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July 30, 2014

Questions surface about medical care in the Peace Corps

Daily Briefing

A New York Times investigation into the deaths of several Peace Corps volunteers in recent years raises questions about the organization's medical care and "lack of defined leadership" in dealing with seriously ill volunteers.

For the investigation, the Times reviewed audits by the organization's internal watchdog and interviewed former volunteers and the parents of volunteers who have died. The most recent death—of volunteer Nick Castle in China—is currently under review by the Peace Corps inspector general, and a report is expected soon.

 Background on Peace Corps medical care

In each of the 65 counties in which Peace Corps volunteers are located, the organization has at least one agency medical officer—a doctor, nurse, nurse practitioner (NP), or physician assistant (PA)—who is responsible with providing for volunteers "adequate medical care whenever necessary."

Until several years ago, such professionals were hired abroad by agency officials without medical qualifications. The professionals now are hired and given qualifications by the Peace Corps Office of Medical Services in Washington, D.C.

Across the globe, there are 121 Peace Corps medical officers and five regional medical officers who report to the D.C. office. According to the Times, 296 volunteers—less than two-tenths of 1% of total volunteers— have died during the agency's 53-year history.    

2009 death spurred change

In 2009, So-Youn Kim, a volunteer stationed in the Moroccan village of Tamegroute, died "unexpectedly after an illness" in Marrakesh.  At the time, the agency said her death was "not related to her work," however,  a pair of reports the following year found "significant shortcomings" by Peace Cops medical caregivers that "directly impacted" Kim.

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According to the Peace Corps' inspector general, the agency's medical professionals were cited for "medical acts of both omission and commission" and "poor professional judgment." Moroccan medical professionals notified Peace Corps physicians in Washington of Kim's condition less than one hour before she died, when it was too late to transport her to another country for better care.

According to investigators, the incident rose the "question of whether this was a one-time failure or an indication of a larger systemic problem throughout Peace Corps operations." Following Kim's death, the agency began re-evaluating various aspects of its operations, including health care, volunteer training, and recruitment.

2013 death in China raises further questions

Although Peace Corps volunteer Nick Castle arrived in China in "excellent health," he fell ill with diarrhea and fever in October 2012. Jin Gao, a Peace Corps doctor, prescribed Cipro, but Castle was unable to keep it down. His students took him to a hospital, where he was given intravenous fluids and more antibiotics. However, he was not admitted, which would have required Gao to see him in person. 

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 The next month, Castle sent Gao an email expressing concern about his recent weight loss, down 11 pounds from his usual weight of 130. Gao responded, noting that Castle's BMI was "low normal" and sent him a link to an article about healthy ways to gain weight.

In January 2013, his host family noted that Castle "did not appear well" and had "lost weight." The following week, Castle was attending a Peace Corps conference and fell ill again, so Gao came to see him. According to Gao's summary of the visit, Castle had dry lips and appeared fatigued. She diagnosed him with gastroenteritis and prescribed antibiotic Cipro and an anti-nausea treatment. She did not recommend that Castle be admitted to the hospital.

The next day, Castle was discovered lying in vomit-soaked sheets by a hotel maid, and Gao was called to the room. She recorded his blood pressure as 80 over 40, very low, and noted his hands were cold. Gao asked the medical office to send a nurse with intravenous fluids and a Peace Corps car to take Castle to the hospital.

The car Gao called was in use by the county director, and no medical staff member felt "empowered" to ask to use the vehicle despite the dire situation, so the team called for an ambulance that got lost en route and did not arrive for about 30 minutes. 

According to the Times, while attempting to get Castle into the ambulance, the U.S. staff and Chinese medical officers began arguing about whether to place Castle on his back to start an IV and take his blood pressure first or whether to turn Castle on his side to keep his airway open.

When the team arrived at the hospital, Castle was resuscitated and hooked up to a ventilator. But by then it was too late, and Castle was pronounced brain-dead several days later. On Feb. 7, 10 days after being admitted to the hospital, Castle was taken off of life support. The autopsy said Castle had died of "complications of viral gastroenteritis," including dehydration, multiorgan failure, and pneumonia. However, an exact cause of the illness could not be pinpointed.

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Peace Corps response

The Peace Corps sent Thomas Wilkinson, one of its top physicians in Washington, to China for an internal audit.

Wilkinson's investigation concluded there was an "apparent lack of defined leadership" and that Gao may have had an "anchoring bias" that caused her to miss some red flags. 

Jeffrey Smith—an outside analyst from George Washington University Hospital who was asked to investigated the case—wrote that Gao "did not appreciate potential signs of a more serious illness," but noted that Peace Corps medical professionals were not used to "providing high acuity care" and that Castle's situation was unique. He concluded, "any suggested changes in the care that was delivered on January 28th would not affect the unfortunate outcome."

Castle's parents are still seeking answers, according to the Times. David Castle says, "Everybody's sorry, but no one's responsible" (Stolberg, New York Times, 7/25).

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