Image, Event

October of this year, we visited the Norman Rockwell Museum in Stockbridge, Massachusetts. This painting by Howard Pyle gripped my attention. With a sheer force, it thrust my imagination to the horror of the situation. At arm's length, these men are facing each other. Another man of flesh and blood. Horses neighing, alarmed by the clamor, perhaps injured already by whips of terrified master and sharp bayonets of master's enemies. At this proximity, these men perhaps see their enemies' eyes, face. How do they lift their sharp swords or pointed bayonets and shove it into another man's throat or chest or belly? Whoever plants the sword to another's chest must be numb with an overwhelming force. The stabbed one must be terrified as the darkness replaces the light of life. Those who have not yet planted a sword or been stabbed must be scared, terrified, uncertain. This is a feeling of undescribable anguish, horror and terror. 

It is an image that incites an imagination about the event. 

In the past few days, the world has been subjected to an event, that incites an even terrifying image of horror. A young woman in Delhi is lured into a bus along with her boyfriend. Six men assault them with iron rods, rape the girl, and throw them out of the bus stripped naked and unconscious. We learn today that the girl died.  

Who are these men? These six men. How did they decide they will take a bus down the road, lure a woman, rape her, and kill her? What must have happened in that bus? Six lustful evils preying upon a woman. There must have been shrieks, cries, moans. How did these evils' eyes look when they impaled the  helpless woman's belly with an iron rod? This is an image of horror, pure horror. 

Faulty Analysis

Republica had published an editorial regarding failure rates of medical students at Nepal Medical Council (NMC)'s licensing examination. A little irked by shallow analysis I had sent a tad sharp comment online. They decided to give it a space on print edition the next day: 

The licensing exam failure rate of students who went to medical schools in certain countries, namely, China, Russia, is high. I have heard the argument of requiring students planning medical school overseas pass Kathmandu University's medical entrance examination tests, at varied platforms. It might add some safety by helping select qualified individuals, especially if the exam is standardized to test qualities that determine a good doctor (and not just knowledge, as is done now). However, even if this has any significance, it will perhaps be minuscule. The main action will be in what the student gets in her 5 years of medical school. Until we think about assuring a basic minimal quality in those 5 years, any other efforts will be trials with high chances of failure. 

But what we can do immediately is build mechanisms to rehabilitate these individuals who are doing poorly in the licensing exams. For example, we could require anyone who fails twice consecutively to do 2 years of rotating internships at selected academic institutions in Nepal before they can apply for the license. All who fail, either they have done medical school in Nepal or overseas, should be treated the same. This exercise of demonizing students from select countries is a form of bigotry that lumps all grades of students together. It is unfair to diligent students from those places. And it is ultimately going to serve no good. Even these poorly-trained students  have already spent a fortune and ripe youth at these institutions. They are ultimately an asset to health manpower-deprived country. We need to find ways to remedy their deficiencies and give them a proper place where they can  contribute to the care of sick and infirm of this nation.   

A Squatter Settlement

There is a squatter settlement in Maharajgunj, just behind the staff quarter of Institute of Medicine. On my way to and from work, I sometimes take the way through this settlement. There is something about this settlement that gives a positive vibe. 

It is a crowded place. In a narrow strip of sharply inclining land, it is a motley of shanty houses and few sturdier ones separated by tight alleys. A loud whisper is perhaps audible to the settler's neighbor. Wandering chickens and ducks in these alleys, I am sure, find treats at several of the owner's neighbors. 

But this settlement seems cool about the sardined living conditions. In these narrow empty spaces, which are neatly stone-paved, children are jovially playing badminton and hoola hoops. Adult males are engrossed in several groups of carrom board games, back from work and winding down or unemployed and killing time, I do not know. 

Furthermore, the organization of the limited space is quite impressive. All the alleys are paved with concrete. In the slope, there are neat concrete steps in the alleys gyrating down the hill. At the bottom of the settlement, there is a remnant of river, which now flows with sewage composed primarily of  nearby city dwellers' excrement. They have managed to cover the river completely with concrete structure so that the filth is hidden. The only evidence of that horror is the open river, just before the squatter settlement starts. This open disgust snakes up the non-squatters settlement, malodorous and ugly. It seems like no one cares in those turfs. 

 

Compared to the non-squatters, somehow, these people appear to have been able to do something of common good. It is obvious that they have been able to organize things around them. These narrow alleys are clean, they have common space to play, a big water tank with a tap stands upright at about the center of the settlement that everyone can come to collect water, a filthy open sewage is covered throughout the settlement. 

How have they been able to do it? Did some donor do it for them? I doubt it. Are they unified by common predicament that is driving them to work together for common good? Are they unified at all? If so, what is bringing them together? It does look like development. And what does it tell about our constant whining about the lack of funds for development in our communities?

These are some of the questions which a physician who deals with rotten/rotting/degenerating/broken body is perhaps ill-equipped to answer. But the distinction from indifferent settlements surrounding this squatter settlement can not escape his attention. 

Empiric Treatment

She came with her father-in-law. Wasted and pale, she looked withdrawn, dejected, and lethargic. They were from a village in Kavrepalanchowk. Her husband was away for a labor job in a Gulf country. For the past several months, she was having fevers, poor appetite. As it became disabling, she came to our hospital and was admitted for evaluation. Her fevers persisted. The only clue to her disease was the finding of an enlarged spleen. But several diseases can cause enlarged spleen. Even after several days of hospital stay, multitudes of non-invasive and invasive tests, a cause could not be pinpointed. So our hospital team decided to discharge her from the hospital and have the results followed-up as outpatient.

As outpatient, she had several more visits and a battery of additional tests. Her fevers persisted. On this visit, they came with the results of all these tests. I went through each of these tests. They were essentially normal, one after another. I told them that these tests did not tell us what was making her febrile.

At this stage, her father-in-law entered the pleading mode. Help us, please. We have exhausted our money in quest for the cause of the fever. Almost 40,000 rupees have been spent so far. We have been staying in a hotel to have these tests done and fevers haven't budged. We can not afford to stay longer. What are we to do?

Fever is not an endocrinologist's forte. On top of that, one trained in North America. In these shores, where shit infuses drinking water, cattle and humans share abode, almost infinite souls share a crammed room breathing each other's exhaled air, flies cruise feces and foods, mosquitoes camp between man and animals, weirdest of the bugs can cause weirdest of the fevers. A specific diagnosis is a mammoth challenge. Furthermore, my patient is in desperate financial predicament. Any further testing would be adding salt to their sores. What am I to do?

Many of my patients who come with fever also have tight purses, limiting exhaustive investigations. In desperate attempt to deal with these fevers, I have developed my own way of looking at fevers. The way I see it is, what treatment are these fevers most likely to respond to. For this, I put them in broad categories. Are they, for example: 
- Feces fever (caused by microorganisms found in feces)
- Viral fever
- TB
- Tarai fever (caused by several parasites)
- Non-infectious fever, etc. 
Another big category I have invented is doxycycline fever. This pseudo-scientific category includes a whole bunch of fevers caused by atypical organisms that respond to an antibiotic called doxycycline.  

