Kalikot as seen by Dr Amogh Basnyat

These are some of the lines from an article published by dr basnyat in J Family Med Prim Care. 2013 Jul-Sep; 2(3): 218–221 about his experience while working in kalikot district hospital. The impression I got from reading his writing is that time has changed in nepal but not for the doctors. His impression and his writings are more emotional than scientific. His outburst regarding the mismanaged hospital management, pain of being in remote places and lack of support in a lonely environment is clearly evident from his words. Here are some of his words....... "Kalikot is a district located in the mid-western development region of Nepal and is one of the districts of the Karnali zone which is touted as the most backward and underdeveloped region of the whole country. Kalikot was placed in the 72nd position among the 75 districts in terms of its district health office performance in a report issued by the Ministry of Health this year. No doubt, the general health scenario and related public awareness in the area are abysmal." "As in any other district hospital, lack of awareness as to its assets of all kinds and consequently the lack of their maintenance are rampant in this hospital too. Hence, the prevalence of “disuse atrophy” rather than wear and tear due to use is more visible regarding almost each and every biomedical equipment and other devices. It's indeed very disheartening to see the same tendency in terms of the government-supplied drugs as well." "The state of the cleanliness, orderliness, and the measures for the infection prevention are nominal even when described in the most optimistic term. No need to mention that like any other district hospital it's understaffed, underresourced, and too often overexerted. The fact that it's linked to the rest of the country by a highway track that is meagrely a fair weather road and remains clogged throughout the rainy season only makes the matters worse for it. In the majority of these procedures, I have myself provided the SAB. In a few of these, another doctor has done the job. But mostly, I prefer the junior doctor to be assisting me in the surgery rather than looking after the anesthetic part. Usually, a nurse stands by for the anesthetic monitoring. Sometimes, I would have to be operating entirely with the nursing personnel because the other doctor would be out of station. Not forgettable at this point is the fact that operating without suction machine and cautery has become a norm here because neither the landline of electricity nor the generator (which is mostly out of order) is able to handle the extra load. Mostly, I do not even have the “luxury” (?) of having an oxygen concentrator by my patient's side. During bad days, I operate under quarter power solar lamps that look and work more like dinner lights in restaurants rather than properly focussed and powered operating theatre light. Most important of all is the fact that one is able to play the role of a real, complete doctor for an entire community; this is one of the last remaining opportunities left out to be exercised by a quickly vanishing breed of health care providers in the present global scenario. One must feel blessed to be able to exercise all these privileges. Hence, despite whatever dismal conditions I am working under I also have my own reasons for solace." This is how a doctor who is working in such conditions describes his plight and the policy makers just repeat the same dialogues again and again in the comfort of capital of this country that it's doctors who is to blame for not being able to work in remote areas. I believe no single doctor can work in such conditions for a long time. His capacity need to be upgraded, he need to have better facilities and he should be supported with other manpower preferably by another mdgp. Dr basnyat should take the initiative not only to point out the problem but also to formulate the solutions.

nepalishealthy.com: "They died because they were in Okhaldhunga"

nepalishealthy.com: "They died because they were in Okhaldhunga": I stumbled across this blog and was amused reading the first hand account of a doctor , Dr Arbin Joshi, who served in Okhaldhunga. In this p...

........a giant leap for me - from Okhaldhunga to Inverness! I know, to label this as a giant leap, will be an understatement. From Okhaldhunga to Inverness. From basics to luxury. From scarcity to priviledge. From turmoil to smoothness. Perhaps no common thread. In a flicker of second, I can sense the majestic aura of this place called Britain (belayat......thats how we know this place in Nepal). There is answer to every question in this place.......solution to every problem, reason to every action and reaction to everything. People virtually can predict the future, plan their tomorrows and flow with their plannings. They know what future holds for them. Its a programmed country. You know what button to click and what to expect when you press the wrong one. In surgeries, I can see that insides of the human is same all over but not sure, why outsides is so different in these two places. Worries are different. In okhaldhunga people worry about their food, security, future, rain, conflict, disease, transport and lots of other things that people in inverness must have never thought of. This place never stop surpring me as i see people worrying about their holidays, gadgettes, systems, services, benefits, weekends, relations and yes, lots of other things that people in okhaldhunga must have never dreamt of. It must have taken years of hardship, loads of wealth and galaxy of thoughts to build a country like this. I can see people still contributing to maintain what they already have. I have seen them worship their work. Some little change they bring in the place they live, site they work and environment they breathe when put together forms a different world for themselves. We have a long long way to go...... okhaldhunga to Nepal is just like inverness to United Kingdom. No clue at what point people in okhaldhunga or similar places in Nepal should start to bring the changes. Probaly a to-do-list or a flowchart might bring things in order..........otherwise where there are too many things to cook and too many cooks, you can imagine what the broth will taste like.

“you are paid for this, doctor”

“you are paid for this, doctor”

I knew I won’t be able to work my whole life in okhaldhunga. That was the reason I thought I should inspire other young doctors (GP residents who used to come to Okhaldhunga for 5 months for their rural postings) so that may be they will decide to work in rural regions at least for certain time in their career. I thought I was inspiring people, the way some people have inspired me in my early career………….

