A PHYSICIAN HEALS HERSELF Unfulfilled despite her six-figure Seattle practice, Dr. Juliette Engel chucked it all to help deliver babies in a run-down maternity ward in Moscow. Though she's rapidly depleting her savings, she's happier than ever.

(MONEY Magazine) – Naked and exhausted after 20 hours of unproductive labor, a heavyset woman lies in a tiled operating room that smells of dried blood. The room is open to the hall through a small wash-up area where doctors are expected to sterilize their hands despite the urine-filled bedpan and uncovered plastic bucket of bloody rags nearby. The six-person medical team has finally decided on a caesarean delivery, but there's a delay now while a nurse leaves the room in search of surgical masks. Ready again, the team gives the woman a dose of anesthetic gas; safer intravenous anesthetics are simply not available. The woman jerks, vomits and, mercifully, loses consciousness. One doctor makes a sweeping incision in the woman's swollen belly and lifts out a baby girl (at right), who's covered in blood and still looks distinctly blue. The doctor places the infant in a metal pan. A nurse carries the pan into an empty room, and then spends minutes jiggling a plastic breathing tube down the coughing baby's throat. That accomplished, the nurse leaves her alone wrapped in a dingy cloth on a thin pallet in a metal crib. The mother, denied visitors during her entire ordeal, will not be allowed to see her daughter for at least 24 hours. That is the custom. Welcome to childbirth, Russian-style. Dr. Juliette Engel, 44, an American radiologist who observed the delivery, has seen all this before. "Newborns can get cold," says Engel, stroking the infant. "They can stop breathing." Her normally gentle voice rises: "Thanks to that delivery, this beautiful baby will probably suffer pneumonia." Engel is in Moscow on a self-imposed mission to improve such obstetric care. Five years ago, her life was unremarkable, except perhaps for its financial success. Specializing in ultrasound exams for expectant mothers, Engel was pulling down $300,000 a year in a Seattle practice that employed six assistants and treated 4,000 women annually. Today, the divorced mother of two -- Max, 15, and Madeline, 13 -- heads Miramed, a nonprofit group she founded two years ago to provide equipment and training for so-called birth houses (mostly hospital maternity wards) in the former Soviet Union. As Miramed's director, she spends four months a year teaching Russian medical personnel Western methods and training them to use donated up-to-date equipment. She devotes most of the rest of the year to raising money for Miramed with the help of two part-time, volunteer staffers in Seattle. Engel's career switch may have been dramatic, but her reasons sound all too common. Like many others of her generation in medicine, she wanted to do more with her life than just accumulate money. At the same time, she disliked the growing intrusions by outside forces into the doctoring profession. "There was less and less freedom," remembers Engel, "and more control by insurance companies, by HMOs." Summing up, she says, "I wanted to do something more expansive." Doing good on a global scale demands vision and drive. Engel has both. Running such an organization, however, also requires mastery of endless details -- which is not her strong point. There are other strains as well. Engel misses her children, whom she normally leaves in Seattle with their father while she's in Russia. And because she has yet to draw any salary from Miramed, the good doctor is jeopardizing her financial security. Prior to 1988, the expansiveness Engel craved described her lifestyle, not her career. She and her former husband Greg, a successful orthopedic surgeon, owned a $1.36 million, six-bedroom house on Seattle's tony Lake Washington with a tennis court and a full-time housekeeper. They also owned an interest in a 55-foot yacht. "We had a complete disagreement on values," insists Engel. "I identify with the Russian people because my life has been a long struggle." She stresses, for example, that she put herself through college and medical school in part by working as a typist for as little as $1.40 an hour. "Money and possessions don't mean a lot to me. I didn't like my kids growing up feeling they deserved all those material things." Engel estimates that her 1988 divorce cost her a hefty $200,000 or so in attorney's fees because the parting became increasingly acrimonious. Those fees nearly swallowed up the $211,000 she got from selling her practice in 1988. Greg provides no alimony but does pay her $1,500 a month in child support. They have joint custody; the kids live six months with each parent. After the divorce, Engel spent more than a year working part time at Overlake Hospital in nearby Bellevue (1989 earnings: $63,000), remodeling the $290,000, three-bedroom Tudor she bought in 1989 (cost: $60,000), writing poetry and traveling. "The hardest part," says Engel, "was self-worth. It takes a total mind shift from 'I am important because I make $300,000 a year' to 'I am important because I have other resources.'" In January 1990, while touring Russia for the first time, she visited several of the 2,640 state-run birth houses. She was appalled. The birth houses often operate without basic medication and diagnostic equipment. Even surgical gloves are so scarce that doctors frequently treat several women before discarding them. As a result, says Engel, about half the 1.6 million Russians born each year contract staphylococcal infections, which can be fatal. The rate of infection among full-term U.S. infants is estimated at 0.7%. Furthermore, Russia's 1991 infant mortality rate was 17.8 per 1,000 births, according to its Government Committee on Statistics -- or twice that of the U.S. And Russian women die during pregnancy, childbirth or just afterward at six times the American rate. Beyond all that, Engel was repulsed by the "absolutely dehumanizing" treatment patients got. Russian medical personnel often let women labor for hours without help. The careless application of pressure to mothers' bellies during delivery -- supposedly done to speed birth -- sometimes breaks women's ribs. And the only way patients can see family or friends is by waving to them from the windows of their rooms. During that 1990 visit, says Engel, "I realized Russia is the place to be." By mid-1991, after several trips and meetings with Russian health officials, she had arranged to work with Moscow's Municipal Hospital No. 70 -- recently renamed Savior's Hospital for Peace and Charity -- to improve its 300-bed birth house. She dubbed her fledgling organization Miramed, a combination of the Russian words for "peace" and "medicine." She also taught herself passable Russian from books and audiocassettes. Still, doubts existed. "I'd wake up at night and wonder, 'God, how will I do this?'" says Engel. "But once you know there's a world out there, you can't go back." Today, her new world has settled into orderly chaos. While in Russia -- usually all summer and one month in winter -- she lives and works like the average Muscovite. She rents a studio apartment with peeling wallpaper in a seedy middle-class building for $200 a month, the going rate for foreigners in her southeast area. She travels by subway (10 rubles, or 1 cent ). And she shops at an open-air food market two blocks from her office where a loaf of bread costs 57 rubles, or less than 6 cents , rarely in the more expensive hard-currency grocery stores. Result: Her food costs run $100 a month compared with $800 in Seattle. ^ "I like living that way," Engel says convincingly. She's unfazed by the annoyances of Moscow life, such as the need to boil drinking water or the fact that the city shuts off hot water for two weeks every summer. What trips her up are the emotional roadblocks. Because of her kids, she remains tied to her old life in Seattle. "The hardest part is that they're caught between two such different worlds," she says sadly. Last summer, for example, she invited her daughter Madeline to Moscow. But, according to Engel, Greg's gift of a new puppy and a horse helped keep the teenager at home. He responds: "Madeline didn't want to go." Insists Engel: "Her coming to Russia was threatening to him. God forbid she grow up to be a strong woman." Engel can console herself with the improvement she's bringing to Savior's birth house, which until recently lacked even fire doors and safe wiring. Thanks in part to her efforts, the building was scheduled to close for six months starting in September for renovation, including upgraded heating and electrical systems. Cost: 500 million rubles ($500,000), supplied by the Russian government. "We'd need at least $3 million more to bring it up to U.S. standards," sighs Engel. One of her goals is to educate Savior's staff to continue improving without Miramed's involvement. "We'll probably fade out of Moscow within the next year," she says. Likely spots for future projects: St. Petersburg, Kiev and Nizhni Novgorod (formerly Gorky).