After talking to the patient and examining her, I tentatively put this patient as having doxycycline fever. But as you may guess by my wobbly expertise on fevers, I can never be confident. What if this patient deteriorates? There is every likelihood that I will never see this patient, even if this patient is visiting my hospital everyday, just because of the way disorganization works here. Patients bounce back and forth between departments without someone taking up a responsibility. If she goes home, which she is highly likely to do because of financial issues, who knows what happens in some remote corner of Kavrepalanchowk? So I asked them if they have cell phones. Both the father-in-law and my patient had cell phones. I took their numbers and explained to them that I want to try a medication which she can take at home. I told them they have to come to the emergency room if fevers do not go away in 1 week. Otherwise, I will call them in 2 weeks. I put a diagnosis of ?Brucellosis on my chart and prescribed her doxycycline. 

At 2 weeks, I called her. She sounded perked up, and rather overwhelmed that I called. She said she was doing very well. Fevers were gone, her appetite was up, she felt that she was back to her normal. 

It was a big relief. Based on the results, this might sound like a wise decision but it is hardly that clear at the time of decision making. We call this empiric treatment. A treatment decision made based on hunches without hard evidences. Especially in academic setup, like the one I work at, this is frowned upon. Primarily because we see patients everyday who are indiscriminately put on many medications without compelling reasons. We emphasize to our students and trainees that there should be evidences and compelling reasons to make treatment decisions. 

Yet, when you face social and financial constraints to do expensive investigations you will have to make decisions on empiric treatments based on your clinical judgement. It is a fine balance of how much to investigate and when to treat empirically. For short term illnesses like these febrile illnesses, I am getting much more inclined towards empiric treatments. It's hardly relevant to the patient if the fever was caused by Brucella or Leptospira or Mycoplasma. If the fever goes away and they can get along with their normal lives, structure of the cell membranes of these micro-organisms hardly disturbs their dreams.

As everything else in life, diseases do not always submit to clarity. This demands for an approach which is equally fuzzy. Perhaps this is when the realm of the art of medicine starts. 

Horrid Butchery

Samuel Gross, a trauma surgeon from the 19th century, had this opinion about thyroid surgery: Horrid Butchery. Thyroid is a very important gland in the lower part of the neck. Several maladies can ail this organ. Some of which, for example, cancer, require surgical treatment. But this gland is enmeshed with blood vessels; there are precarious nerves, large blood vessels, tiny but important glands, and airway in vicinity which make surgery quite tricky. From 19th century's Horrid Butchery, this operation has evolved to quite a safe surgery in trained hands. But risks are still substantial, especially if the operator is not well-versed and surgical safety protocols are not properly followed. Where I trained, we had national pioneers in endocrine surgery, and we endocrinologists felt safe to send our patients for surgery at a relatively low threshold if there was a reasonable indication for surgery. But I have had to leash my natural inclinations for my lack of sufficient knowledge about available expertise and facility for thyroid surgery in Nepal. I remind myself, this was once a Horrid Butchery, until I get a good confidence about our surgeons I will send patients to surgery only as a last resort. 

At clinic today, an intern came up to me to discuss a patient that she was seeing. The patient was sent to medical clinic from surgical department to get blood sugars controlled before surgery. This was a 69 year old woman from Saptari. She noticed some pain in the neck nearly 6 months back. When evaluated at Biratnagar, she also got an ultrasound of the neck which showed two small swellings in the thyroid gland. They biopsied these swellings. There was no evidence of cancer. She was given thyroid hormone with an idea that it may help shrink these swellings. But she continued to have some vague pain in the neck and was referred to Kathmandu for further evaluation. 

At Kathmandu, she underwent a repeat imaging of the thyroid gland which again showed those same swellings. One was described as complex (had areas of fluids separated by solid tissues) another was less than a centimeter in size. The radiologist, reported it as having a possibility of cancer based on the "complex lesion" and that it needed a biopsy for evaluation. She underwent a biopsy of these swellings: this did not have enough tissue to make a diagnosis. On the repeat biopsy, it was reported as not having any evidence of cancer. But the surgeon who saw the patient was worried about the report of possibility of cancer on imaging studies. So he decided to have patient undergo surgery. She was admitted to the hospital. But her blood sugars were out of control. Surgeons hesitate to operate when blood sugars are high because it increases the risk of wound complications. They consulted medical team. Medical team started her on insulin but blood sugars were still not controlled and surgery was cancelled. She was transferred to medical ward for blood sugar control and after a few days, since her sugars were still not controlled, discharged home with instructions to follow-up at OPD to adjust insulin dose gradually. 

Having been trained in the problems of thyroid, I looked at each of these investigations. The description of the "complex nodule" and also the printed pictures of the nodule was something called "spongiform nodule." For the size of the nodule that the patient had, it is recommended not even to biopsy spongiform nodules because the risk of this being cancer is very low (99.7% of these nodules are not cancers). So the radiologist had over-called the finding. The surgeon relied on a misleading interpretation. By this time, the patient had spent several days away from home in Kathmandu, many of those in hospital bed, scared she had a neck cancer, ready to have neck slit open, forget about the rupees than vanquished in this anguish. 

So what do I tell her? 

I explained to her what I thought of her problems and investigations so far and that her chances of having cancer is extremely low. I told her, if I were her or she was my mother, I would not have the surgery. She looked very relieved by this conversation. But she did ask, "Why did I have to go through all of  this?"

I do not know. I can not put blame on any one person. Radiologist over-called it, but it was not a mistake. They try to be safe than sorry. You do not want to miss a cancer but in this process you have some false positives. Surgeon was also not wrong to plan to take out the gland for a concerning radiology report. But what patient went through was a real hassle and a real risk. 

For me, this has been a lesson. A lesson in the backdrop of the debate on specialization. There is a rigorous debate about patient outcomes and specialty care. Studies are divided, some studies show patient outcomes are better with specialist care. Others show equally good or better, yet cost-effective care by generalists. So there are believers in specialist care and proponents of generalist care. Although I am a specialist, I have had warm feelings for generalist care. Especially in the context of resource poor Nepal. That is one of the reason I have been doing more of internal medicine at this public hospital, than my specialty of endocrinology. Besides, our public healthcare systems are so rudimentary and rooted in crisis mode (doing patch work for crises that come along) it just does not seem conducive for specialty care. 

