Around the World: In a Nutshell

It is the ninth of May, two-thousand and thirteen, and what a year it has been.  In the past eight months we have circumnavigated the planet, with the majority of that time being spent in the hills and valleys of Far Western Nepal.  We have flown in airplanes of all sizes, traveled on open-air trains, crammed ourselves into buses, jeeps, and vans.  We have been whisked along aboard ocean- and river-going boats.  We have walked, swum, and climbed.  We have slept in huts, houses, and hotels.  We have seen lives begin, and we have watched them end.

Now that we are standing, firmly, back on home soil (insert your own definition of “home” here), it seems apt to ask what this all means.

  • It means that there are things that we will never again take for granted.
  • It means that we have learned to fight battles that we never knew existed.
  • It means hope and ambition, tempered with sorrow and apathy.
  • It means new definitions for more words than I can list.
  • It means things that become newly apparent each day, not least of which is that Health–capital H Health–is something to be thankful for every day, for ourselves and for others.

The next question that seems appropriate, for this “in a nutshell” monologue, is what comes next?

For me personally, or perhaps professionally, the past year has reiterated the importance of long-term commitment and community involvement.  It has solidified my determination to pursue all training necessary to provide a meaningful service to the people of whatever small town we take root in.  It has reinforced the fact that one must always “think outside the box.”

In the next 10 days, not only will I be starting another graduate program, but Ryan and I will be getting married.  Both of these events marking the beginnings of new and exciting adventures, not entirely unlike our around-the-world year.  These adventures are sure to take us to as many exciting, bewildering, and inspiring places as all of the trains, planes, and rickety automobiles have.  My thought is: “Bring it on.”

In the meantime, we’ll be roasting here in the desert of Arizona, riding bicycles and climbing on rocks.

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A huge, heartfelt thank you to everyone who has been there for us along the way.

Registration Time

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A typical morning at the Bayalpata Hospital Data Office, where patients come to register before receiving outpatient services.  Colpina didi is responsible for registering all patients who arrive during the morning hours, recording their basic demographic information, and providing them with a registration card and patient number.  The patients then wait outside of the Outpatient Department  (OPD) until their names are called, signaling the availability of an examination room.  The hospital’s OPD may see anywhere from 10 to 300 patients per day.

This is, in addition, the area where many patients will congregate to “view” me, while I am sitting at my computer typing.  Children in particular (though not only children) will often stand with their noses pressed against the window for up to 20 minutes, observing whatever is going on inside.  My general rule is that if someone stares for more than 15 minutes, I get out the camera and take their picture from the inside of the window.  It likely doesn’t convey the message that I’m trying to send, but it’s always fun.

A Place of Hope

…And that’s how I found myself pushing intravenous narcotics in a jeep on the side of the road.

Oh wait, perhaps I should start at the beginning.

The beginning is a small, open cook fire; a feature that every home in this region has. In the cold winter months, most people spend more time in the kitchen, and huddle a little bit closer to the fire. Sometimes too close. This week alone, we have had 5 children in our inpatient department (IPD) with severe burns, one of whom passed away. The little girl who this story is about was more fortunate, though she has a long and painful recovery ahead of her. When her clothes caught fire, she suffered 2nd degree deep burns from her mid-abdomen to mid-thighs. Her family brought her to the nearest healthcare facility, which could not treat her injuries. Her mother then carried her for two days to reach the hospital.

The little girl’s name is Dila, and even with daily dressing changes, antibiotics, fluids, and observation, it was clear that her wounds needed advanced treatment. Barring infection her burns may eventually heal on their own, but even so, the resulting scar tissue would cause severe contracture, limiting her mobility and posing lifelong challenges. This is where Watsi, a fantastic organization that allows people to directly donate to an individual patient’s treatment, enters the picture. Dila’s family had no way of paying for advanced treatment, much less the multiple days of travel required to travel to a major city that they had never seen. In less than a day following the posting of her profile on the Watsi site, 13 donors from around the world changed Dila’s destiny. They provided her with the means to seek treatment; a fighting chance to grow up and live a normal life. Thus began our journey together.

