Childhood Education

George Rodgers' plane circled Bucharest Airport, waiting for clearance to land, as he and a fellow physician from the University of Louisville School of Medicine prepared to enter a country on the brink of chaos.

It was the spring of 1991, and Romania's iron-fisted dictator, Nicolae Ceausescu, had been forced from power 18 months earlier in a coup d'état, summarily tried for crimes against the people and executed by firing squad.

Ceausescu's death ended a police state that kept the former shoemaker in power for 24 years, and the last vestiges of the once-powerful Community Party had begun to wither away. But progress was hard-won in a country largely isolated from the West since the end of World War II, when Romania fell into orbit behind the Iron Curtain as a Soviet satellite state.

Rodgers, a UofL pediatrician, could see plenty of evidence of that on the ground beneath him as his plane descended for landing. Artillery batteries and tank brigades stood watch over the airport's taxiways while a platoon of Romanian soldiers guarded the dilapidated terminal with Russian-made AK-47s.

Rodgers, who also holds a Ph.D. in organic chemistry, had been here before. He and a group of U.S. health-care experts first visited the Eastern European republic in September of 1990 along with David A. Jones, chairman emeritus of Humana Inc. Their mission was simple: help Romania rebuild its health-care system, which had fallen decades behind the West thanks to the brutal deprivation of Ceausescu's reign.

On this particular day, Rodgers and UofL pediatrician Tom Badgett, M.D., stepped off the plane to find a greeting party of nearly a dozen Romanian doctors. The reception was so large, Rodgers says, not because UofL had promised much-needed assistance. After all, the Romanians had been promised help before.

The difference this time was the fact that the promise-makers came back for a second visit.

"The country's senior pediatric professor, a gentleman named Mircea Maiorescu, threw his arms around me and started crying," Rodgers recalls. "He said to me, 'We thought you would be just like all the other people who came to help: They look, they go home, and we never see them again.' "

Maiorescu then said something that seemed to crystallize the sense of isolation so many Romanian physicians had felt through the years: "I can remember waiting for the Americans to come and liberate our country in 1945, but your bombers flew over and blew up my father's house instead," he said. "Now the Americans are back. We've been waiting for you for 50 years."

The Americans were indeed back -- specifically, a group of Louisville health-care experts led by Virginia K. Judd, executive director of The Humana Foundation, which had just established the Romanian Assistance Project to provide funding and logistical and administrative support for a variety of health initiatives in the struggling nation.

As chief of UofL's International Pediatrics Section, Rodgers was tapped to spearhead the project's pediatric efforts, and over the course of the next 15 years, hundreds of Louisville-based pediatricians, nurses and technology specialists would return again and again to help Romania modernize its medical schools, patient care and research infrastructure, reshaping medical education for a generation of Romanian physicians while vastly improving the lives of hundreds of thousands of Romanian children.

"When the program began, the Romanian pediatric health-care system was probably 40 years behind the U.S. in terms of knowledge, technology and facilities," Rodgers says. "In most areas today, they're probably only about 10 years behind us. I think the program has clearly made a very deep impact."

A Presidential Invitation

It all started with a call from President George Herbert Walker Bush.

The Berlin Wall came crashing down in November 1989, bringing Eastern Europe's repressive isolation with it. When the dust began to settle, Bush decided that America should step in and help former communist states establish functional democracies. One means of accomplishing this was the Citizens Democracy Corps, an economic-development initiative staffed by senior-executive volunteers from private industry.

And so Bush phoned up Humana's David Jones in February of 1990, requesting that he look into the health-care systems of Eastern Europe as part of the Citizens Democracy Corps. Jones agreed, taking on as his partner Boone Powell Jr., then CEO of the Baylor Health Care System in Dallas.

After careful analysis, Jones and Powell decided to focus their efforts on Romania, which appeared to have the most antiquated health-care system of all the former communist states. He put together a team of health-care experts, including Rodgers and Louisville heart surgeon Allan Lansing, M.D., Ph.D., and flew everyone to Bucharest in September of 1990 for an intense fact-finding mission.

The initial visit produced some sobering findings, especially in the area of pediatrics.

"I visited an 800-bed children's hospital that had no ventilators, no monitors for patients, and very limited ability to do laboratory tests," Rodgers recalls. "Nothing came back fast. Simple tests that, for us, take an hour or two would, for them, take a day or two. And most tests weren't available at all."

Tania Condurache, M.D., an assistant professor of pediatrics at the University of Medicine and Pharmacy in Iasi, Romania, says shortages included the most basic diagnostic equipment.

"There were times when we didn't have access to an x-ray machine -- and this was a huge university hospital," she says.

Even light bulbs were rare.

"At one hospital, there was one working light bulb in the hallway," Rodgers says. "So the staff assigned a person to move the light bulb from one fixture to another as we walked down the hall during our visit."

