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By Andrew Schlabach

Created: 22 February 2015

For as much as we glorify the medical profession it is actually a much simpler job than it seems. Don’t get me wrong, being a medical provider requires years of training and experience. In the developed world, medical providers are held to extraordinarily high standards. They should be as they are compensated very well for their responsibilities and we need their skills. My observation has less to do with expertise and more about attitude. 

“How can I help you?”

This simple question should summarize our relationship with our patients by placing us in a role of service to our patients. Unfortunately, all too often, the question is presented more in the light of “What is the problem?”. This slight difference in language changes our role and places patients in our service rather than us being in theirs.

Nothing could be more clear in the developing world than the disparity between those who have money and those who don’t. People with money receive good access to medical care and are generally regarded with respect when visiting a clinic or hospital. Those who don’t have money, well… they are ignored. In Nepal, I have witnessed on many occasions, doctors who never made eye contact with their patients. I have seen them talk on their cell phone while they rifle though the patient’s records and summarily write prescriptions, sending their patient on their way without so much as two words exchanged. For the patient, this impersonal visit is often at the cost of their family’s land and livelihood. Again, there are many doctors who do very fine work and I’m not denying that hospitals, doctors, labs and technology do not cost real money —of course they do. As professionals, we need to make a living the same as everyone. The question is more one of, how do we serve our patients equally? How do we see each human being as a unique and valuable part of our community, equally entitled to our attention? For that, our profit driven system seems to fail us.

This year, I worked with one of our volunteer practitioners trying to manage a very persistent outer ear infection in a young Tamang girl. After several weeks of treatment with saline and vinegar flushes, topical herbs, oral and topical antibiotics, and topical anti-fungal agents, she still presented with a deep abscess just above the tympanic membrane. We referred her for a tuberculosis test to rule out a rare form of skin TB. It came back negative. Here is where it gets difficult for us, because we run up against the family’s ability to pay for other more extraordinary care. We appealed to the District Health Office for assistance and they requested that we obtain a referral from the local health post. After consulting with the doctor at the heath post, she agreed that the girl needed surgery to clean and close the abscess. However, she declined to write us the referral because “She [the patient] can’t afford the surgery, so what is the point.”

Now, dear reader, please don’t worry. These road blocks do not stop us and we generally find a way to help our patients. It is also not my intention to single out this one doctor because this is an attitude that pervades the entire health system. I would like to say it pervades the system “in Nepal” but I feel the problem is more far-reaching. 

In my mind I ask, how can this be an acceptable response? How can it make sense to allow a persistent infection progress into permanent hearing loss or worse? How can that possibly serve the community? 

In Nepal, the answer is that the doctor is not a part of the same community. He or she is separated by a gulf of education, opportunity and other socio-economic advantages. Doctors lose sight of the purpose of their service. 

The other issue is that healthcare providers often don’t look beyond their own conclusions for treatment. When we have been trained to think an abscess equals surgery, it is hard to back away from that edge in order to think about other possible solutions or approaches. To remedy this, we need to take a more holistic approach to patient care. On an individual level, we talk about holism in the context of the patient, where we don’t just look at the disease process but rather we look at the whole person and how the disease is effecting their overall wellbeing. We need to extend this thinking to how we look at our overall system of delivering care. Instead of looking at medicine as individual modalities or treatment specialties, we need to go back to pondering how we can best alleviate a patient’s suffering. Often times it has more to do with providing information and education than it has to do with intervention, but it is impossible to arrive at this conclusion if we immediately jump to treatment. 

Look at the fact that many research studies [1][2][3] show that the strength of the patient/practitioner relationship has a direct correlation to the patient’s medical outcome and it should be obvious that treating each and every individual with kindness and respect should go without saying. Yet, in my experience, this relationship seems to be lacking. This is especially true in the rural areas of Nepal where our patients are mostly illiterate and lack the education to ask even the most basic questions about their health. The doctor (I use this term loosely because usually the patient is seeing a health assistant and not a doctor) asks “what is wrong with you?” and then prescribes them a list of medications. Of course the patient has no idea what the medications do, they just believe that they will be cured. When they are not cured, they do not know what to do next. We have found that by just taking the time to clean an infected wound while explaining how to use simple soap, water and exposure to direct sunlight not only kills the infection and heals the wound but also prevents future infections. This simple practice injects new information into the community and effectively inoculates many would-be patients through dissemination. This is so much less-expensive and safer than the common practice of treating superficial infections with antibiotics.

