Throw Mud on the Wall

Last week I asked Mahabir the following question: “Years ago when Nangi clinic first started you told me your goal was to have foreign doctors staff the clinic six months out of the year. Are you still wanting to achieve this or has the TeleMedicine program and help from Kathmandu Model Hospital changed your plan?”  He replied: “If we find a doctor to stay in the village for sometime, that will be good. The idea has not changed.” Mahabir’s solution is simple; just find someone, anyone to provide care. He does not care to discuss the difficulties associated with foreign medical volunteers as discussed in the previous post. That is because he is a throw mud on the wall and sees what sticks kind of man.

Mahabir Pun displays his Magsaysay Award 2007.

There is something to be said for this style of entrepreneurship…a sort of put your head down and plow ahead grabbing success when it’s available and disregarding failure and it’s debris. Its basis seems to be hope and a belief that you will eventually succeed if you try hard and keep throwing mud. No one can argue that Mahabir has not been successful. He has connected hundreds of villages with his wireless project. He has received many awards, the most notable being: The Ashoka Foundation, the global association of recognized social entrepreneurs, elected him Ashoka Fellow in 2002 and in 2007 he received the Magsaysay Award, which is described as the Asian equivalent of the Nobel Prize. But this method has consequences and in this business some argue it works against him.

Because I’m a planner it’s been one of the most difficult interfaces I’ve had with Mahabir…his disregard for preparation, especially when it comes to financing projects. And I am not alone in those sentiments after interviewing dozens of people who have worked with him. He is notorious for forging ahead on projects without plans or funding. He is impatient and the process of planning, fundraising and precise execution of a project is not only his weakness but also his Achilles heel. It makes it near impossible to apply for grants, especially from top-notch organizations like the Gates Foundation, when you cannot show financial transparency or organizational long term plans. Yet, somehow it works…he has touched lives and changed their trajectory.

Have you ever volunteered for an organization and discovered it wasn’t what you thought it would be? Your experience doesn’t need to have been abroad because your local school, church or scout group can test your dedication. Share your experience in the comments section and help others understand the ups and downs you faced and how you dealt with those challenges. See you next week with some fun pictures of Nepal.

Nangi Clinic – Who’s in Charge?

Aama Suma (mother’s group) watching video on choking maneuvers for children at Nangi Clinic.

There are upsides to having foreign medical providers volunteer at the clinic. It is an opportunity for continuing medical education not only for Lila and Rupa, but also Chitra the dental hygienist, the teachers, mothers group and community. Providers from other countries gain insight into the challenges of medical care in developing countries. Some commit to provide financial support and return on a regular basis to teach. A great example is a specialist in epilepsy came this past spring to lecture about epilepsy. People with epilepsy are marginalized in Nepal. She showed a Nepali made film debunking the myths surrounding seizures and had a tremendous response from the villagers.  She continues to work with the Nepali Epilepsy Association and will return next year to continue her educational lectures.

There are negative impacts that are unintentional but can’t be ignored. Most of us can’t leave our practices for longer than a few weeks. For the majority of doctors in solo or group practices the burden of covering clinic hours, hospital admissions and night call falls to already fatigued colleagues. I was fortunate that my emergency medicine colleagues stepped up and covered my shifts for six weeks when I first went to Nepal, but that was all the time I could take. Factor in travel time, which ate up one week, and that’s a mere five weeks of coverage for the clinic.

Open wide!

Even well meaning volunteers lose interest or move onto other projects they consider more important, needy or of personal interest. It’s important to develop “stick-to-it-ness”. If you are thinking of volunteering no matter your occupation or experience, do the research. Know the organization before committing and ask yourself; “Why do I want to volunteer” and “What do I have to offer?” It’s not enough to want to do good…everyone wants to do good…stick that in your back pocket…what you need are skills and experience to be of value.

The language and cultural barriers lead to misunderstandings even when using local interpreters. During my first visit I couldn’t understand why villagers showed up at the volunteer house in the evenings for treatment when we had the clinic open for ten hours daily, six days a week. I was exhausted by nightfall and became annoyed, not wanting to treat minor ailments…until I finally understood these people had been working in their fields and could only come in the evenings.

Combine all these reasons and it adds up to sporadic, unreliable and inexperienced clinic staffing if you depend on outsiders. It also undermines the confidence in the local health-care workers (HCW) when we come as the experts and fosters delayed care when villagers wait for the “foreign” doctor to arrive instead of seeking care for serious problems from the local HCW. But most importantly it implies western medicine gets it right with respect to healthcare…and we don’t.

Can you think of other reasons it’s good or bad to have foreign health providers come to Nangi or any under-served country?  Click on the comment tab and share your thoughts, as Jonni did last week. I’ll continue this topic next week with Mahabir’s version. Thank you to everyone for supporting my book blog this year…I cherish your comments and interest…wishing you all a wonderful holiday season.

