Akabare Khursani

I waited at a school teacher's house for the jeep that's the main transport out of this village. The school teacher lamented about his trouble with the "gastric" while I listened to him attentively. Obviously, gastric needs no definition to those who know any Nepali. He described how he had tried all medications without much benefit until Akabare Khursani (Translated literally: King of Chili Pepper) came to his rescue. On a scale of 0-5 with 5 being the hottest imaginable, I would say Akabare Khursani would score 5 in its hotness and would be the sole chili pepper to do so. It is no toy for fickle-hearted among us! Earlier, it was a mantra not to take hot, spicy and sour (tato, piro, amilo) if you came down with gastric; now the tide had turned towards extreme hot/spicy. From the earlier proscription to the current splurge I thought we had made a full circle with our remedies for the gastric. 

The school teacher insisted that I take a sapling of the Akabare Khursani to Kathmandu. He brought a healthy sapling with roots in soil wrapped in a plastic bag. I put it at the side pocket of my backpack, the upper part of the plant breathing air. I rode out on the pick up of the jeep, breathing fresh air and dust. However, the road was blocked midway and we were asked to take another bus on a detour route. The bus was crowded. Little girls in the bus giggled at me constantly after seeing a sapling dangling out from the backpack. As I was pushed back by the crowd in the bus it seems like the sapling poked at the face of a mom of one of those girls. The mom shouted at me and I adjusted my angle. At Dumre I switched to another bus to Kathmandu. The conductor of the bus pronounced that the Khursani will not survive when putting my backpack at the trunk. It was wilted when I reached Kathmandu. 

The wilted Akabare Khursani has risen up now, green and perky in its pot of paint tub. It is steadfast in its quest to cure gastric that ravages countless souls in this nation with its mighty heat. 

At the Health Post

I hike up several hours to the health post. On the way, I pass through a school that is having a new building constructed through the grants of the Indian government, through a forest with robust density of trees, and through a small town of sparse houses and activities of people. A group of people have gathered and slaughtered a buffalo, which is now being chopped to small pieces and distributed in small piles atop banana leaves. Health post is located on the outskirts of this small town. I ask a shopkeeper how I could reach the health post. He points me the way and says, "doctor was also around just now he must still be there." He points me to a nearby house alluding to the health assistant working at the health post. The health assistant is locking up his shop (pharmacy) and leaving for the health post. It is about noon, he must have come home for lunch. I introduce myself and we walk together to the health post, which is a few minutes walk, chatting.

The health post was constructed when one of the locals was the Deputy Minister of Health during the Panchayat era. It has several single-floor stone house buildings. One of them is the patient care building with offices, another is staff quarter, and there is one more that is now rented to a private school. These buildings stand elegantly on the side of a hill.

However, it is deserted on this day. The only other person at this health post is an office helper who is sitting at the porch of the health post. The auxiliary nurse midwife, who was sent to the health post recently after a long period without any, is on a leave for Teej; she has gone home which is quite a distance from the health post. They speculate that the health post is empty because it is just the next day from the Teej. We sit on chairs at the porch and chat for the next few hours, undisturbed, except for the songs of cattle herder, noise of cattle, and occasional children's shouting.

The office helper is a local and her home is just a few minutes walk from the health post. The health assistant is also from the district but quite far from the health post. Even then, his wife and kids live in Kathmandu. He has been at the health post for more than a year now. He came through a program of National Planning Commission to send temporary health workforce to areas that are having difficulty staffing. "It's like a volunteer program," he says. Health assistant who was here before him had left the health post to take up a position in Kathmandu. From what he told, he is given an allowance but not a salary. I didn't ask how much he got in allowance. He was hoping that this work experience will help him get a salaried government position. "I will work for the next few months and if there is no job opening I am planning to leave," he said. Before taking up this work, he was working at a private set up in Kathmandu but he complained that there was not much money in the private sector. The government job came with easier work, guaranteed salaries, opportunities for trainings, and multiple additional benefits. He would definitely take a government job if there is an opening, he declared. He had gone to a private school to have his health assistant training and had spent a fortune for that.

