Peace Corps death leaves trail of mistakes

Man died amid major changes to agency’s health care system

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BRENTWOOD, Calif. — Nick Castle had just graduated from the University of California, Berkeley, when he loaded up his backpack with Mandarin-language books and set off for rural China to teach in the Peace Corps.

Seven months later, in January 2013, a 2 a.m. phone call jolted his parents awake. “Your son Nick is very ill,” a Peace Corps official from Washington told them.

Mr. Castle, weak from diarrhea and vomiting, had collapsed that day in the city of Chengdu and was in a hospital in a coma. His parents — David Castle, a police sergeant in this Northern California city, and his wife, Sue, a former nurse — flew to China, where days passed before they learned the truth: Their son was brain-dead.

On Feb. 7, 2013, Nick Castle was taken off life support. He was 23.

A Peace Corps spokeswoman called Mr. Castle’s death, from a gastrointestinal illness, “a tragic experience.” To examine its own conduct, the agency took the unusual step of engaging an outside U.S. expert, whose report concluded that despite medical missteps by a Peace Corps doctor who missed signs of serious illness, Mr. Castle’s death could not have been prevented.

But the story of Mr. Castle’s death — pieced together from interviews and confidential reports and documents, including his autopsy — raises serious questions about Peace Corps medical care, and how the agency responded to a volunteer’s dangerous illness.

Mr. Castle died as the Peace Corps was making extensive changes to its health care system, after a scathing internal report that exposed lapses in the care of another volunteer who died in Morocco in 2009. In that case, the agency’s inspector general blamed Peace Corps medical professionals for “medical acts of both omission and commission” and “poor professional judgment” in caring for the volunteer.

The circumstances of Mr. Castle’s death came to light during a monthslong examination of the Peace Corps by The New York Times that included a review of audits by the agency’s internal watchdog and dozens of interviews with returned volunteers and parents of those who died. Mr. Castle’s death is now under review by the agency’s inspector general after The Times’ inquiry. A report is expected in coming weeks.

“My son wasn’t going into the Marine Corps in Afghanistan,” David Castle said. “And that is something I have said to Peace Corps over and over, in multiple conversations: You don’t go to the Peace Corps to die.”

Although deaths in the Peace Corps are rare — during its 53-year history, 296 volunteers, or less than two-tenths of 1 percent of the total, have died — the death of the Morocco volunteer, along with the highly publicized murder in 2009 of another volunteer, in Benin, has prompted what the agency’s director, Carrie Hessler-Radelet, described as a top-to-bottom push for reform.

She declined to answer questions about Mr. Castle, but Ms. Hessler-Radelet said that since 2010, the Peace Corps has been re-examining all aspects of its operations in what she called “a period of incredible, intense reflection and action.”

From the moment Nick Castle arrived on the Berkeley campus in the fall of 2008, he made his intentions clear. He promptly joined the campus Peace Corps club. “He was beyond driven,” said Chris Castle, Nick’s older brother. “No one worked harder than Nick.” An aspiring diplomat, he was thrilled to land an assignment in China, a country that had fascinated him since middle school. After two months of training in Chengdu, where he lived with a host family, he was sworn in as a Peace Corps volunteer and sent to a university in the ancient city of Tongren, in rural southwestern China, to teach English for two years.

In October 2012, not long into his teaching stint, Mr. Castle — who had arrived in China in “excellent health,” records show — became sick with diarrhea and fever. He called the nearest Peace Corps doctor, in Chengdu, Jin Gao, who trained in gynecology and in 2005 joined the Peace Corps to work as a primary-care physician. She suggested that Mr. Castle take Cipro, an antibiotic in his Peace Corps-issued medical kit, but he was unable to hold it down. His students drove him to a local hospital, where he was given intravenous fluids and antibiotics.

The next month, Mr. Castle sent an email to Dr. Gao expressing concern about his weight loss — a sign, his parents believe, that something was wrong. Dr. Gao told Mr. Castle that his body mass index, at 18.6, was “low normal” — below 18.5 is underweight — and sent a link to an article about healthy ways to gain weight.

