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.

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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.

Out on the Town

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December 9, 2012.  Dillibazaar, Kathmandu, Nepal

Briskly marching by us as we stopped to examine a particularly lovely “Pringles” logowear jacket, was this brigade of goats.  Clearly, there is nothing abnormal about taking your goats out for a stroll on a lovely, inner-city morning.

IMG_4203December 21, 2012.  Kathmandu, Nepal.

Throughout the city, you can see people transporting goods by any means possible.  Two men on a motorcycle, one with a 10′ x 6′ sheet of plywood on his head, in 5:00 traffic is not an uncommon sight.  The young men pictured here are transporting what is likely 500+ pounds of bent rebar, using their converted roto-tiller, tractor-trailer setup.

The Day after the World Didn’t End

We awoke this morning around 5:30 a.m., to the standard background of doors opening and closing, people coughing and hacking, and dogs barking.  This particular time, however, the sounds seemed somehow less abrasive—brightened by the humming background of a few hundred Tibetan monks chanting.

While across the continent religious fanatics were seized for distributing doomsday materials (China), and 1000 Russians huddled deep underground in Stalin’s bunker, having paid $1500 each to be protected from the world’s end (Moscow), we sat watching hundreds of Buddhists going calmly about their morning prayers around a giant stupa in Kathmandu.  In Serbia, coal shafts were opened to shelter the masses following the impending emergence of an evil sorcerer inside the mountain, where people could hide as he went on to destroy the world.  Gendarmes blocked access to a peak in the Pyranees, where a giant UFO was expected to beam up gathered devotees (France), and the annual winter solstice celebration at Stonehenge took on larger-than-life dimensions despite declarations by the party’s Druid hosts that they had no end-of-world expectations (United Kingdom).  Another party raged in Cisternino, complete with hot air balloons and sleepless nights (Italy), while the only notable doomsday gathering in Sirence was that of journalists hoping to document “believers,” to the great dismay of local shopkeepers (Turkey).  Perhaps the epicenter of end-of-world festivities, being affiliated with the Mayan prognostication that had spurred all of this ruckus, was Chichen Itza, a Mayan ruin on the Yucutan Peninsula (Mexico). Here, however, people were gathered to celebrate the dawning of a new area.  Presumably, there were countless smaller and less documented ceremonies of celebration, mourning, anticipation, and fear across the globe.  I would hate to think how many disappointed faces left these events, returning to desk jobs, mortgages, and everyday rituals that they had finally forsaken.

What I marvel at is how common these events are.  In my mere 25 years, I have already witnessed the mass-hysteria of Y2K, doomsdays, and the end of civilization “as we know it.”  Is humanity so bored as to need more drama, tragedy, and panic than genocides, guerrilla warfare, action thrillers, and so-called “reality TV” can provide?

While I pondered the humor embodied in these mass demonstrations of some intrinsic human fascination with the absurd, I found great comfort in the calm river of grandmothers, children, and monks alike that circumambulated the stupa, spinning prayer wheels and holding prayer beads.  They all made their way around the circle at their own pace, quietly paying homage before continuing their daily work, studies, or travel.  Just another day.

Traffic Tickets

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December 10, 2012.  City Center, Kathmandu, Nepal.

Judging by the co-mingling of cars, buses, tractors, motorcycles, bicycles, rickshaws, goats, cows, pedestrians, and any other moving body one might feasibly imagine, we had drawn the conclusion that traffic enforcement was nonexistent here.  We were, however, caught off-guard the other day, when we witnessed an actual traffic ticket being issued.

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On Parade

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December 10, 2012.  Human Rights Day Parade.  Kathmandu, Nepal.

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As we made our way to the Kathmandu Model Hospital, to meet with a group of surgeons about our developing collaborative relationship, we came to a barricade in the street.  We initially assumed there to be some sort of demonstration, which is not uncommon here, but had the relatively pleasant realization that the hold-up was due to a “Human Rights Day” parade.

Schoolchildren, hippie-types, and military groups marched together, all carrying various signs and banners to promote awareness about human rights violations.  The marching band in particular caught our attention, with a whole squadron of bagpipers, none of whom were actually playing the bagpipes.