We take a tour of the health post. It is quite well-stocked with medications and basic surgical supplies. The consumer committee pays a person to go to the district office to get the medications and the supply is reasonably consistent. Recently the center has also sent an electric autoclave; they are planning to use it. The facility is clean. There is a meeting room, an office for the health assistant, a birthing room with reasonable birthing table, an outpatient (OPD) room with education materials pasted all over the walls, and a pharmacy. It is an excellent set up!

The staff quarter is deserted. I peek through the windows, they were designed very well: kitchens have sink, tap, there are built-in cabinets for storage, walls are neatly platered and the floor has glossy plaster (now covered with dust). The health assistant complains that it is not maintained. There is no flowing water, windows are falling apart, that's why he stays at a rented place in the nearby town (where he also runs a pharmacy). They have grown some vegetables at the compound. Gourds hang alluringly, ready for harvest.

A total of five patients have visited this health post so far this day. The health assistant says that people come to the health post mostly for free medications. He says that people do not trust the health post. They would go to nearby bigger cities if they needed to get "real medical care." There are no laboratory tests that can be performed at this place. Many of them, he says, go to nearby town to a health assistant's private practice who had worked at this health post for several years. They have posted the total number of OPD visitors in a chart hanging at the corridor of the health post. For the past fiscal year the total number of OPD visits was 4899, down from 7821 the year before, and similar numbers in the year prior. The health assistant is not sure why there has been a significant drop in the number of visits.

Another big part of his responsibility is outreach in the region. Every month they go to 6 places for immunization, these have fixed dates each month. They go to another 4 places for outreach clinics. He says these outreaches happen consistently. The staff at the health post cover for each other during these outreaches and try to keep the OPD open. He has to prepare reports of these outreach services and has monthly meetings with the district hospital for which he travels to the district capital each month. There are some days in the month when he has to close the health post OPD services because there is no one to cover for him.

As we are chatting, a young man arrives to avail the services. The helper registers him recording all needed information in a register. We then walk to the OPD room with the patient. He has been having fever. The health assistant asks several questions, checks his temperature and blood pressure. He tells the patient that he might have urine infection. He prescribes an antibiotic and multivitamin tablets. Then he explains to the patient that he will get free antibiotic from the health post but has to purchase multivitamin from outside. We then go to the medication room and he gives him Ciprofloxacin (an antibiotic). I thought this was quite well done for the level of health care facility. This appeared quite competent work for the immediate medical needs of this village community.

We get back to the porch and resume our conversation after sending the patient away until it is time to close the health post. But just at about this time, two families arrive with their sick children. The health assistant politely reminds them that it is time to close the clinic but he agrees to see them. I stay outside talking with the office helper.

Once he is done, he plucks out a gourd for the office helper from the garden, she locks the health post, and we walk out together towards the town. I offer them to have Coca-Cola but they decline. We are near his home/pharmacy now. One of the mothers who had just brought her child is walking ahead of us. Our health assistant calls her out and points to his pharmacy telling her that this is where you would get multivitamin solution for the child. She turns back and keeps walking, almost ignoring him. I hike down the hill. 

In the Village

We sit in the balcony, done with the dinner. Moths and butterflies flutter around the light bulb; electricity is more regular here and the insects abound in this wilderness. Some of these insects come tumbling down, perhaps burnt by the heat of the light bulb; you should be equipped with robust reflexes lest they find their way into your eyes. Beyond the light from this light bulb is darkness of the night that oscillates with the rhythm of the lunar glow. The darkness of the night however is not vacant. Chirping of the crickets fills this emptiness, almost deafeningly. Crickets appear to rule this place at night. In the colossal darkness of an abandoned village where puny lights make a feeble attempt to compete with the night, crickets sing songs of glory to their mighty delight, almost mocking the flaccid human presence. At this time of the night fears are different: tigers, snakes and solitude. What draws my folks to this wretched place, I wonder.

