Part 2: Where there is no doctor

My first posting was to Sindupalchok, a district to the northeast of Kathmandu. It is monsoon season, so the mud roads are deeply rutted and slow, and frequently blocked by landslides. We set off at 6am in the PHASE 4×4 hilux; Max also came along to see where I would be working and stay a night with us before cycling back to Kathmandu. The journey took all day, despite only covering about 80km! After driving for six hours we had to leave the hilux at a river crossing where the road bridge was down. We carried on uphill on foot for an hour or so, and then met a pickup truck to take us up to the village. It was hard to believe what the truck could handle; mounting landslide debris and fording rivers. There was at least one moment when I was convinced it was going to tip over, but the other passengers seemed totally unconcerned!

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This area was badly affected by the earthquake, and two years on many people are still living in temporary housing, made from tarpaulin and galvinised steel. It’s hard to imagine what the villages must have looked like before as most of the buildings were completely destroyed. Our staff accommodation was basic but cosy and clean, and we shared a yard with two families and their inquisitive children. We spent a lovely first evening eating and getting to know everyone.

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Makeshift houses, two years after the earthquake

The first challenge was working out how to address my new colleagues. Nepalis are extremely polite and always address others by their title, or family role, in order to show respect. For example, ‘dhai’ for a man, meaning older brother, or ‘didi’ for a woman, meaning older sister.  Senior colleagues are usually addressed by the English ‘Sir’ or ‘Madam’ suffixed to their name. This is so enshrined that the female ANMs addressed their male supervisor as ‘Sir’, even though they were all a similar age and very familiar as they were living together and all sleeping in the same room! I found this system quite difficult to adjust to as it essentially enforces a strict hierarchy in every aspect of work and home life. I was shocked to learn that women are expected to address their husbands as ‘Sir’, and use the more formal verb conjugations, but it is not necessary for their husbands to reciprocate. It shows just how deep the gender imbalance is in Nepali society; there is evidence that things are improving, but it seems that even the rules of language need to change in order to achieve equality! PHASE office policy is to use the more neutral suffix ‘-ji’ to show respect, as it can be applied to everyone regardless of their status in the organisation. So I intended to use this with my mentees, and hoped they would do the same for me. However, in reality they were intensely uncomfortable with ‘ji’ as they felt it didn’t imply enough respect to me, and too much respect for them!! So after uncovering this minefield we reverted to them calling me ‘Doctor’, and me using just their first names – which I could apparently get away with as a foreigner. Phew!

Our day started around 7am with a mug of sweet black tea, spiced with ginger or black pepper. Then it was outside to wash up last night’s pots under the hosepipe. Water containers were refilled and the bedroom/kitchen swept clean. I was strictly banned from helping with any of these tasks because I was a guest – a couple of times I tried sneaking outside with the washing up only to be discovered, and the cloth literally wrestled from my hands! In the end I had to graciously accept being waited on hand and foot, as guests are honoured and this is the Nepali way.  Next the girls set to work in the kitchen, and the hissing of the pressure cooker signaled the first meal of the day.  Nepalis eat two main meals of the traditional ‘dhal bhat’ (lentil soup and rice.) This is accompanied by tasty curried vegetables; ‘tharkari’ and a dash of sour chilli pickle; ‘achhar’. Local shops sell staples like rice, salt and sugar but for fresh produce it was normal to go from house to house asking people depending on what they had. Often our patients or neighbours brought us gifts of vegetables they had grown or collected from the jungle. It was obvious that the healthworkers are well known and trusted and I’m sure that one of the reasons for this is the fact that they are living and sharing in everyday community life.

One perk of being here in the monsoon is that ‘niguro’ are in season. On walking back from our home visits in the neighbouring villages we would stray off the path to go foraging for these juicy, young green ferns, yum!

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So the food was simple, local and healthy (apart from the mountains of carbs!) and although almost every meal was the same it felt natural. I’ve always aspired to eat more like this at home, but am too often tempted by what’s on offer in our supermarkets. It’s an interesting insight that when the temptation isn’t there, I’m not actually all that bothered..those who know me well will not believe this but I even stopped craving coffee!

The clinic opened at 10am, and the pace was unsurprisingly much slower than I’m used to. The population is about the same size as my practice in Leeds, but geographically much more spread out (practically vertically in both directions, as we were perched on the side of a typically steep mountainside!) People only attend if they consider it important enough to lose a day’s work in the fields which is significant here. Missing a day in harvest season could genuinely impact on their family’s food security for the year. It also explains why parents often send their children to the clinic alone, or why people are reluctant to go to hospital even in an emergency.

The worldwide reputation that Nepalis have earned for being tough was certainly borne out from my short experience. We saw an elderly man one day who was seriously ill with a urinary tract infection. He had three daughters but they were all married and living away. So, late into their 70s, he and his wife were still working in the fields to support themselves. After intravenous fluid resuscitation and antibiotics in the healthpost, we let him home to rest. When we visited early the next morning, he was already up tending to his buffalo!

I was lucky to have time to visit four different villages and work with different teams of healthworkers. Every time I was warmly welcomed and treated like one of the family. The most remote, called Kashigoan in Gorkha district, is still fairly close to kathmandu, but this time the journey took two full days. We had to leave the hilux behind again when it got stuck in the mud, and hitch on the back of a another pickup, perched on top of sacks of potatoes!

