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By Sheri Barrows

Created: 20 February 2016

I have been filling the role of secretary/treasurer of Acupuncture Relief Project since 2008 when Andrew’s dream reached the point where it shifted from idea to action. When meetings with bankers and lawyers became necessary; when he needed my “type A” brain to figure out how to manage the mounds of information we were accumulating; and when the piles of legal documents needed to be filled out and filed – that’s where I came in.  Since I am neither an acupuncturist nor a health care practitioner of any kind I have always felt a bit removed from the practice side of ARP.  I handle the receipts for needles, otoscope’s, cotton balls, electro machines, foot stools, blankets, moxa and every other item used in the clinics and yet I have only heard second hand the stories about how the supplies have made a difference in the lives of the patients.  Until now!  This year I am extremely fortunate to have the opportunity to be here in Nepal for several months. To spend time in the clinics and to connect with the patients, practitioners and interpreters first hand.

Every day has been a learning experience and a gift but I am most affected and inspired every time one of our stroke patients comes to the clinic.  Sure, I have watched the video on our web site of Birbahadur Thapa, showing his progress recovering from his stroke and I have heard the stories of other patients but it wasn’t until I actually witnessed the impact of acupuncture on a stroke patient for myself that I truly understood how important these clinics are.

Most of the stroke victims in Nepal are sent home from hospital with no physical therapy and no instructions on what they and their families can do to try to recover lost abilities, therefore they rarely experience any improvement after their stroke.  Since a large number of our patients are illiterate, they also don’t really understand what happened to them and what “stroke” means so understandably this creates a lot of fear. When they come to our clinic they are often totally hopeless and demoralized because they have been in their condition for at least a year and often for many years.  After just one or two treatments they experience noticeable changes and begin to feel hopeful.  It is that shift to hopeful that moves me so deeply. 

There is one man in particular that I have become very attached to.  Jagat came to the Bhimphedi clinic for the first time with several family members because he needed their physical support to get to the clinic and, since he could not speak at all, he needed his wife to translate his facial expressions into words. I don’t believe I have ever seen a man as dejected as Jagat was on that first day.  He is 35 years old with a wife and 3 kids and all of a sudden he cannot take care of his family nor support them financially.  He no longer has a role in his community and people have stopped making eye contact with him – he has become invisible because he cannot participate in life and therefore he no longer matters.

His ARP doctor, Rachel Hemblade, went through multiple physical and vocal tests with him to determine what his abilities were, treated him with acupuncture and physical therapy, and then created a homework plan. Rachel recruited his family members to help him at least twice a day and taught them how to perform the physical therapy and voice coaching themselves. Jagat is very fortunate to have a caring family and everyone stepped up and said they would help.

The way Rachel fully and cheerfully engaged with Jagat and his family and her deeply compassionate manner had to have been reassuring for them on that first scary trip to the clinic. 

On that initial visit, Jagat could not make any sound at all for two of the vowels and could barely sound the others. His entire right side was severely stroked. Hand in a claw like grip, shoulder barely mobile, unable to lift his arm up from his side, leg could move forward to walk at the hip only, foot had no motor control, face totally expressionless. Eyes immensely sad.

His home is a 4-hour walk from the clinic and thus would make daily treatment unreasonable so thankfully he was able to make arrangements to stay in Bhimphedi with friends. 

When he came back to the clinic for his second treatment you could see an ever so slight sparkle in his eyes. For the first time since the stroke he had felt his body change and suddenly, he had hope!

When he arrived for his third visit he was excited to show us that he could now pronounce all of his vowels.  I will always remember that visit because it was also the first time he was able to smile and his smile lit up the whole room.

By his fifth treatment he no longer needed a family member to interpret his facial expressions because he could answer Rachel’s questions himself, albeit slowly, and each treatment since has continued to bring improvement.

The crooked smile he directs at me when I exclaim with joy at his progress is a gift I will never get tired of receiving.