At its glorious days, this village hosted nearly 20 households. Now the count is only four. Earlier, they started moving to Besi (lower part of the hill). More recently, they have moved to cities or abroad. Older buildings have been brought down and their construction materials reused. Or, they have toppled down on their own, their walls and beams crumbling down from lack of care; their ruins now remain hidden underneath the wildly growing grasses and shrubs nourished by monsoon rains. The village is a relic of the past, now a playground for the nature.  

In the morning, I venture out to Besi to visit villagers. This is how you do it: start at one corner and go house-to-house saying hello. You do not pre-inform them. So you never know who you will meet, what they might be doing when you meet. One of them was taking shower in the open when I met. We pretty much completed our entire conversation while he was taking shower, me sitting on a bench, him answering and questioning while applying soap, washing, and changing his underwear. He even took the opportunity to point out to me the scar of his inguinal hernia that was repaired at Bir Hospital, unperturbed that his pubic hairs were peeking out. Most of the households have older people only. The younger ones are away: to cities or abroad. The village is not without activity, however. The fields are still plowed and planted. Many of these households still have cattle; actually it was noticeable how goats were bustling in several of these houses: bird-flu has made goat sale quite profitable. The whole of the Besi has running water now (it has actually been nearly a decade since they used the local government fund to set up water supply; money was used for the construction materials, they contributed the labor). While fetching water took significant portion of their time before, that is not a concern now. Rather, some of these houses have set up make-shift ponds using water from these taps and put fish in it. I hear there are a few folks around the area who have been doing commercial fish farming and made a fortune out of it. Electricity has reached each of these households. Villagers carried the electricity poles on their own and planted these poles to bring electricity. Many now have TVs at their homes. They have even connected the village with a dirt road to the nearby larger road (which still is a dirt road but it is included in the government’s plan to be paved). They had asked for the local government money to get a dozer to trace out this road. These inner roads, however, are not useable. Rain has taken away parts of it and it remains covered with grass for the most part.

You go from one house to another listening to the stories and struggles. They are the stories of a 79-year-old man cutting grass to feed his cattle and that of this city-dwelling brother who had to have heart surgery in his 50s, a retired government officer who comes to the village to fill his vacant time: his driver cooking food and him tending the fields inherited from his father, of a school teacher torn between his job and difficulty of getting workers to tend to the fields, of a young girl who has come to another villager to ask for Hari Bansha Acharya’s “Chino Harayeko Manche” and who gets it with a precondition that she returns it in 2 days without any stain, of an old man who is hurt by how he has been treated by others, of all the women who have gone out to a nearby temple to celebrate Teej and have been dancing to the Teej songs shrieking out of a cassette player, of the village empty of the women because all of them have gone away to the temple, of a young man who has returned from Malaysia and plans to go back soon and of his pot belly; of his green shirt with iPhone written on it,  of a child who has been having fever and vomited once; of his pulse and temperature and belly, of an old man who is sad that all his orange trees are ruined by a disease…

They are stories of livelihoods, of a drive to pursue prosperity and comfort, of fears, of happiness, of envy and of disgust. This society has already seen some of the darkest days in the political wrangling. But what struck me was how they have more or less stayed the same. Even before I could search my memory to come with a proper identification of these villagers, they would have already addressed me with: Eh Kanchha, when did you come? It was as if I was never gone for them. The village seems to have a life of its own pace, certain constancy. Things might change around them, but they are steadfast in their daily strives and everything else is peripheral, transitory and fleeting. 

Westward

After you pass post the road roughed by the transport of construction materials (and prominent on the right when you exit Kathmandu), you truly leave Kathmandu. Smoke, dust and smell-filled air starts tailing off. The confines of a densely-populated city eases out. It starts opening up.

At the roadside, are huts and houses. Some of them appear as if they were built half-heartedly: naked pillars jut out of the roof, walls are not plastered, they appear as ugly lumps of concrete and brick. Devoid of any grace or elegance, they appear as if they are challenging the whole sense of aesthetics, almost mocking, “this is what I can do to you!” But who knows why they stand? Maybe it’s a tentative act in the larger toil of earning a living by using means never known to them, in a place never known to them, creating structures never known to them.

