The Tarpley’s African Adventure
After 28 years of VA service and 2 years in the Public Health Service, our distinguished AVAS Past President John Tarpley ('08-'09) "retired" from the VA June 30, 2016. John served as Associate Chief of Surgical Service at the Nashville VA Medical Center as well as program director at Vanderbilt University Medical Center General Surgery residency program for nearly two decades.
"Retired" is a relative term, as his post-retirement life will be focused on service with Vanderbilt International Surgery and the Vanderbilt Institute for Global Health in East Africa for the next 5 years. On July 2, 2016, John and his wife Maggie arrived in Kenya to work at African Inland Church Kijabe Hospital (AICKH). Maggie has been a central figure at Vanderbilt as a senior associate for the Section of Surgical Sciences. She also served as webmaster for the Association of Program Directors in Surgery (APDS) for 20 years.
Opened in 1913, Kijabe Hospital overlooks the Rift Valley in the Central Highlands an hour outside of Nairobi. John’s role will be to support the general surgery residency program at AICKH which graduates 2 residents annually in both the clinic and operating room. He has been working with "multi-trauma plus huge clinics.” The training program is affiliated with both the College of Surgeons of East, Central, and Southern Africa and Pan-African Academy of Christian Surgeons (COSECSA, PAACS). John will join Vanderbilt faculty at AICKH including Pediatric surgeon Erik Hansen, M.D., and Pediatric anesthesiologist Mark Newton, M.D. Kijabe also has residency programs in Pediatric surgery, Orthopedic surgery, and Family Practice and affiliations with the University of Nairobi in Neurosurgery and soon will start Pediatric Emergency Medicine.
The Tarpley’s began their travels to Africa to teach residents first in 1978 where John trained residents at Baptist Medical Centre in Ogbomoso while Maggie worked as a seminary librarian. After receiving his undergraduate and medical school degrees from Vanderbilt, John completed a General Surgery residency at the Johns Hopkins and National Institutes of Health. Upon completion of his training, the Tarpley’s moved to Baltimore. In 1993, The Tarpley's joined the Vanderbilt and Nashville VA faculty. Their enthusiasm for teaching in Nigeria has never waned throughout their careers.
The sentiment throughout the VA and Vanderbilt campuses has been of mixed emotions as people are sad to see the Tarpley’s leave but happy as they will be engaging in endeavors that will impact thousands if not millions of lives as they train surgeons and staff in Africa.
When we spoke with Dr. Tarpley, we asked several questions:
What words of advice do you have for individuals contemplating following your footsteps in embarking in a long term mission in Africa?
“Mission trips” can be short-term (usually a minimum of two weeks, though occasionally one week), mid-term (a month or months), or long-term (a year or years). Long-term trips can be through faith-based organizations (FBO), NGOs, or via contracts with a government or medical school abroad, etc. Many organizations exist that help volunteers with the paperwork and arrangements. A good resource for short-term visits is the ACS’s Operation Giving Back (https://www.facs.org/ogb). For those using the FBO route, ask what your own denomination might have or consider World Medical Missions in Boone, NC. For those more comfortable going with a non-FBO, consider Health Volunteers Overseas (HVO). These options will help with logistics for both short- and mid-term outings. Longer-term outings options include Medicine San Frontiers/Doctors Without Borders, the Peace Corps, various denominational and non-denominational FBO routes, and advertised contracts with host governmental positions like public hospitals and/or medical schools.
It does not seem as if the decision to move to Africa was spur-of-the-moment.”
Correct. My first ‘job’ was with the Southern Baptist International Mission Board (1978-1993) based at the Baptist Medical Centre, Ogbomoso, Nigeria. I was also on faculty at the University College Hospital of the University of Ibadan College of Medicine. We spent 3 years in Nigeria and then one year back on faculty at Hopkins with my clinical posting at the Loch Raven VA. We completed 4 such cycles with 12 years in Nigeria and 3 years in Baltimore over this 15-year period. We returned stateside in 1993 with the hope we would return to Nigeria or Africa. I fell into an incredible opportunity at Vanderbilt in surgical education and served as Program Director for General Surgery from 1995 until November, 2014 when I retired as PD once I reached age 70. I retired from the VA June 30, 2016 with 30 years of federal service--~28 years’ service with the VA plus my 2 years in Public Health Service. During 2015-2016, Maggie and I visited several centers in East Africa and accepted offers to join two former Vanderbilt residents for six months each as a “terminal sabbatical” for the 2016-17 academic year. We were with Erik Hansen MD, a Pediatric surgeon, at the FBO AIC Kijabe Hospital from July to December, 2016 and then moved to the University Teaching Hospital Rwanda in Kigali, Rwanda from January to June, 2017 to work under Robert Riviello with the NGO HRH (Human Resources for Health) which is a consortium from UVA, Dartmouth, and the Brigham to help develop surgical, obstetrical, and anesthesia capacity in Rwanda and elsewhere.) This was our first outing with a non-FBO NGO, and we looked forward to it.
What are the subtle, obvious and profound differences in caring for patients in Africa?