This is but one example from the hundreds and hundreds of patients ARP practitioners treat every year.  And this is why I will never again be able to file a receipt for needles or pay for an order of cotton balls or any of my other secretarial duties without being deeply touched by my experience here. I am immensely proud and appreciative of everyone who makes this project function on a daily basis  – Tsering, all the interpreters and practitioners, all of the advisors – and I cannot begin to express my admiration for the dedication, love and energy Andrew has given to make this project happen, year after year.  When I signed on as a board member 8 years ago, I never could have imagined the significance it would have in my life. --- Sheri Barrows

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By Stacey Kett

Created: 15 February 2016

It’s the dry season here in Nepal. It has rained a few times since we arrived in the beginning of January, but just a little bit. The village of Bajra Barahi, that houses the Acupuncture Relief Project clinic, is a rural farming village. Most of the people that live here are subsistence farmers. Almost every inch of open land is terraced fields. My previous career, before becoming an Acupuncturist, was an organic farmer. I love seeing how people farm here in Nepal. In the late winter/ early spring they grow a lot of potatoes, cauliflower and mustard greens. In the summer, after the potatoes are harvested, they grow a lot of corn, rice, peppers and tomatoes. 

When we arrived here in January, the fields were flat and fallow. Then people started to work up the land, using oxen, rototiller-tractors and hand tools to form rows. They began to bring compost to the fields and dump them in piles spaced evenly around each field. Many people have livestock at their homes and are able to make their own compost mixed with pine needles and other foraged materials. People have their fields somewhat near their homes and transport the compost in baskets that are carried on their backs with a trump line across the top of their heads. 

This is where the acupuncture clinic comes in. The life of a subsistence farmer is hard work. In the clinic we see a lot of aches and pains. We treat a lot of people whose neck is compressed, from carrying loads on their back and head, giving numbness and tingling down their arms and into their hands. We are able to treat the villagers for issues such as this. But the problem is that they have to continue to farm, carrying heavy loads to and from their fields. I think that they have a beautiful life. It’s better than sitting in front of a computer all day. Or at least that is my opinion. Our team of practitioners have had many conversations about what to do to help and we end up with no real answers. Farming is hard work, whether you carry a wheel barrel, shovel into a flatbed truck or carry loads on your back and head. But we can treat them with Acupuncture, discuss posture, exercises, help them manage their aches and pains and support their hard work.

So after the compost is delivered to the fields, it is spread out by hand into the rows that were already created. The potatoes are placed in the rows on top of the compost and the soil is hilled up over the potatoes in beautiful rows. The entire family seems to participate in the farming. There is a job for everyone. We have seen little kids carrying baskets on their backs with light loads. The older people are sitting on a tarp in the field, cutting the potatoes, preparing them for planting. It was unexpected gift to get to see the potato planting in what seems to be so early in the year.  It appears now, that most of the valley is planted in potatoes and we are waiting for them to sprout, waiting for green. --- Stacey Kett

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By Andrew Schlabach

Created: 20 January 2016

One brisk morning in Makawanpur, as our team was finishing breakfast and preparing to head over to the clinic, a man stopped by to ask us if we could have a look as his mother. The man is a carpenter who has been helping us with our new clinic building and the weary expression on his face speaks volumes as to what might be going on with his mother. I grab one of our mobile kits and ask one of the other practitioners and an interpreter to come with me up to the carpenter’s village. 

As part of my work in Nepal, I really enjoy visiting patients’ homes and doing house calls. Too often we don't have time or the resources to spend walking out to neighboring villages, but when we do, I always find the experience enriching and illuminating. For example, a couple of weeks ago I was returning from a house call when I was stopped in the street by another patient who asked if I could look at her mother. She told me that her mother had suffered a stroke more than a year ago. When I went to their home and saw her mother however, I quickly realized that her mom had not suffered a stroke, rather she was in the advanced stages of Huntington’s Disease. On my walks, I find many disabled, paralyzed and elderly people; I also get acquainted with the village drunks. Sometimes I discover a few cases of mental illness and birth defects lurking in the population. All of these conditions exist everywhere in the world, it’s just that we rarely get to see them all in one place. That is the beauty and nature of working in a village; our patients are everywhere. They vigorously greet us in the street, offering tea or food while giving us updates on their progress and interest in acupuncture. “Ma Dhukdhana! (I don’t have any pain)” an elderly Tamang man shouts while pointing to his knees and throwing his walking stick to the ground. “Deri Ramro! (Excellent!)” I reply while giving him a thumbs up sign. (I have no idea what that gesture might mean in Nepali but it usually makes people laugh.)