At our clinics, we have the advantage of seeing our patients many times and we start to know them and their families. We laugh and joke with our patients (something unheard of in Nepal) and we start to understand their unique needs. We earn their trust and that trust allows us to help them in ways that transcend medical intervention. I am certain that our volunteers get tired of me telling them that a patient has the right to know their diagnosis. They should know the details of the prescribed plan (or medications) and what the expected outcome is. It is so simple. However, throughout Nepal’s medical system (and probably our own), patients lack this basic information. If they were armed with this information, they could make their own choices regarding their care. They could agree to be served by us, they could seek other advice, or they could do nothing. It would be in their hands.

This year we hosted our first ever formal community and press meeting. We invited our patients, community leaders, district health officials and members of the local and national press to hear what we have accomplished in Nepal and our ideas on transforming the rural care system. It was sort of a grandiose plan but it was very well attended and received. The District Health Chief spoke very highly of our service in Makawanpur and pledged his support in looking at a more holistic model of providing care. He introduced us to a new area in Makawanpur called Bajra Barahi which is regarded as a model health post in Nepal. Their development committee listened to our presentation with interest but also a heathy amount of skepticism. They had experienced several disappointments from other NGO’s who promised large benefits but delivered shoddy medicine with many poor outcomes. They were also very concerned about the sustainability of our efforts.

My response was simple. “We either earn the trust of your community and show you that we can be effective or else it doesn't matter if we are sustainable or not. We offer a simple, safe and effective addition to your health system in which we work side-by-side in partnership with your existing staff and facilities. If we show you that our system is effective, it is easy to adopt and sustain without us. We will show you how and you will have a model which you can share with every district of Nepal.”

They were satisfied with that answer and in the weeks that followed many doors opened for us. Baja Barahi’s development committee offered to give us a small clinic building and land within the existing health post compound. This new partnership with the district government has been the opportunity I have been looking for since beginning this project in 2008. It is our first opportunity to not only care for patients, but to start working on transforming the rural care system as a whole. In other words, now we have the opportunity to put-up or shut-up. 

This is quite the mandate and to meet this challenge we truly have to address our sustainability. Since beginning in Nepal, we have recognized that it is not practical or cost-effective to sustain our project with foreign practitioners. Unfortunately the problem of training and properly certifying acupuncturists has been a major obstacle. A system of accreditation and licensure does not exist and we envision training a type of health-care worker that does not yet exist. Ideally this hybrid “Rural Care” provider would be trained in both basic allopathic medicine (same as the existing health assistant) as well as acupuncture, bodywork and medicinal herbs. They would support other doctors, heath assistants and health post staff but also provide holistic health advice, simple and effective treatment and be an advocate for integrated patient care. In order to be useful in strengthening Nepal’s rural health system, these new providers would need to be able to work independently in some very remote regions. 

Our solution materialized in the form of a small acupuncture school in Kathmandu that was struggling to get started. Founded by a Japanese NGO and staffed by a few Nepali acupuncturists that were trained in China, the Rural Health and Education Service Center (RHESC) was able to acquire certification through Nepal’s vocational education system in 2013. That is a start but falls short of certifying the kind of provider we are looking for. This year we were able to form an alliance with the RHESC and I was honored to be given a position on their Board of Directors. My task is to write a curriculum that will be accepted by Nepal’s Health Professions Council, allowing them to offer a bachelors degree in Acupuncture and Rural Health Care.

I had the privilege of teaching a five-day seminar on the shoulder joint to the RHESC’s second year students and was impressed by their appetite for opportunity and education. Our challenge is to inspire them to work in rural areas where they are needed most. Starting in September 2015, we will be hosting 12 RHESC students as clinical interns. This mentorship program will allow students real-world field experience under our guidance and offer the district government the opportunity to see the potential of future employment of RHESC graduates. We have encouraged several of our current interpreters to compete for government scholarships available to students in rural areas for enrollment in the RHESC program. This will be the key to sustaining our clinics in areas like Kogate which is too small for us to sustain a permanent clinic. 

