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By Andrew Schlabach

Created: 02 January 2014

One brisk afternoon in a remote village in the Southern district of Makawanpur, Nepal several men and women, bundled in many layers of brightly colored wool clothing, sat in the sun waiting for their turn to see the “Doctor”. Many of them had never been to see a medical provider their entire life. Now, in their small village of Kogate, our team of practitioners moved their chairs out into the small courtyard in front of the rustic clinic building, as it was too cold to treat indoors. Some of the villagers waited many hours for their turn to tell the doctor about their pain, injury, or other health concern. Around the low stone wall that surrounds the courtyard, a dozen children and adults watched their friends and neighbors being treated.  How strange this must have looked as our practitioners inserted several small needles into their patient’s bodies. A constant chatter filled the air as the villagers discussed the scene and asked their friends if the needles hurt. “Dhukdaina” they replied. “It doesn’t hurt”.

Sometime in the mid-afternoon a small boy of about 8 years was ushered into the clinic with a gaping head wound. Blood poured from a two-inch gash and his skull was clearly visible in the opening. The practitioners quickly assessed the boy for a concussion and interviewed the clearly shaken mother about the cause of the injury. It was determined that the family did not have the resources to transport the boy to the regional hospital, which was nearly 3 hours by way of a very expensive, four-wheel drive, ambulance ride. The team advised the mother about what they could do and what care would be required in the following days. They then proceeded to carefully clean the wound. A topical anesthetic (Lydocaine) was applied to help numb the area as damaged skin was clipped away with a scalpel and scissors. Finally the wound was closed with a medical-grade super glue and suturing tape. The boy was given a mild dose of Tylenol to help with the pain and some herbal antibiotic (clear toxic heat) tablets to help reduce the chance of infection. The mother was given a cup of tea while the practitioners did their work. After the procedure was finished the team educated the mother on how to look for signs of a concussion or infection. She agreed to bring the boy back the following day (even though it was a several hour walk to the clinic) or sooner if the boy took a turn for the worse. They agreed upon a contingency plan to administer Dicloxacillin (an antibiotic drug) if the boy exhibited a fever or other signs of an infection.

This kind of visit to our clinic is not at all unusual but may seem atypical to an “Acupuncture Clinic”. In fact, much of our clinic practice does not involve acupuncture at all. Our teams have assisted with child birth, responded to mid-night emergencies, diagnosed cases of cancer, parasitic infection and diabetes, and reported suspected cases of polio to the World Healthcare Organization. We see our clinic as new model in the delivery of primary healthcare in rural and developing regions. In this model we utilize what we call the “best care available” rule in our treatment planning. We pride ourselves on our expert diagnostic and evaluation skills which help us determine our plan. We start by asking ourselves “What is the best care for this condition?”, “Is that care available to this patient?” and “How do we help our patient’s access that care?”. Many times we conclude that acupuncture is the “best care” available because it is effective in treating many conditions, especially pain and other inflammatory pathologies. Acupuncture is also very inexpensive, safe with very few side effects, and easy to teach to other healthcare workers. Chinese herbal medicine, local Ayurvedic herbs, and naturopathic supplementation are also employed wherever they are deemed effective--and they are very effective when used properly. In addition, we are authorized and provided 40 listed allopathic drugs by the District Health Office. We use this pharmacology sparingly and wisely. For some of our patients, who have the means to travel to a regional heath post, we order labs and imaging (x-rays, ultrasounds, MRIs and CT scans). Many times we refer patients to specialists (surgeons, neurologists, gynecologist, etc). We partner with the local government and attempt to guide patient care though accurate reporting, good referral procedures and followup.  Educating patients and healthcare workers is sometimes more important than all of our treatment modalities combined. Soap, water, and general hygiene become one of the most effective antibiotics. In Nepal, pharmaceutical antibiotics are commonly over-prescribed. This results in resistant strains of bacteria, allergic reactions and a general weakening of the patient’s digestive system. There is no counting the number of patients we have seen with damaged hearing due to uncontrolled chronic ear infections. Many of these patients have been given Amoxicillin irregularly for 10 or more years. The result is very hard to kill infections and irreparable damage to the tympanic membrane and middle ear structures. This affects many young people in Nepal and is completely preventable with better training and patient management.