On this particular day, it takes us about 45 minutes to walk a few kilometers into the hills just to the west of our clinic. Small, two story, stone and mud houses are clustered tightly together along the hillside in this old Newari village. The Newar heritage can be seen in the intricate wood carvings around the windows and the sweeping uplifted corners of the rooflines. It looks like a 14th century movie set save for a few sad-looking satellite dishes and the modern water tanks. The road is so steep and rocky it’s only passable on foot, and yet, I see two decrepit motorbikes parked about midway up the hill. In most of these houses cows, water buffalo, goats and chickens are kept on the ground floor with the family living upstairs. The air is thick and stings my nostrils with the acrid wood smoke of cooking fires. Evidence of the recent earthquake can be seen everywhere with collapsed roofs, cracked walls and sometimes completely destroyed buildings. On the other hand, there are what appear to be centuries old buildings standing completely unaffected. Damage aside, there is no doubt that life goes on as the village is abuzz with everyday activities. A woman who looks to be at least 150 years old, offers for us to drink rakishi (local distilled alcohol) with her. We happily decline, as it is only 9:00 AM, and wish her a good day. 

In the villages of Nepal, people do not live inside their houses. The house is really just for storage and sleeping with very small living spaces and low ceilings. Creosote coats the walls and roof beams from years of cooking fires and the smell of livestock, mold and dust permeates the air. Most daily life takes place in the small courtyard in front of the house. This is where meals are prepared, laundry is washed, crops are dried and where neighbors gather to socialize while they work. Thusly it was no surprise that when we arrived at the carpenter’s house, his extended family (about 12 people) were all gathered in this outdoor space enjoying the morning warmth from the sun and busy with their daily chores. On a hand woven grass mat in the middle of all of this activity, two younger women support and offer a cup of water to a woman who appears close to death. 

I take a deep breath to calm my mind and offer a silent prayer. “Steady,” I think as I look to my assistants. Then we begin. Make contact, exam, vital signs- is the patient lucid? Barely. My interpreter and I listen to the family members tell their story and we ask many questions. Bit by bit we slowly begin to understand the situation. 

The woman is nearly 80 years old (in Nepal, elderly people do not know their exact age as they do not celebrate birthdays and they do not have any government issued birth documents.) She is as thin and frail as you can image a person to be. Her daughter-in-law claims she weighs less than a sack of rice (40kg or 80-90 lbs). When we try to take her blood pressure, her upper arm is less than one inch in diameter and even our smallest cuff will not fit her. Her vital signs are so weak they are almost imperceptible. Her abdomen is distended and tender. Every bone in her body is visible through her thin and dehydrated skin. Cancer? Internal bleeding? She is in some discomfort but not in agony and periodically she speaks a few words, usually asking to be moved to a different position. “Sit me up,” she says, then after a few minutes “Lay me down.”  She has been this way for 5 weeks, gradually declining. She has not eaten in three days and she is only drinking a few sips of water now and then. 

I look around and take in the scene. “How many people are here?” I think. 10? 20? 30? Family? Neighbors? Every one fascinated by the activity; all looking to us for answers. I look at the carpenter, his weathered face with deep crows feet accenting his high cheekbones. In his eyes I see the question, “What do I do?”

Who is my patient? The woman who is dying or carpenter or the whole family… maybe the whole village?

Of course if I was in the U.S., I would just dial 911 and, like magic, a team of paramedics would materialize within a few minutes, whisking her away to the lifesaving miracles of modern medicine. I wouldn’t even give the slightest thought to how much that might cost. But here… the nearest hospital is 4-5 hours away by kidney-busting roads. Even if she survived the ambulance ride (I use the term ambulance loosely because it is just a four wheel drive truck with a flashing light and lacks any medical equipment or trained personnel) what hospital would we send her to? What can the family afford? If the patient is put on a respirator she could easily drain the family’s resources beyond their basic survivability. 

