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BY: PATRICIA A. WILLIAMS
Ms. Williams is vice president, Trinity Health International, Farmington Hills, MI.

A patient we'll call Mary lived on one of the outer atolls of the Republic of the Marshall Islands (RMI), where the U.S. Navy had conducted nuclear testing in the late 1940s and the 1950s. Although the test site's residents had been relocated to other islands, the tests there were more than 40 of them resulted in pulverized radioactive coral that rained down on many of them. One island disappeared completely. The power of the bombs was equivalent to 1,000 times those dropped on Hiroshima and Nagasaki combined. Bikini became home to the largest hydrogen bomb ever detonated in the Earth's atmosphere.

Mary was a patient of the 177 Health Plan, a program in which the U.S. government provides funds for the care of affected people and their descendants. She was therefore eligible to receive care managed and provided by Trinity Health International (THI) and funded by the U.S. government.

Getting access to this care was another matter, however, because the RMI comprises 64 islands spread over 750,000 square miles of ocean, some of which have only limited boat and air service.

Mary was having seizures. Unfortunately, there was no physician on her island. Her physician, employed by THI, was at a clinic in the capital city of Majuro, many miles away. Over shortwave radio, and with the assistance of an interpreter, a health assistant on Mary's island described her symptoms to the physician, who then made a long-distance diagnosis and provided a treatment plan. He prescribed a critical medication which was not available on the island. The THI program sought a way to get the medication to Mary. The program administrator and the physician arranged with the national commercial airline to divert a plane from its normal flight path so that the pilot could drop the specially packaged medication out of the cockpit window. The health assistant then picked up the package and administered the medication to Mary.

Such are the complications involved in health care access in developing countries.

About THI
THI is a wholly owned subsidiary of Trinity Health, Novi, MI. For 24 years it has served the poor and underserved in both developed and less developed countries. Based in Farmington Hills, MI, THI is a 501(c)3 company that provides management, training, technical assistance, and consulting services to hospitals and governments around the world. Since Trinity's founding, more than 360 staff members have completed more than 900 assignments in 43 different countries. Those assignments have included:

• Assisted in development of the first Catholic health system in Australia
• Developing a national mental health program in the Federated States of Micronesia
• Providing care, for 18 years, to 14,000 residents of the Marshall Islands
• Organizing a hospital in Nigeria
• Providing management training at a hospital in Tanzania
• Providing infection-control training in Zimbabwe
• Managing hospitals in Saudi Arabia, Mexico, and Bangladesh

In 1984, in recognition of its work, THI was awarded CHA's Achievement Citation for Meritorious Service. In 1995, a CHA survey found Trinity Health to have the most extensive international program among U.S. Catholic health care systems.

Why International Health?
In the 16 years I have been with THI, I have often been asked: "Why international health?" "We have enough challenges here in the United States," people sometimes say. "Why do we need to provide services beyond our borders? Why must we support and assist other countries in their health care mission?"

I believe that those of us who work in health care have a vocation. Why should that vocation stop at the border between one nation and another a mere line drawn in the sand? I also believe that we who work in Catholic health care have an added responsibility, because our vocation is based on the values found in the Gospels.

We at THI share the common values of compassion, care for the underserved and underprivileged, respect for others, and dignity. I've yet to see those values limited by geographic borders, race, ethnicity, or even religion. I've had the pleasure and the privilege of providing values-based services in countries where the predominant faiths are Islam and Buddhism. Disease pays no attention to geographic borders. We are called to care for people in need, regardless of their origins.

In some cases, THI staffers can provide that care as teachers. Because health care is a highly complex field and because U.S. hospitals, with all their advanced technology, are even more complex than most U.S. Christians working overseas have much to teach the attentive student. Although U.S. health care today serves as a model for other countries, the lessons Americans overseas have to teach aren't always about what U.S. health care does "right"; they also have lessons to teach about methods and processes that don't work so well.

The global community is much smaller today than it was 10 or even five years ago, and opportunities abound for different nations to both teach and learn from each other. By passing on the lessons we've learned, Americans provide opportunities for organizations overseas to engage in discussions that will improve health care in their communities. For example, value is added when an infection control nurse from the United States works side by side with a counterpart in Zimbabwe, just as it is added when organizational theory developed in the United States is applied in a strategic planning session in a hospital boardroom in Kuala Lumpur.

The surprise for most people working overseas occurs when they suddenly realize that they have become the student rather than the teacher. In those circumstances, we see that we are learning new lessons about culture, acceptance, compassion, and yes the art and the science of health care. Shorn of the sophisticated technology we take for granted at home, we are challenged to find new ways to do the same job, to "think outside the box" (as the saying goes) and accept answers that in other circumstances might not seem logical. In doing so, we grow.

