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| James Srour, M.D. |
He took his first two years of medical school at the University of the Philippines in Manila in 1972 and 1973. And as he carried his travel bags off the plane his eyes were opened; he saw a different world. He saw people standing behind and pressed against the fence surrounding the aging airport; he didn’t know why they were there. He saw uniformed guards with submachine guns slung across their shoulders; he guessed why they were there.
And what he eventually saw in this typical third-world country was “chaos wherever you go.” Particularly after the brutal, corrupt, and extravagant kleptocrat Ferdinand Marcos declared martial law on September 22, 1972. (This lasted until the People Power Revolution in February 1986 that rose up against regime violence and electoral fraud).
Despite this, Jim told me that his close experience with a different culture was “a great thing” and that he “loved it.” So it was here, in The Republic of the Philippines in Southeast Asia, that Dr. Srour felt the stirrings of his interest in medical missions for the poor.
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| A wide view of Manila (from Pavel Sinitcyn) |
He did not plan to journey thousands of miles from home for medical school. Nor was it planned that he would witness the burden of ill health and extreme poverty on people and that this would affect him so deeply. But we are jumping ahead in our story and will return to that part later.
Jim’s father, Farid (1918-2018), was born in Syria, in Tartus, a large city on the Meditteranean coast, a vacation spot, and a still-valued Russian naval base. He came to the U.S. at 26. After he arrived in New York he did odd jobs for a while. He moved to D.C. and went to Washington Missionary College, where he met and married his English language and literature professor, a London-trained Brit with roots in Northern Ireland. He wanted to be a doctor but biology got in the way as Jim was conceived and born. And since Jim’s father now had to support a family (with three more children to come) and could not go to medical school that meant that Jim would be next to be given that task. Hence, the small black bag.
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| Tartus, Syria (a postcard from ProZ.com) |
Dr. Srour said that he started his college career at George Washington University, but after a few years he “needed to get away from home.” He moved down to the University of Alabama to finish up. He eventually realized that he would not be able to “make a living” as a marine biologist, as he had naively hoped. Since his fate was predetermined he took a few additional required courses and applied to medical school, “a bit late.”
After the two basic science years in Manila, he came home and went to the University of Maryland for the two clinical years. He did ER and Internal Medicine rotations at the York Hospital and was impressed. He decided to do his internal medicine residency there, against the unyielding advice of his best friend who thought community hospitals were not rigorous enough (he was wrong). As a resident at York from 1976 to 1979, Jim enjoyed working with GI specialists Drs. Iain MacKenzie and Bill Thorsen and decided to go into that specialty.
But he had two months between finishing the residency and starting his two-year fellowship at Johns Hopkins. What would he do? Simple, he would go to New Zealand!
Why New Zealand, you ask? An island country nine thousand miles away from home? This is a bit complicated.
His future wife, Cushla, a native New Zealander, had befriended one of Jim’s cousins (his maternal uncle’s son) when she was in college. There is a tradition among Kiwis called the Overseas Experience (OE): when you are in your 20s you pack a small bag with the essentials, leave home, and go somewhere else in the world to work and to expand your view of life. You usually stay abroad for a year or more. Since Jim’s cousin had come here for his OE he thought that Cushla would also have a good experience in the U.S. So she came to the States and she stayed with Dr. Srour’s parents for a while. Are you with me?
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| Sheep grazing on South Island (from crbette-Getty images) |
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| Dr. Marvin Schuster |
Dr. Srour did his GI fellowship with, as he told me, the “phenomenal” Dr. Marvin Schuster (1929-2017) at Baltimore City Hospital (now Bayview). Dr. Schuster was “really sharp” and an “uncanny diagnostician” who recognized the importance of appreciating the psychological aspects of gastrointestinal disease and incorporating them in the treatment. He was a world-renowned pioneer in the field of GI motility, of seeing how things move (or don’t move) through the gut.
(The long tube of the digestive tract, you see, has an extensive nervous system, the so-called enteric nervous system, to coordinate its muscular activity as nutrients are absorbed and waste is discarded. It has, one might truly say, a mind or intelligence of its own.)