Rodgers praised Romanian physicians for their ability to diagnose and treat patients under such austere conditions, but he also identified issues with outdated medical knowledge and ineffective pharmaceutical protocols.

"They had been isolated from Western medicine since the second world war, so their medical knowledge emanated primarily from the Soviet Union," Rodgers says. "Soviet medicine is very good in some areas, like ophthalmology, but most of their basic medicine was 20 to 40 years out of date.

"It was technically illegal to bring in publications from the West, which included journals and books, they didn't have current drugs and they were using methods of treatment that we had discarded decades ago. It was an across-the-board problem," he says.

All of these factors resulted in what Marius Bembea, M.D., Ph.D., called a "bankrupt medical system."

Bembea, a professor of genetics at the University of Medicine in Oradea, notes that Romania had one of Europe's highest infant mortality rates in 1990, with 27 deaths per 1,000 live births and a global ranking of 75th out of 189 countries, according to the United Nations. Germany, by comparison, recorded seven deaths per 1,000 births, while the United States logged nine.

Mihai Leonida Neamtu, M.D., Ph.D, shared his colleague's bleak assessment.

"The effects of the declining health-care system were disastrous for the general population, and especially for the health-care provision for children," says Neamtu, head of the Pediatric Department at Lucian Blaga University of Sibiu. "I often find myself thinking of those days, and those are memories I would rather forget. But I can't."

Train the Trainer

Before returning to the United States, Rodgers was asked to submit a report offering his recommendations for assistance. It was clear that Romania needed modern medical equipment, current pharmaceuticals and improved research infrastructure, all of which would require a substantial monetary investment.

But Romania also needed up-to-date medical knowledge, and UofL could easily supply that. Jones proposed that Rodgers and other UofL pediatricians travel overseas to instruct Romanian faculty at the country's 11 state-supported medical schools -- a "train the trainer" program. Romanian faculty would then disseminate the knowledge across the country by educating other physicians, residents and medical students.

Within two months, Jones gave Rodgers the green light to launch the program, beginning 15 years of educational activities in Romania and a dynamic partnership between The Humana Foundation and the University of Louisville Department of Pediatrics.

From 1990 to 2005, more than 250 Louisville health professionals traveled overseas to share their clinical skills with hundreds of Romanian physicians, who then passed that knowledge on to others across the country.

"In this manner, we basically taught an entire generation of pediatricians in Romania," Rodgers says. "We were in every one of their major medical centers, teaching routinely in the same way that we teach here.

"We also talked about some of the more subtle aspects of medicine, like how you deal with patients and families, which are particularly important in pediatrics."

Romania's medical system was built on an authoritarian model, Rodgers explains, which contrasts sharply with the more family-friendly style of Western medicine.

"Their philosophy in dealing with patients and family was that you tell them what to do, and send them out the door. They didn't spend a lot of time talking with a family about what was going on, what the future might hold, what the prognosis was going to be."

Neamtu says that kind of approach was, regrettably, borne of necessity.

"Poverty and everyday lack of necessities inevitably leads to authoritarianism," he explains. "When you don't have any disinfectant to use in a hospital, you can't even let relatives visit their family members."

The Humana-UofL program expanded in its second year by bringing Romanian physicians and, later, nurses, back to Louisville to observe patient care at University Hospital and Kosair Children's Hospital.

"We started with the Romanians who had the responsibility -- the top clinicians -- so that they could go back and affect change in their country," Rodgers says. "And through the years, we've brought well over 200 Romanian physicians and nurses to Louisville."

Visitors also were exposed to the management of medical care in America, including physician conferences, hospital structure and departmental committees.

"We have a very democratic system in some ways, and that was totally foreign to them," he says. "A lot of this, however, has now been adopted in Romanian hospitals."

Modern medical equipment, including respirators, ventilators and laboratory gear, soon began appearing in many Romanian hospitals, thanks to the efforts of Humana and UofL, which purchased or solicited donations of equipment and supplies valued at more than $11 million.

"The addition of ventilators was a revolution in neonatology in Romania," Condurache says, helping drive the high infant mortality rate down 29 percent in just 10 years, to 19 deaths per 1,000 deliveries in 2000, United Nations figures show.

UofL and Humana also made a substantial impact on medical research in Romania by sponsoring the country's first annual medical symposia, giving physicians a home-grown forum in which to present medical papers.

The end result of all this effort, Rodgers says, was vastly improved medical care for Romania's children. Hospital stays are now shorter, survival rates are better and infectious disease rates are down.

"We weren't the only factor driving these changes," Rodgers says. "There were improvements at the government level, including increased funding for medical care. But we made a tremendous impact on medical knowledge, which is extremely satisfying to me."

Bembea notes that Romanian technology still lags behind that of the West -- a problem which can only be cured through the allocation of more funds -- but he credits UofL and Humana with making "a huge impact" on pediatrics in Romania.

