On Citizenship

We were students in the kerosene stoves days. Pumping up these stoves, we would whirr up a flame,  cook our rice and daal, fry up some potatoes enhanced by extra bits of chillies. The darn stoves used to clog up at the kerosene outlet. So we had "pin' handy in our rented rooms (dera). There was no survival without the "pin" which was a small flat aluminum sheet with a thin wire jutting out at the end. On our knees, we bent over, and with precision of a watchmaker, we put the thin wire into the outlet  clearing up the clog to allow the kerosene flow.  A clearer whir after we lit the match assured us of the success. We gobbled down the food, dominated by huge portions of rice, and headed our way to the school.

I must have been thirteen at the time. After spending the school vacation at home in the village I was heading back to Kathmandu's dera. I must have had my bags stuffed with vegetables, dried food, perhaps even a heavy sack of rice from the village; I do not recall. But I do recall that my family had given me a cheque to cash out at a town nearly 6 hours walk from my village. I was to cash out that cheque and take a bus to Kathmandu, the money would fund my next month's stove enterprise. 

It was a Friday and the business would close mid-day. I rushed to Nepal Bank Limited, the only bank in town at the time, as instructed by my parents. I presented my cheque. The guy at the counter pushed back the cheque and declared that I won't get the money. My heart pounded, I started sweating, I turned red like a beet. I was doomed, it was 6 hours walk back home and my school would start on Sunday. What was the reason? I had not endorsed the cheque. "Oh I could do that now!" No! he said. You have to sign in front of who wrote the cheque. How would we know if you just found the signed cheque? I stood there devastated. He might have a point but the result was that I was doomed. He scolded me for not knowing the procedure and asked me to go back and come with a cheque endorsed in front of the person writing the check. But I pleaded if something could be done. After some more harassment. He finally said, just because I know your father I will cash it out. I felt grateful that it was finally done. But my palpitations took a while to settle down. 

After adding many more years to that young boy, traveling, studying and working in many different systems, as I look back at that event, I now find something viscerally wrong about how I was treated at that time. It was my money that he stored in his bank, that funded his opulence and livelihood. But there he was, exerting his power using language that I did not understand, fooling me with seemingly logical sounding arguments, and dismissing my potential hardships from the action. He had no right to give me that sense of doom. 

After being away from the country for several years, I returned back to Nepal for over 2 years of stay. I have deliberately tried endorsing cheques at bank counters and nobody dismissed me this time. But it was Kathmandu, they were private banks competing for customers, and I was a neatly clothed confident man. I don't know what still goes on in Dumre with that young man, nervous about something going wrong, clothes soaked in sweat from 6 hours' walk from village.  

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Perhaps some options have expanded. Especially because, the state power is now more fragmented than before. You are likelier to have access to people in power just based on plain mathematics, movement outside the country has somewhat expanded, private enterprises have expanded. So if you happen to have access to people in power, you are agile enough to navigate the strictures in moving out, or you have enough money to buy out services, you are better off. But if you are an ordinary, poor citizen of this country without access to people in power, this remains a viciously callous power structure ever ready to relish on your helplessness to attest its power. They will cite you rules (and they are very good at that), they will sometimes throw in kindness (that's how it is stabilized) and keep you enslaved. 

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How do you relate to such a birthplace?

Perhaps most of us don't even think of our society as having such grave problems. This indifference, or complacence, seems to be rampant among the better off amongst us; especially those in power. Perhaps we have no choice and we accept it as what it is. We depend on the sporadic kindness that come along the way, we placate the power and play by their rules so that mercy would be granted upon us. Poor and powerless amongst us seem to go by it. And it is a stable sentiment, not a martyrdom. More in line with how Coetzee would characterize innocence (In From the Heart of the Country):

The innocent victim can only know evil in the form of suffering. That which is not felt by the criminal is his crime. That which is not felt by the innocent victim is his own innocence.

Or Amartya Sen on hopelessly deprived people (In Idea of Justice):

...typically adjust their desires and expectations to what little they see as feasible. They train themselves to take pleasure in small mercies. 

Perhaps we, who are fortunate enough to be able to detach ourselves from the daily grinding of this society, in places abroad or secluded abodes of comfort at home, create our fantasy land of the nation of certain culture, of natural beauty, of certain religious or family traditions, of certain physical infrastructure and technological developments, and all variations imaginable. We then have a sentimental relationship of our own variation. A nostalgia that blossoms in isolated conversations, social media posts, hobbies that always have the protection of choice. 

But how do I relate to this nation of mine? I had no strong and spontaneous sentimentality that I could cling to. Rather, a certain sense of distaste to some of the commonly used propaganda mantras of nationalism. The sense of problems in the society had magnified after seeing other more advanced systems. Was there a moral duty to your nation?

I had no certain answer. And that uncertainty was one of the reasons I had decided to pack my bags after completing my training abroad to spend time in the country. After over 2 years of stay, the question of national identity has found its own share of experiences. 

I am clearer about one thing: our power structure is dominated by cold viciousness. And it is an important distinction to make. Not for playing the blame game but for finding solutions. Our people are still powerless. They are still ruled by a few powerful people. Their freedom is still narrow. As a collective society, our ordinary people still don't have any rights assured, unless they use violent means. Reasoning is still not an accepted way of finding a solution. We remain a poor, backward society. We are fragmented at all levels: along haves and have nots, along religions, along cultures, along regional divisions, and along all terminologies experimented by our politicians and thought leaders in the country. We have no unifying national identity that we can relate to. 

