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 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.

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, http://www.nyayahealth.org, 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 19^th 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.

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.

Lila cooking in the volunteer house kitchen.

This is my fifth trip to Nangi in the past ten years. The walk gets a little harder the older I get but when I arrived at the volunteer house there was Lila, my friend and one of the community healthcare workers (HCW), cooking dal bhat and tarkari, a spicy blend of lentils, rice and vegetables. The sight of her made the fatigue of the journey fade, replaced by her smiling face and laughter…Lila is one of those people who possess boundless energy and the ability to see humor in everyday life.

So began ten days packed with a schizophrenic potpourri of activities. Usually I just work in the clinic and teach emergency and wilderness medicine topics to the HCW but this trip I had planned several projects.

100 year old thatched home in old Nangi Village.

Collecting material for the book was a priority. I interviewed dozens of people including teachers and villagers who knew and worked with Mahabir. I visited the old part of the village where he was born; the site of the old school he attended; and walked the forest and fields to appreciate what it must have been like back in the 1950s and 1960s. I filled two notebooks with interview notes, quotes, observations, musings and as many facts as I could verify. What surprised me was everyone’s willingness to talk…and talk candidly about Mahabir.

As a member of the HEF executive board I visit the many projects to prepare a report for the board. In between collecting material for the book I visited the wireless projects; new volunteer projects in and around the Nangi area such as the water collection system in Mohare Danda; met with the school’s principle and teachers to discuss school issues; supervised a paper bead making class for the paper makers; observed the Lotka paper making process; and reviewed and visited the income earning enterprises supported by HEF such as the community trekking lodge and fish ponds.

Moti contemplates his cracker after a visit to the clinic for stitches…two days later I saw him running madly around the school yard…surprisingly with his bandage intact.

But my favorite times are spent in the clinic working with Lila and Rupa, the community HCWs. I taught emergency and wilderness medicine topics which suit the wilderness environment. Lila, Rupa and I taught CPR and choking maneuvers to the Aama Suma, which is the mother’s group.                                                                                              Join me next week as I describe the clinic, patients and these two amazing women, Lila and Rupa, who provide medical care with confidence and compassion in this challenging austere environment.

In 1994, two years after finishing his undergraduate degree in Science Education at the University of Nebraska in Kearney, Mahabir was teaching and living in Nangi. The village school, partially funded by the government, paid for education only up to the seventh grade. Mahabir had added an eighth and ninth grade. The teachers’ salaries for the eighth and ninth grades were funded by private donations from colleagues and friends in Nebraska. More students came from distant villages to study at the higher level. Despite this success he was not satisfied; donations are not sustainable, nor do they foster self-reliance.

View of Himalayan mountains from campground in Nangi.

That year he collaborated with a Japanese organization called The Institute for Himalaya Conservation to build a campground in Nangi. His principles were closely aligned with IHCs major goal to nurture creativity, and self-reliance for village development so it was a symbiotic partnership. The IHC funded a campground along with a community dining room, kitchen and shower/toilet facility. Ground was leveled in tiers to accommodate the large tents used by trekking agencies. Trekking companies, both foreign and Nepali based, started bringing groups of trekkers. For two years the camping business grew and provided income for the school…Mahabir’s dream was taking flight…only to be literally shot down by a civil war.

Tek, head chef for the new lodge which replaced the campground in 2011.

In 1996 the Nepali Civil War erupted between the government and the Communist Party of Nepal (Maoists). Over the next ten years Mahabir’s dreams were sidetracked by a civil war that killed more than 15,000 people and disrupted rural development. Yet despite a civil war, fleeing tourists and NGOs pulling financial support he managed to fly under the war’s radar and continue a personal war against poverty and ignorance.

Join me next week for the continued saga of my trip to Nangi…meet my old and new friends…especially the children.

Someone asked me last week what the past few posts had to do with the book about Mahabir? Good question. My reply was; to understand the man you need to understand his  country and I think reading these stories can build better insight into both. Each story started with Mahabir’s dream; just like this story about bead making.