However, with the event like above, it seems to me that specialist care will be profoundly important for Nepal. What this patient went through was a totally unnecessary hassle with an incredibly high risk. It could have been prevented if a trained endocrinologist had at one time evaluated the patient. It is not the same Nepal, from 8 years ago when we finished our medical schools. At 4000 rupees you can now get a CT scan and it seems like there are more Nepalis now who find paying few thousands of rupees not a very big deal. Multinational laboratory chains have made it possible to get any lab test you want done for few extra bucks. The volume of investigations patients go through is astounding. Perhaps done unnecessarily many a times, driven by profit motives, in many of these for-profit institutions and private practices where they get financial remuneration for ordering lab works. Accordingly, complexity of information available on the patient's illnesses and lab findings is growing massively. This gives an opening for misinterpretation of these lab and investigations results. There has to be someone who can focus on specific areas and build expertise to interpret these complex results.

Study data on specialists vs. generalists may be one thing, but when I think about this patient, and ask myself, instead of me if any other endocrinologist had seen this patient, would they have prevented this hassle and risk? The answer is a solid yes. These are basic stuff in our training. 

There must be several other patients who are getting their sugars controlled right now. They will undergo a Horrid Butchery with splendid sugar levels. Knowing that these patients did indeed need surgery would be nice. Wouldn't it?

Manufactured Success

"Kidney transplantation at Bir Hospital is world-class," declared an article in Kantipur. Perhaps elated by this apparent achievement, it even published an editorial praising the success. 

Great!

It sounded like something to celebrate. Especially when we are working in such resource-poor setting with several limitations. Such success should be morale-lifting for anyone working in the field. 

But the news sounded too good to be true to me. Primarily because of extremely sloppy care my patients had received when I sent few with advanced kidney disease to the same folks that tout these results. My earlier sympathy for a fellow public institution has faded and I have stopped sending them patients.

Are they doing such superb job? Maybe I had misunderstood them. I do not have access to their original data. But going by what data have been given in these newspaper articles, it does not actually look very celebratory. 

The only data that I could make sense of was transplant rejection rate. It says Bir's kidney transplant rejection rate is 11% compared to global average of 20%.  I assume this is annual graft rejection (the transplant program seems to be just 4 years old to give a longer-term outcome. And 20% global outcome data is for 1 year graft rejection rate based on my non-expert search of web. The range was actually 10-20%). 

All these transplants are living donor kidney transplants. So the 1 year graft survival rate is 89% for Bir's program. Corresponding data for whole of the US is 96%. This seems to be a huge difference from a claim of world-class outcomes. Perhaps it could be claimed that Bir's outcomes approach that of global average. But being closer to global average does not mean being a "world-class" in the usual sense of the word. All this hoo-ha appears to be self-congratulatory chest-thumping from statistical white lies. 

While it may be very healthy to celebrate success, however small, this propensity to manufacture delusions to feel good might be rather detrimental. From what I see everyday working at a public hospital, humility and self-reflection to rectify and improve our dismal healthcare delivery system is more important than ego quenching from such manufactured successes.  

Bags of Medications

The way health care operates at public hospitals in Nepal offers very little opportunity for outcomes based improvement. We do episodic cares. If the patient is admitted to the hospital, care is targeted to the acute illness. Once the patient leaves hospital, fate alone determines if you will see this patient ever again. On the outpatient care, where a long-term patient follow-up should be the rule, our clinics are so disorganized, patient hardly ever sees the same doctor on subsequent follow ups. In essence, our outpatient care is also episodic. So our doctors rarely get to see the outcomes of their deeds. While it deprives the doctors an opportunity to improve based on outcomes, provide continuity of care to the patient, I think it also contributes to an epidemic of of cocksure, megalomaniac doctors with god complex in our society.

Unfortunately, heroic enunciation of a well-read doctor does not seem to be enough for a good patient outcome. Well-written prescription alone does not suffice. Small detail can make a huge difference. I am witness to these differences as I see patients everyday at the outpatient clinic. 

I so often see patients with heart failure who come to the clinic bloated and breathless. They have been off medications for several days to weeks. When asked why they were off medications for so long, they say they ran out of medications they got at the last visit and they were not due for next visit until now. I am surprised by how often they think medications outside Patan Hospital don't work and that they can get medications at local pharmacies by showing their current medications without a prescription. A simple conversation would have perhaps helped. 

This demands of a thoughtful doctor. But that might be the next level. More concerning is the plethora of medication error. Sometimes a medication is missing. At others, a medication that was started for short-term is being continued indefinitely for no good reason. Unable to trust what is written in the charts, these days I have made a habit of asking patients to pull out their medications and tell me what they are doing with each of them. Some of what comes out of this exercise, while exasperating, is also heart-wrenching. 

For a large number of patients with breathing problems we use medications that are inhaled. The types we commonly use in Nepal come in hard capsules. Patient has to put the capsule in a device which twists and breaks them releasing medications to inhale. The patient I had the other day was from somewhere remote. She was breathless and cachectic. As I unpacked her plastic bag with medications, the twisting device was nowhere to be found. But she did have those breathing capsules.

Are you taking these medications? Yes. How? I am eating them in the morning and the evening. 

She had no idea that these medications were to be inhaled using a separate device. It is not just errors that I have encountered during these bag inspections, some are moving improvisations family do trying to help their loved ones. 

A mother-daughter duo from remote Nepal came to me a few days back. The mother had liver failure from excessive alcohol use. In addition to medications, we had instructed her to  absolutely abstain from alcohol. As I was going through her medications one by one, at the end, her daughter also pulled out a Mountain Dew bottle. She was boiling Mountain Dew and giving it to her mother in hopes that it will satisfy her cravings for alcohol. 

 The simplicity of our patients begs for aggressive meticulousness from our doctors. 

Patan Hospital Protests Updates: A Mess

The Prime Minister, also the chancellor of Patan Academy of Health Sciences (PAHS), decided to suspend the newly appointed vice-chancellor of PAHS. He reversed his decision [ultimately he is the one who appointed this controversial vice-chancellor (VC)].

But the tale does not find its coup de grace there.  This VC has decided she wants to fight back legally. We are told she is taking help of some star lawyers. The court has given a stay order. So the sacked VC is officially still our VC. 

With this, we have officially joined the typical mess our larger political system is in. In this mess, a rich philosophical discourse can be conducted in purely technical/philosophical terms about what is right and what is wrong. 

In the court, perhaps an intense debate will happen. Who is right? Who is wrong? What is right? What is wrong? What are the evidences?

But for a novice physician like me, who saw an overnight transformation in energy and work ethics of care providers in the hospital from a political appointment, fundamental questions will be: Why did it happen? What did it do? 

High-Rises

High-rise buildings like the one in the middle of the picture are growing in this city. Amid the shabby concrete houses of this city, their grandeur stands out. When the darkness of the night wraps the valley, unruffled by our perpetual load shedding, these buildings glow with lights perhaps generated by backup power systems. The contrast at night is sharper. They are the survivors in this city where night favors darkness.