As Dila was having her dressings changed, Ryan and I were packing our bags in preparation for our departure from Achham. Having received word that Dila’s profile was complete, her mother carried her, freshly bandaged, to our waiting jeep. The doctor handed me a syringe of morphine and asked if I knew how to push meds. I do now. Though 25% of her body is covered in severe burns, the only sounds Dila made throughout our winding, bumpy, 12-hour jeep ride were a few slight whimpers when we hit extra large ruts in the road. She only cried when I came near to give her medications; afraid that I might be trying to change her dressings. The rest of the time she lay there in complete, stoic silence.

The next day, we made our way to the airport, where Dila and her mother had to board a different plane than ours, as they had received last-minute tickets. Neither of them had even flown before, and I spent a moment reflecting on the injustice of a small girl being too badly injured to be able to look out the window on the world from above. The important thing though, was making sure that she was comfortable during the flight, and that she and her mother did not feel lost in the Kathmandu airport when they arrived. I fumbled with my limited Nepali phrases, all semblance of grammatical correctness lost, but managed to convey a few simple messages. After giving her one last dose of pain medicine, and hoping that she would sleep soundly through the flight, I stood on the runway and watched their plane set off, carrying them at hundreds of miles per hour toward a strange, new place. A place where Dila’s future has more options than infection versus contracture. A place where the technology exists to treat her injuries. A place of hope.

Dila underwent the first of multiple skin graft surgeries two days ago. Her condition is stable, and she still lies quietly in a hospital bed, waiting to see what comes next.

A Tale of Waste Management

The History of Waste Management – Part 1:

Prior to 8 months ago in Achham, all waste was burned in a burning barrel or a brick chimney type incinerator.  Plastics, medical waste, paper, bottles, and cans were all burned, or in riverside communities went directly into the water source.  The local joke is that “It’s ok because it all ends up in India,” though some people might not think this is very funny.  This is the way in Achham: everything gets swept into a small pile and burned in a small fire in the street, yard, rice field, or anywhere else it might develop.  So inevitably the smell of smoldering trash is as much part of the environment as the smell of dead fish is part of the ocean.  As a practice in the general community, when you open something that generates waste you drop it where you stand or, if indoors, simply throw it out the nearest portal to the outside world.  There is more consideration of where you might spit, and certainly of where your dishwasher, laundry water, or post-foot-washing water may end up.

The Non-History Current Practice/Vision of Waste Management – Part 2:

A “sustainable” waste management system was developed and decided upon about 8 months ago, complete with green concepts and money-making potential.  These are either the facts, or at a minimum the facts that I have deciphered via mixed stories, power struggles, emotional toil, and scattered half-English, half-Nepali conversations:

  • About 8 lakh ($9,200) or more (the bills are still rolling in) was spent on the project.
  • A business from Dhangadhi was going to buy the sorted recyclables for between 1 rupee ($0.0085) per kg for paper, and as much as hundreds of rupees per kg for metals.
  • Hazardous medical waste is sorted by hand, then autoclaved, and finally buried on site.
  • “Mercury-free” designation was hypothetically gained.
  • A future food-producing garden was envisioned, with dirt supplied by composted biodegradable waste (proposed not launched).
  • A “biodigestor” would be employed for methane collection and use as cook stove fuel (proposed not launched).
  • This system would stand as the paragon of environmental sustainability practices in Achham.
  • In a few years, it was projected that this program would fully fund itself.

How the System Works (from the perspective of a waste-generating individual):

At two select exterior locations (the main Outpatient Department double doors, Inpatient Department, and the Emergency Room door) you can find the full monty: a commingled paper/plastic bin, bottle/can recycling, and biodegradable composting bins.  To supplement the main locations listed above, paper/plastic bins are placed in about every room.  For clinical staff, waste management trolleys were custom-fabricated by a local welder.  They hold 4 large bins, 4 smaller bins, and 2 micro bins.  These carts can be found in two locations: Emergency Room (ER), and Inpatient Department (IPD).  The clinical staff should be able to easily decide the proper receptacle of waste generated, based on the following labeled bins: “infectious, syringe style glass medicine container, needle, syringe, plastic odd ends/plastic tubing and non infectious waste bins.”