As a citizen, my personal experience was that the inner question of citizenship surfaced primarily during the interaction with larger society; public places and public services. And,  naturally, it was a very unsettling experience. But what kept me afloat was the idea that were certainly more powerless and unfortunate persons than myself, who would undergo much more hardship than me. In addition, the acquaintance of a rare few who have lived in the fringes, bearing all the insults coming their way, striving for a better society, amidst a desperately disconsolate society was pacifying. 

As I move away from the country, to a new phase in life, I miss the camaraderie of the few with whom I shared the struggle in desperation (even if it was for a short while) and the feeling that they will have one less person on their long journey of relatively isolated strives. I also miss the powerless patients and persons who appreciated my concerns. 

Perhaps that longing for my colleagues and powerless people amongst us is my national identity.  

Praxis

A dear friend had gifted me a book “A Theology of Liberation” by Gustavo Gutierrez. From it, I learned a new word praxis. It was at the time I was working at Patan Hospital. It was also a time when every day was laced with empty high-sounding words. My vocation was slowly blending into the garbage of verbiage. Amidst that despair, the word praxis hit me hard. In the book, Reverend Gutierrez further elaborates on his emphasis on praxis in the context of his theology:

"This is a theology which does not stop with reflecting on the world, but rather tries to be part of the process through which the world is transformed. It is a theology which is open-in the protest against trampled human dignity, in the struggle against the plunder of the vast majority of humankind, in liberating love, and in the building of a new, just, and comradely society-to the gift of the Kingdom of God. "

How profound! Especially in the context of a vocation that dwells on transcending the worldly matters. 

I had observed several issues at the hospital immediately after joining it. And accordingly voiced my concerns and worked on plans to rectify those. But I was not succeeding. The praxis was not happening, just talk and empty promises. I knew the relationship had to stop. But I also carried an obligation to the issues I had thought so compelled to talk about. At the least I needed to try.

Coaxed by a moral duty to this profound notion of praxis, I decided to try working on these issues at a separate setup. I negotiated with an institution called Biomed to establish a practice that focused on diabetes. The institution agreed to running this practice by certain

principles (see the picture). For over a year now, we have been working based on these principles. We have guaranteed everyone access to a doctor regardless of their ability to pay (those with financial difficulties choose how much they want to pay instead of the regular doctor's fees-- no questions asked). We have protocolized care wherever possible, including the workflow of the office and clinical care of diabetes. Pharmaceutical representatives are not allowed in the patient care area, we interact with industry only as a group if we need to. We have pledged not to receive commission for ordering tests, imaging, prescriptions (which is quite rampant in Nepali healthcare). A strict scheduling system is maintained to ensure fairness. We have trained a diabetes educator (based on curriculum by American Association of Diabetes Educators). Two junior endocrinologists have joined me. We have tried running a horizontal power structure with open communication among us, avoiding hierarchical rituals ("sir", "sister") and encouraging patient advocacy. Our diabetes educator does not hesitate to pick up the phone and remind me to reply a patient email or phone call if I slack. We emphasize on educating patients on lifestyle changes, rigorously adhering to scientific evidence base, using only medications with strong evidence of benefits (and lowest cost with most benefits), treating diabetes comprehensively (not just looking at the blood sugar levels and adjusting medications). 

Now that it has been over a year of our work, we decided to see how we were doing for our diabetic patients. Were we doing the things that we needed to do? Were we changing the outcomes by having those measures in place? Here is the outcome (you might have to click it open to have a better resolution):

In summary, we were seeing older patients with long-standing diabetes and significant co-morbidities. Our adherence to the stuff we needed to do was quite robust. The patients' blood sugars were much better after joining our practice (we generally aim for HbA1c <7% which reflects on longer-term blood sugar control). Most of them had their blood pressures and cholesterol levels at where we wanted them to be. When needed, we were using more medications that are known to reduce certain complications in diabetes patients besides controlling blood sugars. And we were doing this by cutting their cost of diabetes medications to almost half, seeing them only once every 3 months on average (we encouraged more telephone communications/emails when possible to reduce their cost of doctor visits). 

Objectively, I would like to think these are quite good results. Our grumbling was that we needed systemic and structural processes in place to insure that diabetes care is done comprehensively (not based on whims of physicians, their memories and moods). The processes we put in place seem to be paying off. At least at a small scale, at least for the time being. And the results are substantially better than what we found when looking at outcomes at my previous workplace with few foreign students on an elective rotation. 

We didn't objectively evaluate patient perception of our services. Well, several of them have offered me marriage of their daughters/granddaughters (one recently sent an intermediary to check my interest!). I don't know if that qualifies as an indicator of patient satisfaction!

Anatomy of a Success

Kranti hailed from remote Gulmi. She was doing her Bachelors in Education (BEd) in Tamghas, the capital of Gulmi, staying at a rented place. She noticed that she was losing weight, was dizzy and was thirsty all the time. With this she saw a doctor in Tamghas who dismissed her complaints. Unsatisfied, she saw another doctor who checked her blood sugars and discovered that it was quite high. He started her on oral medication but her symptoms kept on worsening and blood sugars kept on escalating. Seeing this response, the doctor appropriately explained to her that she has a type of diabetes requiring insulin for life. They were not convinced and decided to come to Kathmandu. She came to us.