In each of the 65 countries where it operates, the Peace Corps has at least one agency medical officer — a doctor, nurse, nurse practitioner or physician assistant — who works on contract and is responsible for providing “adequate medical care whenever necessary.” Worldwide, there are 121 Peace Corps medical officers, supervised by five regional medical officers who report to the Peace Corps Office of Medical Services in Washington. If volunteers develop complicated conditions that the Peace Corps cannot handle, the agency pays for a medical evacuation to another country or back to the United States.

In November 2009, So-Youn Kim, 23, a Stanford University graduate who was a Peace Corps volunteer in the Moroccan village of Tamegroute, died “unexpectedly after an illness” in Marrakesh, the agency said. Friends said the Peace Corps had assured them that the death was “unique to her, and not related to her work.” But in a pair of 2010 reports — one heavily redacted when released to The Times under the Freedom of Information Act — Kathy A. Buller, the inspector general, identified “significant shortcomings” in the care that Ms. Kim received from Peace Corps medical professionals. The reports reveal that Peace Corps medical professionals failed to “recognize changes” in her health, which led them to misdiagnose her ailment at first.

“The question of whether this was a one-time failure or an indication of a larger systemic problem throughout Peace Corps operations remains,” the investigators concluded.

On Friday, Jan. 25, Mr. Castle went out with other volunteers for pizza and felt ill afterward. Others also seemed to have stomach bugs. But at 8 a.m. Monday, Jan. 28, Mr. Castle’s roommate called Dr. Gao. A case summary notes that Dr. Gao thought Mr. Castle sounded “mildly distressed,” and that she went to see him at 9:30 a.m. Dr. Gao made a diagnosis of acute gastroenteritis and prescribed Cipro, along with an anti-nausea drug. Dr. Gao did not return to Mr. Castle’s room until about 2 p.m., after a hotel maid discovered Mr. Castle lying in bed in sheets soaked with vomit.

The hotel room scene quickly became chaotic. Mr. Castle’s blood pressure was abnormally low. His hands were cold. “We realized this is critical situation,” Dr. Gao wrote in her notes.

An American physician assistant arrived at 3:15 p.m. She found Mr. Castle to be “lucid,” but with no detectable blood pressure, and the team called for an ambulance. The ambulance became lost in Chengdu’s streets and did not arrive until 3:45 p.m. At West China Hospital, Mr. Castle was resuscitated and hooked up to a ventilator.

The Peace Corps’ medical team monitored Mr. Castle and awaited the agency’s regional medical director, Cedric Yoshimoto, an American, to come from Thailand. The Castles believe that the team was waiting for Dr. Yoshimoto, who had trouble getting a visa to enter China, to say what everyone else already knew: Their son was brain-dead.

On Feb. 7, 10 days after Nick Castle was admitted, Dr. Yoshimoto arrived. He and the Peace Corps medical team met with the Castles after scans showed worsening swelling in Mr. Castle’s brain. The parents gave written consent to withdraw life support. That evening, the veteran police sergeant held his son’s arm as a doctor turned the respirator off. “I felt his pulse,” David Castle said, “until he didn’t have a pulse anymore.”

The autopsy, conducted at Dover Air Force Base in Delaware, listed the cause of death as “complications of viral gastroenteritis,” which led to severe dehydration, multiorgan failure and ultimately pneumonia. A Defense Department medical examiner could not pinpoint how Mr. Castle had become sick, and he did not test positive for any unusual illness.

The Peace Corps sent Thomas Wilkinson, one of its top physicians in Washington, to China to conduct the agency’s internal inquiry. In Dr. Wilkinson’s report, he not only raised questions about the “apparent lack of defined leadership” — in short, that no one seemed to be in charge in the crisis — but also said Dr. Gao may have suffered from “anchoring bias” —that her awareness that others had had stomach symptoms colored her thinking. “Some red flags might have been missed,” he wrote.

The Peace Corps also asked emergency medicine specialist Jeffrey P. Smith at Washington’s George Washington University Hospital to do an unpaid outside analysis. His report, focused on care Mr. Castle received at the hotel, found that Dr. Gao “did not appreciate potential signs of a more serious illness” during her morning examination Jan. 28. But he noted that Peace Corps medical personnel were “not in the business of providing high acuity care,” and deemed Mr. Castle’s illness a “very challenging and unusual case to manage.”

United States - North America - East Asia - Asia - China - Greater China - Africa - California - North Africa - Chengdu - Peace Corps - Morocco


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