The next leg involved a terrifying ride on the public bus, crammed with people two to a seat plus all the available standing room. This time I knew my fears were justified, because as we crossed the river and the vehicle swung wildly from side to side, the local passengers were screaming! It was a reminder that here, not only is travel unreliable and time-consuming, it can also be genuinely dangerous. The next day we hiked for seven hours up the steep hillside, testing out part of a newly built trail facilitated by PHASE. After gaining more than 1500m in altitude, we reached the beautifully positioned village of Kashigoan, with rare but stunning views of Bouddha Himal through the clouds.

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I was immediately impressed by the PHASE healthworkers given that they are essentially doing the job of a rural GP, midwife and health visitor all in one, with a fraction of the training. On top of this, they often have to deal with problems that we would refer to hospital back home. They are living away from family and friends who they may only see once every six months. Our newest recruit, straight out of training, was only 17 years old! I sensed a real camaraderie between them that must come from sharing everything they have, and being on a steep learning curve together.  I never once heard them complain, and everyone pulled their weight (apart from me, because as I already mentioned, I would be physically restrained) In the evenings we had a lot of fun drawing anatomy diagrams, practicing examinations on eachother and doing role-play. There was a good helping of laughter and joking, and for me it was a joy and a privilege to be able to share in their lives for a few weeks.

Despite the slow pace, we had a steady stream of patients and a huge variety of cases, which was perfect for teaching. It’s funny how primary care is the same the world over, and how familiar a day’s work felt here. People have the same concerns and fears, and illness impacts on our lives in much the same way. Probably the most useful teaching I could give was in clinic, using patients to demonstrate clinical signs, or discussing cases they found difficult, which often turned out to be mental health problems.  With my encouragement, it was satisfying to see the healthworkers starting to enquire more about social context, and to observe how it helped them understand and connect more deeply with their patients. We also saw cases that I would never normally see or be expected to deal with in the UK: We saw a young lad who had fallen off a roof and his arm was badly broken  – we attempted to realign and then plaster it to minimise the discomfort of a bumpy six hour jeep ride to hospital where he would need an operation to fix it. We had to manage a case of self-poisoning with organophosphate weedkiller, a teenager with suspected typhoid fever and a six year old boy with mastoiditis (a serious ear infection that has spread to the bone of the skull).  I admit that there were times when I felt out of my comfort zone, and realised how much I take for granted that in my inner city practice, my patients can be transferred to an accident and emergency department within minutes. It brought home the reality of working in such a remote place and gave me a glimpse of how isolated the healthworkers must feel in situations like this. The harsh reality here is that occasionally people die from illnesses that would be easily treatable if a hospital was within reach.

In Kashigoan we saw a woman who had delivered her first baby the previous night, but by the next day had still not delivered the placenta. This is dangerous because of the risk of bleeding and infection. She was an hour’s walk away from our clinic, along a rough mountain trail, so four men from her village carried her to us on a stretcher. The retained placenta was expertly removed by the ANMs, and she was given antibiotics, nutrition advice and some assistance with breastfeeding before leaving the clinic in a much safer condition. It is cases like this that show what a huge difference the PHASE service is making – with the nearest government healthpost a minimum six hour hike away, they may not have sought help at all, or may have resorted to other risky traditional or private practices. It is no exaggeration to say that access to skilled help here probably made the difference between life and death.

The hope is that, given time, PHASE services will be integrated and eventually taken over by the government. In some areas this has already happened successfully, for example after they reopened a much needed healthpost that had been damaged by a landslide in the far west of Nepal. PHASE supported the service until it was fully restaffed by government workers, and they are now back up to speed, seeing up to 50 patients per day. The interface between the government and NGO however can sometimes feel tricky and sensitive – and I was acutely aware that my presence could potentially make this worse. I visited two clinics where we were working alongside government staff. In one of these it was clear that I was not welcome, but it was easy to see why they might be sceptical of me, not being able to speak the language and having only a very superficial understanding of local health needs. I found working here my biggest challenge; trying to build their trust and avoid being critical, whilst gently pointing out any unsafe practices. In another village however, the government staff were friendly and keen to join in our teaching sessions, which made my time there feel much more positive.

Although the clinics are clearly valued and important, perhaps the work which is having the greatest impact is the community health education. They cover subjects like hygeine, handwashing, purifying water, and many different aspects of maternal and child health. In Sindupalchok I watched the ANMs teaching a class of 15 year olds about puberty; an important precursor to sex education that few, if any of the students are likely to have been able to talk about at home. They also tackled the subject of ‘chaupadi’; a traditional practice where girls are secluded during their first menstrual period.

In Gorkha I accompanied the staff to a meeting of local mums, where they answered questions about contraception and child nutrition. It was clear from the number of attendees that this form of health education is hugely popular. We heard afterwards that some of the mums had mistakenly thought the meeting was in the morning. They had walked several hours to get there only to discover it was planned for the afternoon, but had decided it was important enough to wait!

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My brief time working with PHASE surpassed my expectations and I gained a huge amount from it personally. It was wonderful to get back to the basics of primary care, without the risk of missing something due to lack of time, the fear of complaints and the ever-mounting pile of paperwork. We were able to give patients the time they needed and focus on what was really important, and it reminded me that General Practice really is a unique and rewarding career.

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The sense of peace that I experienced in these village communities is hard to put into words. In contrast to life at home, I had so much time to reflect or to just ‘be’. I was surprised that rather than finding myself at a loose end I actually really enjoyed this newfound headspace. I felt so lucky to be able to get to know people – patients, neighbours and most of all the healthworkers I was living with – I learnt so much from them and from the natural rhythm and simplicity of their lives. I also had some of the best quality sleep I’ve ever had!  It’s going to be a huge challenge with all the temptations and distractions we are constantly bombarded with, but I really hope I can hang onto this experience and somehow transfer it into my life back home.

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