Paper making using Lokta fibers in Nangi. The bark is cooked and spread on mesh screens, then dried in the sun.

Mahabir believes education is the key to improving all aspects of Nepali life. Education needs funding and people should be funding their own education. Based on this linear principle he has worked to establish income earning projects in the villages to support the school and provide jobs. These include; yak breeding, cheese production, fish farming, community trekking and paper making which is one of the oldest projects. The paper making industry produces paper made from a local renewable resource, the Lokta shrub. This provided the materials needed for paper bead making.

Lokta paper beads in a bowl made from a sheet of handmade paper.

Paper beads are rolled from long, thin triangles of either new or recycled paper. Using the local Lokta paper, recycled papers and machines donated by Spellbinders, a craft supply company; steel rule dies donated by Apple Die, a metal manufacturer; and bamboo bead rollers donated by Janice Bautista, a paper bead artist; ten women from four villages participated in the workshop. They experimented with different weights and colors of paper to create paper earrings, necklaces and bracelets. The jewelry is sold to tourists who visit the villages and in Kathmandu.

Urmila wears her creations.

The jewelry is a source of income and artistic accomplishment for the women. I asked them what they would do with the income. The answers included buying basic food products such as oil, salt and rice to purchasing school pencils for a younger brother to buying clothing. The effect is indirect but unquestionable. Improving a household’s income strengthens a family’s ability to care for themselves and opens options not previously available, such as sending a child to school beyond the ninth grade.

Join me next week as I describe the community trekking business…sure to make you want to grab a walking stick and amble through fields of wild flowers while gazing at the Himalayan mountains.

Dr. Debra Stoner and Chitra Pun at Khopra Ridge, Nepal 2009.

Chitra Pun is the HEF Field Officer and initial contact for volunteers once they arrive in Nepal. As the field officer he coordinates and tracks the various income earning  projects, which are scattered across the 887 square mile Myagdi District in western Nepal. Since 2004 I have coordinate the HEF volunteers before their arrival in Nangi. We had worked together via email for years to ensure the transition was as seamless as a developing country in the middle of a civil war would allow. There were many bumps in the road but he always managed to absorb the shocks. It wasn’t until 2007 after the war ended that we met. That year I spent close to three months in Nangi and would see him off and on. But in the spring of 2009 I spent a month traveling with him around the Myagdi district and realized the extent of his work ethic, which is herculean. The following story gives you a sample of his abilities and dedication.

That spring I was teaching a series of medical classes including cardiac life support to the rural healthcare workers along with basic CPR and choking maneuvers to the “Aama Suma” which means Mother’s Group. We also visited four health clinics to assess their needs for supplies, equipment and structural improvements. He organized my travel for the month throughout the district including getting supplies to all four villages, setting up the schedule, notifying the healthcare workers, getting participants to the classes and keeping me fed and housed along the way. He, outfitted in a woolen hat, vest and jacket, easily plodded over ridges and down slopes, gaining and losing thousands of feet in elevation over dozens of miles. I, on the other hand, huffed and puffed along in as few clothes as decency would permit due to the heat but barely kept up with him. All the while he juggled the multiple projects he supervises for HEF, which included; papermaking, fishery, mushroom growing, cheese making, yak breeding, reforestation, the trekking lodges and the volunteer projects.

2012…a modern version of Chitra with cell phone.

This year was no different…except for the cell phone. All the way up to Nangi for six hours his phone rang non-stop. It was clear it made his job both easier, for obvious reasons, but also harder as he was constantly at the mercy of whoever needed him. Yet I have never, in all these years…heard a sigh of fatigue, a disgruntled word or seen him shirk responsibility. He is a rare man who consistently does what is right and not what is easy…and in Nepal, doing what is right is never easy.

Next week join me for the story about the new paper bead-making project we started on this trip…it will string you along and make you wish for more stories.

The taxi hatch, roof and every inch around me in the backseat is loaded with supplies.