Putting It in Perspective
We Westerners live in what is generally a "culture of entitlement." When we are ill, we expect the best possible care, in the fastest possible way, with the lowest possible cost, and the best possible outcome. If we fail to receive it, we tend to think it was probably someone's fault. In developing countries, however, people tend to live in cultures of hope. They hope for access to care, hope to have their basic needs met with dignity, and hope to survive. If none of this occurs, they tend to think it was probably God's will.

Neither perspective is necessarily right or wrong. Each arises from a distinctive cultural and social environment. However, the reality is that we Americans do have tremendous resources and much skilled expertise in comparison to many other parts of the world. In case of sudden illness or injury, most of us won't have to walk miles to reach an emergency room. Once we get there, we will in most cases be seen by a qualified physician. That physician will usually have the technology needed to conduct diagnostic tests. Electricity will be available to operate the technology. And, once a diagnosis is made, we will be provided with the necessary medication or other treatment necessary to help "fix" us.

But not every person in the world has access to such care. In parts of Tanzania, women in labor must walk miles to the nearest clinic in order to give birth if they need medical assistance; sometimes they don't make it and are found dead on the side of the road. Some hospitals in Nigeria have no running water. One physician who works in a clinic in the Republic of the Marshall Islands bathes in a nearby lagoon. At a hospital in Malaysia, women religious handle the radioactive isotopes for cancer patients because there is no protection available for the nursing staff. A hospital in the Federated States of Micronesia has no sheets for its beds, and rats roam freely in open hospital corridors.

Despite such problems, people in these countries smile, say "Thank you," and appreciate every ounce of care and compassion they receive. There is no guarantee that emergency room waits will not exceed one hour. In fact, people sometimes return, on foot, day after day until a physician can finally see them.

In such environments, we Americans learn lessons about gratitude and graciousness. As prospective patients, we learn to appreciate the fact that most health care professionals are caring and will put forth their best efforts to help us. We learn to be less skeptical of our health system and our doctors and more grateful for the privileges and gifts we enjoy. As health care professionals, we realize gratefully that, although our medical technology may not come equipped with the latest bells and whistles, it is great technology. We learn that, although our computers may be a little slower than we'd like, we can at least count on having electricity to operate them. These are lessons in gratitude and humility we should all receive.

Health Care and Infrastructure
In the countries we serve, communities face many challenges. In Nigeria, average male life expectancy has dropped to 48 years of age. In the Tanzanian hospitals in which THI staffers have worked, one in five of the hospital staff members was HIV positive; an entire generation is being devastated in that nation. In the Pacific, diabetes and hypertension have become common in places where they were rarely seen 30 years ago.

Fortunately, there are ways to mitigate the spread of disease, ways to reduce the effect of disease, and ways to better care for patients who suffer from disease. We Western health professionals have an opportunity to improve the quality of life and the quality of health care and thereby affect entire communities that are suffering and impacted by the burden of disease.

Good health is critical for any society's economy. Without a healthy workforce, an economy will be sorely affected as has been shown by the many African countries devastated by AIDS/HIV. For example, the ability of the United States to conduct trade with other nations depends to an important extent on those nations' ability to maintain healthy workforces. And the maintenance of healthy workforces requires stable, effective infrastructures. If Nigeria, for instance, did not have basic telecommunications, electricity, and water infrastructures, that country could not provide its citizens with basic health care services. Good health and basic infrastructure reinforce each other. Good health care services promote healthy and productive workforces, which then develop and maintain infrastructure, which in turn aids the development of health care services and the economy as a whole.

By helping other countries improve their health care, we who serve Catholic health care:

• Broaden our own horizons and challenge ourselves to grow intellectually and spiritually
• Learn that, as teachers, we ourselves become students and gain a treasure of knowledge and experiences to share with our colleagues back home
• Learn humility, graciousness, and gratitude for the gifts we have and continue to receive
• Help improve the quality of other nations' health care services and quality of life
• Contribute to both the local and global economies and help develop stable infrastructures

As Catholic health care providers, we have a calling that is based on values, mission, and a vision strong enough to withstand any fear, trepidation, or doubt. Long ago, the founders of our organizations brought their mission to the United States from across the Atlantic. We are simply carrying that mission another step of the way.

THI's Guiding Principles

Trinity Health International, Novi, MI, is guided by these basic principles:

• THI wishes to serve as an enabler, teaching and assisting local health personnel to develop and improve their own programs.
• THI regards "human capital" a society's composite intellect, ingenuity, technical skills, and dedication as important to successful health care delivery as tangible capital.
• THI believes that training and technical assistance must be tailored to meet the needs, resources, and belief structures of each particular culture.