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In the canteen, they have been issued 2 extra large bins, for bio-degradable compost and commingled paper/plastic, as well as a 3 outdoor, aerated composting containers.  The dirt from these compost bins was envisioned to eventually go to a garden that would grow vegetables to be cooked at the canteen.  Lastly, once all previous stages had been completed, a “Biodigestor” would be installed.  As very few people fully grasp how this system works, I will cite the Biodigestor website: “You put cow manure in one end and get out usable cooking gas and organic fertilizer.  The odorless gas is piped into the kitchen where it can be burned for 4-5hrs a day, replacing the need to collect firewood.  The liquid fertilizer is rich in nutrients to boost crop production.  And, the patio is no longer littered with cow manure.  Biodigestors are relatively simple to construct and made with cheap local materials.” At the hospital, there is no shortage of cow manure.

Unforeseen Shortcomings of the Waste Management System – Part 3:

The final cost of this project was far greater than the expected/approved cost.  The system’s tangible goods include but are not limited to: a mid-sized room, an outbuilding attached to designated room, signage, waste buckets, 2 rolling waste trolleys, 2 autoclaves, digital thermometers, rubber gloves, landscaping tools, shelving, aprons, masks, trash bags, and 3 additional staff.

There is a recurring cost of autoclaving used needles pre-burial, and ideally there is sufficient electricity to run an electric autoclave.  However, from what a waste management staff member tells me, electricity is not available as often as you would think, and therefore they must occasionally run a generator to supply power to the autoclave (they now have the old hospital gasoline based generator for this).  At 150 rupees per liter (about 25% more than US prices) this practice can get a touch spendy to prep garbage before its buried.  The other option is to use the second autoclave, which is propane based, and which we have the supplies to run but propane is not cheap either.  The details of how often this autoclave is used and any particulars about this method were unfortunately lost in a series of conversational tangents.

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When viewing the storage outbuilding for the sorted and baled recyclables, you cannot help but notice that each partitioned segment intended for a certain type of waste was overflowing; literally spilling over the top and now building up around the exterior of the shed and canteen building.  After a brief talk with the waste management staff, it came to my attention that the “business” from Dhangadhi has never come to hospital to pick up or purchase the processed material, despite being contacted on a regular basis.

As for the composting it has completely fallen into obscurity and I cannot even find the containers despite much searching.  The canteen staff now feed the cows with the compostable material.  The nonexistence of a garden may be my own failure, as I was asked to pursue it and make it happen.  I researched potential materials, costs, size, and the staff support surrounding the issue.  As for my findings about the cost/size: a small garden with fencing is not too expensive, and would cost less than $50  using locally available materials.  But to make a garden that could even remotely offset the cost of the kitchen would be out of my scope of practice, not being a gardener in the slightest, and from what I could speculate would be quite expensive compared with the cost of produce.  This also would require a fair amount of labor-hours to run and I didn’t dare suggest another staff member to add to recurring costs knowing it was a touchy subject.

The waste management staff does not use the designated rubber gloves to sort the waste.  These gloves must either be inferior in some way or must be regularly unavailable.  The sorting staffs seem to greatly prefer sterile surgical gloves instead.  At $3-5 a set, sterile gloves boost the cost of the program without even hitting waste management cost radar.  All modest efforts to redirect staff members back to using appropriate reusable cleaning gloves have been unsuccessful.  Without being able to understand the underlying reason for this behavior, no change can or will be made.

What was Learned Versus What was Gained – The Non-parted Segment:

In a nutshell, I feel as if this whole tale sums up the reality of being in Achham.  The plan, the construction, the well-intentioned improvement, all spiralling to a complete and utter standstill as dedicated volunteers leave semi-aborted projects behind and businesses fall through on agreements.  This is where I will stop with my own conclusions as I’m often told I should stop one sentence short of a complete thought.   Instead, I will add a few more bits of what I believe is speculative fact into this story.  As a true believer of the proverb “Don’t believe half of what you see and none of what you hear,” I’ve seen no better waste management system in all of Achham.  Although its just bundled up in bales sitting about the building, excess infectious waste isn’t anywhere to be found, nobody is hauling trash down to the river and dumping, the air doesn’t taste of smoldering plastics, ever.  Three local community members (actual locals, not transplants), of mixed castes now make a living by bettering their environment.  This is what I call public health net gain.