What to do? How can I possibly answer this question for everyone.... Here is the reality. Like it or not, I am the senior trained medical provider in this village. This family is asking for my professional opinion, on which they will base their plan of action. “What is best?” I ponder. What advice will relieve the maximum suffering? What is ethical?

I begin by clearly stating what is happening. I look the carpenter in the eye, take a long pause, and say… “Your mother is dying.” I go on to explain that I do not believe there is any medicine that will prevent this from happening and that it will likely happen soon. I tell him that she is in some pain and that the hospital would be able to give her medicine to relieve that pain but it is unlikely they will prevent her from dying. It is my opinion that the ambulance transfer to the hospital will be very stressful and possibly fatal for her. It is my sincere feeling that she would be better off in the care and surroundings of her home and family. I empathize that it is a difficult but necessary choice he would have to make for himself, his mother and his family. Under the clear blue sky, surrounded by his extended family and neighbors, the carpenter received this news with stoic silence. He began to cry a little and then he said, “Thank you”.

What came next was an amazing sigh of relief. Everyone gathered there suddenly knew exactly what to do: make Ahma (grandmother) comfortable. They ask lots of questions. We show them how to keep her bedsores clean and advise them to change her clothing and bedding daily. We show them how to massage her dry skin with mustard oil and we explain that she needs to be out in the sunlight and with the family as much as possible. “Don’t leave her indoors, alone in the dark during the day. Hold her hand and speak with her even if she can not speak back to you.” 

We left them saying that if her condition changes or if they felt her pain was becoming intolerable, “Just call us and we will come.” 

The day after our visit the woman sat up on her own and asked to sit in the courtyard with the other women while they worked. She sat all day in the sun and sipped tea. This was the first time she had sat up under her own power for over a month. The women asked her what she was thinking about; sometimes she would reply and sometimes just sit quietly. That night she passed away in her sleep.  

With every decision I have to make there is a consequence. I don’t alway get it right. Many of you might think that I made a poor decision in this case. You may be right. As much as I try to understand what is “best” for a patient, I never really know the answer. What I do understand is that every day our practitioners go to the clinic and try to palliate life. With simple acupuncture and herbal medicine we reduce pain and alleviate many conditions, helping people return to work and to the care of their families. With our assessment and diagnostic skills we help people access and understand the care they need, often guiding the treatment of other physicians. All the while we are working on those aches, pains and injuries that rural living delivers to the body, we’re getting to know our community. We are diligently surveilling for tuberculosis, cancer, hypertension, respiratory dysfunctions and infectious diseases- constantly scanning for signs of mental illness, depression, domestic violence and substance abuse. Maybe our treatment is just the context in which we relate to our patients and community. I can live with that. 

Patients often tell me, “I’m afraid to ask my doctor a question.” In Nepal especially, questioning a doctor will likely earn you a prompt scolding. This fact really breaks my heart. Doctors rarely, if ever, offer a diagnosis or explain the drugs or procedures they are giving to the patient- even to us- and we ask. Illiterate patients (most of our villagers who’re over 50 years old) are totally at the mercy of the medical institutions and they are often frivolously over-treated and overcharged. When I end a patient visit with the query, “Do you have any questions for me?” my patients are stunned. How can such a simple concept go overlooked? Just like the carpenter and his mother, when we take the time to explain what is going on and what can be expected it make all the difference because it enables patients to make their own choices. If nothing else, hopefully through our example here in Makawanpur and through the students that we train, we can begin to get this idea into practice.

In the end, I’m not all that interested in what acupuncture (or any other medicine) can cure. For me it is enough to just struggle with the question, “What is best for this patient?” and to give my utmost effort to provide practical solutions and compassionate care.

Author: Andrew Schlabach, MAcOM EAMP
Director, Acupuncture Relief Project
Bhimphedi, Makawanpur, Nepal