These are all just the first few wobbly steps in the right direction and while all of these developments are exciting prospects, I try to root myself in my own experience. From there I see that when it comes to patient care, sometimes I can have a major impact on a person’s life. Other times I struggle to offer even the slightest relief no matter how hard I try. Either way I hope that I never fail at making my patients feel cared for. With this simple idea, I believe we can make a ripple in a much bigger pond. 

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

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By Debbie Yu

Created: 20 February 2015

“I believe that through open dialogue of not only my successes, but also my fears, challenges, and weaknesses, I will come to a greater understanding of myself and will help others do the same.” - ARP Volunteer Handbook

February 9, 2015

It’s our day off and we are traveling to a “palace” about 3 hours away for a team picnic. Our bus is full, and the trunk is packed with cooking supplies and food. We make one stop for more fruit and food, and another for this sugary milk fat condiment, kua. And then we just keep driving…

We arrive! But we have to walk about fifteen minutes up to the top.  I carry a large stainless steel bowl of more bowls and utensils atop my head because that is the only way I’ll be able to manage. I get a glimpse of what the average day is a like for the average Nepali woman, and how life taxes their bodies. Life taxes our bodies in the States too…just in a bit of a different way.  

Auntie, Jessica, Urmila, Suman, and Ritesh immediately get to work. They are all speaking Nepali and moving quickly. I’m not sure what is happening, but I want to help. I assist with washing and prepping the vegetables. That I can do without much communication. 

We walk down to the “sink” about 100 meters away. The ergonomics are not the most ideal for our bodies, but there is so much beauty in the scene that it doesn’t matter. There are five of us squatting around this stone sink. We are washing a five liter bucket of tomatoes, julienning daikon, and slicing onions, all against a backdrop of mountains, trees, blue skies, and the clear horizon. Though Urmila and Jessica are chatting away in Nepali, we are all still there together, working together, creating a meal together. It’s just…great. 

"DUDH CHIYA!" Ah, the milk tea is ready. We’ve had so much milk tea since arriving, and this is probably the best yet because it was made over a campfire and because it was made with all of us there! 

Then we have our bacon egg sandwiches for breakfast! Whoa is right. We are all feeling protein deprived, and this is certainly a treat. 

As we clear the plates, I see Auntie preparing a giant pot of beans. “She’s cooking more?” I ask Tiffany. “Yeah, lunch” I thought the sandwiches were lunch! Nope. There will be more, much more. So, while we digest before lunch, we go for a walk and tour of the palace. 

I’m sitting atop a stone wall where cannons were once placed, looking out into the horizon. 

I didn’t intend to, but the space was calling. I find myself in lotus position. 

Tell me the secret. 

My eyes softly close. 

Nothing. 

Wind brushes my skin. Do I go with the flow- with the wind, and let it carry me? Do I stand like bamboo and find flexibility? Do I stand like an old thick tree and stay as still and strong as can be? Tell me. 

Then the wind stops. I feel the sun warm my neck and back; it envelops my heart. The sun nourishes me. It lets me grow and be loved. 

My spine is straight, my shoulders are back, my eyes closed, and my heart is open. I hear footsteps and wanted to open my eyes and break away from this moment…but don’t. Its not like I feel danger, just don’t want to be seen like this. But if I open my eyes, will I be shaming myself? Won’t I be illustrating that I am not good enough – for this love I am receiving and worthy of? 

Why am I here? 

If I can’t receive, how will I give? How will I become the practitioner I want to be – my whole purpose for this trip? I want to be the practitioner who not only who treats with competence but more importantly with care and compassion. 

Hmm maybe that is what I needed – to know that I am worthy of love and compassion, and to forget all that bullshit and questioning of the pathway – whether or not I am on the right one, or doing the right thing. It doesn’t matter in the end. In the end, it all boils down to love and compassion (how many times can I say those words?) Cliché? Maybe. But so true.

