthquake in Bam, Iran, December 27, 2003. International rescue workers were scouring flattened debris for survivors in Iran's shattered ancient Silk Road city of Bam, after a violent earthquake killed more than 20,000 people.
It took a trip across the world for me to learn this lesson because it was then that I felt empowered to be unconventional and to have faith in my decisions in a setting of limited resources. In addition, I felt inspired by the healthcare providers I worked with, who had put aside their own personal commitments in order to serve whole-heartedly.
When I think about Bam, it is the people I remember: Dr. Eva Sola from Finland; Dr. Durandeesh, a general practitioner from Bam who had lost his family and belongings but asked only that I send him a stethoscope; Zeenat, a 9-year-old rescued by her father; a 20-year-old woman who lost the Internet café she had created but received a loan and donated computers to restart it; and a man who showed me the pride and dignity of Bamis when he said, "All we want are loans to rebuild what we already had." The experience was built on relationships. With those relationships comes a responsibility, and I would like to keep my end of the bargain.
I am committed to continuing the exchange of ideas and professional experiences with the people of Iran. Volunteers from all over the world - Iran, India, Malaysia, Norway, Finland, Sweden, Japan, China, and the United States - had the chance to meet and work in Iran, which seldom happens. Each of us became an ambassador of good will as we discovered the similarities rather than the differences among our people. Many Iranians were excited and anxious to find out as much as they could about medicine and life outside Iran.
The Iranians expressed that they endure a great amount of suffering at the hands of a system that does not always value their human rights. At times it felt unethical to remain neutral in face of their struggles, but I have come to value the political neutrality associated with being a physician. The simple act of engaging in professional exchange with Iranians, hearing their versions of the situation, supports them in their struggle for human rights. What they asked of me is to tell others what they experience. In the words of Nobel Laureate Shirin Ebadi during a lecture I attended at the University of California, Santa Barbara in May 17, 2004, they wanted me "to neither exaggerate nor downplay their experiences, just to shed light on them." In addition, I will make a continuing effort to find practical ways of helping the people of Bam.
I share my experience in Bam to emphasize the importance of getting where you want to go, and doing it while you are a resident. Accomplishing this is challenging for residents because finding elective time and funding can be difficult. I have found funding through a course in grant writing, networking, and a lot of persistence.
A course in grant writing teaches you, essentially, not to fear asking for money, and that there actually are a number of source. For example, my medical school donated $10,000 to a student exchange with Iran based on a grant written by our students. There was no grant available or advertised before we asked for funds; we simply asked for the money because we believed in the project.
To network, look for people doing what you would love to do, such as attending conferences, and then stay connected with them. Don't be afraid to ask them how you can get involved in their work. Also, treasure the relationships you make while you are abroad, and try to keep in touch with the people you work with there.
Finally, and especially because I sought funding for travel to a country lacking diplomatic ties to the United States, be persistent. Seek faculty who will believe in your project abroad, and don't be discouraged by the initial results of your Internet search because international connections can be arranged by many means. The earthquake in Bam affected my husband (an orthopedic resident) and me deeply, because we both have family in Iran and have done some international work there.
We contacted many agencies about going to Bam during an elective month two months in the future. We found that as residents we didn't qualify for most positions. Doctors without Borders, the Red Cross, and others required 2 years of experience postresidency, board certification, and a 6-month commitment as a minimum. Nongovernmental organizations often will require longterm relationships and applications far in advance.
One agency, Direct Relief International, did not send physicians to Bam but needed help finding its contact person in Iran for a shipment of relief goods. We were actually able to help locate him; he happened to be head of the Iranian Red Crescent, and he agreed to have us travel to Bam to work with his group. This partnership developed quickly and unexpectedly, but ended up being quite rewarding. Direct Relief International donated a large quantity of orthopedic supplies to our trip and has helped us share our experiences there in an effort to further assist the people of Bam.
Arranging electives abroad requires a certain commitment, effort, and persistence. No matter how such electives are ultimately arranged, it seems they are always worth the effort required to make them happen. Residency programs should support their residents in these endeavors because the experience gained is nearly always life altering, worthwhile, and serves to solidify in residents a desire to help those most in need both here and abroad.
1. Earthquake in Iran. International Federation of Red Cross and Red Crescent Societies Web site. Available at: http:// www.ifrc.org/what/disasters/response/ir an.asp. Accessed September 10, 2004.
2. McClean D. Bame's unique referral hospital. International Federation of Red Cross and Red Crescent Societies Web site. January 14, 2004. Available at: http://www.ifrc.org/docs/news/04/040l 1 401. Accessed September 10. 2004.