The diagnosis was quite clear to us. She had type 1 diabetes (T1DM) and the second doctor in Tamghas had made a correct diagnosis and placed on the correct treatment. T1DM is a life-altering diagnosis. The patients with T1DM do not produce insulin at all. And if insulin is not given from outside, over time, patients emaciate and die. Even missing a single dose of insulin can precipitate a catastrophic complication.

We explained to her what her disease was and decided on a dose of insulin. Our diabetes educator took her a class where she explained about her disease, about things she will need to consider about diet and lifestyle, taught her how to check blood sugars at home and inject insulin, talked about the symptoms of low blood sugars and how to treat it, discussed about what kind of monitoring she will need to do in the future and gave her our contact information asking her to send us blood sugar results.

She used to call our diabetes educator, who is an excellent communicator and a wonderful and caring human being. After discussing her results with us she used to call Kranti with new doses of insulin and specific instructions.

Kranti came with her father after nearly 4 months from her first visit for follow-up. I knew that things were going well for her based on the phone communications she had with our system. But I did not know that it was going extraordinarily well. She handed me a notebook where she had maintained the log of blood glucoses that she had checked at home. We aim for having fasting blood glucoses between 70-140 and blood glucoses after 2 hours of meals between 70-180. At the beginning, her blood glucoses were off target. But lately, they have been wonderfully on target. Her HbA1c, which gives an idea of a long-term glucose control, was 6.2% (It was over 12% when we started her on treatment; and we generally aim to have it at <7%). Furthermore, she was not having much low blood sugars which can happen with such tight blood sugar control, actually just one episode over the past month. 

Her overall outcomes are as good as it gets for patients with T1DM, even with most advanced technologies and therapy existent in advanced economies. But she was achieving that with the cheapest type of insulin, living in Gulmi. How did it happen? I think, the larger part of the answer lies in the other pages of her notebook. 

She had written down everything our diabetes educator had taught her; several pages of them. It was clear she owned the disease and was determined to do her best. And she had indeed achieved the desired outcome. 

This is success. And it also tells of the ingredients needed for the success. A confluence of determined patient and responsive healthcare institution that she trusted was the key here. Not all patients have Kranti's determination but they do fall prey to the viciousness of diseases. In those situations, the role of healthcare institutions is furthermore important. We were fortunate enough to have opportunity to respond to Kranti's determination.  But the challenge for us is to also work hard for those with lesser determination.

A Disheartening Day

As people still lie buried in a massive landslide in Sindhupalchowk and Sunkoshi river swells up behind the massive dam created by the blockade threatening countless lives, "The D-day has arrived," declares an editorial of a Nepali newspaper. Of course they are talking about Indian Prime minister Narendra Modi's arrival in Kathmandu. The landslide is a done story for Nepali newspapers, after just 1 day of coverage, because the mighty Modi is here.

With the Panchayati era's zeal of King's Sawari streets are being washed with water, potholes closed, hoarding boards removed, road signs placed, street lights placed, citizens asked not to take the VVIP route. For whom? An Indian guy who has yet to prove anything but does carry the stains of bloody religious violence.

The sycophancy is disheartening but also disgusting. Shamelessly they are begging India and China as the first response to a disaster which is perfectly manageable if they just believed in their own people and resources but put the zeal they so blatantly displayed in placating this guy whose country's social indicators trail behind Sub-Saharan Africa's. While the injured victims are being shifted among hospitals because that would suit the government's needs, those injured, those destitute from the disaster, those who lost their beloved ones, weep and cry in desperation, these sycophants will celebrate Modi's visit, closing down the schools for children during the visit, in a temporarily created glitter.

It is a sad day, it is a day to be disheartened for what we have thought of as democracy in this society. 

Treat Me Right

I felt a little vindicated by a recent NEJM article. Once you get into this business of shouting at the fringes, doubts do haunt, especially when routinely your voice hits a wall of silence and reverberates back in a prickly, acid form. Realization that someone else is thinking the same thoughts and that you are indeed not alone is somewhat soothing. More than consoling, however, some of the facts pointed out are terrifying.

There is one study cited in the article. The link to the article is here. It is worth looking at some of this study's findings.

Funded by Bill & Melinda Gates Foundation, the study authors were a team of multidisciplinary folks: economists, anthropologist, health policy experts and clinicians. Technically a very robust study, it was conducted in India to understand what factors determined a good quality of medical care. It is a very similar setup as ours and I can see no reason why the findings cannot be extrapolated to our context. Allow me to point out key findings in a plain language:

- Most of the health care is provided by private male providers (perhaps with big bellies, although the study did not measure the providers' abdominal girth!) both in rural and urban areas.

- Villages get quacks, cities get doctors.

- But the patient outcomes between quacks and the doctors are hardly any different.

- The providers hardly listen to patient or examine, they go straight to the prescription pads and write a robust list of medication.

- They don't talk to the patient. Well, don't start grumbling because even if they did talk, their mouths were more likely to spew disaster.

- You are more likely to receive unnecessary or harmful treatment than the correct treatment when you visit health care providers.

- "High patient volumes", "lack of infrastructure" for poor quality of care are just lame excuses.

- Whether a quack or a doctor, they performed better in private sector. Provider effort might be the key to quality outcomes.