From slicing vegetable with friends to my own meditation, there are many ways for me to practice. I’ll grow as a practitioner. I’ll grow as a person. - Debbie Yu 

Details

By Bex Groebner

Created: 01 February 2015

He's sitting in an 8x10 concrete room with two beds in it. There is a small space heater and a post where the rusted, gigantic oxygen tank is tied with a bow made of hemp cord. There are three mudas, or woven stools, sitting on the floor. His family members usually sit on these stools but they offer them to Debbie, Ritesh, Bibeck, Pawan, Milan and I because we've come at this late hour for a house call. 

He is cross-legged on the bed, propped up against four stacked pillows. There is a fleece blanket draped over his shoulders, like something you'd find in a young American girl's room; cream colored with orange and white flowers. He wears a maroon sweater over two shirts and a thick, knitted beanie with a pom pom on top. Despite this, he's still cold and it's an effort for him to stick his fingers out of the blanket so that we can put the pulse oximeter on it. He does it patiently and for as long as we ask and when we are done, he quickly puts his hands back under the blanket. I see that he is anxious, he's afraid to die. I take his right hand and massage it gently, while I check the pulse oximeter on the other hand to see if the number has gone up. He sticks his left arm further out of the blanket and motions to a large area above and below his elbow. I ask him, "What happened?" Ritesh translates: "He got these at the teaching hospital in Chitwan, they kept trying to take his blood." I look more closely, some of the bruises are the size of baseballs, two on his upper forearm, one at the medial elbow and three more below. He points to a small dot at the mid-forearm telling us, "They were finally able to get the blood when they tried down here."  

I feel my face get hot as I look into his sweet eyes. More of his arm is bruised purple than not. First, Do No Harm. I am overcome for a moment as I imagine the nurses or doctors at the hospital sticking him over and over with needles as he's having breathing difficulties. He puts his arm back into the blanket with a small shake of his head about the bruises. I look at Ritesh and I see that he understands I am mad. He says, "There's nothing you can do." I know it's true and I swallow it down and move on.

Debbie gently rubs his back between his scapulas. We are both sitting on the bed and doing everything we can to calm him down. Terry, our team lead, is in Kogate and Andrew is in Kathmandu. We can get them on the phone if we need to but otherwise we are on our own. There are four interpreters with us, everyone is watching us.

The tank is bubbling in the background, but as Bibek checks it, the pressure meter slowly falls to zero. We look at the pulse oximeter and see that our patient's blood ox levels have dropped into the low 70's. Ritesh makes a phone call for more oxygen. 

The tank arrives and it takes three people to carry it in the room. It's five feet tall and looks like something Jacques Cousteau pulled up from the depths of the ocean. I expect an old metal diving suit to be attached to it, but nothing is, which is part of the problem. The neighbor takes his time fussing with the hemp cord around the old tank. Debbie calls out, "Can you please hook up the oxygen before you tie the tank up?" Bibek translates. The neighbor ignores us all, like we are flies in the room where he is doing some serious negotiation with the ratty cord. Debbie repeats. Bibek repeats. We are ignored again. 

Twelve minutes have passed since the oxygen ran out. Our patient's cells are starving. I am scared and I can tell Debbie is too. We have to get the oxygen levels up but all that's going up is his pulse rate: 103, 106, 108.  Debbie's thumb sits gently under his clavicle bone. She is counting his breaths. "Forty." "Forty-four." "Forty-six." His respiration rate is grating in the background like nails down a chalkboard. His eyes are pleading. He is drowning. Everyone is quiet. None of us can breathe. I check my watch: Fifteen minutes at 70%. 

I look to the neighbor; should I grab the damned tank and do it myself? He has finally tied the bow and inserted the valve piece. Now he is fumbling with a wrench to tighten the seal. His incompetence is maddening. I think I could do it faster, yet I don't budge. I don't want to stir the calm. I stay frozen like all the others, watching, waiting, hoping for that top number to start trickling up so that we know his cells are going to live. I am trusting that something higher, perhaps one of the thousands of gods or goddesses that live here, is in the room with us to help this guy get his wrench dialed into the right setting and set the oxygen to flowing. They say that the Nepalese have so many gods there are three for every human. That makes twenty-seven gods in the room with us. Eighteen minutes. 