"The program covered all geographic regions of Romania and provided medicines, health-care supplies, medical equipment, up-to-date literature, major textbooks and excellent exchange programs," Bemba says. "The improvement in Romanian medicine is dramatic when compared to the situation 15 years ago."

Mircea Nanulescu, M.D., Ph.D., agreed.

"For many of my colleagues, (the Humana-UofL program) was their first 'taste' of the modern medical approach," says Nanulescu, former chair of the pediatrics department at Iuliu Hatieganu University of Medicine and Pharmacy in Cluj-Napoca.

"We were all enthusiastic, and we became more familiar with this approach as we became more deeply involved in the program. It changed our mentality, and through that, it changed our lives and our patients' lives."

Neamtu credited a "full-package" approach for the program's efficacy, noting that other agencies had tried to improve Romanian health care in the past but met with far less success.

"Before now, Sibiu's Children's Hospital had received numerous funds from our Western friends, but none of this activity had been conceived as a unified program," he says. "Thus, it did not truly fit the definition of the word 'aid' in that we had been given some fish to eat but had not been taught how to fish!

"The University of Louisville-Humana international pediatrics program changed all this."

The program also has resulted in some truly deep-seated friendships, Rodgers says.

"I've been in most of these people's homes, and many of them have been in mine. We've developed a huge number of very strong friendships, and, I think for all of us, they've been one of the things that has kept the program going for so long."

Indeed, Rodgers met his wife though the program: He and Condurache were married in 2004.

And UofL faculty learned a thing or two, as well, Condurache says.

"Most American physicians are used to jumping to the diagnostic tools to get to the diagnosis as soon as possible" she says. "Since they have those tools available, why not use them? But Romanian doctors have developed a lot of physical-exam and history skills, and they shared them with the American teams."

Polish Assistance

Besides the 15-year campaign in Romania, Humana and UofL's International Pediatrics Section also helped organize a seven-year program to improve medical care in Poland.

The Polish initiative began in 1991 with a request from the United States Agency for International Development, which asked Humana to help improve neonatology in Poland. Humana once again partnered with UofL, this time focusing on ways to reduce perinatal mortality, which was inappropriately high because of poor resuscitation efforts in the delivery room, says Larry Cook, M.D., vice president for health affairs at UofL.

"One of the first things we did, recognizing that we didn't have the money to address their lack of funding, was focus on education," says Cook, who led the Polish effort.

"So we took a program called NRP -- neonatal resuscitation program -- which is a sort of cookbook approach to resuscitation, and translated the training materials into Polish. The following summer, we returned with resuscitation training equipment and, over a two-week period, trained about 80 instructors at four academic medical centers.

"With ongoing grants from The Humana Foundation, we eventually were able to supply them with resuscitation mannequins and resuscitation equipment so they could establish their own training centers at those four sites. So it became sort of a daisy chain, and over the years, thousands of individuals were qualified in neonatal resuscitation in Poland as part of this program."

What began as a neonatal resuscitation program then blossomed into a parallel program to the Romanian effort, Cook says.

"Over the course of the subsequent years, we developed regular relationships with not only those four original academic medical centers, but even with incremental medical centers. At least once a year, sometimes twice a year, we would take a team of educators -- predominantly from UofL, but also drawn from a national base -- over to conduct multi-day symposia on site.

"And virtually every month of the year we would have a different team of Polish physicians and nurses here in Louisville as observers, studying side by side with our staff. I would say we trained about 50 individuals from Poland that way."

Like the Romanian effort, Cook says the Polish program was extremely beneficial to pediatric health care.

"There are probably hundreds of people alive today who otherwise wouldn't have been because of that program," he notes.

"To be honest, however, Poland doesn't need us anymore, and Romania is quickly getting to the same point. That's a testament to the efficacy of both programs."

Indeed, Rodgers is now winding down his involvement in Romania, although smaller, more-focused projects will likely continue there in such areas as pediatric intensive care. The future, however, lies in programs planned for Latvia and Moldova, using funding provided by The Humana Foundation and the David Jones family, and employing the same educational formula that proved so successful in Poland and Romania.

The first group of Moldovan pediatricians visited Louisville in November 2005, and work is already underway to support further Moldovan exchange programs in other areas, thanks to the support of faculty like Dan Stewart, M.D., a senior UofL neonatologist, and John Distler, M.D., a clinical faculty member in the Department of Ophthalmology. Further down the road, UofL will investigate more international learning opportunities for students and residents.

"There is no doubt the Romanian Assistance Project has been the most rewarding thing I've ever done in my professional career," Rodgers says, looking back on 15 years' worth of tremendous accomplishments. "But there are other countries who need our assistance now, and I find it very gratifying to know our work will continue well into the future."

Judd concurs.

"Since 1990 we both have had this incredible adventure with our Romanian and Polish friends to improve health care in Eastern Europe," she says. "We are so proud of all the participants and hope the university will be able to replicate the pediatric model created in Romania to help other deserving countries."