“All politics are local politics.” Each situation is different, even within one country or area of a country. Given the huge disparities in economics, utilities, workforce, etc. the major challenges are often either non-availability of resources we in the West take for granted or –if available--the inability of patient to pay. CTs and even neoadjuvant chemo/XRT have limited availability but whether or not they are affordable is another story. In addition to “eminence-based, emotion-based, evidence-based” decision making there is a fourth “e”, “economic-based” decision making. For most low-middle income countries with per capita annual income < ~$4000, practice is resource-, infrastructure-, imaging-, technology-, and especially safe anesthesia-challenged often in settings with erratic electrical and water supply. There is no ERCP capability as a rule, an interventional radiologist, frozen-sections, or a reliable blood banking/supply system. The phrase ‘dearth’ of infrastructure is applicable at many locales, especially outside the capitol and major cities.
Are there differences in the operating room regarding flow and teamwork?
My experience thus far has been confined to Sub-Saharan African Hospitals. I find that turnover times can be most efficient in some, terrible in others—just like in the US. The major issue would be the quality and availability or lack thereof of safe anesthesia and airway management.
Any difference in the perspective of the patients regarding their care?
I think patients have a more realistic and accepting attitude to disease and death. Death is very much a part of life as opposed to a “death-denying” mentality frequently seen in the West. Transportation costs are a huge factor in follow-up. One can perform a technically-perfect tendon transplant or hand operation but the post-op PT or OT visits are key for success. Such services are likely not readily attainable in most of SSA and if available not readily affordable unless the patient stays nearby the facility rather than come frequently from their home which may be 6 hours away for the requisite therapy. We have commented in prior decades that there is “malpractice but not litigation”. The latter is changing in many countries. On the whole, not unlike VA patients, the patients are most grateful and appreciative for their care and do not enter with an adversarial attitude.
The implementation of the WHO checklist by Atul Gawande, M.D. in Africa has had profound effects. What about the approach there allowed this initiative to succeed?
The WHO checklists have been helpful. In reality, introducing an intervention is easier than maintaining it, whether a checklist for an operation or a well for water.
Is the support for patient safety improvement different there than in the West?
The buzz words for the past decade or two stateside are “Quality” and “Safety” as noted by the 2000 Institute of Medicine Report To Err Is Human: Building a Safer Health Care System. My take is that SSA countries are addressing quality and safety issues currently, led by the various Colleges --West African College of Surgeons (WACS), College of Surgeons of East, Central, and Southern Africa (COSECSA), The Association of Surgeons of South Africa (ASSA), and the more recently created Pan African Association of Surgery (PAAS). I believe that care provided in SSA countries lags behind the emphasis and state of quality and safety as experienced in the West. This is a work in progress.
What are your words of advice in life and in a medical career that you wish to share with trainees and faculty?
My granddaddy taught me: “Nobody owns a cow but that the cow owns them.” There is a difference between “vocation” and “career”. Does your job, your career own you or vice versa? Find something that excites you that you would be willing to perform, do the rest of your life even if they did not pay you. They may not. John Cameron M.D. likes to say: “If you love what you do, you never have to work again.” There is some truth here but every job has its own scut. A failed anastomosis, adverse outcome, looming credentialing report, or litigation event can diminish one’s joy for a bit. But the key is to find something you like, not something that appears to offer a better life-style or a lighter vs. no call duty.
Aphorisms I have found useful: “Keep your relationships in order.” “Adversity is a given; misery is an option.” “It is a mighty thin board that has only one side.” “Fret not.” Psalm 37:7b “Don’t empower anyone to take your joy away.”
“He who angers you controls you.” “Return good for evil and heap coals on their head.” (OT & NT)
Several keys to success: Know/remember folks’ names….and ideally their kids’ names. Ask about their family. Outwork and out-nice folks. Write real letters to folks to congratulate them or encourage them as indicated.
Treat every student, resident, junior colleague as if they may be your boss someday. It happened to me.
Hoe your spiritual garden. Daily.
What do you know now that you wish you had known earlier?
Maggie raised our first two who were born April of fourth year of medical school shortly before starting internship and in my PGY II year. Our third son was born post-residency some eleven years later while in Ogbomoso. I took the family to medical meetings for my vacation time. I do not recommend that. Lesson learned: Family is key and deserves a top priority. Osler stated that medicine should be your spouse or your mistress. I would say medicine (surgery) should be in the top three, one’s relations with the Supreme Being, one’s family, and one’s vocation/career. Few surgeons on their death beds wished they had done a few more gastrectomies, pancreatoduodenectomies. I expect a lot wished they had seen more ballgames, plays, recitals by their kids and spent more time with their spouse.
1. Tarpley, JL, Tarpley MJ, Meier PM, Meier DE. Operating in the Global Theater. Surgical Rounds. November 2007. http://www.hcplive.com/journals/surgical-rounds/2007/2007-11/2007-11_02.
2. Meara J, McClain CD, Rogers SO, Mooney DP, editors. Global Surgery and Anesthesia Handbook: Providing Care in Resource-Limited Settings. (See especially Chapter 4 “Preparing for a trip: OR management” and Appendix “Safety, security, and survival considerations for health care providers in remote, hostile, and disaster areas”). Boca Raton: CRC Press. 2014. 3. Global surgery 2030: evidence and solutions for achieving health, welfare, and economic development. 3. The Lancet Commission on Global Surgery. April 2015 http://www.thelancet.com/commissions/global-surgery