Chitra Pun, the Field Project Manager for Himanchal Education Foundation (HEF), and I spent a few days buying supplies in Pokhara, then set off at 5 am one morning for Nangi. The 3-hour bouncing taxi ride from Pokhara to Beni is a nail bitter with washed out roads, potholes the size of elephants and enough dust to choke a rat. Beni is a classic trading town clogged with huge trucks, cheap Chinese goods and dozens of Nepali men looking for day jobs as porters. There is a

Kali Gandaki river in the foreground as it meets the Myagdi Khola river in Beni. The Kali Gandaki is a holy river as evidenced by the many cremation pyres and burial mounds along the banks. It courses through the deepest gorge in the world just north of this site.

road from Beni to Nangi, but still impassable after the rainy season. I prefer walking and it felt great to start hiking to Nangi…at least for the first 3 hours…the 10 miles isn’t bad…the 5000 feet elevation gain isn’t so friendly.

Along the way we encountered people going up and down the mountains carrying store bought goods and local produce. My favorite sights are the “walking haystacks”. It’s grass-cutting season, when grass is cut, carried in huge baskets and stored for animal feed much like our hay in the USA. All you see are feet walking under mounds of fragrant grass. I’ve tried it…cutting grass with my Nepali friends…the delightful aroma is soon lost to the backbreaking, sweating work of bending over and swinging a small hand-help scythe for hours.

The most astonishing sight was an elderly porter carrying a 19-inch TV set in its box. He had been hired by three women to carry this all the way from Beni to Nangi. He did this using a traditional head strap, called a namlo, which is secured around the box and then worn across the forehead. The extent of his labor was not lost on a single person who watched him trudge a few dozen feet…pause…sigh …and repeat the whole brutal struggle. I shifted my small daypack and decided to stop whimpering for the last two miles.

Walking haystack.

Next week meet you’ll Chitra Pun. He is a man who rides through life much like water in a stream flows around boulders. He is the person who overseas all the projects and activities of HEF and the village. If Mahabir is the brains then Chitra is the brawn…and sweat…and tears.

Kathmandu would be my last stop before leaving Nepal so after arriving at this capitals chaotic international airport, I took a hop, skip and jump to the equally chaotic domestic airport next door and caught a 45-minute flight to Pokhara. Pokhara is a popular tourist city and the beginning of several treks into the Annapurna and western areas of Nepal. Phewa Tal is a lake that anchors the western part of the city and provides fresh fish for the local tourist menus. I never could convince myself to try the native fish in a country where dumping all waste into the local rivers is the accepted sanitation system, but I hear it’s good.

I stayed a few days at Mahabir’s home giving me a chance to visit and interview Ommaya and his daughters Juna and Jharana. Interviewing Ommaya proved the hardest of all the interviews even with Mahabir away in Kathmandu. She is shy, my Nepali is as bad as her English and my questions proved to be a cultural hurdle. We sorted out her demographics and important dates such as when they met, were married and had their first child but esoteric questions such as; “How do you feel about Mahabir being away most of the time?” were met with puzzled looks. It was a way of life for her, it wasn’t an issue and she offered no opinion or answer, as I don’t think she had thought about it. When I asked Mahabir about it, he said, “Nepali women are used to this”, but I am still skeptical and searching for answers from other Nepalese women.

Jharana and Juna Pun.

I spent the most time with Jharana, aged seven. After school she would get her homework and sit on the floor working through her math, reading and social science…all in fluent English. In the evenings she would watch me type emails and correct my spelling…when I pointed out auto correct she frowned and said, “you can’t learn that way, you must look it up!” She had little patience for my poorly pronounced Nepali and would simply shake her head, roll her eyes and repeat the word using her most exasperated schoolteachers voice. It was quickly apparent she favored her father. Juna, aged thirteen, seems more like her mother but I saw little of her because she left for school at 6 am and returned at 7 pm. She would tease Jharana in the only way a big sister can during dinner and like all teenagers she fussed with her hair before having her picture taken.

In the tradition of all Nepalese families this home shelters an extended family of sister-in-laws, brothers, cousins, children and miscellaneous former Nangi students attending college. I am always welcomed, sheltered and fed making it hard to say goodbye the morning I departed for Nangi. Next week please join me for a riot of photographs describing my trek to Nangi.