travel bursary reports
Imagine for a moment the perfect patient examination, you find clubbing, a heart murmur and discover signs of heart failure. Rheumatic heart disease appears on your differential; and you’ve made the perfect diagnosis. However this isn’t just an exciting case allowing us to congratulate ourselves on our medical skills, this is a real patient. She’s the same age as me, has 3 children, and has travelled 3 days from Northern India for treatment. She can’t speak the language, has no money and has left her children behind. What’s the solution?
I certainly don’t have any notable answers, but I did set out on my elective hoping to learn from the Nepalis and learn more about God’s heart for these people. Tansen is described as a romantic medieval hill town, which sits on a hilltop above the Kali Gandaki River, 12 hours by road from Kathmandu, with occasional views of the majestic Annapurna mountain range.. The mist which sits over the valley every morning has earned it’s nickname as ‘White Lake’. It was once the capital of the Magar Kingdom of Tanhun, which rivalled Kathmandu for power of Nepal in the 16th C. Magar power weakened in the 18th C, and Tansen became an important trading post between India and Tibet. The narrow winding streets mean it is too steep for many cars. Sadly it’s had quite a troubled contemporary history, and the town has been attacked by Maoist rebels on several occasions, most recently with a bombing of the main square in 2006. Sandwiched between the superpowers India and China, Nepal’s health concerns are very much related to the social, economic, religious and political climate.
Consider the man who’s presented with sores covering his body and mouth ulceration so bad, his lips are black. He has a family to support, and finding no work in Nepal took employment abroad in the Arab states like thousands of others. Living away from his family for perhaps a year or more he contracted HIV. He’s also got TB, as a result of living in cramped illegal workers camps, with no rights to protect him. Yet he can’t start treatment yet as the hospital machine for CD4 count has gone to the capital to be repaired. In the hospital you are meeting immediate needs, but continue to battle against bigger and ever expanding issues of foreign work, economic stability, worker’s rights and sustainable agriculture in Nepal.
Think also of the old man with reactivated leprosy, who’s travelled from India with his wife. He really needs to stay in a long-term centre for treatment, but he doesn’t have that luxury. The couple are elderly, with no children and need to return to their land in India, which provides their only income. Then there are suicide attempts through fertiliser poisoning, as famers struggle with government land repossession in the absence of any social security net.
Here, more so than in the UK health is inextricably linked to economics, and conditions are less associated with individual lifestyle choices as the microcosm they inhabit, whilst global powers play out their games. Certainly there are cases of COPD through smoking, alcoholic liver disease, heart disease and diabetes on the wards. Yet if the economic climate has enough risks, the physical climate and daily existence hold their own hazards, particularly for the poorest people. In the fields there are the buffalo who gored a farmer, hornets which attack and snakes which bite. Cutting grass fingers were routinely sliced with scythes, and people of all ages fell out of trees picking fruit. There are hidden hazards too; liver flukes from eating crabs in the river and neurological disability through neurocysticercosis from eating undercooked pork. In some cases I was shocked by the level of needless suffering through traditional practices. Monsoon is snake season and farmers in particular are at risk. In traditional culture it’s considered bad to kill a snake which has bitten someone, until the person has fully recovered. Because of this there are plenty of dangerous snakes hanging around houses, and family members were bitten by the same snakes. Sometimes the affected limb would be bandaged so tightly to prevent the spread of venom, that by the time they presented to hospital several days later they were suffering from a massive oedema. Often the wound will be cut with a knife at home, and a chick’s bum would be applied to the wound to ‘suck’ out the venom. The assumption is that if the venom has been sucked out the chick will die, and if not they try the hospital. This highlights the importance of public health education.
A further case the importance of public health education and the issue of patient confidentiality and rights. A local family picked some mushrooms and took them home to eat- quite a luxury. Unfortunately young mushrooms look much the same, and these mushrooms were poisonous. The family shared a spoonful each and all developed a brief gastroenteritis. However one 17 year old girl went into fulminant liver failure. On consulting the family it was decided to provide palliative care. However in Nepali culture it’s not seen as right to tell someone they will die, or to talk about death. Despite the fact the girl was married, the family refused to let the doctors tell the girl she was going to die. Consent is very different here to the UK, and it’s seen as a family affair, rather than the right of an individual patient. As a Christian that’s something I find hard to think about, that someone might be denied the chance to think about what might happen after death. Sadly in the same week 7 people died in Nepal from mushroom poisoning, and it’s similar every year as locals ignore public health warnings against picking mushrooms.
One of the reasons patients come from far and wide is the reputation of the hospital, not for profit, but for meeting the needs of the population. Unlike many of the other local hospitals, as a mission hospital patients know there will be no unfair charges, expensive medications or unnecessary tests. If patients are unable to afford their treatment the pastoral care team can assess their finances and help with food and bills, and prevents these patients from being treated as second class citizens. These four principles summarise the mission of the hospital i) equality and access for all ii) service especially to the poor iii) integrity and forgiveness iv) competence and training.
The behaviour of the hospital staff also challenged my observations in the UK. Many residents have trained in different countries e.g. India, China, Bangladesh; and have varying degrees of practical and theoretical experience. Yet residents are not berated or humiliated publically on the wards, but are encouraged to develop their abilities and skills. The expat doctors also have the humility to recognise their own limitations, admit mistakes and learn much from the residents particularly with language and culture. You would rarely see F1s and consultants chatting and sharing ideas over tea in the UK. Why should anyone foster a culture of entitlement and arrogance, when we are only in the positions we hold by the grace of God and the gifts given to us? Tansen was founded when the local people requested a hospital be built, and still today as far as possible the community are consulted about hospital developments. There is currently a project to build an ecological reed bed to process hospital sewage. Such an encouraging example of low cost solutions and good environmental stewardship , particularly when locally most of the sewage flows directly down the hillside into stinking pools. The community are also regularly involved in ‘open days’ where they can comment on the running of the hospital and foreseeable problems. The staff were recently very humbled in recognising mistakes in the disrespectful way some doctors were treating patients, and took steps to resolve this. This gives the community ownership and investment in their health and community.