They must be the lucky ones who get to live in these buildings: ones who do not have to depend on the electricity that the national power grid supplies. The power grid that is raped by scarcity, incompetence, corruption and ruthlessness. I hear you have to pay millions of rupees to buy these apartments. But if you own that fortune, you do get a chance to escape the darkness of this city.

These glowing buildings at night are the epitome of power structures in Nepal.

If you have enough money, you get uninterrupted electricity (fair enough) and water . If you know somebody at a public hospital, you do not have to wait in line to be seen. But be prepared to let those people in front of you, even if you have waited in line since early morning, if you are a nobody. Hospital beds can be emptied if you hold some power (political office, connections,... you know it). But be prepared to be shoved out to another hospital if you are a nobody. Even if you are paying a substantial sum, do not expect to get a reciprocal quality of care if you are a nobody, either at public hospital or private ones. Be prepared for endless tomorrows to meet the government regulatory requirements if you are a nobody but everything can be done from home if you are in the power structure. 

Let me give you an example: our government gives a subsidy for hemodialysis to patients who have kidney failure. For that, they ask you to get photocopies of citizenship certificate, few passsport-sized photographs and a statement from VDC stating that you need financial assistance. If you are an illiterate peasant from Sankhuwasava, imagine your ordeal. Do you have a citizenship certificate at the first place? How are you going to go to Sankhuwasava to get a VDC statement while you are lying breathless in a public hospital floor? But if you are a local political somebody, you will make a call to the VDC secretary on his mobile phone and have a villager hand-carry the letter to you the next day.  

I get a sense that the plight of powerless is growing. Our government is growing and so are the ones with access to power. Our intellectuals have run out of imagination, their only solution to all of our woes is additional regulation. Our oligarchs are ecstatic about bringing any new regulation. It creates an opportunity to exercise power and extort money. In this game, ease for those with power is still secured but life for the regular folks becomes tougher. 

It seems to me incompetence of our institutions is a bigger issue than a lack of elaborate regulation. Unfortunately, our incompetence and corruption is growing and these institutions are getting larger.

Stones

In my relatively rare taxi rides, I have found our taxi drivers chatty, in a good way: an unusual attribute for our service providers. This might be just a coincidence or perhaps they are primed by potential return in tips by this exhalational exercise of vocal cords.

Today's was a master of them all. His oration that spanned a ride from Tripureshwor to Maharajgunj would have convinced a novice that this bloke was the most knowledgeable person in the area of kidney stones.  Let me summarize:

Our conversation started with me pointing out dust in the air that was made more apparent by the bright car lights at night. You know, he began, the dust can make kidney stones. It makes 10% stones. If you live in Kathmandu enough, with all this dust, you are bound to have kidney stones. The smoke, chewing tobacco, all of them get deposited slowly and make kidney stones. Tomato is the most notorious one, it makes 50% stones. Another one is palung (spinach) that makes 20% stones. I learned all of this from a book that a bideshi (foreigner) gave. 

Was it in English? I ask. 

Yes, he says, it was both in English and Nepali. 

You need to drink 5 liters of water after each meal not to have kidney stones. Stone is a huge, huge problem he perseveres. 

Have you had a kidney stone? I ask. 

Yes, he says, himself and his wife. His wife got operated 2 days back for a kidney stone. It was this big, he shows me with his fingers. I used this same taxi to bring her back home from Dhulikhel Hospital yesterday, he declares. Then he veers off to a lengthy praise of Dhulikhel hospital; how they did operation with a total cost of Rs. 23,404 when at private hospitals they were estimating Rs. 150,000........

Risks, Benefits and Trust

In a heart condition called atrial fibrillation, electrical activity in the upper chamber of the heart goes haywire. The squiggly muscle contraction generated does not pump blood effectively. Resulting blood stasis predisposes these patients to blood clots which can break off and reach the brain causing stroke. In these patients with atrial fibrillation, you may be able to prevent stroke by using blood thinning medications. One of these, aspirin, does so by reducing stickiness of platelets which have a major role in clot formation. It generally has low risk of bleeding and does not need monitoring blood tests. Another medication, warfarin, does so by reducing chemical substances involved in clot formation. Warfarin carries a significant risk of bleeding, especially with injuries, and a blood test has to be done regularly to ensure a safe dose of warfarin. Warfarin is more effective than aspirin for reducing the chances of clot (and stroke) while there is a higher risk of bleeding. 

Which one do you choose?

It is a complicated decision. Not everyone has the same risk of stroke with atrial fibrillation. So a risk-benefit assessment is employed. In lower risk patients aspirin is preferred while warfarin is used in higher risk patients. It turns out age and certain comorbidities accurately determine risk. In clinical practice, there is a scoring system called CHADS2 which gives certain points for these characteristics and overall score is used for treatment decision:
    Score 0: Give nothing or aspirin
    Score 1: Use aspirin or warfarin
    Score 2-6: Use warfarin
Let's say my patient scores 2. Untreated, the annual risk of stroke is 4%. Aspirin use reduces annual risk to 2.5% and warfarin to 2%. Is warfarin use a risk worth taking for 0.5% risk reduction? Does the study that came up with these results take into consideration peculiar circumstances of my patients: bumpy roads where you routinely levitate few inches out of your seats stretching blood vessels in the brain, need to climb trees to fetch fodder for cattles, availability of money to do blood tests, availability of blood tests nearby,...the list goes on. All these factors make warfarin a risky choice because of increased likelihood of life threatening bleeds. But is the risk justified for the benefits? 

If this exercise has been confusing, it indeed is. You hope and pray your doctor has done this exercise for you. 

I do routinely see atrial fibrillation patients taking warfarin at my hospital's outpatient clinic. When I ask them why they are on it, many of them answer their doctor asked them to take it or they were discharged with this medication after the hospital admission. They faithfully do blood test (which is required every 2 weeks many a time) and come for warfarin dose adjustment. If you allow, I would venture a guess that my patients have no idea about above risk-benefit calculation (if it has ever been done). But they are doing it because their doctor told them to, that it may be good for their well-being and longevity. 

This is just an example. Our clinics abound with patients suffering from non-communicable chronic illnesses. The treatment decisions entail risk-benefit calculations. What is the potential long-term benefit? What are the potential risks? These are more or less abstract notions both for patients and doctors but especially for patients. A patient with high blood pressures is treated to reduce the risk of heart attack, stroke, in future. Why should one agree to take medications daily for something that one cannot feel? What are these patients actually taking medications for? Are they calculating their risks? Many of my patients don't even know that high blood pressures can increase the risk of heart attack. They have been taking medications because they reduce the blood pressures to normal values. How did these abstract notions about benefits of normalizing blood pressures come? Is it a transmitted knowledge from others experiences? Is it a transmitted notion of benefits of their doctors?

Whatever it is, it expresses as a faith  in doctor's recommendation in my day-to-day patients. However much we hear about increasing lack of trust between doctor and patient in our debates,  in daily doctor-patient interactions, most of the decisions are done by reflexive trust of patients to their doctors. When I think about it, as a doctor, it is an overwhelming responsibility, to deliver to that trust. 