When I ask my rural patients what their parents died of, they give very generic answers. They died of shortness of breath, swelling, suddenly with chest pain, they tell. With our health care systems, we bring these patients and tell them that they have squamous cell cancer of lung with massive pleural effusion, end-stage renal disease, massive acute myocardial infarction. Then we ask them to spend a fortune in proving these esoteric diagnoses. We then ask them to undergo risky treatments like radiation, chemotherapy or write medications that always have a potential to inflict harm.

What right do we have to bring these patients from their lives of simple diagnoses, simple deaths and give them esoteric diagnoses if we have no capability to actually alleviate their suffering?

That might be a fair question. Our debates have focused on improving access: access to health care facilities, access to qualified medical professionals, access to modern technologies. We have hardly thought about how to use those professionals and technologies so that they are delivering what they are actually intended to deliver. 

Furthermore, not all access issues are created equal. Some are so urgent that their existence, regardless of quality might be important: for example, medical transport. Others are not urgent and if a sound basis of quality can not be established it might be dispensable: for example, diagnostic ultrasound for non-emergency problems.

There is no excuse for doing wrong things capitalizing on the vulnerability of people. If we have no capability to run things that are largely dispensable, we have no right to experiment on people and cause harm. Ensuring basic minimal quality of care is as much a talk about doing things right as it is about avoiding bringing unnecessary suffering to vulnerable citizens. At the least we have to make sure effort is being put; provider effort being a marker of better outcomes according to the study. It also means our institutions should stop being cots for sloths. Lives are harmed or lost while they snore and dream their dreams.  

The Line

When I first went to the US, I was very impressed by how people respected your turn in lines at public spaces: at coffee shops, bus terminals, airports. Once you were in a line, you held certain visibility and authority of your turn. It was in sharp contrast to public spaces in Nepal: here your visibility was determined by a complex set of factors that ultimately determined your power. Your turn at public places had a more blatant display of power play and authority. Most of the times, there were no lines, just an aggregation of people, pushing and pulling, more aggressive among the dogs snatching the bone first.

I thought the lines in the US were profoundly right. Especially impressive was when people would open and hold doors for others, especially women and children. This is profoundly and deeply right, I used to tell. And I tell myself now. For a South Asian in America, there was no option to disrespect this system, but I deeply admired it, regardless. I would follow these rules with a full conviction. I thought the habit had hammered in deep, irrevocably.

Apparently not!

I was with two other doctors, chatting, and we walked in the cafeteria. We ordered our coffee and were doing back and forth about one of us wanting to pay. A young woman who was ahead of us suddenly raised her voice.

"Why did you not complete my order?" she asked the man in the counter. Then she turned to us and said, "For him I am garbage. No. 1, I am a woman. No. 2, I am not wearing the white coat you guys are wearing."

What had happened was, the boy in the counter just stopped mid-order with the woman and took our order. We didn't even notice that the woman was ahead of us. She was short woman in simple kurtha surwal.  And in our jolly disposition we catered to the attention the boy in the counter paid us. It seemed all natural. And probably would have gone unnoticed in the incessant flow of things in this mighty nation of Nepal. Except that this young woman did not have penchant for the order of power in this cafeteria.

Suddenly I felt completely ashamed. But more than that I felt terrified. Consciously, and in deliberating mind, I would have never used my masculinity and white coat to trample over the line. But here I was, doing exactly that. Against the value I held dear. In this unconscious exercise, the woman without a white coat was an entirely invisible figure.

I apologized to her profusely. But the saltiness deep inside couldn't be washed away with those apologies. The uneasiness persisted for days.

In Ralph Ellison's fiction "Invisible Man" the reason for invisibility of the main character is largely racial. Or, at least, the narratives suggest such. It is one basis of invisibility. But in our society, as I ruminate, the bases for invisibility are plethoric.You could be a woman. You could be a consumer. You could be a filthy fellow covered in city dust or village mud. You could be old. You could be a child of a farmer. You could be a patient at a public hospital who does not know any body in the system. You could be a village student trying to get a citizenship certificate at the district administrative office....

We are a society of invisibles. Visibility assured only after mounting ourselves on top of other invisibles. Bigger the pile of those invisibles underneath our feet, the higher our cliff.

No one is spared in this dog fight, it seems. If you hang around long enough. However much you trumpet on the solidity of your moral foundations. 

River Ghost

She had a poetic aptitude for expression.

"I would let the chickens out of the coop. As they grazed, I would stare at the river. 'This is it, this has been the life for me that is about to end,' I would tell myself.

I was shaking. I was losing weight. I was sleepless at night and heart used to beat in a terrifying way. 'The river ghost has caught me and is bringing me down,' I thought. Little did I know that it could turn around so fast. I feel reborn," she narrated. A little perked up on this visit after medication dose adjustment on the last visit, a few days ago.

For those of us who have chosen medical subspecialties, this is as dramatic as it gets for the change in patient outcome. We are not the doctors who slit open the chest to plug the bleeding heart or crack open the skull to chop out a tumor from the brain or fix a broken leg after just a few hours of work. We are the ones who listen to vague prattle of patients, attempt to find what's bothering them by doing tests and tweak their physiology by several means to see if that helps. The outcomes are not necessarily dramatic.

At some level, the creed of medical subspecialty is an abstract one. We have to listen to vague words, grab non-verbal cues to direct us to the culprit. We do tests to explore our hunches. Abnormalities in these tests, we are asked to infer, reflect abnormality in certain body parts or processes. Based on these results we give our patients medications. We do not see these medications working with our bare eyes. But we take a leap of faith based on what someone else has told us about how it works. We work based on perception, hunches, and faith on certain tablets, capsules, injections or devices. It's a mushy field.

