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?

***********************************************************************************

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. 

Blame it on Poverty

When we debate about making some changes in Nepal, our default tendency is to put blame on the lack of resources. It is easy, and natural, because we are a poor country. But I have noticed that this default mode is somehow crippling. We have learned to postpone our responsibilities and put blame on our poverty for problems and inefficiencies in our system. 

Obviously my experience is primarily limited to the public hospital where I work. Here, I see several opportunities to facilitate patient care without any additional resources. It is a question of organizing things better. Most likely, we won't be even working harder than what we are doing. Yet, do it in a more gratifying and meaningful ways.

The challenge is for the people to see and accept the alternative forms. There is a natural reluctance to change. It is not unique to Nepalis, I had noticed the same while in North America and working as a chief resident. The challenge for anyone who wants to better the system is to be able to negotiate, convince and get people on board.

Defaced City

Kathmandu is a defaced city at this time. We are expanding our roads. In the process, the encroaching houses, shops lining the roads have had to nibble off their faces. Side walks are all covered with rubble. During the day, sounds of electric breaking hammers or the manual hammers chipping away the concrete walls permeate the city. At night, empty roads with the sides filled with rubble and ragged tarpaulins making feeble attempt to cover the vast ugliness give a spooky feeling. I heard one person say the other day that at night the city looked as if it had been bombarded.

In a defaced city, we live in filth and chaos. At least, this is the impression you might have if you just landed in the city from North America. But give it some time and the filth and the chaos will gradually sink in. You will recognize that in the dust covered lives of this city exact same humanity ticks with all its passion. There is an unmistakable order in this chaos. An order which people have a natural respect for and rely on.

The humanity is especially lively in the bottom echelon of the society. It is easier to connect to the people squeezed to inhumane levels in microbuses, sick people lined up to see a doctor in public health institutions, an uneducated man trying to open up a bank account, a patient's family trying to negotiate entry to the hospital ward during the day time in a public hospital, a fruit seller from Tarai trying to make some profits out of a mango sale: everyone pursuing basic instincts in the given circumstances. It is simple.

Our Questions

One aspect of clinical practice in Nepal has stood out: the distinction between right and wrong is not very complicated, mostly. The comfort of conviction is rather gratifying.

Some of the questions we ask are:
- Do you regard patient as an individual and treat with dignity due to a free individual?
- Can we organize ourselves better so that, without any additional resources, we provide a more systematic care?
- Is spending some time explaining patient about her diagnosis or treatment worth it?
- Do we actually need to listen to a patient or her family?
- Where should be our loyalty be directed to: patients or our "sirs"?
- Should we work while we are at hospital?
- Can we demand of others what we can't do ourselves?

Do not get me wrong, my colleagues are good-intentioned people in general. The roots of our current structure of debate are perhaps quite complicated and beyond my understanding. But to work in this environment, one of the biggest allies you have is the force of conviction in some of these issues. The philosophical clarity is soothing to the conscience too.

Life is hard but not uncomfortable. 

Why

It is gradually settling down. However prepared you might think you are, the chaos is overwhelming and it takes time to find your footing. One of my new mentors says he takes this as an opportunity to practice patience. Because, he says, anger does not seem to be the right solution. 

Practice patience indeed. I am certain it takes a lot of it. My mentor must have sensed the ambitions and phantasmagoric footing of a young idealist.

Especially overwhelming is the rapidity of events in this chaos. We just lost a patient, a young girl in her teens from somewhere remote. She came ravaged with tuberculosis. It had spread everywhere: lungs, stomach, brain perhaps. She was passing blood in her stools. Prostrate in the bed, she barely had energy to respond. Her father was worried she was not eating anything. We put a nasogastric tube and started feeding "Sanjibani", a locally prepared nutritional solution. She was getting medications for tuberculosis. 

Next day, during morning report, resident on-call overnight reports that the patient passed away. 

The force of this declaration is stunning, rattling. First off, you have seen this patient once, on a rushed rounds. You have not known this patient, as a good physician should know. Secondly, you don't know how this patient was handled once she started going down the path of death. It is likely that there were signs of deterioration before she entered the point of no return. But in this chaos where the hospital is laden with sick patients like her, who knows how long it took before it came to the attention of nurses or physicians on-call. How would her father know if her oxygen saturation was dropping, blood pressure was low or heart rate was high? He had a sick child, until that child remained no more. 

You are left with several questions, surmises, an achy heart, and restlessness. Why should a young girl die in a hospital bed from a disease of overcrowding, filth and poverty?