Especially humbling in the setup I work is the fact that our power structure is oblivious about this responsibility. Rather, I sense a feeling of entitlement among us doctors and administrators who hold the power. It is not uncommon to hear, in one of our grand eloquence, that the root of the problem in several of our disorganized institutions is illiterate, irresponsible janata (people) behaving haphazardly. We can elaborate on every solution that does not involve ourselves.  As I see a swathe of patients navigating the torturous disorganization of a public hospital just to see a doctor who will tweak their cholesterol medications, I have been increasingly disillusioned about the idea that our patients are illiterate. It is time that our doctors be literate.  

Article

This article might be of interest regarding emigration/retention of Nepalese doctors: 
http://www.bmj.com/content/345/bmj.e4826

Public Transport in Kathmandu

If you have been used to thinking yourself as a dignified individual, you are better served shedding off that illusion before you embark on public transport system in Kathmandu for a ride. In a journey from Maharajgunj to Purano Bus Park you are a lump of flesh worth Rs 15 and from Purano Bus Park to Lagankhel, Rs 17. Microbuses will stop at any place if you give a slightest hint of potential ride but stopping at your destination is a different matter. Availability of space is a secondary consideration. I have come to a conclusion, space in our microbuses is an abstract notion. It is almost limitless. Gas in your belly that can be squeezed out counts as available space. In these flesh carrying machines, if you have been stacked somewhere in a seat close to the corridor, there is a good chance someone's butt will rub against your face. And if this soul has Giardia swirling in his bowels or has devoured a sumptuous meal with fresh radish salad, you are toast. Even if you have been prudent to find a window seat in the second or third row, scourge of wet cough remains. A peculiar snorting sound heralds a maneuver which entails delicate opening of the window and spitting out into the open, throwing droplets of phlegm into the air, some of which may find way into your face if you are not agile enough to close your window on time. Furthermore, resemblance of the sound of cough to many of my patients with TB offers no consolation. 

A Tale of Trouble

My hospital reeks of violence these days. We are used to suffering inflicted by violent diseases and injuries. But not the violence borne of testosterone infused stupidity.

Muscular males garrisoned the protest area instead of the regular folks. I am told, they are political folks supporting the newly appointed vice-chancellor. They are looking for trouble, someone warns. Protesters are asked to go to the attic of the hospital instead, for the regular one-hour protest.

One of my colleagues tells me there is a trouble at the ICU. A very sick man with liver failure from alcohol abuse died. There are men who blame the hospital for death. They are seeking compensation. He tells me these are people who negotiate compensation with the hospital and split the money between the family and themselves. I don't know the truth. The chaos outside is fertile for these kinds of things. It won't be surprising if true.

When I go to see patients at the outpatient clinic, hallway is packed with patients, clogging the entrance. My first patient is an 83 year old man who took a microbus from Balaju to come to Patan Hospital. He says, he has been coming to Patan Hospital for more than 15 years. Only the medicines given here help me, he declares. Another patient is a woman again in her 80s from somewhere close by. Sharp as a tack, she comes to show me a medicine because it looked different from the ones she was used to. Patient after patient, it is a different story, a different suffering, a different ailment. We attempt to negotiate solutions. In this relationship, I look for those muscular men. They are nowhere to be found. Where are they? What is their vocation? Why are they outside? 

Laxmi Puja

The city that suffers perpetual darkness beams with colorful lights tonight. Decorative lights have replaced traditional candles and diyos. Kathmanduites appear unperturbed by unreliable electricity. They are adamant about taking chances on the stringed decorative lights in lieu of the more predictable candles.

Attempting to keep the government promise of unobstructed electricity for Tihar, our lightbulbs danced in and out of illumination for most of the evening today. Perhaps the hydropower turbines missed the memo.

It is late into night now. Electricity is more stable; peak demand has dissipated, I presume. People keep their doors, lockers open to allow unimpeded access to the goddess of wealth Laxmi on this festive night. They stay up late.

For a public hospital employee on a fixed salary, this proposition does not sound too lucrative. Rather, warm blanket in this cool night offers more appeal. As I head to my bedroom, a familiar screeching sound of microphone emanates from nearby. This is a deusi bhailo group, a more sophisticated one, which has set up loud speakers to do an elaborate program. Loud noise (?music) reverberates the whole neighborhood. I guarantee you, they are not aware that this can be bothersome to someone else, especially someone trying to sleep. You better learn to sleep in loud noises.

Protests at Patan Hospital

We have heard of the King Midas from Greek mythology. The one endowed with the Midas touch. Everything he touched turned into gold. Whatever the long-term implications were, the power was a reward Midas had asked for. In an instant, he could turn anything into coveted gold. 
 
What if you had the same power, but this time you were able to turn things into disarray? More like Tony Soprano from the television show Sopranos: I'm like King Midas in reverse, here. Everything I touch turns to shit.
 
Unfortunately, our current political system exhibits Tony Soprano characteristics in abundance. Here is an example:
 
Patan Hospital has a lot of desirable things. In this hospital, if you go to the emergency room sick, you are guaranteed a treatment whether you can afford it or not. Unlike other hospitals in Kathmandu, you are not asked to go buy everything before you can get treatment. It is the same in the wards too for the most essential stuff. You are billed at the end. If you cannot pay, social services department generally helps. In this way, they have been able to care for many sick patients who would otherwise have difficulty elsewhere.
 
They have been able to do this by faithfully abiding to the core principles they agreed upon at the outset: to take care of the patients regardless of their ability to pay. This conviction forms the spirit of the institution and people ascribing to it work together to achieve the goal.
 
The hospital as it stands now is a legacy of Christian missionaries' charity work.  It started as a clinic in 1950s gradually evolving into the current ~400 bed hospital. It is surmisable how much of hard work and sacrifices must have gone into establishing a non-profit organization serving poors. Expanding on its role in training health care personnels, Patan Academy of Health Sciences (PAHS) was established in 2008. While managed earlier by United Missions to Nepal (UMN), currently, Patan Hospital is administered by a board and PAHS is an autonomous public institution whose vice-chancellor is appointed by the Prime Minister of Nepal.
 
I joined PAHS just about the time the tenure of founding vice-chancellor was ending. There were small squirmishes between the administration and the hospital unions regarding salaries and benefits. It did not bother me much. I found a core group of people who were selflessly dedicated to the institution. It was wonderful working with them, bound by common aspiration to serve and better the institution. "Espirit de Corps," one of my colleagues used to say when we were discussing some changes that would be difficult. It was during this excitement that I left the country for nearly one and a half month. A new vice-chancellor had  just been appointed at that time. Folks were not excited about her but I did not hear any outright opposition. 
 