After Baltimore, Jim returned to York. He worked with Dr. Thorsen for a while and then started his own practice. He was very happy when Dr. Duane Ahlbrandt joined him. The respected practice grew as other physicians came on board. The field of gastroenterology, like all of medicine, has changed dramatically since Jim’s training years.One of the most striking, he noted, was a better understanding of peptic ulcer disease. Stomach and duodenal ulcers, long thought to be triggered by stress and diet, are, in the end, caused by the damaging effect of acid. Until 1976 yucky-tasting liquid antacids were given around the clock to neutralize this. They were partially effective, and many patients needed major surgery to treat the complications of ulcer disease, especially life-threatening bleeding.
When cimetidine, the first so-called H(istamine)-2 blocker, was released in 1977 acid production could be suppressed and surgery could usually be avoided. The more potent acid preventers, the proton pump inhibitors (PPIs), became available in 1988. These cut the acid by 99%, and general surgeons had to find other things to take care of. (Dr. Srour was careful to say that prolonged use of PPIs may have negative consequences for health, even though they are sold over the counter now.)
But after the bacterium Helicobacter pylori was identified In 1982 ideas about ulcers changed as it was found to be associated with nearly all ulcers. The twisty bug burrows into the lining of the stomach to hide from the immune system, and it stays there unless treated. It can cause local inflammation, gastritis. This allows the acid to injure the thin protective stomach lining, leading to an ulcer. So...ulcers are caused by infection!
H. pylori is found worldwide and is especially prevalent in poorer populations. Most carriers have no symptoms but have a 10%-20% lifetime risk of developing an ulcer. Getting rid of the infection usually gets rid of the ulcer. H. pylori is also associated with stomach cancers.
This specific bug is only a very small part of our gut microbiome, the enormous collection of microorganisms (trillions of them!) making themselves at home in our GI tracts. They play critical roles in digestion and directly influence the immune and endocrine systems. And they produce neurotransmitters we usually associate with the brain including (our good friends) serotonin and dopamine.
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| The vagus nerve (in yellow) sends signals from the gut to the brainstem (from Nicole Miller) |
Aspirin and other nonsteroidal drugs like ibuprofen or naproxen cause most of the approximately 10% of ulcers that occur without the presence of H. pylori. Additional factors in ulcer disease include alcohol, smoking, high physical stress, a sedentary lifestyle, and lower socioeconomic status. Diet, said Dr. Srour, contrary to medical folklore, does not play a role.
Dr. Srour told me that the identification of the hepatitis C virus in 1989 was also important in his practice. Chronic Hep-C infection, a worldwide problem, may result in cirrhosis or liver cancer. Before 2014 this was treated with injections of interferon for 6-12 months. But the cure rate was less than 50% and there were severe side effects of the treatment. Direct-acting antiviral drugs, introduced in 2014, result in a cure in more than 90% and are well tolerated (but are very costly). Anyone between 18 and 79 should be screened for the virus since asymptomatic infections are common.
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| Prevalence of Hepatitis C 2015 (from CDC Yellowbook) |
Another area that changed dramatically, as in most of the field of medicine since the 1970s, is that of imaging. For gastroenterology that mostly meant endoscopy. The flexible fiberoptic scope, invented by South African Dr. Basil Hirschowitz in 1957, replaced the rigid (ouch!) scopes by the 1960s. It was said by Wilcox that this was "the singular transformative event of the last century for gastroenterology." Dr. Srour would, I think, agree.
The diagnostic capabilities were soon complemented by therapeutic applications, including removal of colon polyps with a wire loop snare. The CCD (or TV) camera endoscope was developed in 1983, and you could see and record the goings-on along the lining of the GI tract in living technicolor.
And, Dr. Srour said, the routine search for and removal of colon polyps by colonoscopy prevents their transformation into colon cancer. Since almost all cancers arise from polyps this is the only clinical situation, he noted, where cancer is actually prevented, not simply picked up at an earlier stage. Countless lives have been saved.
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| Slow progression of colon cancer (from Biovendor) |
There have also been tremendous advancements in treating inflammatory bowel disease, where worrying about patients sometimes kept Dr. Srour up at night. And we know more about the common problems of irritable bowel syndrome and heartburn.
The day-to-day practice itself changed, too (as we have seen in previous stories in this series).
One notable change, he said, was the nature of communication between doctors. Early on, after Dr. Srour saw a patient he often made a phone call to the referring physician to discuss his findings. He then sent a letter. Over time, the style of communicating changed. It became cooly digitized, without the warm nuance of the human voice. Without a carefully-crafted narrative.