This year, the Acupuncture Relief Project undertook a courageous challenge of opening three experimental clinics in the remote regions of Bhimphedi, Kogate and Ipa, all villages in the District of Makawanpur. For the first time since we began working in Nepal (2008), we achieved a full partnership with the local government. Operating under the Nepal Social Welfare Council in cooperation with the Makawanpur District Health Office, we are now subject to the necessary oversight, inspection and reporting requirements of other governmental and private healthcare institutions. While this adds some level of expense, bureaucracy and complexity to our operation, it also allows us a new level of authority and access to government assets such as facilities and medications.

In our first three months here, we provided over 7000 primary care visits. Our volunteer practitioners work 6 days per week and they tackle some of the most difficult medical cases found in any modern hospital. Tuberculosis, diabetes, stroke, domestic violence, alcohol abuse, and seizures are common to our treatment rooms. Many times the “best care available” is the “only care available”... and that would be us.

Since we were attempting to operate in a new region, it was necessary to select and train several new language interpreters. We began by advertising for English speaking locals three months before opening our new clinic. We interviewed many and finally invited 15 students for training. There is so much more to being an effective medical interpreter than just speaking English and we looked for students who not only possessed good language skill but also demonstrated empathy, sensitivity and a profound interest in their communities. At the end of our initial three-week training session, we offered employment to eight. Our new crew of interpreters, aged 18 to 24, had never met a foreigner or spoken to a native English speaker.  What they lacked in confidence, they made up with in determination. Each week on their day off they attended classes taught by our volunteers. Classes included medical terminology, anatomy and physiology, safe clinical procedures, Chinese medical theory, concepts of therapeutic relationships, diet, and exercise. They also learned some basic auricular acupuncture protocols and massage techniques. All of this helped them become better at advocating for the information that practitioners needed to make a proper assessment.

Our interpreters are crucial to our success in the clinic. When starting in a new village, it is imperative that we gain the trust of the community and the skill our our interpreters enables us to make that critical personal connection to each of our patients. This is no easy task. Our practitioners and interpreters work side-by-side all day, everyday, slowly perfecting each others rhythm, emotion and syntax until they seamlessly work as one. Once this happens, it is a magical experience for the both patient and practitioner. People start to get better.

One of the things I find the most interesting in working with the interpreters is that they experience a truly unique perspective on what it is that we do here. They are not familiar with our medicine... or any medicine for that matter. They are interested in what we do but they are more interested in what they are doing for the people of their communities. At a recent training meeting, I tasked our interpreters to list 10 ways they thought our clinic was helping the people of their village. I think every healthcare professional should take note, only one of their answers had anything to do with acupuncture or medicine at all. Their number one answer was... “laughter is good medicine”. When I asked them to explain this, they elaborated that no one in Nepal had ever experienced a doctor that laughed with them, or took the time to know anything about their life outside of their health complaint let alone explain a diagnosis, treatment plan or medication. The fact that everyone was treated exactly the same, with kindness and patience, regardless of their ethnic group, caste or socioeconomic status, was what our interpreters saw as our greatest contribution. They also commented that self-care, proper use of medication and dietary advice we offer empowers people to take better care of their own health. Can it really be that simple?

As this project strives to integrate so many modalities and medical concepts into a model of accessible, effective and ethical care, I am struck by the notion that there is really no such thing as alternative medicine. When people work together because they truly care about the wellbeing of others... this is medicine.