Yet, we choose this field with a notion that it helps suffering patients. And just like religious people who talk about their "doubts" on their god, we do have our doubts in our faith-heavy creed. I sometimes find myself asking, what are we really doing, when I see a patient who has to swallow twelve medications a day.

But the experiences of patients like our poet patient are what pulls us back to the vocation. Reaffirming our belief in the power and value of this creed.

However, Ms. poet's plight has another layer of story. Her suffering was largely inflicted on her and totally avoidable. The suffering, which spanned a length of life and death in her perceptual realms, was rather easily treatable and preventable. 

She saw a doctor about a year ago with several vague symptoms. Her doctor found out that her thyroid gland was not producing enough hormones. He put her on a relatively high dose of thyroid hormone. But she never had a follow up after that. Her thyroid hormone levels were never checked and she kept taking the medication. That dose was excessive for her and caused all her symptoms.

At technical level, it was a very simple and routine problem. There was not much of threat to her life and the problem was easily solvable. But her suffering was indeed not so benign. She thought she was dying from the wrath of an unkind river ghost.

The question of why she had to endure such a suffering is a complex one. Perhaps she ignored the doctor's instruction to have blood tested after a few weeks. Maybe it was entirely her fault.

But what bothers me is that more likely the fault was entirely ours. If you have interacted with our Nepali doctors and power holders, as a nobody, I am sure an impassive face will come to your mind. This face is quiet, distant, and almost conceited. For the things you need to do, you are expected to find out using intuition. By heavenly mistake, if you happen to inquire this godly creature, wrath might spill out in violent waves, drowning you in an utter indignity. So it would be no surprise if this patient was never explained that she needed to have levels of hormones tested after 6-8 weeks or she heard a babble that she didn't understand but didn't have courage to ask.

For those of us who have chosen medical subspecialties, making our patients understand things is not a luxury but a basic necessity. Their outcomes and sufferings depend on it. We will not succeed always. But we have no right to put on our smug face and ask our patients to intuit us. In our mushy world, our conscience demands that at least we try. 

(Addendum: This got published in Republica with some addition + editing on June 24th, 2014. They changed the title to "Cold shoulder" which I have a hard time relating to. But our mighty editors do not seek writer's consensus to change things. They just do it! Still, I have to take a solace because it is less cringe worthy than being changed to almost bigoted "White man's burden" for an article that guilelessly talked about "Resources and physicians" just because the patient context was the US.)

Chiraito and Kidney Damage

Mention of Chiraito (चिराइतो) terrifies me these days. Chiraito (Swertia chirayita) is a plant that seems to be widely used in alternative medicine. Nepal apparently is the major exporter of Chiraito, to such an extent that IUCN has listed it as a "vulnerable plant" because of "over-harvestation." My introduction to this herb was through a cousin's husband who told me a tale of his kidney damage in his venture to quash diabetes through the bitter solution of this plant. Luckily, after stopping it and spending a fortune in investigating the reason for kidney damage, including a pilgrimage to Indian healthcare system, his kidney has slowly started normalizing. It has now been several years since his initial tryst with the bitter devil. Although he still has a happy go lucky attitude to difficult struggles in life, I am sure it has left an aftertaste. 

I had not made much of Chiraito but recently another patient with diabetes came to me. This  man had taken Chiraito and his kidney functions went from completely normal to those requiring dialysis within a span of a month. I referred him to a kidney specialist. Who knows which direction his kidney functions will go, but its for sure that he will have to endure a suffering attributable to apparently benign Chiraito. Herbs don't have side-effects compared to allopathic medications, we have been told. But not to these two people and perhaps many more that I do not know.

This time, I decided to look up if there was any information about Chiraito. There was a recent lab study conducted in India that showed that it has a bitter chemical called amarogentin that inhibits an enzyme called COX-2 (cycloxygenase-2). Inhibition of COX-2 is a process used in several pain medications. And we do know that several of these pain medications can cause kidney damage if used for long time and at high doses. What must have happened with two of these Chiraito patients is that they had too much and too long of this substance.

That is an uncertain territory we enter with alternative medicine. We have no systematic  information about the substance that we are given. It is based almost entirely upon a blind trust: of a kabiraj or a relative who swears to its usefulness. It might work or it might be a poison. But it would be a mistake to claim that all herbs are innocuous and without side-effects.   

About Our Work

Our work has received some attention. Annapurna Post has listed us as an innovator in Nepalese health field on their especial publication commemorating their 13th anniversary of publication. Dr. Karki is a dear friend and mentor, we would like to thank him for his kind words. Here's the scan of the publication:

Bring Back Our Girls

They must have run around the ground of the boarding school at the afternoon break. A girl giggling after another one tripped over. That girl might have cried, angry that she was giggled at. Finally, after the boring classes were over, they must have returned to the hostels, changed their clothes, had their snacks, and huddled in a class room to do their homework. They must have repeatedly looked at the wall clock, for the time when they would be allowed out of the room. As soon as the clock hit the time, they must have rushed out, only to be back to bed. In the quiet of the night, ceiling fans must have made whirring noise, fighting off the Nigerian summer. The girls must have been deep into sleep, dreaming perhaps.