All the homes on the hospital compound livid in by hospital staff have didis (the aunties who cook and clean). The hospital have a scheme to provide employment for some of the most vulnerable and least respected women in Nepali culture- those who are widows or abandoned. They are provided with training in domestic skills, regular educational sessions and social events. Exodus 22:22 ‘Do not take advantage of the widow or the fatherless’.
I’ve also seen much ingenuity in situations where aren’t the resources for normal solutions. For example on the wards ‘spaces’ for asthma inhalers are made from old IV fluid bottles, with holes cut out and taped to make a good seal. In the absence of any national system of bone marrow donors there’s a new internet Facebook movement, created by Nepalis, to find donors and recipients. There’s also a case the pastoral care team were involved with. A teenage boy presented to the ward with sudden onset of personality change and hyperactivity. After ruling out other pathology the diagnosis was psychological. The boy had a difficult family background, having been abandoned by his parents, and cared for by a grandmother. There’s no child mental health service, particularly not for those who are poor. The pastoral care team devised a programme of teaching and activities for the boy, so he had structure and a surrogate family unit around him. The boy and grandmother would travel 2 hours every day to reach the hospital, and it’s been a great encouragement to see his behaviour improve, and to sit and have chats together in Nepali whilst we watched football.
Language lessons whilst I was at the hospital gave me the confidence to be able to communicate with patients and understand what was happening in consultations. As a student I was fully involved with ward rounds and encouraged to be part of the diagnostic process. It was a different type of medicine where in the absence of immediate test results, you were forced to be precise in clinical examinations and work with colleagues to reach a diagnosis. None more so than when patients presented with Krate snake bites. These snakes heat seek and bite at night, often undetected, and as the venom only contains a neurotoxin there is little local oedema or inflammation. Therefore patients often presented with a varied set of neurological symptoms, such as the girl with ptosis, exophthalmos and muscle weakness.
Whilst for much of the placement I was learning and observing, I enjoyed the opportunity to help implement a new diabetic surgical protocol in the hospital, As diabetic patients had a 50% post-operative mortality rate. I was fully welcomed into the hospital community and was able to lead Sunday school, teach tennis and attend children’s birthday parties. It was encouraging to be able to worship with believers in Tansen and Hebron churches in the bazaar. I was also able to travel to a ‘low caste’ village church which was only a few years old. Together we read Psalm 47:
2 For the Lord Most High is awesome, the great King over all the earth…
7 For God is the King of all the earth; sing to him a psalm of praise.
8 God reigns over the nations; God is seated on his holy throne.
9 The nobles of the nations assemble as the people of the God of Abraham, for the kings of the earth belong to God; he is greatly exalted.
God doesn’t care about caste, and knows and cares for the people of this tiny insignificant village in rural Nepal just as much as you or I. Another great encouragement was a half day ‘retreat’ for the hospital Christian Medical Fellowship. This represented a whole range of professions within the hospital, including cleaners, lab technicians, OPD staff, nurses, doctors, dentists and pharmacists. We listened to a sermon on Jonah and God’s compassion for the nations, and even those who hated him and were despicable. The Nepali staff then prayed for all the Bideshis, and they thanked God for the faithfulness of Carl Friedricks (who started the hospital in the 1950s)- and how this hospital has continued to bless generations on Nepalis. How wonderful to be surrounded by a crowd of Nepalis all praying together at the same time, and to know that I will see these brothers and sisters again. On the wards I also had the privilege of being able to pray with patients before their operations. Each day the chaplain goes round and explains to those on the operating list that he’d like to pray for them during their operation, and the reason why and asks the patients if they would like to be prayed for. I was astounded that all the patients we spoke to were Hindu, but they all asked for prayer from the chaplain. It was encouraging to speak to the social care team staff, many of whom were from Buddhist or Hindu backgrounds and had suffered persecution from their families for deciding to become a Christian. Why do the pastoral care staff do they job they do…is it just because they are ‘nice’ kind people …is it because they expect praise from their actions? I think the below verse (The Message translation) go some way to explaining this- we love as God first loved us: Matthew 5:43-48 “You’re familiar with the old written law, ‘Love your friend,’ and its unwritten companion, ‘Hate your enemy.’ I’m challenging that. I’m telling you to love your enemies. Let them bring out the best in you, not the worst. When someone gives you a hard time, respond with the energies of prayer, for then you are working out of your true selves, your God-created selves. This is what God does. He gives his best—the sun to warm and the rain to nourish—to everyone, regardless: the good and bad, the nice and nasty. If all you do is love the lovable, do you expect a bonus? Anybody can do that. If you simply say hello to those who greet you, do you expect a medal? Any run-of-the-mill sinner does that. “In a word, what I’m saying is, Grow up. You’re kingdom subjects. Now live like it. Live out your God-created identity. Live generously and graciously toward others, the way God lives toward you.” Tasen has also made me consider my skills and career- the doctors weren’t working there because it gave them special status, better career progression or wages, but because they realised that to those whom much is given, much is expected. With the immense privilege of a medical degree, we have a choice over how we use this - to benefit ourselves or others.
Read our reports from those we have supported through bursaries!