As I gaze away to a distance, in the hills, a certain calmness  pervades: almost akin to permanence. Also adorned with beauty and grandeur. The ugliness of the roadside contraptions and the elegance of the distance contradict glaringly. Almost suggestive of our society at large: our struggle to seek new has created certain ugliness in the calmness that might have existed (or I would imagine it to have existed, at some point in time).

But you don’t always have to peek out the distance for solace. There are patches on this highway devoid of these businesses. Grass hugs the highway, Trishuli river flanks its side and the hill banking the side of Trishuli is carpeted by greenery kissed by the Monsoon. It’s almost blissful until interrupted by another patch of tentative buildings, huts with tin sheets pressed down by rocks as the roof.

In my journey westward, I get down and change a vehicle. From a bigger urban bus to a smaller village bus. The bus is packed with women and accompanying children travelling for Teej. The cries and wails of children and shouting moms mix with the loud high-pitched Teej songs emanating from loud speakers in the bus. Although a departure time is told, out of a ritual I guess, the actual departure time is determined by how much space is available in the bus and what the potential is for the passengers to arrive. Once the squeezable space has been amply utilized, our bus roars up the hill with deafening noise as if it is a person with lung disease trying to get some air.

I get down before my destination, to walk, mainly because I have travelled to this place walking, in the

past. These roads are new; it would be nice to see things from an older perspective.

Much of the older walking path is taken up by the new road. The road is being upgraded. It has electricity poles on the sides, drains flank the sides where needed, gravel stand atop. It is being readied for paving. Vehicles are rare on this road. It is nice to walk on this road although the sun is scorching.

In the final few hours of walk, I get to use the older path. It seems like people have stopped using these tracks. They probably prefer the road which is more convenient to walk; although a little bit longer. Or, maybe, they hardly walk these days. There were rare pedestrians on my hike up. Perhaps most use the vehicles. In silence, lush green paddy fields still spoke of human activity although humans were scarcely seen. Grasses covered these tracks. In the grasses that covered the ruts, memories were still to be found.

 

A few hours of hike across the paddy fields, rivers, streams, hills, chautaras (rest stops with trees), a small bazaar and I reach my destination. I have to concede, I did not dearly miss the bus.

Comments

Here are some published comments on the article: 

Republica, September 7th, Print Edition. 

Republica, September 8th, Print Edition.

NMA Statement

It does seem like the article I published yesterday regarding ethical violation in handling of the Adhikari couple and the ethics of doctor's involvement in the forced-feeding was able to get the attention of Nepal Medical Association. They have put out  a statement with the same arguments and similar examples as was used in the article. Let us hope they will take the lead in creating a robust voice to prevent a grave atrocity of forced-feeding against this couple's wishes. 

One portion of the statement is however concerning. The chairman of NMA is quoted as saying, "If they were unconscious, it would be a different matter...." It would actually not be. The doctors should be asking this couple now what their wishes would be in terms of feeding if they become unconscious. Those wishes should be carried out even when they are unconscious. 

They also steer clear of the concerns of ethical violation in the handling of the Adhikari couple at Bir Hospital and Mental Hospital. I don't know if it is in their purview. 

Medical Profession’s Handling of the Adhikari Couple

The sight of a couple is very familiar to us now, from the print media and the television. The woman is a motherly woman with spotted blouse and the man a haggard-looking man with unkempt beard and hair. A deep seriousness and sadness pervades these images. After nearly nine years of their silent and personal struggle in search of justice, our society has been finally introduced to Mrs. Ganga Maya Adhikari and Mr. Nanda Prasad Adhikari, who are now over 40 days into fast-unto-death.  

This couple’s story is deeply heart-wrenching. Their 18-year-old son was abducted and killed by Maoists in 2004. From what media tells, even after their son’s murder, the Maoists and the state have pestered this family. Because they had registered a FIR against the suspected murderers, they were repeatedly threatened by Maoists, their livestock were killed and they were ultimately chased out from their home. Despite all of these threats they have persevered in their search for justice which has largely remained elusive. They demand that action be taken against the murderers of their son. When the usual channels of justice offered no recourse in sight they started hunger strike in front of the Prime Minister’s office in the capital city early this year. They were allegedly detained at a police station for 48 days and then taken to Gorkha, handcuffed, to be dumped. But they returned back and staged a hunger strike.