What must it be like when they were woken up with noise, perhaps of gunfire, of crying and screaming friends? Bearded men brandishing machine guns in their hands must have grabbed their collars, pulled the girls out from their bunk beds, dragged them through the hallway while they were screaming and crying, loaded them in the truck like garbage bags and speeded through the dirt road, the truck jumping at the bumps, synced with the screams of terrified girls.

James Orbinski, who witnessed the horror of Rwandan genocide first hand as one of the only few doctors daring to care during the carnage writes, "...Over the last twenty years, I have struggled to understand how to respond to the suffering of others. I have come to know perhaps too well that only humans can be rationally cruel. Only humans can choose to sacrifice life in the name of some political end, and only humans can call such sacrifices into question...."

Boko Haram, a religious extremist group, kidnapped 276 girls from a Nigerian boarding school on the night of April 14-15. They are yet another testament to that rational cruelty. Hell needs not be imagined in various religious forms, the face of the evil ruling that hell can not be any crueler than of these kidnappers.

Rhetoric and Reality

(Note: This article got published in Republica with minor edits)

If a newly diagnosed diabetes patient came to see me at Patan Hospital’s general medicine clinic, I would perform several tests to ensure proper care. I would check hemoglobin A1c to assess her severity of diabetes, test her kidney function, evaluate if she is throwing out protein in urine, test if liver is functioning properly, and measure cholesterol levels in the blood. For this visit, she would pay NRS 25 for registration but about NRS 2310 for the basic minimal testing that she requires for appropriate diabetes care. After all this, she will have to go home with a bag of medications that comes with obvious cost. Patan Hospital might take a pride in saying that it charges a meager 25 rupees for a patient visit, but that is just a miniscule portion of the patient’s actual healthcare cost.

The point is, doctor’s fee is a rather small portion of a patient’s healthcare cost. Main drivers of cost are tests, medications and medical devices. It gets especially ugly if unnecessary tests are performed and medications prescribed. And it is no news that our healthcare providers are incentivized to do exactly that. We have heard of our doctors receiving “cuts” for sending lab tests, prescribing certain medications and even referring patients to certain institutions or providers.

So, if I were a deliberating patient, I would choose a doctor based on how unlikely she is to order unnecessary tests or medications while not missing what are absolutely essential. I would like her not to have incentives tied to prescriptions and lab orders. I would happily pay a much higher fee than NRS 25 if these were ensured, because that extra cost is just one unnecessary test away.

Lately, newspapers have reported that the Ministry of Health and Population (MoHP) is planning to cap and enforce doctor’s fee. Furthermore, Republica reports that even the prevailing fees are lower than the cap. Why is this non-issue taking a front row seat? One has to concede, the MoHP officials are either very disconnected from patients’ realities or they are plain and simple stupid.

Even this cursory exercise tells us, doctor’s fee is not the biggest determinant of a patient’s healthcare cost. Accordingly, there are multiple high-impact potential targets for cost control. We have to ask, how we can cut down the cost of lab and radiological testing. How we can reign in an unethical practice of ordering unnecessary tests and medications for financial incentives. How we can make equipment and medical devices more accessible and affordable. In addition, we need to ensure that the cost of medications is reasonable. While the remedies are not as obvious or simple, any genuine cost cutting effort cannot circumvent debating and deliberating these issues.

Furthermore, whatever is a patient’s financial means, what matters ultimately is the health outcome. We want to get better at any cost. We sell our cattle, our land, and our hard-earned savings to seek treatment. When we put so much trust in these medical interventions, what should matter most is that the healthcare system delivers to that trust. We are not just seeking a cheap treatment but also an effective treatment. Quality medical care is actually what we seek. Of course we would like to pay less for it.

Unfortunately, our public debate hardly acknowledges the intricacies of patients’ needs and the corresponding complexity of delivering to that demand. It is no surprise that rhetoric of  “free health care” is so rampant. Anyone pausing for a moment and thinking can realize that there can be no “free health care.” Delivering health care needs infrastructure, personnel, medications and equipment that come with a cost. The best we can do is pool our risks and minimize the cost for the victims of diseases and injuries. It would indeed serve us well if we root ourselves on practical realities than rhetoric. This proposal of capping a doctor’s fee is a rhetorical exercise disconnected from the real needs of our patients. It is far detached from the potential to bring down costs.

Finally, it is about time that we are done with doctor bashing. The reality is, after we pass past the dreamy aspirations of medical school, we doctors walk a blurred line amidst necessities, greed and professional obligations. Larger structural issues, checks and balances in the system largely determine how we behave in our daily practice. The society in general and government in particular has the responsibility to address these structural issues and ensure effective regulatory mechanism. Yes, some of us have crossed professional ethical boundaries and behaved poorly. Where are those regulatory processes? Where is our government to hold us in check at those instances? More importantly, we should not forget that numerous of our junior doctors work in the muggy air of crammed emergency rooms with air laden with tuberculosis, intensive care units with bare minimum support and protection, medical wards with surfaces laced with resistant bacteria and filth, deprived of sleep, and for exhaustive hours that is inconceivable in any other profession. They work at incredible personal risks. While their peers, who work in lucrative development jobs, writing reports and policies that never see the light of the day, come home with a six-figure salary, these doctors satisfy themselves with NRS 10,000 per month. Vilifying these doctors in the process of lumping doctors for rhetoric’s shake would be an utter injustice.