Earthquakes and Exorcisms

Part I: Earthquakes

Ryan was startled awake two weeks ago in the middle of the night, convinced that there had been an earthquake, which I told him he had only dreamed.  The next day, everyone he asked denied having felt it.  Even Aama, who we had heard get up and check the front door after Ryan awoke, did not seem to respond to his inquiry about the event.  The process of inquiring, however, was priceless.

Two nights ago, a mere hour or so after going to bed, we both awoke to the ground shaking, complete with the gripping fear of realizing that we live in a shoddily-constructed, concrete house.  The next morning, the late-night quake was all the talk at the hospital, with everyone sharing their fears of being crushed alive in their mud, stone, or concrete homes.  Ryan was informed by a local man that he had too had felt the quake two weeks prior, and he shared his interesting theory that the current seismic event had been “the wave coming back” from across the valley, a recurrence of the recent geological activity.  When we came home that night, armed with the Nepali word for “earthquake,” Aama confirmed that she had indeed felt both quakes, and Ryan had a moment of celebratory smugness, having been right all along.

Directly next to our bed, mostly obscured by the mosquito net, is a crack that runs the length of the wall.  It was likely there when we moved in; has probably been there for years.  We never noticed it until the other day though.

 

Part II: Exorcisms

The first exorcism we witnessed within our home was on a sunny afternoon.  We were on our way back from having lunch in Sanfe Bagar with friends, and were just stopping home to pick up warmer jackets for the evening.  From down the path, we could hear shouting coming from a locked room downstairs.  After a few minutes of eavesdropping (which was hard not to do, even from a great distance), our friend Bhinnata informed us that the shouting was directed at a demon, which appeared to be located in someone’s head.  We knew that one of the girls in our house was having “mental problem,” and we assumed, correctly, that she was harboring the demon in question.

We were also informed that it is common practice for a thorough whacking with a broom to accompany the banishing of mental demons.  Thankfully the brooms here do not have handles, but are rather made of craftily-sewn grass bundles.

After a short discussion with the family, and a request that the girl be brought to the hospital, we hoped for the best.  The following day, we saw, or rather heard her wailing in the Emergency Room (ER).  There is little recognition of depression, mental illness, or any sort of psychological malady in this region.  Hence, it is often difficult to convince people that medical attention is an option for ailments of invisible origin.  Numerous staff members have attended trainings on mental health topics, but it is often challenging to engage patients in mental health counseling nonetheless.  After much attempted discussion in the ER, a failed attempt at IV placement, and more wailing, the girl was taken back home, having refused any sort of treatment.

Two days later, she was gone.  We neither saw nor heard about her for weeks.  Now she is back in the household (people come and go constantly), seemingly “good as new.”

Last week, a whole group of people showed up on our front porch, clearly undertaking another exorcism event.  This one was complete with readings from a book, flowers, chanting, incense, wailing, etc.  We’re not sure whether there is a high frequency of paranormal activity within our household, or whether this is the next best thing to reality television, in an area where there’s not much else to watch.  Either way, it’s a little wild.

All the Pretty Nurses

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Bayalpata Hospital Nurses, Tara Bhattrai, Gauri Sunar, Satya Khati, Sangita Nepali (right to left) entering patient data into the Inpatient Department registers.  These lovely ladies can also be credited with not only compassionately installing an IV in my arm and dosing me with fluids and antibiotics during my recent bout of amoebic dysentery, but also with making sure I had enough blankets to keep me warm while the cold fluids chilled me to the core.  I had never  considered the effects of storing intravenous fluids at wintertime “room temperature” in unheated buildings.  Now, however, I can vouch for the fact that injecting a few liters of cold saline into one’s arm is rather unpleasant!

The Bayalpata Hospital Clinical, Data, and Research Departments have been working collaboratively to improve patient data management systems.  I have personally built and re-built some of our forms 5-10 times, in an effort to reach consensus on what was most “user friendly.”  This week, the nursing staff is piloting the use of a new patient vital sign monitoring form, which is hoped to streamline the process of documenting patient vital signs around the clock.

