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By Eliot Sitt

Created: 12 January 2015

I knew I wanted to volunteer with the ARP when I first heard of it four years ago, during my first year of acupuncture school. Now, sitting in my guest house in Kathmandu with dogs barking and gentle Nepali conversation drifting in through the window, it’s sinking in that I’ve fully realized that intention. I’ve spent more than six weeks treating patients in rural Nepal, doing my best to help however I could manage. 

Earlier today I met a man named Rajesh playing guitar in front of his friend’s collectibles shop, and I ended up hanging out there for hours. Turns out he grew up near Kogate, the small village where Rachael and I ran our free clinic, and he told me how happy he was that I’d been volunteering to help people in his hometown. I told him I felt grateful to be there, far from the bustling noise and bad air of Kathmandu, where I could get a glimpse into the heart of Nepal. Most of Nepal is as rural as Kogate, and I feel lucky that I could live in such a small but beautiful community. 

Most of the team stayed at a town called Bimphedi, which itself is hours away from Kathmandu. Kogate is about a three hour hike up the hill above that. Although Bimphedi seemed tiny when I first arrived there, its few dozen shops and paved main road made it feel like the city after my first week in Kogate. There no roads are paved, and the only traffic besides the occasional motorcycle is a rickety bus called the Himali Tiger that makes its slow, bumpy way up and down the mountain once a day most days of the week. Even this luxury is relatively new: there was no bus service about seven years ago. One patient shared the story of when his wife hurt her knee badly enough to require surgery. He and his neighbor had to carry her down the mountain to Bimphedi to catch a bus to the nearest hospital in a town called Hetauda. At that time, any supplies from Bimphedi also had to be carried. 

Rachael and I stayed at the end of the bus line with the parents of one of our interpreters, Suman. They asked us to call them Ama and Buwa (mother and father), and they welcomed us into their home like family. We shared their same food, and our only extra luxuries besides what we brought were an electric kettle and a filter for the water from the outdoor faucet. Even electricity is relatively new to Kogate, set up within the last couple years, and Suman told me that the village didn’t change all that much as a result. Mamta, his sister in law and our other interpreter, also stayed with us, and our receptionist, Lanka, met us each morning after an hour’s walk from her home down the hill. 

During our stay, Rachael and I slowly became recognized community members. We’d meet our patients and their relatives on our walks to and from the clinic and exchange enthusiastic Namaste’s with schoolchildren. I played soccer with the boys who hung out near the clinic, and kids often watched our treatments from the stone wall that surrounded our clinic. One of my most regular patients was also Suman’s good friend, and we hung out together outside of the clinic. I taught Suman a little tai chi and had a blast teaching them both to juggle. Rachael did a great job memorizing all of her patient’s names and began to recognize which of her patients were related. We’d see one patient herding his buffalo and another her goats near the clinic. Even our bus driver came in for one treatment. We were much less busy than the Bimphedi clinic, which served many patients that came from many hours away, but almost all of our patients knew one other as members of the same community.

On the second to last day of clinic I got a new patient who was visiting his daughter in Kogate from a more remote place. He has an enormous lemon-sized cyst under his right tricep compressing the nerves in his arm, causing pain down his hand and reduced motor function. He had gone in for surgery three years ago, but after draining fluid from the cyst, it swelled up again, becoming larger and more painful. He came back the next week, and he told me that at that point they wanted to amputate his entire right arm, which he refused. (I’m hoping this was a miscommunication, and that they meant to explain that completely removing the cyst would cause nerve damage in his arm that may then lead to such deterioration as would need amputation.) He also has knee pain, and when rolling his pant legs up for the acupuncture I saw severe psoriasis on his right foot, which he scratched to the point of creating sores that were open and bleeding. 

This patient really drove home the issue of access to me. His hometown was a 2-3 day journey away, so it was impractical to refer him for treatment during the next camp in Bimphedi. The two treatments he would get from me would be all the care he was likely to get, and I knew there was only a little I could do. I explained that I couldn’t help decrease the size of the cyst, but we would try for some temporary pain relief for his arm and his knees, and I bandaged the open wounds on his psoriasis. He understood and wasn’t upset. He said he didn’t mind because could hide the cyst from sight under his jacket and the pain was managable if he was careful not to bump it, and the psoriasis he’d had since childhood. At his second treatment he at first reported “no change,” but went on to say that he’d had no arm pain at all the previous night and had noticed that his knee pain was less. I know this relief will be temporary, but it’s something. 

On a larger level, I worry that our time in Kogate likewise provided only temporary relief for long term problems that we can’t fix, problems that boil down to a lack of adequate health care access. Over the next two months, the smaller number of volunteers for the colder season means that the ARP can only be there once a week instead of five days a week, and because of the lower patient numbers, I don’t know if the ARP can sustain a clinic there long term. The volunteers’ time could be better used in a busier clinic, and Kogate is already closer to the Bimphedi clinic than the hometowns of many of its current patients. But after being welcomed so warmly it was hard to leave not knowing how much continued care our patients would receive in the future.