Inspiration has no limit. We might get inspired from any thing, from anyone and at anytime of our lives. This sounds funny, but I was once inspired by a character played by Shaharukh Khan (popular Bollywood actor) in a movie called ‘Swadesh’. It was definitely not the most successful movie he has acted but the character of a scientist working in NASA gets moved so much while he witnesses the plight of the villagers living in his abandoned country India, that he decides to return to India and work in the place where he has grown up (needless to mention, his new-found love in India also plays a role to hold him back to India). This sophisticated young aspiring scientist gets a jolt of his life when he has to leave his equipped wagon and has to travel in a passenger boat in the heat of the sun in a rural India. I suppose he gets to see ‘hungry’ people for the first time in his life and may be he understand the real meaning of hunger at that time when the poor farmer, exhibiting his bare body with just skin and ribs, requests him not to take the food out of his children’s tummy by asking to pay the debts.

I happened to read the book called ‘microsoft dekhi bahun danda samma’ (a nepali translation of Leaving Microsoft to change the world). It is really heart warming to know that people when gets determined can really change the world. It is actually very diffcult to bring any change in people’s life. In fact, I really don’t know how much change ‘Room to Read’ (organization formed by John Wood) brought in the lives of children in Nepal but it was definitely a good thought. The fact that an Aussie working in US has come to our country with loads of books just because our school in Bahun danda was lacking books in the library is, for me, a matter of shame to us. This book has really dared to capture an important moment in Wood’s life that really changed the whole course of many lives and he has well expressed the thoughts boiling in his heart. I wish I had written that book.

I had the similar feeling when I read another book called ‘Hospital at the end of the world’ written by a male nurse Joe who was volunteering at Tansen Hospital when I worked there. I was convinced that whatever little things we do in our lives if brings a better changes in other people’s lives we should go ahead with it.

_______________________________
I failed to be another John Wood and I apologized Okhlahdunga for that.
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But one day…… in okhaldhunga hospital, some politically motivated bigwigs from okhaldhunga gathered to solve an issue in the hospital. We were trying our best to make them understand that we are also working there in a difficult situation and detrimental remark about the hospital actually lowers our moral. But a self-acclaimed ‘i-know-it-all’ type of teacher from Rumjatar School told us not to glorify what we were doing in the hospital. He further added all the things I did in Okhaldhunga is just because I was paid to do that…….

I thought I was inspiring people, I thought I was trying to make a small change towards a brighter future of my country. But the incident made me realize that I was actually paid to do whatever I was doing. And I should not do more than what I was asked to do. I failed to be another John Wood and I apologized Okhlahdunga for that. That day I told my wife that we should look for another places where they pay us more……..And there were plenty of them.

Technology???

Technology???
…….after spending five years in rural Nepal ( three years as a resident and two years as a GP), it is difficult for me to decide whether I love or hate the technologies. In all these five years I have seen people being fixed purely by human efforts. Clinical judgment was the best available technology we had in those areas. After coming back to Kathmandu and in the course of my surgical training, it came as a frightening knowledge for me to see how people depended heavily on technologies. Clinical knowhow is placed at the backseat and major decisions are made solely depending on technologies like lab reports or CT Scans or sometime on Histopathology reports. All the hotshot doctors are seen boasting about the piece of surgical gazettes they possess or they had witnessed during their foreign tours. Three chip laparoscopic cameras, Harmonic scalpels and single hole laparoscopic instruments are marketed in the lavish auditorium of five star hotels followed by equally lavish cocktail dinners as if they are here to create a permanent solution to all the health problems of this country. Laser surgeries are advertised and congratulated in the papers in such a way that it looks like they have achieved the Millenium Development Goals. This is the unfortunate picture of all developing countries where solutions for the problems of the poor dying population of the country are searched in the comfort of the capital city amidst the so-called ‘cocktail dinners’.

One of my Australian friend in one of such program declared ‘this cannot be considered a developing country!’ He had just seen an elite jet-set local businessman rushing towards his health club and talking about holidays in one of the resorts in Pattaya over his cell phone in the hotel lobby. This Australian friend of mine, who worked as a doctor, in a rural Nepal for five years, when met some of the Nepalese doctors in a conference, was dead surprised to know how these urban doctors were divorced from the harsh reality of their surroundings and its health conditions. He had a good laugh when same people delivered lectures on making primary health care accessible to the rural population of Nepal. That is the sad picture of Nepal. How our policymakers are supposed to realize the agony of the people scrounging for food and clothing, lacking basics like safe drinking water or sanitation, for whom primary health care is an unknown luxury.