The problem at hand does not lend to a simplistic assessment and equally cavalier attitude of using the governmental power. People do have a choice in whether they want to see a doctor who charges NRS 1000. We don’t need our government to father us in making that choice. What we do want is help in ensuring that we are getting our money’s worth. That is and should be the purview of a democratic government. But it is also exactly where our government is utterly ineffective and our government officials have no wit, will or ability. For starters, our tax paid government officials would do much service in cutting cost if they even just focused on stocking low-priced quality medications, performing quality affordable lab tests, and consistent and reliable radiological tests at public institutions. Instead of coming up with these wacky ideas!

Kafal Sellers of Sworgadwari

Whose Kafal (Bayberry) should I buy?

Pardon my business acumen, but would it make more sense to spread out and sell? Wouldn't that increase your likelihood of making money for your own?

There is a certain innocence and cuteness in this group of Kafal sellers huddled together at the same place. With their baskets, wrapped in cloth, stashed with the produce from the wild. In their Kurthas, Surwals, Pachhyauras and Chappals.

These shy girls are huddled together, perhaps for each other's company. To survive strangers' exoticism. What will happen if they overcome this shyness and decide they want to make profits by competing with the other Kafal sellers? There's a certain harshness associated with this change. Cute innocence is trampled over by selfish motives. It feels as if something precious is lost in the process.

But that is a sentimental observation of an outside observer. Their act of Kafal trade is hardly cute. It is a chore you need to endure, fighting the glare and foreignness of strangers, in hopes of making some money that stoke vivid dreams. Cuteness and innocence are not what is celebrated here, not even remotely.

Mr. Maharjan

Amidst a patient visit I received a call on my cell phone. I ignored. But it rang again. So I excused myself from the patient and answered the call. On the other end was the daughter of a patient I used to see while working at a public hospital. The patient, Mr. Maharjan, had a long-standing diabetes. It had damaged his kidneys. The damage had now progressed to a stage where he was no longer able to throw out enough water and toxins through urine. As a result, fluid built up in his body. He had difficulty breathing and extreme weakness. They had brought him to this public hospital. He underwent emergent dialysis to remove fluid and toxins from his blood. 

"They have told us that we will be discharged. And they have asked us to find a place to have dialysis two times a week because there is no empty dialysis slot at the hospital. What are we to do?" she pleaded. With a shaken up voice, she continued, "we are poor, there is no way we can pay for dialysis unless we do it in government-subsidized place." "How can they just ask us to find a place when this is the only place we have been for all these years for his diabetes treatment?" she lamented. 

"I didn't know what to do and remembered you because you had treated us nicely at the hospital. Would you be able to help us?" she asked. 

What must it be like: to be drowning in your own water, gasping for breath, knowing that there is a way to relieve it, and yet being left alone to your own devices? As a society, we have actually already agreed to help out those who are in such needs. Government pays for dialysis at several government and non-governmental facilities. We tax payers, including Mr. Maharjan, are paying for this assistance. Multitudes of dialysis centers have popped up in Kathmandu. So why is Mr. Maharjan, amidst dire health condition, given a violent sentence of uncertainty?

Our doctors become quite animated about larger political, structural influences in health care systems. Many of the concerns are very legitimate and valid. And larger, systemic, political and structural issues do need to change for this health care system to be more accessible, just and fair. But many of these issues do not fall under our daily activities of patient care and doctoring. What we don't realize is that there are much more urgent issues directly under our power and capacity that we ignore. And to a ruthless extent. Which bureaucrat or politician will be able to understand the plight of Mr. Maharjan, real time, better than a doctor treating him? Yet, we choose to ignore to act. Rather, we take a delight in pronouncing dooms, telling this patient, good luck brother: find a place to get dialyzed on your own. Did they even consider what kind of ordeal it might be to the patient, a simple man without much education and means, to find a place where government offers subsidies for dialysis? Would it be easier for us who know hospitals and health care system to look around or it is best left to the patient? How can we just open the door and tell a gasping patient: out you go, do whatever you want? Is it even moral to dispose a patient to his means when we know that there is a solution, or at least an attempt could be made? 

I told her, "let's see what we can do." 

I first made a call to a friend who is a nephrologist at a medical school which houses a large subsidized dialysis facility. He told me there were no empty slots but asked to send the patient anyway to see if he could figure out a solution. I asked the daughter to go meet him. The best they could come up was an alternative way of dialyzing (called peritoneal dialysis) but it came with an upfront cost for tubings and devices to be connected to the belly, it was not an ideal option. So I searched out the contact for the chairman of a non-governmental organization which has been organizing dialysis facilities at multiple places. I told him the story and asked if he could help in any ways. He generously offered to do free dialysis at his private hospital. It was a big relief. We arranged an appointment for the patient at his clinic and I asked the daughter to go to that appointment. In the mean time, I wrote a letter to the chief of the service at the public hospital where the patient was admitted, and who I knew as a man who would go extra miles to help patients in need, detailing their plight and pleading, "you can very well imagine in what dire straits this patient is." In a few days, the chief of service from the hospital replied me saying that they were able to arrange dialysis within the hospital. 

Wow! That was it? There was not a magnanimous gulf separating possibility. But why did the patient have to undergo this distress of uncertainty while gasping for breath? 

The daughter called me to thank. 

After a few phone calls and few keystrokes of a computer, I will be able to get my good night sleep. But that can't be said of Mr. Maharjan and his daughter. Their ordeal has just begun  and it will end only with his death. 