When I returned, I was shocked by what I saw. Almost everyone was against the new vice-chancellor. They wanted her to go away at any cost. And for that, they had ample reasons. 

Allegations were flabbergasting. Bypassing the executive committee, she single-handedly appointed a friend from outside institution as the Rector and informed only after the appointment while there were much more qualified persons within who understood the missions and goals of the institution better. She was disparaging to the people who have worked numerous years designing a novel curriculum and selection process for MBBS students geared towards producing doctors for rural community. Ignoring the established tradition of group work and raising a suspicion about her motives, she decided to centralize all procurement decisions to herself. She went to the senate with a proposition to centralize all the power to her without consulting with the executive committee (which was rejected by the senate). She lies, speaks disrespecfully to the officials, teachers and students of the institution. 

The hospital is in protests now. So far, clinical services have not been interrupted much. Vice-chancellor is not allowed within the premises: protestors stay at the gate from 8am to 4pm. Her office has been padlocked several times. We see riot police in our hospital premises, clad with riot gear. Some of our students have received baton charged already when trying to padlock vice-chancellor's office. Protests are bound to grow. I see interruption of non-emergency services coming. From what I understand, vice-chancellor has got to go.
 
Why did this happen? When my colleagues went to the Prime Minister, they were convincingly told how he had caved in to the complexities of maintaining a coalition during this political transition. He assured them he knows Patan Hospital is a different institution. That's why he even held signing the name recommended by the selection committee for 2 whole weeks. But he did not hear anything from Patan Hospital so he went ahead and signed. They were tremendously impressed by how attentively he listened and empathized with them. Had Patan Hospital lobbied for someone, would this situation have been averted?
 
The inside story of the appointment, which I tend to believe is this: The vice-chancellor is politician Sarat Singh Bhandari's relation. It was by political lobbying through him that she got the post. It is for sure, she was not given the position because of her credentials. And it is increasingly clear she has no skills to hold a leadership position.
 
I go to hospital searching the excitement I left with. Everything is at standstill. When the clinic is closed from 10-11am, I join the protests with my colleagues, hospital staff and students. Many of them are animated and excited. I have no doubt they are excited for the cause. But I can't avoid thinking, how much the fact that they don't have to work during that time is responsible. A look at similar other public institutions where protests like this are commonplace offers no solace.
 
We have been given a Tony Soprano. I still subscribe to goodness in people and believe that this blatantly unqualified vice-chancellor will be removed sooner or later. My worry is how much damage the whole exercise would have inflicted upon the institution by then; and will it be able to pick up from the place where it left?

Some Notes from the Past I: Election of Baburam Bhattarai to the Prime Minister of Nepal (Written on--August 30, 2011)

Baburam Bhattarai is the new prime minister of Nepal. His election to the post appears to have lifted spirits of people- as I gather it from the blogs and the news. Why not? He has always been a person people have looked up to. I, myself, in my youth, have received numerous lectures from my mom to aspire to be as studious and smart as Mr.Bhattarai. Folklore has it that he always scored highest in his class throughout the grade school and even in the Intermediate of Science (ISc). This was held in special regards because he came from a lower middle class peasant family. He epitomized the success of hard-working peasant kid: the barriers that could be navigated through, promises each child toiling the snaking trails to reach a school in the middle of nowhere held. Mr. Bhattarai did not stop there; he proved to be a grand idealist. He questioned the very society; he saw injustices, inequalities, exploitation. He devoted himself to struggle for what he envisioned as a better society. The culminating overthrow of monarchy and establishment of republican Nepal is claimed by many as a success in that direction. Now, he is not just an idol of academic success but, many claim, of political success/ideological success. It is not hard to understand why the spirits of the countrymen are high.

I sincerely wish for the success of Mr. Bhattarai. And I will gauze it only by two things: completion of inclusive constitution writing and conductance of elections for the parliament during his tenure.

But, I am afraid, the ecstatic nation is headed for a disappointment at the least. First off, the notion about Mr. Bhattarai appears to be almost fantastical, almost godlike. This is too big a burden to start with. No single person is capable of transforming a society as heterogeneous as Nepal in a magical way. Transformation of Nepali society is going to be a systematic process with all her citizenschipping in. I imagine more banal-appearing work and changes before the structures are in place for the progress of the society. But I doubt that our expectations from Mr. Bhattarai carry along this acceptance of banality, we are in for a radical overnight transformation.

Secondly, we do not fully understand Mr. Bhattarai. It is easy to wishfully imagine this man in light of his academic achievements but we do not yet have hard evidences at our hands to attest to his capablity to lead in a democratic setup. Fourteen thousand people lost their lives in the country in the bloody conflict that contributed to the overthrow of feudal monarchy. There will always be some of us who will question this as achievement, when such gory violence was used. Perhaps, many of us will be able to close our eyes and succeed in suppressing the memories of these dark days if the political process progresses to a better end. However, this much is clear, the violent political movement carried out by Mr. Bhattarai and his ilk does not qualify as a clear success. If anything, it attests to a violent inclination whatever his ideological defenses might be.

In any case, Mr. Bhattarai has been elected to a position with historical challenges and huge burden placed on him by unrealistic expectations. It is an opportunity to see this man of almost mystical image work. My sincerest hope is that he succeeds. My greatest fears are consolidation of tyrranical aspirations of Maoists. A

Some Notes from the Past II: Wandering Peacocks (Written on-- June 16, 2011)

 As I am preparing to take out pork stir-fry for dinner from my refrigerator there is an unusual, and loud crowing noise from outside. There are two peacocks in the lawn. A woman is on the other side with a camera, it looks like she is videotaping. The two birds appear completely oblivious- that they are in the middle of an urban human settlement where men and women do not generally venture out of their privacy to their lawns lest they disturb the privacy of fellow beings, or expose themselves in the open space to scrutiny and interpretation of unknown souls. One of the bird is close to the window of an apartment. I am not sure what its vocation there is, it does not appear to be feeding itself, just gazing, with it's neck bent in the shape of "S" and long beaks protruding out. The other one is in the lawn, moving mostly, picking the ground at times, perhaps some insects invisible to me. They did not stay for long. Without any declaration, they moved out, slowly, in pair, crossing the road, watching the traffic perhaps, onto the other side, and then out of my sight. Where will they go? Do they know where they came from, and do they have directions to return back to their homes if they have any? What if they don't? Perhaps they just travel. Each day to a new place, with one grazing, and the other gazing out with neck bent in a "S" shape and beaks protruding. What were they looking for in my settlement? What did they see?

Some Notes from the Past III: Goodbye (Written on-- June 16, 2011)

She has an extremely rare form of cancer. It is called adrenocorticalcarcinoma and is a cancer of the adrenal gland. Within a span of two weeks her cancer had grown from 9cm in size to 20cm. She underwent surgical resection which was essentially a complete resection. However, within two months cancer had spread to her liver, spleen and lungs. I had initially seen her right after the diagnosis, in preparation for surgery. Post-surgically I was involved in her care for treatment with a drug called Mitotane that is generally managed by endocrinologists. She has failed this treatment. Experimental study that she participated in another center also did nothing to halt her disease process. Now she is participating in a combination chemotherapy with quite toxic medications that will be managed by oncologists.