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

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By Liz Kerr

Created: 25 December 2013

The inevitable gastrointestinal irritation happens when traveling and especially when living in rural Nepal, and I was the target this week. As I laid there staring at the ceiling between the bouts of bodily functionings, I was trying to recount all of the possible causes for it. Was it something I ate? Or the water when I washed my toothbrush off under the spigot? Was it that yogurt that the lovely couple offered to me and then poured for me on that house call the other day? Or was it all those school children at the satellite clinic in Ipa who were holding my hands and playing with my hair? Did I remember to wash my hands? Regardless of the reason, it was happening. And although being sick is never fun, this time it allowed me to see a different side to health care. A type of care that is apart from the allopathic anti-diarrheal, anti-nausea pills, and is unlike the rebellious stomach qi (the medicine we have been practicing here each day). I went to a witch doctor.

Three days of the sickness nonsense is just not pleasant, so I was willing to give anything a go. When our native Nepali ARP officer Tsering suggested that I go to the local Shaman I leaped (slowly) at the opportunity. He explained that in the culture here it was important to heal the spirit because sickness is the result of something attacking the person's spirit. The translation of the attacker is a witch. A witch bite is a bruise or unexplained mark on the skin. For me, it was a little more than a bite, I was attacked. A witch had attacked me from in the jungle surrounding our village, or from in the river water, or from a spirit of someone who had passed, and as a result, I had fallen ill.

The Shaman (who happens to be the father of one of our interpreters) conveniently lives just up the hill. He is not like the Disney'fied' witch doctors that one might imagine, with wild hair and a wild outfit, he is a down to earth father, husband, and worker of the land who is also a talented Shaman. He took my pulses, asked a few questions, just as we as acupuncturists practice, then went into the house to get his supplies. The supplies included a bowl of dry rice and red powder, another small bowl of ash, two cigarette-like sticks of herbs burning, a knife, and a cup of hot water mixed with salt and turmeric. As daunting as these sound the process was quite calm. He performed what I can only describe as a cleansing type ritual with the burning herbs, and tossing of the rice and red powder. I drank the salty water, and the knife was only used to stir it. At the end, I was told to rest and sleep for about an hour before returning back to the clinic house. And that was that. I returned feeling a little dazed and curious about what had just happened. It seemed a little surreal at the time, but as I sit here three days later feeling a whole lot better, I smile to myself, and think there must have been something to it.

Remembering the spirit is an important lesson. The medicine that is found in pills, or from acupuncture needles is effective, and does heal, but these medicines are not everything. Watching the ebb and flow of the three medicines - allopathic, traditional Chinese, and traditional Nepali intertwine and crisscross over one another here in Kogate is such an amazing dance. They support one another. It's a shame that we try so hard to keep them separate. -Liz Kerr

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By Haley Merritt

Created: 27 November 2013

I’ll always hold space for Nepal in my heart, my soul and my hands.  My hands because my hands are my tools, they are the hammers that deliver the nails (or the needles in my case) and they got a lot of action let me tell you. All of my experiences, including and probably especially the hard ones, have changed me in many ways. Some ways that I can see now and some ways that I think will continue to unravel as my life goes on. I didn't just improve my acupuncture skills, I became a primary care provider. Mostly, the experience taught me about myself. 

It taught me about different ways of living or being that make it easier to understand what happiness is. I learned that I just need to relax and breathe it in. Be open and let it flow me. To cherish what I have and the people around me. It taught me a lot about cultivating true relationships and friendship.

In Nepal, there is no hiding who you really are when you live with the only other five people for miles around who can speak the same language as you and you are totally cut off from the outside world. There's no getting all made up and putting in a cute outfit to look your best. There is no going home when you're tired, grumpy or uncomfortable. You show up everyday with grease in your hair and dirt on your face and you bear it all, good or bad. And you know what? People will still love and accept you for who you really are. I got closer to my clinic team than I have to many of the people who have come in and out of my life throughout the years.

Thank you Nepal for bringing these people into my life. Not only did this experience teach me about making true connections with the people I lived with; it taught me about connecting with people that don't speak the same language as I do, my patients and all the other people who live in Kogate.