Engel's schedule may prove overly ambitious because the bureaucracy that irked her at home is thriving in Russia. "I've been waiting eight months for a permission letter from the Ministry of Health to get a $9,000 heart defibrillator into the country," she complains. "How do you get equipment from here to there? How do you get volunteers to Russia? How do you keep them safe from crime?" Crime is a serious concern in a country where last year's urban inflation rate was 2,318%, while the average worker recently earned just 23,559 rubles ($23.55) a month. Engel's personal strategy? Dress inconspicuously and avoid speaking English in public. Still, she remains vulnerable to those who see Americans as prey. In late 1991, a "quasi-governmental group" she refuses to identify demanded $65,000 to ensure the safety of herself and Miramed volunteers. She resisted, explaining that Miramed is nonprofit -- an unfamiliar concept in Russia. Complimentary local press coverage of Miramed convinced the group to back off. Engel's overriding challenge since founding Miramed has been getting funding. She took out a $65,000 personal loan at 9% from a local bank to pay start-up costs (monthly payment: $415) and assumes Miramed will repay her someday. But the grants that she innocently figured American foundations would fork over never materialized. So Engel began storming Washington for government assistance and searching nationwide for donations from medical equipment manufacturers. After two years, she's landed two ultrasound machines and 11 anesthesia machines, now at Savior's. She's persuaded Lufthansa to supply free freight services and to shuttle her between Seattle and Moscow two to four times a year at a discounted $700 rate. Plus, the U.S. State Department awarded Miramed a $14,000 grant in October 1992. Still, her inexperience with grant writing shows. Miramed lost a sorely needed $450,000 awarded by the federal Agency for International Development (AID) last November because Miramed had agreed to name then-partner Magee- Womens Hospital of Pittsburgh as the sole recipient -- and, according to Engel, Magee never gave Miramed a penny of the first $93,000 installment payment. By the summer, Magee and Engel's group had separated and the grant was suspended. Magee president Irma Goertzen responds: "The structure that was set up to manage the project did not work as originally designed." Miramed's future remains far from certain, mainly because Engel balks at soliciting donations from individuals. "I have doctor friends who could support this whole program, probably," she confides. "But I don't feel comfortable asking them." So she must continue to pump in her own money -- $20,000 last year, including $15,000 in travel costs for herself and volunteers. That money comes out of Engel's savings because she doesn't have enough income to cover her close to $79,000 in personal living costs. Besides the $18,000 that she receives annually in child support, Engel receives $24,000 in interest and dividends from her investments, for a total income of $42,000. Besides her $2,136 monthly mortgage payment (interest rate: 10.25%), many of her expenses, even in Seattle, are low: Large deductions mean she owed no income tax in 1992. Both her 1986 Jeep Wagoneer and her 1983 Alfa Romeo Spider are paid off. And a $45,000 trust fund that was set up for her children's education covers Max's $6,000-a-year private high school. Still, Engel had to liquidate nearly $57,000 worth of stock and bond investments last year. Her remaining $700,000 portfolio includes $69,000 in stocks and five different stock funds, $56,000 in bond funds, $9,000 in cash and money-market accounts. She has two life insurance policies with a cash value of $54,000, plus $324,000 in Individual Retirement Accounts, invested mostly in equities. Her big mistake: the nine tax-shelter limited partnerships she bought for $376,000 in the early '80s. They are probably worth no more than half that now. But Engel pays little attention to financial matters. She has other things on her mind. She's concerned that Miramed might have outgrown its board of directors -- mostly doctor, attorney and executive friends who have no experience seeking government grants. She plans to establish a for-profit consulting business that would help hospitals and other institutions in Russia to buy medical equipment from U.S. companies -- and, incidentally, help her earn some money (though she's not sure how much). And she's busy writing a book about her experiences. Characteristically, she's unconcerned about finding a publisher. "I'm a very good writer," she says with a shrug. The one thing Engel doesn't have -- besides sufficient income -- is regrets. "I feel as though I've been let out of a cage," she says earnestly. "This is living in the fresh air."