I saw her two days back in my clinic. She was not crying, she was not disheveled, she did not appear desperate, she did not appear depressed, she did not appear hopeless.. She smiled as always and was extremely polite and pleasant. I learned, her father passed away the day before yesterday. She was planning to go to funeral the next day. I wanted some blood tests which had to be done in the morning. She told me she will do this in the morning before going to her father's funeral. Depending on this blood test I was planning to make a decision about one hormonal medication, which could be stopped if her cancer was producing it in excess. After that, there was no point for her to see me, and undergo all the trouble one has to take to see a doctor, since there was nothing more to offer her from my specialty.

Today, I got the results. She does not need the hormonal medication; cancer is producing it in excess already. I called to let her know about this.

She is dying, in a few weeks to months. This is an unusually aggressive cancer for which there is no effective treatment available. The measures used are desperate ones but without any consistent benefits. Death is fairly rapid. At the end of the conversation I found myself scrambling. This is a goodbye, at it's true meaning. This is most likely my last conversation with her. What do I say? Goodbye? It sounds like a mockery to her plight. A mere word authenticating her doom. Consolidating inevitability, as if one has that authority. Does one say, good luck? As if the fate had not been clear enough to remind her of the injustice. Does one say, I hope you feel better? When, in fact, she has arrived at your clinic the day after her father's death, aware of her own diagnosis of terminal cancer, smiling and cheerful, conscious not to be pitied upon. What word will actually say bye, and a good bye?

Some Notes from the Past IV: Bus, Clinic (Written on-- November 1, 2011)

Through her thick glasses she is focused on a delicate task at hand- clipping the nails in a running bus. Across the aisle, occupying the whole seat, she has thrown her green duffel bag. Of all the places why did she choose to clip her nails in a running bus is beyond me. I sense defiance, as if she is trying to break monotony, poking the orderliness- silent passengers cautiously avoiding eye contacts- with her nail clipper and nails, making high pitched sounds of nails chopped by sharp, incisive, ruthless jaws of a nail clipper, the fragments flying around. She appears unperturbed by the flying bits of nails into a public space, by the clicks of nail clipper- starkly loud in a silent bus.

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A well-healed surgical scar with dark pigmentation stands out in her lower neck. I extend my hand for a hand shake, she has cold moist palms. We had sent her for a surgical removal of her thyroid gland because it was very large and over producing hormones.

She says she is doing markedly better. Much of her symptoms are gone but she still has a sensation as if something is stuck in the neck when swallowing. Surgical healing has gone very well, there is no obvious explanation to why she still has those symptoms. We plan for an endoscopic exam of throat and esophagus. Her thyroid hormone replacement is perfect.

Decision to send her for surgery was made with trepidation but the objective outcomes are perfect; we are happy.

I happen to examine her wrist and forearm. There are transverse scars extending all the way up from lower wrist to the bottom of middle third of her forearm. Perhaps 20 of them. They shout out loud she has tried slashing her wrist, several times, in the past.

That sight evokes a deep sense of melancholy, dragging you into the darkness of her despair, you feel like crying, with her, in loud roars and wails, beating the chest. Will she allow it-- to a perfect stranger, to a specialist dealing with her thyroid?

Note

I will be taking off from the blog until the end of October 2012. Thanks for checking in!

A Story of HbA1c

We measure something called HbA1c in blood to get an idea of long-term blood sugar control in patients with diabetes. Lower the HbA1c better is diabetes control. Having sugar under good control reduces the risks of having complications such as blindness, kidney disease, nerve problems and heart disease from diabetes. Typically, we aim for HbA1c below 7%. 

I was positively surprised when one patient after another who came to our diabetes clinic had HbA1c consistently below 7%. In North America, I was used to seeing it above 8% most of the times; perhaps it was because we dealt with only referred cases of diabetes who failed treatment in primary care settings. Still, having HbA1cs in so good ranges is rare even in primary care settings as I recall from my residency days. Then why is this difference? Are we doctors doing a phenomenal job at this public hospital?  

Before we reach that conclusion, we should look at who these patients are and what they undergo before they reach our office table. 

This is a picture taken in the morning where people are lined up in several parallel lines to get a ticket for visit to a doctor. This is just a small segment of the crowd; the total length of the line is much longer. People start queuing up from 4am. Ticketing counter opens at 8am and closes at 11am. After they receive this master ticket, they then go to their assigned clinics, submit the ticket and are assigned another number. Depending on the number, they may be seen in the morning or it may be late during the day. So, for many of these patients it is a whole day deal. It's not just the time, you should be committed to put up with the push and pull, sniffling, spitting, coughing, body odor, loud cellphone conversations, crying children, rude people, rude counter staff, rude and dictatorial doctors. 

In summary, anyone who comes back to see a doctor by going through all this is a very highly motivated patient concerned about her health. We know that the common type of diabetes is a disease of lifestyle and a motivated person can make a huge difference to diabetes control just by simple lifestyle changes and compliance with medications. It is hardly the doctors, but most likely patients themselves who are making the difference. Just our clinic set up is giving a skewed snapshot which when taken in proper context tells us a more complex story. 

But what is worrisome is what's happening with the non-motivated ones? Those are the ones who actually need doctors: just to push a little bit in each visit. Diabetes does not cause pain and disability immediately. You can go along with the disease without having much discomfort until complications start developing. The whole goal of treatment is prevention of those complications. This should be happening in the clinics. But exact same patients are missing from our clinics. There are plenty of these patients in our hospital wards who are admitted with complications from diabetes. Our clinics are clearly not targeting the ones who need us the most. And this is a problem if we look at the changing pattern of diseases in our country and the subcontinent. 

Even in 2008, WHO estimates attributed 50% of total deaths in Nepal to non-communicable diseases (Source: http://www.who.int/nmh/countries/npl_en.pdf). Most of it related to cardiovascular diseases (CVD), for which a major contributor is diabetes, although diabetes on its own is responsible for a small number of deaths. This pattern of deaths is a change from historical pattern which was primarily of communicable diseases. And this is expected to grow exponentially over the coming years. 

The way our clinics run currently are definitely not set up to address the changing disease dynamics. The change is urgent. 

Night Rains

If anything can silence Kathmandu, I have realized, it is the night rain. Especially obstinate are our dogs but rain at night seems to do the trick. Monsoon rain is a solace anyways. Its musical torrential downpour incites a sense as if it is hard at work to cleanse the filth of our city. Indeed, air is fresh, sight clear, when the rain stops and sky clears, at least for sometime. Whimsical monsoon rains tickle our hopes of clean Kathmandu better than our metropolitan city managers. 