According to Asian Human Rights Commission (AHRC) appeal letter, they were arrested in mid-June and taken to Bir Hospital. The appeal letter says, “The doctors there recommended their transfer to a mental hospital. They were transferred to the Mental Hospital Lagankhel, Lalitpur where they were diagnosed with mental illness and decided that they should stay in the mental hospital.” They were forced to stay in the mental hospital for 35 days. On discharge, they apparently revised their initial diagnosis as wrong. Now the couple is back in Bir Hospital, but this time with a pledge to fast-unto-death until the justice is served. They are in the intensive care unit in dire strides. On Tuesday, we learned that the Supreme Court has ordered the government “to either coax them into breaking fast or force-feed them” according to Kantipur newspaper.

As a citizen of this country, it is chilling to learn about the fate of this couple. Whatever might be the details of this case, what is clear to us is that a son was murdered and his grieving parents seek justice. Is it too much to ask for? Rather, the power holders are persecuting this couple using their institutions and personnel. What kind of society are we living in? Shouldn’t there be a shame?

As a physician practicing in this country, however, I would like to focus on the involvement of my profession in this injustice based on the reports from news media and AHRC.

Bir Hospital and its doctors and the Mental Hospital and its doctors have been involved recently with the Adhikari couple. Apparently, Bir Hospital doctors recommended transfer of this couple to the Mental Hospital where they were diagnosed with mental illness and detained for more than a month. What should be clearly understood is that these two institutions and the responsible doctors have identified this couple (not just a single person) as mentally ill (concomitantly) amidst a political protest and used their creed and institutions to help detain them against their will.

If they indeed did this deed, it is a serious violation of medical ethics. Stance of the medical profession is quite clear on this. Code of Ethicsof Nepal Medical Council, to which all doctors registered to the council are signatories, mandates the doctors to declare before they are registered, “Even under threat and duress I will not use my knowledge contrary to the norms of humanity.” Furthermore, in its 2003 Resolution on the Responsibility of Physicians in the Denunciation of Acts of Torture or Cruel or Degrading Treatment of which They are Aware, the World Medical Association provides specific guidance to physicians who are in this situation: “Physicians should report to the appropriate authorities any unjustified interference in the care of their patients, especially if fundamental human rights are being denied.”

Several questions remain about the handling of Adhikari couple in these medical facilities. Did these doctors make decisions under pressure or political influence? Did they debate their ethical obligations? Did they seek help if they felt pressured?

These are the questions that the authority tasked with ensuring ethical practice of medicine should be asking. Since the registered doctors are signatories to the Nepal Medical Council’s declaration, it seems like the Council should be taking the lead to investigate the participation of medical profession in this injustice. However, we have yet to hear any words from the council.

Another recent development is the Supreme Court order to force-feed the couple if they do not comply. Again, in this, the global stance of the medical profession is clear. World Medical Association Declaration categorically says: “Where a prisoner refuses nourishment and is considered by the physician as capable of forming an unimpaired and rational judgment concerning the consequences of such a voluntary refusal of nourishment, he or she shall not be fed artificially. The decision as to the capacity of the prisoner to form such a judgment should be confirmed by at least one other independent physician.” Jeremy Lazarus, the President of American Medical Association, had paraphrased the exact same declaration in a letter that clarified the Association’s position that the forced feeding of detainees on hunger strike at Guantanamo Bay Naval Base violated the core ethical values of the medical profession.

As a profession, we should not comply in force-feeding the Adhikari couple if we are to maintain our ethical integrity.

The reports raise questions of serious ethical violations by the above mentioned institutions which should be investigated seriously by the Nepal Medical Council. The medical profession should stand clear that it will not comply with force-feeding of the Adhikari couple who are using hunger strike as the last measure to seek justice in an utterly unjust and callous power structure. Otherwise, we should be prepared to bear the shame of a disgraceful deed. 

Note: This article was published by Republica with title "Violation of Ethics" on September 5, 2013 along with some edits.