THE ADVICE Generate income. "That's her absolute first priority," concludes William Morrissey, a certified financial planner in Mount Vernon, Wash. "If she doesn't leave her investments alone, she's in deep trouble -- fast." He estimates that if Engel continues to spend at her current rate (and Miramed doesn't repay the $65,000), her $700,000 worth of investments would last only until the year 2001, assuming 5% inflation and an 8% rate of return. But if she can earn enough to live on, she would need save no more to achieve a comfortable $63,000-a-year retirement at age 65. Refinance your mortgage. A 30-year fixed-rate loan at 7% would lower the monthly payment on her Seattle house from $2,136 to $1,530, says Morrissey, saving her a sizable $7,282 a year. Cultivate individual donors. Engel is relying too heavily on government grants, says Jim Burns, a Seattle fund-raising consultant. "She's got to develop a structure for funding Miramed that relies 90% on individuals," he says. She should hire an experienced development director (likely cost: at least $35,000 a year) who would be effective at recruiting big donors. She also should consult another expert, a so-called nonprofit development planner, for two or three days to create a comprehensive five-year plan. Such a plan would help convince donors that she's committed for the long haul. For a list of planners, she can call the National Society of Fund-Raising Executives ($20; 800-688-3463). Build an effective board. Engel needs affluent, well-connected and experienced board members who believe in her vision and will work hard for it. "They'll give her valuable perspective in decision-making," Burns adds.

Engel has installed an interim board and is looking for permanent directors "with experience in soliciting donations." She hopes that Miramed will begin paying her an annual salary of $60,000 in a year or so. "I don't want to get so overextended that I have to go back to my old career," she says.


Although this divorced mother has a million-dollar net worth, at the rate she is spending to indulge her dream of bringing better obstetric care to Russia, she will be broke in eight years. Engel's immediate concern: earning enough income so she won't have to return to her less satisfying career as a $300,000-a-year Seattle radiologist.

INCOME Sale of assets $56,564 Interest and dividends 24,000 Child support 18,000 Total $98,564

OUTGO Mortgage $25,636 Miramed donations 20,000 Food, clothing 15,000 Entertainment, vacations 6,050 Loan payments 4,980 Medical costs, insurance 4,400 Phone, utilities 3,930 Property tax and insurance 3,728 Home maintenance, repairs 3,600 Life insurance, babysitting 3,200 Car insurance, gas 2,640 Rent for Moscow apartment 2,400 Gifts 2,000 Miscellaneous 1,000 Total $98,564

ASSETS Savings and investments $700,000 House 420,000 Vehicles, other property 176,000 Loan to Miramed 65,000 Total $1,361,000

LIABILITIES $ Mortgage $230,000 Personal loan 62,500 Total $292,500

NET WORTH $1,068,500