Finally, the pump is turned on. Debbie and I haven't helped hook a patient to an ancient oxygen tank before. We don't know anything about this old bubbling gauge, nor what the setting should be on. Regardless, the oxygen finally flows and the number on the pulse oximeter flashes up to 74. The heart beat goes down to 102. Debbie lets her breath out and whispers, "Forty four." We are moving in the right direction now.

It's been eleven days since that first home visit to "Uncle" Lal Lama's. Since that time, we've stopped by his house almost every day, sometimes three times a day, to monitor his vitals. This has to be done during our lunch break or after a full day of work. It requires that one of the translators gives up some of their downtime to come with us and we are so appreciative of their willingness to do this. 

We have communicated to the family that our recommendation is for them to go to the hospital. They have refused, saying that the hospital in Chitwan said there is nothing more than can be done for Lal. They don't trust the hospital either, due to a series of negative experiences that have made them quite scared to go there. The hospitals here can be very scary places. Our team can't do much more than monitor Lal's vitals and provide some anxiety relief with acupuncture and we've let the family know this. They still refuse hospital care.

Our Uncle is not getting better. For the first week after our initial home visit, he was able to get off the oxygen tank for 10 or 15 minutes and venture into the concrete patio outside of his bedroom. Each gigantic oxygen tank would last for around 48 hours. This week, Uncle cannot get off the tank without plummeting into respiratory distress. Some tanks last for less than a day.

He is pinned in his small, dark room, like a undersea diver who is just visiting this life for as long as the oxygen will last. I have seen him moving through the stages of grief as he realizes that his time here is short. I have moved through these stages of grief with him. One afternoon, Ritesh and I arrived to find him in a splendid mood. He was telling us stories about his boyhood. He was living in Kathmandu and had gone to art school. He would travel up to the Monkey Temple and look over the Himal. He would draw or paint the Annapurna range in a series of mediums, ranging from charcoal to watercolor. He was also a sculptor and carved a number of animals at popular temples. He won an award from King Bhirendra for a gigantic elephant he created and painted, poised on springs so that as it was wheeled in front of the king, a spring popped and the large trunk swung up to salute the patriarch. He was an entertainer and dancer in a comedy troupe and it brought him great joy to give all of his gifts of creativity to his community and country.

The day that Uncle told us these stories about his life, I started crying as I was behind him, checking his lung sounds. Ritesh could see me as he translated and I wiped the tears away and tried to regain a professional demeanor. I took deep breaths and sat with Lal until he was finished telling his stories. On the walk back home, I tried to hold it all in, until I could get to my bed and bury myself in my sleeping bag to cry. I couldn't make it and burst into tears about 50 meters from the patient's house. I took off my white coat and held it over my face, as if it would stop Ritesh and the town of Bhimphedi from seeing me do this. Ritesh put his hand on my back and said, "It's okay. I can't cry so maybe you can cry for both of us." 

It was awful to walk up to the house and find the whole team sitting outside. They saw me crying and there was no way to explain it. Lal was in a better mood than he'd been in for days but they all worried that something bad had happened. I told Andrew he was fine but listening to Uncle, I knew he was going over his life and that he was getting closer to his death. I was also starting to realize what an amazing person I had just been sitting with. I know we are mortal, but as I sat there I saw that no matter how amazing we are, we will all die. I will die. No matter how I love, how I live or where my hopes lay, I will die. As I sat on my bed crying, I saw that I was crying for myself, not Lal. I was crying for the mirror that Lal had just held up before my own life. I am just another diver in this ocean, a diver with a tank that is a little bit more full than his, but who is equally exploring this beautiful shipwreck and will have to go up to the mysterious surface again at some point. 

I applied to ARP and I came to Nepal to find myself because I had started to question my identity this year. Each patient and every team member here is holding up a mirror for me to look into my own soul. I have spent so many years criticizing myself and never finding myself good enough, but some of these mirrors are shining back a spirit of generosity that I never acknowledged. Lal is showing me that I need to honor this amazing part of myself and I need to continue to live life as fully as I can. I need to spend my time in this adventure looking for the treasure that I know is there. I miss all of you back home and I send the greatest amount of love to you all. --- Rebecca "Bex" Groebner