Nangi Clinic – Care or Chaos?

Nangi Clinic was relocated last year to a new building with better lighting and larger rooms.

Mahabir and I did not see eye to eye when it came to the future of Nangi Clinic. His goal was to have the clinic staffed by foreign doctors who would volunteer six months out of the year. I never thought this was practical, sustainable or respectful of the local healthcare workers…more on why in the next post. Suffice it to say, my goal was education of the local HCWs. Despite my reservations it was with great pride that he sent word to dozens of local and distant villages during my first visit in 2002 that an American doctor was in Nangi.                                                                                                               The first week we were busy treating local villagers but the second week was my introduction to the caste system and how every action has a re-action. On Monday of the second week chaos broke out in the waiting area outside the clinic. I heard shouting and crying. I walked outside to see about a hundred villagers from the Beni area pushing and shoving the local villagers out of line. They were a higher caste who demanded “a good check-up” and “aushadhi” which is medicine. No matter the complaint they compared their medications with others, pushing their way back into the clinic, interrupting exams and yelling to demand more medicine.

Rita, age 6, likes to hang out at the clinic after school. She was sent to Nangi by her family to attend the school when she was five years old. She lives with an aunt.

Lila and Rupa, who ran the clinic, were caught in the middle of the cultural crossfire as members of a lower caste. Despite treading lightly, due to my cultural ignorance, the three of us had no tolerance for mistreating the sick, elderly or children. We decided caste system or not we would triage patients and started giving out numbers, treating the very sick, elderly, pregnant and young first. Everyone else was given a tag and told to come back. It was an interesting dilemma for the higher castes. They wanted the exam, they wanted the medicine because they perceived it as the best…but Hindu’s practice a complex set of beliefs and foreigners or non-believers are like “untouchables”…the lowest of castes…I was an untouchable. But in the end, want trumped religion and they begrudgingly obeyed the clinic triage system.

So why do I object to foreign doctors when I myself have been there five times? Why does Mahabir want foreigners and how has he balanced his clinic dream with the reality of staffing a remote clinic? Do you think western medicine has the answers for medical care in developing countries? Share your thoughts in the comments and stop back next week for more discussion on this weighty topic.

Lila and Rupa – Nangi’s “Nurses”

Neuton, Lila and Deb.

Here is a little background about healthcare in Nepal so you understand why and how Lila and Rupa got started. The American Nepal Medical Foundation lists over 130 hospitals in Nepal. Most of these are private, money making ventures and located in large urban areas. In reality there are few government hospitals outside the large cities. The smaller towns, such as Baglung, do have hospitals but by world standards these are merely clinics staffed by a nurse, laboratory and x-ray technicians and/or Community Health Worker (CHW). The government paid doctors are often absent because they are managing their private clinics and hospitals in the cities. These facilities are poorly stocked and managed, often without the ability to perform life saving surgical procedures such as cesarean sections.

Pablar, Sangita, Boj and Rupa in Nangi. Rupa is wearing her clinic uniform.

Access to the facilities is difficult because the majority of people have to walk hours and even days to get there. The care in government hospitals isn’t free, so even if you could get there most people don’t go because they have no money to pay for the care. There are a few exceptions to this dismal reality such as Nyaya Health,, a non-government facility that provides free health care in western Nepal. There are rural government “health posts” located in small villages. These are staffed by government trained CHW and provide basic services such as treatment for pneumonia, child birthing and some free government programs such as vaccines, Vitamin A supplements and family planning.

Nangi was a three-hour walk to the government health post and a day’s walk to the nearest hospital. Immediate care in Nangi was administered by family members, such as grandmothers assisting during childbirth, or by Shamans, the spiritual healers. The village decided they needed their own trained HCWs to care for people in a more timely fashion. Lila and Rupa were sent at different times about 15 years ago for training. Their training was funded partly by the village, themselves and non-governmental organization (NGO) funds.

Lila records a patient’s name, demographics, diagnosis and treatment into the clinic ledger. Individual records are recorded in small notebooks and kept by the patients. Lila and Rupa have a remarkable ability to recall patient visits and find them in the ledger…they consider it their form of “electronic” records.

Technically neither Lila nor Rupa are nurses. They did not graduate from an accredited nursing program. They graduated from Community Health Worker (CHW) programs. Think of the training as the advanced equivalent of a paramedic in the USA. They were trained to diagnose and treat common medical conditions and minor trauma, administer medications and IV fluids, suture simple wounds, splint broken bones and deliver babies. They are excellent at what they do. They are also phenomenal because they do it in a resource poor environment hours from any back-up care. Their excellence lies not only in their abilities as practitioners but also in their ability to recognize when a higher level of care is needed…they know their limits. Now, thanks to Mahabir’s wireless systems, they can call using the computer or cell phones for a quick consult with either a doctor in Pokhara or Kathmandu. There is also a jeep that can get someone down to the road faster then by foot, but only during the dry season.