Now that my time there is done, I have to take comfort in knowing that we did what we could, and for better or worse, all our actions there have created ripples. People came in for anything and everything, including cuts that needed bandaging, common colds, rashes, sore backs and knees, headaches, and gastritis, and we did what we could to help whether or not acupuncture and herbal medicine were indicated. We used whatever we had: pain patches, moxibustion, massage oil, eyewash, anti-itch cream, cough drops, and ibuprofen – anything appropriate. Rachael even used a few candles and layers of acu-tape to even out the handles on the crutches of one of her patients to help his structural imbalance. And although we’ve left already, for a time at least we were there and genuinely willing to listen and help, a sentiment often missing in local hospitals. (The woman who was carried down the hill for a knee surgery, for example, came back with her knee cap sewn back on too far up, in spite of her husband’s unheard attempts to object while watching the surgery.) One of our friendliest and most talkative patients, who enthused that our treatments gave him “a new life,” told us he thinks a big part of his improvement was due to our kindness and smiles. And on our last day, we were overwhelmed by the handmade necklaces and bouquets of the fragrant orange flowers our patients brought us to wish us a safe journey home.

I know my experience in Nepal will have ripples in me as well. In the face of different complaints and fewer resources, I found myself doing such doctor-like activities as dressing wounds, taking blood pressure, monitoring blood glucose, taking temperatures, looking down throats with a tongue depressor and penlight, and examining painful eyeballs for irritants. This experience, in addition to the practice with acupuncture and herbs, will help me give better and more complete care to my future patients. I’ve also come away with the realization that people aren’t so different all around the world, and that I didn’t necessarily need to travel halfway across it to find folks who need more or better medical care, particularly in rural areas. Regardless, I will miss my Nepali patients and friends, and if whatever community I find in the US can spare me for long enough, I hope to return to Nepal to come see them. - Eliot Sitt

Project Director's note: Don't worry about Kogate. It is a village very near to our hearts and we will continue to support it as we develop our sustainability plans in Makawanpur.  In fact, I hope to retire there one day.... I have my hilltop all picked out. -Andrew Schlabach

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By Helena Nyssen

Created: 08 January 2015

Here in Nepal, very little is convenient. Nothing is handed to you on a platter ( except our dinner, thanks Auntie). The modern world of convenience has not yet arrived to Bimphedi. Their is no internal plumbing in the houses, nor heating, nor appliances. There is wifi though? Bizarre.

Everything takes 10 times longer because of this; cleaning clothes, having a shower, making coffee, making food etc. And we live in luxury compared to most locals. We enjoy hot water, electricity, and wifi! 

It is much more apparent and more emotional at clinic. At home when someone presents to my clinic, they have probably already seen a doctor, and had some scans or tests (depending on their condition). They may already be under the care of a specialist. They usually know what they have and have a pretty good idea of how they got it. For the most part, patients arrive with a clear cut medical diagnosis. (NB. I'm talking about the Australian system here, our national medical system is, thankfully, very good). If they don't already have a diagnosis, it's free/cheap to obtain one. I can simply say, 'Go consult your Doctor, then come back to see me' and I can be  confident that it will be taken care of on the other end. After this has been done, it is my job to apply Chinese Medical thinking and methods to their health problem.

At home, lumps are scanned, biopsied, and removed. At home, digestive ulcers are viewed by endoscopic cameras, medicine is given, and dietary advice is understood. Alcoholics have access to the help they need. STIs are tested for and managed. Lower backs are x-rayed and orthopaedically tested. The list goes on. 

In Nepal, this is not the reality. Patients will come to our clinic with the problem, and no information beyond that.

Like the lady with the grapefruit-sized lump on her inner right thigh. It hurts. It's been there for 5 years. Can you help?

Like the woman with sore breasts for 6 months. They hurt. There are lumps. What's wrong?

Like the man with the chronic leg infection. Sometimes is weeps pus, sometimes it doesn't. 

The children with paralysis from high fevers that weren't treated.

The out of control diabetes and high blood pressure.

The huge number of alcoholics.

We are triage; It is our job to ask all the right questions. Get an accurate symptom picture. Know which diseases are indicated. Know which tests will confirm or rule out these diseases. Hope that when we send them to the local hospital, they will actually perform the tests, prescribe the right medication, and if we're really lucky, explain what's wrong to the patient. This is all only if the patient can even pay for it at all. 

We are also medical counsellors; We explain what is wrong to the patients as the doctors never seem to. And give good advice, a crucial part of health care in my opinion. How can people care for themselves and their families when they are given no information and their illiteracy prevents them from accessing it themselves. 

And, then of course, we are doctors ourselves, performing treatments and providing ongoing care.