When we talk about transplants and bypass surgeries, I think about the woman who lost her life because there were noone to attend her obstructed labour. This discrepancy in health care is inevitable when we cannot prioritize our needs. On one hand, we know that our crying health needs are drinking water, sanitation, public health and preventive medicine and our prime problems are rampant malnutrition, malaria, tuberculosis and infections. On the other hand, there is so much enormous pressure from the healthcare industry of the developed countries to sell their products in the name of ‘development’, it is almost impossible to resist this temptation. Laparoscopic surgery and recently Laser surgeries are the end products of such pressures. Dr Udwadia, who introduced laparoscopic surgery in India, stated in one of his book that sadly but inevitably the true picture of the developing world is a varied tapestry of all these perceptions with every gradation of inequality and deprivation in between. In contrast, Dr PK Sen who pioneered cardiac surgery in India lambasted those regressive minds and said ‘there are sanctimonious do-gooders who never accomplish anything, who will fight any form of medical progress as an expression of sympathy for the poor.’ He added ‘if we were to wait till everyone had water and sanitation, it is very possible we will have neither drinking water nor surgical progress’. What he said in 1957 is worth thinking over today. What we need at this hour of transition is to strike a balance between technology and basic need of a typical developing country.

That is the reason why, at this stage I am not sure whether I should welcome technology or denounce it. These technologies should not make poor more poorer in the name of advancement. Laparoscopic surgery is of course ‘the’ example of technology with the potential ‘usefulness’ for the whole country, as far as, patient convenience is concerned and already there are few laparoscopic centres in rural Nepal. But single hole laparoscopy or natural orifice laparoscopy, for me, is total absurd. Following the principle of ‘Cutting edge advances should be made available to all people at all places’, we should look for technologies that might serve the rural population too. Telemedicine, CDMA phones, ropeways are few examples that might bring change to new Nepal. Mahabir pun type of information technology, Grameen Bank – a Bangladeshi bank of microfinance that won Nobel Prize to its founder, our own –aafno gaon aafai banaun type of campaign, government subsidy for the small hydropower projects are already few examples that had worked wonder to the rural development. Internet connection backed by solar power, DS Manandhar incubator – a Nepal made incubator to keep newborns, alternative power solutions like Gober (cow-dung) gases, ‘sudhariyako chulho – gasless stoves and maternal waiting homes –place where pregnant women are kept to avoid complications are all examples of our-soil-friendly technologies. There are other uncountable examples where technology has crossed lines with rural development. These technologies rarely catch our attention in such ‘cocktail dinners’. Rural friendly technologies, no matter whether they are locally made or imported, should be declared ‘creams’ and all other ‘craps’.

Why........why..........why

Why…why…why…

This is, in fact, a million dollar question??? Why doctors do not come to places like Okhaldhunga? Why doctors always want to stay in big cities? Man is always accused of being hungry for facilities. They are ‘subidhabhogi’. But in none other profession, they are blamed for being ‘subidhabhogi’ as much as they do in medical profession. Doctors are, basically, seen as if they are supposed to be a social worker, a ‘sacrificer’, a ‘giver’, a noble human; in short doctors are supposed to be a ‘fool!’ (…….like me!).

One of my colleague rightly said about this issue of retention of doctors in remote places that there is always a ‘push’ factor and a ‘pull factor’. Let’s talk about the ‘pull’ factor of Okhaldhunga. Hmmmmm……I really can’t think about the real ‘pull’ factor of Okhaldhunga. When a learned man asked me why doctors don’t want to come to Okhaldhunga, I asked him back ‘what is there in Okhaldhunga that other places don’t have?’. He had no answer to that. Then I told him I can count hundred things that other places have that Okhaldhunga don’t have. Yes, money could be one of the real ‘pull’ factor for Okhaldhunga. People might come here for money. Money can do wonders but at the same time, money can not do everything. Yes, it is true money might recruit doctors here but, I am sure, it cannot retain them here. Sometime, accidentally if an exceptional doctor comes here to work here, with a zeal of doing something, he will definitely get an hernia trying to move the world. All his enthusiasm will bite the dust once he faces the stubborn ground realities about the life in remote places.

Now, I will list you the ‘push’ factors of Okhaldhunga that pushes the doctors away from this place. The attitude of the people tops the list. You save thousands of lives, people will take you as granted and they will say, it was your duty. They are right. It’s our duty. But suppose if you fail to save just a single life, they will say the patient died because of you, because of your inability and because of your carelessness. In the recent past, lots of such incidents have occurred in different regions of Nepal, accusing the doctors about their carelessness. Hospitals have paid thousands of rupees to sweep the issue inside the carpets. Careers of the aspiring doctors have received a tragic jolt because of such incidents. In my entire medical career, when my patients died, I had never been told by the patient party ‘Doctor! It’s ok. You tried your best’. I was once dragged by an agitated man in Okhaldhunga to bring back his just died father to life. (I know that is the usual first response of a bereaved family member and I am not sure, I might have done the same thing if that had happened to me). What I personally feel is that, doctors are actually entitled to care not cure. They are here to reduce the pain, to put you in ease and to minimize the misery you are in. And I can guarantee no doctor ever will do anything that will harm the patients. But in reverse, doctors are, in their view, entitled to do the magic, cure the disease and save lives. Such attitude pushes doctors away from this place.