Lila is married with one son, Neuton, who is 13 years old. She staffs the clinic in either the morning or afternoon, alternating with Rupa. She is also the second grade teacher. Her husband works in Qatar and comes home for 6 weeks every two years. During this time she is the sole caretaker for her son, home and farm fields. Yes…she is also a farmer…go back to the November 19th post and look at the terraced fields again. Imagine finishing your work at the school, going to the clinic for a few hours and then picking up your hoe and cultivating several hundred feet of dirt, herding animals, building a fire, cooking dhal bhat, helping your son with homework and calling it a day.

Rupa is also married with one son. She lives with her husband Boj, their son Pablar and his wife, Sangita. She staffs the clinic once daily in either the morning or afternoon. Because the clinic is not busy enough to support a full-time paid CHW she teaches the kindergarten class. I think her life is a little easier because she shares the responsibilities with Boj, who is a teacher. But she also leaves school or the clinic to cultivate fields, chase chickens, cut grass, gather firewood, build a fire and cook…after walking to reach home. Think about that the next time you pop leftovers into the microwave after a tough day.

The village school supports them by paying their salaries which is the reason they multi-task between clinic and teaching. They are respected for their skills and dedication….and every time I work or think about them I am awed by their strength and accomplishments. Join me next week as I delve into the perpetual controversy between Mahabir and me over the clinic’s future.

Nangi Clinic and Womens’ Center

Lila and the best-ever French fries…add nun (salt) and I am in gastronomic heaven.

I met Lila and Rupa for the first time in 2002. Lila is the Community Health Assistant. She had trained for 18 months in both Kathmandu and Pokhara several years before we met. Rupa is the Certified Health Midwife. She had also trained in Pokhara and Baglung several years earlier also. Neither had been to a continuing medical education class or conference since their training. They practiced medicine in their homes, using a few medications they purchased in Beni, old stethoscopes, government birthing equipment and virtually no supplies…they practiced in a vacuum. Imagine, no matter what your career, never reading an article or talking to another colleague or refreshing your skills. At first I was astounded but as the days wore on and we worked side by side in our makeshift clinic my astonishment turned to awe. They quickly became my heroines…we shared our medical knowledge as I introduced them to the concept of wilderness medicine and they taught me about the Nepalese diseases, treatments and culture.

Rupa with little Moti after suturing his forehead…and making peace with some crackers.

Lila is the comedian. She can take any situation and find the humor. Nepali people love jokes and the cornier the better….Lila is a master jokester. She views life with excitement and almost manic energy, which sometimes causes commotion in emergencies…but she is surprisingly a realist. It was Lila who stocked the clinic with condoms a few years ago…for the students. She also makes the best French fried potatoes I have ever eaten. Rupa is a careful and thoughtful clinician. She exudes calm as she cares for the really sick patients, such as an asthma patient…who was wheezing herself blue. She is the thinker and comes up with questions and solutions for everything from improving the clinic to the best way to hold down a squiggling kid for stitches. She also makes the tastiest fried, hard-boiled eggs…I know…who would have thought to fry a hard-boiled egg! They were smart, dedicated and creative when it came to making due with limited resources and practicing in a wild environment.

Nangi village infant getting his well baby exam. Afterwards he was placed in his well padded basket, but protested by batting at the shawl covering him…only to settle with his well sucked thumb.

They were the only healthcare providers for the village, which had a population of about 850 people and catchment area of 2500 people. The nearest hospital was in Beni, a six-hour walk from Nangi. They practiced in their homes unless a western practitioner came to Nangi. The two previous volunteer medical doctors had used two connected rooms as a clinic in the abandoned and dilapidated old library building. Each room was about 8 x 5 feet. One was used to stock supplies on make shift wooden shelves, wash our hands in a bucket of water and discuss the diagnosis and treatment plan for each patient. The other room was for examining and treating the patients that boasted a wooden cot for exams.                                                   The stock room was adequate, but the exam room posed a challenge…not too bad for one patient and three providers to crowd into…but add the three to six family members that accompanied each patient and it was a regular NYC mid-town bus…during rush hour.                                                                                                                                      No one minded except me, the westerner with a well defined personal boundary, but I quickly learned in Nepal there are no personal boundaries…my space is your space and the more crowed the better. I began to understand it is fueled by curiosity, a willingness to help and the very nature of a society where three or more generations share a home with only one to two rooms. I adjusted…after a few weeks I became such a good personal space invader, that even Darth Vader would have approved.

During the six weeks I lived and worked in Nangi with Lila and Rupa we treated over 600 patients in that little clinic. We provided care for everything from birthing to comfort care for advanced cancer, sutured wounds, pulled teeth, performed minor surgery and educated each patient on hand and toileting hygiene. It was exhausting in the way a well-run marathon feels as you cross the finish line. Join me next week to hear more about these amazing women; their training, families and thoughts about providing care in Nangi.