So this is what was meant when we were told that we are now 'Primary Care Physicians'? Ouch

In this setting I am finding the need to step up in a huge way. My clinical knowledge, especially western medicine diagnoses and disease management has had to be expanded in a big way. Not a bad thing, certainly. Thank God for the team of practitioners around me and the Merck Manual app! I've learnt that the important thing is not to know everything, that is impossible. The important thing is to care, and be willing to try and figure it out.

I've never learned so much, in such a hands-on way, in such a short space of time. Thank you ARP, my team mates, and, everyone back home who helped get me here.

Most of all, thank you to my Nepali patients for being the sweetest and the absolute toughest teachers I have ever known. 

Namaste, 
Dr Leni

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By Rachael Haley

Created: 01 January 2015

In my fourth week of volunteering at the Kogate Clinic, I hiked over an hour away to a town in the next valley called Ipa. Suman (my awesome translator) and I were on a mission to see an old patient of the project that has ALS (a degenerative neurological disease) and can no way make it to our clinic.

Bim is in his 80's. He can't walk and can only really manage to go from sitting to to lying by just falling backwards onto a well placed cushion. If he wants to sit back up he needs someone to lift him. He lives with his wife on the top of a hill overlooking Ipa valley. From the other side of the ridge you can see white capped Himalayan peaks across on the horizon. It is really quite picturesque, but because it's so remote walking to and from here can be quite difficult. The road there is very uneven and rocky; even a motorbike would have trouble with the steep climb.

We arrive at Bim's, passing the neighbouring house where a couple of grazing buffalo peeking up at us and a dog barking protecting his territory greet us. Bim is sitting on the porch of his little mud house looking a little blank and weary. His wife gets up to welcome us and asks if we'll be staying for lunch, which we politely decline. She herself is in her 70's, a tiny lady that has obviously worked hard her whole life. She stands so stooped over I can only imagine that having her husband immobile has given her more than her fair share of work each day.   

This is my first experience visiting someone to do a remote treatment. I'm not even sure where to start. I ask how he's doing and we go straight to checking out his worrisome bed sores. After attending to these and educating his wife to keep them clean and dry, I proceed to cut his finger nails and gather more information about his general well being.

While he was still up for it, I gave him some electro-acupuncture to stimulate the muscles in his legs but he didn't last long before getting uncomfortable. Staying in one position for too long was Bim's biggest problem and his wife can barely manage to help lift him from sitting. I'm guessing without any extra help she must drag him across the mud house floor to his bed. 

I chatted and demonstrated to Bim the importance of regularly moving the muscles in his feet and legs to preserve the limited movement and strength while helping his circulation. While I gave his wife an acupuncture treatment I kept checking to see if he was doing his exercises, which he found quite amusing. 

Luckily, I had packed some herbal antibiotics which I prescribed partly for his bed sores and also more concerning was his burning and occasionally bloody urination. I was concerned he had a possible infection, prostate issues, or something more sinister, so I planned to further discuss with the team the logistics of getting him more care.

This really felt like a hopeless situation I was walking into, however, he has no other support; while his wife is doing everything she can. All I could do was the best on the spot healthcare I could provide while trying to make him smile and feel cared for. After spending just over an hour with the couple Suman and I made the trek back to Kogate in time for lunch. On the way Suman said 'I'm so happy today!' I asked him why and he replied 'we got to go for a nice walk and did you see the look on Bim's face when you said we'd be back next week?' I thought, yeah he's right, I feel happy too.

That moment really resonated with me as to why I'm really here.

I went back and visited Bim and his wife two more times before the camp ended. My last visit was bittersweet. I'd had a feeling this would be the case, so when Suman and I were walking to his house that day, I told Suman that I wanted to focus our visit on making Bim smile. 

When we arrived Bim was lying on his porch with a tiny little black kitten by his side. The results from his urine test I had his son get while he was in Kathmandu were not great, but his discomfort when urinating had improved. The hardest part was seeing Bim's decline over the past two weeks. His feet were swelling more and now he couldn't wiggle his toes. We checked his sores, cut his finger nails and I decided only one acupuncture point was necessary as I gave him leg massage instead. We talked about the kitten in which his wife wasn't too keen on, but I could see he liked this cat. The cat had no name so I suggested Bim pick a name for the little kitten. He named her Kali (which means black in Nepali) and took much delight in me asking about Kali and bringing her over to say hello to him.

Once we'd finished his treatment and discussed getting another urine sample tested, Suman and Bim's son lifted him onto a straw mat in the sun. He laid on his side while I gave his wife an arm and shoulder massage in the sun. She looked so relaxed by the end of it. It was as if I'd lifted a weight from her shoulders. I was chatting with her and their son, until Suman pointed across to Bim where I saw him sleeping peacefully in the sun. He had only been sleeping one to two hours a night and in the past week had not been able to sleep during the day. This was a blessing. This was also the last time I saw Bim. And this is how I would hope he passes on when his time comes. Even though I knew I couldn't drastically change his situation I felt I gave him, his wife, and their son a little relief. --Rachael Haley