Nepal has some of the sweetest kindest people I have ever met. I felt so loved in Nepal. I was welcomed with open arms and opens hearts wherever I went. Something that I will never forget are the smiles of those people. They smile with their eyes, which offers you a glimpse into who they really are. A vulnerability, most people in the United States are unwilling or unable share. But its something that means so much and helps me to see how truly connected we all are.

We don't always need words to express compassion and love and kindness as long as we are willing and able to be open enough to connect with one another. The people of Kogate take care of one another they share and barter and feed each other. They drum and dance and sing together. They live off the land and appreciate what they have even if its not a lot and they make the best of it. Patients would come in so happy and excited that we where there to help them they would bring flowers, pumpkins, mustard greens spiny cucumbers whatever they could afford to give away. Most of all they gave us their love and kindness.

Although many of my memories of Nepal are silver lined, it wasn't always rainbows and sunshine. Literally it rained for most of the first month we were there. Some days where a real struggle for me. Living without all of the comforts of home took some getting used to I won't lie... I had to let go a lot of fear. Especially my fear of of bugs because they were everywhere including my hair. They existed in all shapes and sizes but I especially remember the giant ones. I had to sacrifice my ankles to leeches and bed bugs as a peace offering to the insect community.  I had to let go of some of my  control issues as nothing in Nepal seems to work right or on any sort of time schedule. Plans are just an outline for what you'd like to have happen but Nepal defies any sort of structure you may lay out. 

This lesson made itself apparent even into my last days there as Nepal is having its first elections since the end of a long civil war that only ended a few years ago. There was a mass transportation strike around the country and I wasn't sure if I would make it to the airport in time to catch my flight home. And as much as I rant and rave about the people and my patients and their kindness, there’s always an exception to the rule.

This was made apparently clear to me by one of the patients that I treated the most. He came into the clinic everyday. He was suffering from the effects of a stroke that he had last February. He lost his ability to say anything but the phase la in Nepali, which means ok. He had also lost most of the mobility of the right side of his body. He was a very angry man and rightly so. I can only image how frustrating it would be to lose so much of who you are. He got frustrated easily with my treatments because they were often painful and his anger and pain was palpable in my heart. I found it so difficult to treat him as I absorbed his frustration and I quickly became physically and emotionally drained. I found myself dreading the thought of treating him everyday. I discovered that I have a habit of looking to my patients for acceptance and I wasn't getting that from him. I began to close myself off from him, but of course this only made my treatments with him more uncomfortable. 

I spoke to Andrew (our project director and team lead) and he talked to me about the importance of just holding good space for people and keeping an open heart. That sometimes the largest role we can play in our patient’s lives is just showing them that we care and are there for them. This really resonated with me. Suddenly, it all made sense. All I really had to do was show him that I cared about him, that I wasn't trying to hurt him. I was really trying to help and that I was invested in him getting better. Once my attitude changed toward him, he changed his attitude about his treatment and me.  He was no longer so angry. He was actually pretty happy when he came in which the whole team noticed because previous to my change in heart, he would often yell out in anger. He was also making great progress in his recovery. He regained the ability to walk on his own, he had started saying more words and he had an increase in active and passive movement of his right arm.

This was an incredibly important lesson for me to learn about patient-practitioner relationships and it was also one of the hardest and most uncomfortable experiences I had in Nepal. It just goes to show that from suffering comes growth. 

Nepal has taught me countless lessons. First and foremost, I want to remember that humanity is beautiful, don't ever give up on it. There is an incredible amount of people in the world ready and willing to freely share their kindness and love with you if you’re willing to share yours with them. Nepal has also taught me to "Harden the Fuck Up!" (a phrase we would commonly tease each other with when someone was whining a little too much). I don't need every luxury in the world to survive or to even be happy and often what I think I need is what ends up impeding my happiness. I am a lot stronger than I ever thought I was and that is truly empowering and liberating thought. As reflected on all that my Nepal experience has taught me, I can’t wait to bring these lessons home and apply them to my new life as an acupuncturist... and most of all as a human being. - Haley Merritt