Dr. Srour told me that, years ago, the referring doctors, usually primary care family physicians, were “quarterbacks.” They knew their patients extremely well, he said, and “took great care of them.” And they were often able to tell him precisely why they needed his expertise. The “relationship was really powerful.”
And the general internists in the hospital such as Dr. Leo Samuelson, Dr. Jack Kline, Dr. Ronald Reinhard, and Dr. Ben Hoover “did first-class medicine” and “didn’t miss anything. They were genuinely great doctors," said Dr. Srour. They shared information with him and with each other smoothly. He noted, wistfully, that the hospitalists don't seem to be as tightly-knit.
The electronic health record (EHR) was supposed to (among other things) allow the medical team to coordinate care. Jim feels that it hasn’t accomplished that fully yet. He said that it may even perpetuate errors. Mistakes for example, in a patient’s list of medicines or their diagnoses.
Communicating is even more treacherous when there is a language barrier, and this brings us back to Dr. Srour’s wide travels for medical mission work.
When he’s in a non-English-speaking country he talks with patients through an interpreter. But the helpful amateur usually has no medical training and doesn’t fully comprehend what he’s saying. The two sides struggle to understand each other. And yet, he found that the people always appreciate receiving care, however minimal. After waiting in line for hours or even all day, they were happy, he said, “just to be seen.”
Reflecting, Dr. Srour believes that every college student should spend a month in a developing country. It would change their lives, he said; they would not be the same when they returned home.
I asked him what kinds of things he saw on his mission trips, often arranged, he told me, through the Living Word Community Church in Red Lion.
In Mumbai, for example, he came across so-called “pavement dwellers.” These souls are the poorest of the poor. He said that “when you walk down the street you find yourself literally walking on their homes. Homes marked out by the expansion joints in the sidewalk.” He thought to himself, “I can’t do this; these are human beings.” But after a while, you do it “because everyone else does.” Yes, you do it because everyone else does.
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| Indian pavement dwellers (from Vishesh Gupta) |
In a Romanian Gypsy camp, he said, “the best you could do was to give them Tylenol and vitamins. You could do something for pain relief, and for that they were extremely grateful. It was very humbling.”
He was struck by the remarkable “sameness “ he experienced in each of the third-world countries he visited. He saw utter mayhem. There were, he said, no written rules of the road. The winner was the one with the loudest horn or the heaviest foot. You had to be very aggressive just to survive.
He said that we don’t understand how fortunate we are to be born here unless you have been to an area where millions of the poor lack nourishing food, clean drinking water, safe reliable shelter, and affordable health care. But where the super-rich and the desperate-poor often live side-by-side.
But there are also uninsured individuals here too, and Dr. Srour has volunteered his services at the Katallasso free faith-based healthcare clinic in York City. He told me, with some irony, that they use the same computerized EPIC health record as the hospital, but that the well-known hassles of the cumbersome system are avoided since “they don’t bill anyone and don’t need to worry about diagnostic codes.” He said it was a “joy” working there.
After a rewarding career, Dr. Srour retired five years ago. He is enjoying himself. For many years he, his wife, and two of their three sons, both accomplished fiddle players, have immersed themselves in traditional Irish music.
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| The musical Srour family |
Over the past 20 years, they have performed together throughout the local area and beyond. Jonathon is a foot-and-ankle surgeon doing a fellowship in San Francisco. Josh is in the Army in El Paso doing hospital administrative work. Jim’s third son, Jeremy, has Down syndrome and is the family’s “super glue." Dr. Srour plays the bodhrán, the hand-held tambourine-like Irish drum, and the wooden flute.
His small black bag, so to speak, has been carefully placed on the shelf, waiting for the next mission.
Reference and Recommended readings:
2. Marmot, Michael. The Health Gap: The Challenge of an Unequal World. London: Bloomsbury, 2015.
5. Perlmutter, David. Brain Maker: The Power of Gut Microbes to Heal and Protect Your Brain-for Life. New York: Little Brown Spark, 2015. (Maybe a bit overstated, but interesting reading.)
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| Mid-October early morning on the York Heritage Rail Trail (looking north from the Howard tunnel) |