Our Workhorses

The emergency room is 15 meters x 10 meters perhaps. Every available space is taken up, mostly by patient beds, leaving very little space for corridor or work space for physicians. It is always in action. There are sick people: very sick most of the times. We have a lot of communicable diseases. Many of these patients get diagnosed with tuberculosis and other types of transmissible illnesses. In this enclosed space, few ceiling fans and exhaust fans on top of the windows make feeble attempt to circulate the air. The air is muggy. It smells of disease, body odor, and feels warm. There is a deafening cacophony of patients in distress, families in panic, crying children, doctors in conversation, nurses in action. 

There are certain standards for healthy work space, but you need to know of none to get an idea that this is not a healthy work environment. It is not just the emergency room, our wards, outpatient clinics, intensive care units are all the same. 

In these clinical care environments, you will see young doctors scurrying around in their white coats. These are residents and interns. They spend a large amount of their time in this suffocating environment. They are the workhorses in health care. Cheap labor is what health economists call these people in North America. They are paid minimally (rather they are made to pay hefty sums sometimes in Nepal). They work very long hours. The ground work of patient care is in their hands. They talk to the patients first, whenever there is a change in patient's condition they are the ones who are called first and they are the ones available to manage acute crises in patient's health. If anyone in the patient care team knows the patients best, it is the interns and residents. 

You will see several of these doctors sniffling. Respiratory illnesses is very common among our interns and residents and is not difficult to attribute it to the work environment. We hardly have any set up to practice basic hygiene. Crowded small call rooms are shared by several residents. Do they feel exhausted sometimes? I am sure they do. But if they were to express it, my guess is, they will be told everyone goes through this stage, this is the time to learn and not complain. They undergo all this hardship in the name of training. Traditionally, this hardship has been accepted in the medical communities. It took death of an 18 year old Libby Zion in New York after an error by overworked residents and her influential newspaper columnist father to bring into attention the risks of overworked residents. Now, the US enforces strict duty hour rules for trainees. We do not have any such rules. Furthermore, our residents and interns work in a risky environment for themselves and the patients they care for. We are better off if we start talking about these issues now than later. 

Is it Cultural?

During the lunch today, I joined a group of final year medical students from Germany who are on an elective rotation at our hospital. I asked them, one-by-one, what their most shocking experience in Nepal was. One of the students described it thus (the gist of what he said):

I was in the emergency room. They brought in a 3 month-old child who was not responding. Doctors in the emergency room did the required resuscitation for a long period. They placed in an airway tube, gave medications, but the child did not survive. After they were done with the resuscitation, they just left. Tube was still hanging out of the mouth of a dead 3-month old child. The leads of ECG were still in the chest. The dead body was bare. Family came back, they were crying. It was just shocking to me that  people just left without any respect for the dead body. I thought, is it accepted in this culture? In our culture, even if someone is dead, we are expected to pay a basic respect to the dead body. 

Is it cultural?

Absolutely not! We have to just see the patient's family, and stand in their shoes to know that it is not cultural. Who would like to see a dead child with ominous plastic tube hanging out of mouth, chest littered with sticky pads, body bare and abandoned?

Then what is it? In my opinion, it is a plain neglect and lack of empathy. It is very likely that the doctors are doing this out of habit and ignorance but not deliberate evil. They saw it being done the same way by their teachers; perhaps no one has questioned them seriously about that in the past. Furthermore, I suspect, it is reflective of the power structure in a doctor-patient relationship in our medical practice. Our patients hardly have any power. They pay for the care most of the times but still have hardly any say in the care they receive. Doctor imposes his decision. Questioning a doctor's authority is considered outrageous. In addition, our doctors are loyal to their superiors than the patients. You see the same doctor speaking very courteously to his superior while being very disrespectful to the patient. This is again reflective of our hierarchical power system where one's career prospects are dependent on power holders (superiors in this case) than the actual subjects of the creed. In our current system, welfare of our patients and family takes a backseat. This is a problem-- an outrageous one.

Why did the child die?

Anthony Klouda in the book Reaching Health for All tells us a story and posits a question: 

The Story of Charles Masamba

Charles came home heavily drunk and feeling irritated. He had had a fight with his neighbour about a girl in the bar, but he was also satisfied because he had won. He shouted to his wife to bring his food, and then he remembered that she was in the hospital to give birth for the eighth time. That made him remember that he had to feed the child. And that made him remember why he had become drunk--he no longer had a job, as the estates had laid off their labour last week, and he had not enough money to pay the school fees. He cursed briefly and, while cursing, fell to the floor, already asleep. 

Three days later , the youngest child, who had already looked rather sickly, got diarrhoea. Charles bought some tablets at the shop, which the storekeeper said were the world's number one tablets for diarrhoea, and gave them all at once to the child. The child died the following night. 

The neighbour made no remarks, and did not attend the funeral. 

Why did the child die?

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Today, some so called "youth wings" had called for a nationwide strike from 6am to 12pm to protest against the recent price hike in petroleum products. As I was walking back home after a night-call at hospital, streets had very few vehicles. They were still filled with people: walking to their work, schools perhaps. Silent people who have learnt to take whatever comes. I did not see any protester during the walk from Patan until Lazimpat. 

At Lazimpat, there were a few young men (many looked to be in their teens). Some of them carried red flags. A pony-tailed one sprinted in the road, jumping on occasions, shouting; he was headed to a motorcyclist who was already making a U-turn when he saw some activity. There were a few policemen but before this pony-tailed young man could reach the motorcyclist a truck full of policemen arrived with their bamboo batons. They asked him to stop, he started shouting some slogans and kept running toward the motorcyclist. Policemen surrounded him and gave him a good beating of baton. He sprinted back with equal valor, this time without slogans, scared. A teenager testing his limits perhaps. I do not know if he will have same enthusiasm to sprint past policemen to charge a motorcyclist in the future. I do not even know, if he knows what he is asking for in these protests. 


Why is there a price hike in petroleum? Why is this young pony-tailed man sprinting past policemen just to sprint back scared to death? These questions fit the mold of "Why did the child die?"

But it is unfortunate that our political discourse and activities are detached from these kinds of questions. On the contrary, it is dominated by violence. Some goons in these so called "youth wings" can declare a strike from the comfort of their couches and make the streets empty, forcing people to walk to their work or school, daily wage earners to give up their earnings, sick people to stay at home ailing. They hold enormous violent power. And they try to deal with complex problems with simple solutions because it is easy to do so. A patient deliberation, teasing out complex issues requires patience, insight and humility. On the other hand, violence is incisive and instantaneous. We have been fooled by these instant results into thinking violence is justified sometimes. But if we look at our problems, they have hardly been solved. It is time that we get past this intellectual illusion and take up problems with questions like "Why did the child die?" There are no easy answers.