12-26-12x[I have removed all patient names except my own from the above image.  Even though HIPAA doesn’t exist here, and the notion of privacy is largely unheard of, my US-structured patient confidentiality notions wouldn’t let me post the original photo.]

A Common Preexisting Condition

A healthy sixteen year-old girl passed away yesterday, within a few miles of our hospital.  She had no history of illness or trauma.  Her only preexisting condition was having been born female.  In Achham, and much of Nepal, women of child-bearing age spend their monthly week of menstruation separated from their families, as part of the practice of chhaupadi.  Menstruation is viewed as impure, and women undergoing this biological process are segregated in order to prevent “contamination” of those around them.  Traditionally, menstruating women are sent to sleep in a cow or goat shed outside their house, though some families provide more comfortable spaces for their female members.  They are not allowed to enter the kitchen or use the family’s water source, and are often made to wash their sheets and blankets each day.  This particular young woman had started a small fire to try to stay warm in her chhaupadi shed, and was found by family members the next morning, having suffocated to death.

Hers was the third chhaupadi related death in Achham this year alone and such incidents, unfortunately, are not uncommon, particularly in the winter months.  When trying to decipher some sort of reason behind this needless, completely preventable loss of life, the deep-rooted complexity of such issues becomes apparent.  Perhaps she was cold because she did not have adequate blankets, or because the blankets she had were still damp from having been washed that day.  Perhaps the shed in which she was sleeping was not adequately sealed from the cold winter air.  Her family may not be able to afford adequate blankets for everyone, and she may share a bed or blanket with a sister most other nights.  If these reasons fully explained the issue, it would seem that her death was due to the simple but ever-present dangers of poverty.

The truth of the matter is, however, that poverty is not the only answer.

Education, like poverty, could provide some clarity about how these things happen.  It is very possible that, in the same way that we see countless elderly female chronic obstructive pulmonary disorder (COPD) patients, who have been cooking indoors over open fires their whole lives, this young woman simply did not know the dangers of concentrated smoke inhalation.  Had she known, she may not have built a fire in her small room, or may have left a window open.  This would also be a simple answer; an answer which correlated clearly with poverty and social marginalization.  But these simple answers do not fully explain such a death.

In such a recent post-conflict region, there is a distinct and widespread sense of stoicism, embodied by people of all ages.  Small children come to our emergency room with multiple fractures, their eyes devoid of tears.  Women give birth silently, with no local or other anesthesia.  This quiet yet tangible sense of fierce independence, limited trust, and conflict avoidance, frequently results in a “grin and bear it” mentality.  Perhaps the family did have extra blankets, but the young girl did not think to ask for them or the family did not think to give them.  Perhaps the fact that the tradition of chhaupadi has been practiced for generations contributes to elders believing that “If I did it, so can you.”

Potentially the most difficult contributing factor to address in our effort to make sense of this nonsensical situation, is the fact that a female life is not valued in the same way as a male one.  In this patrilocal culture, daughters are raised with the understanding that they will eventually be “lost.”  Sons are expected to bring wealth upon a family, and to care for their aging parents later in life.  Daughters are raised into their teens or twenties, and are then married and moved into the households and families of their new husbands.  Newborn sons are greeted with open arms, while it is not uncommon to see the new mother of a baby girl in our maternity ward wistful and withdrawn, laying with her back turned to the infant.  Perhaps this young woman would have been offered another blanket, or would have felt comfortable asking, had she been graced with a Y chromosome.

As with all such questions, there are simple answers and there are complex answers.  The problem is that these answers are tightly intertwined, and cannot be logically separated.  We are already conducting menstrual education programs in local schools, in an effort to increase understanding of the biological processes that the female body undergoes.  The local community could join together to distribute blankets to those in need, or could launch an educational campaign about the hazards of indoor fires.  These things would likely help, and may actually reduce the incidence of chhaupadi related deaths.  It is, however, unlikely that these efforts alone would prevent another woman from meeting the same fate.  These are but a few of the deeply entrenched challenges faced by the people of Achham, following the years of war that left no one untouched.  Just as infrastructure is redesigned and rebuilt, so must lives be.