Swami Ji

The hall was packed with people; the cleanly-dressed kind that have been sheltered from dust and soot that beclouds the majority. These were mostly doctors who had congregated to talk about spirituality. They were listening attentively. At the stage, Swami ji, adorned in yellow robes graced the throne. Throne, indeed! Long hair flowed out from his head, streaks of grey boosted elegance of his eminent beard. Energy was ebullient. Swami ji had captivated the audience. 

At the end of nearly an hour of his discourse, the message I gathered from Swami ji was: Thought is powerful. I felt that the discourse lacked any substance. It neither offered me any information about why recognizing thought as powerful was important nor it told me what next after recognizing the power of thought. It was an exercise of futility lacking in any direction or intent. It was as if someone spent an hour saying, "there is an apple in a tree."

But the Swami ji captivated the audience. He was a master at that. He had energy and charisma during the talk. Interjecting with rhetorical English statements during his monologue in Nepali, he convinced us that he was no traditional jogi. He would spit out a string of English names, who he informed us were philosophers. "Emerson knew that the East had already figured out two thousand years ago," he told us. "Big bang theory tells us that the world is going to end," he declared. He told us stories, simple ones in very easily understandable language, wrapped in humor, and we laughed heartily. "I consider myself philosopher and not a traditional jogi" he pronounced. He giggled wildly, laughed like a fool. Shouting at times, he toned down to a whisper like some musical exercise. He was a sight to behold.  

As he descended the stage and later walked out of the hall, he was surrounded by numerous young men from his organisation, clad in fluorescent jackets (like those of traffic police), people surrounded him, bowing, heaping praises, he was offered money and those young men in fluorescent jackets collected the money. Swami ji swaggered out the door smiling at a captivated audience, waving his hand, blessing perhaps. More young men started collecting many of the audio visual equipments that had been set up for Swami ji's discourse. It was a massive enterprise; the act of discourse. Even after the Swami ji left the premises, the young men lingered along with numerous video cameras and microphones, interviewing the attendees and taping the responses. 

There can be a discourse that transcends reasons: that of faith and things beyond reasoning. But that can be a coherent, meaningful discourse. There can be a discourse of matters using reasons and facts. His was neither of those. It was an entertaining talk by a charismatic man using pseudoscientific gibberish. 

And it had impressed the audience. It was terrifying that just the style of a substanceless  monologue had glossed over their critical reasoning. And it was furthermore terrifying that many in this audience claim the intellectual authority in this society. No wonder the Swami ji blankets Nepali TV stations in the mornings. 

Weather Forecast and Nepali Healthcare

Radio was our access to the larger world. In the silence of the night when crickets were chirping, in the dull sunny day punctuated by shouting of someone ploughing the fields using oxen driven ploughs, in the evenings when the sun started hiding behind the hill splashing gold in the horizon, or in the mornings on a clear day when mountains at distance glowed in glory, radio ruled. For us kids, music was the lure but we had to endure the news that the older ones prioritised. At the porch, we assembled around the radio. The news from "Radio Nepal" had a fixed format. At the end came the weather. They would quote the "Department of Hydrology and Meteorology" (DHM) and provide weather forecast for different regions of Nepal. Had you asked us kids at that time, we would have recited you the exact sequences of the regions they would forecast. But we would have told you that if the forecast predicted rains, it was almost a guarantee that there would be a sunshine. As I recall, it was hardly ever accurate. We trusted more our elders looking at the sky and predicting based on clouds than our trusted radio for the weather forecast. But the ritual continued unabated. It even continues to date.

How did this ritual come into place and why does it endure despite dismal track record of outcomes?

When I first went to North America, I was surprised by how much weather was common in social conversation. At the end of an interview someone would say, "tomorrow is going to be beautiful, you may want to explore the area." People planned their recreation based on weather forecasts, made sure that they had shovel in their cars if there was a prediction of snow in the evening. The weather forecasts were quite accurate. It was a completely different culture compared to what I was used to. We hardly ever planned things taking weather into account. In summers we were always ready with our rice seeds. We waited for the rain and when it poured down, we ran to our fields. Agrarian life was simple: it revolved around the crops and the activities dictated by whims of the weather. There was no point in planning out things but being prepared to comply with the dictates of the weather.

What must have transpired when the Nepali government decided to adopt the practice of forecasting weather back in 1962? Did someone who had learned about modern governance say, "we need this component of modern governance?" Or, perhaps, they looked at departments established in Indian government and say we need this too. Maybe foreign donors suggested establishing it.

How must they have first started the services? Did they get experts from outside who were used to doing this work regularly? Did they send personnel overseas to get the training? What kind of technologies they must have first imported? Were the initial weather forecasts accurate? Regardless, we know that in the nearly half a century of this exercise, the DHM's weather forecast has not been able to gather people's trust. These days, if we need any information on weather, we would rather turn on our Yahoo weather app than tune into Radio Nepal. Despite its futility and irrelevance DHM's persistence continues unperturbed.

It was an introduction of a new technology to a society where there was no real demand. Over the years it has degenerated to irrelevance. The outcomes are dismal. The whole process is now a bizarre exercise far away from the intent. The weather forecasts' such failure might be benign, but we have adopted many other technologies where the failures are not at all benign.

We lost 18 lives recently to an airplane accident in western Nepal. It is dizzying if we look at our aviation accident data. Every single year since 2010, we have had plane crash taking away lives (See here: 2010, 2011, 2012, 2013, 2014). And this is out of just about 20-30 events in the whole world (that includes incidents as well, not all crashes). European Union has blacklisted Nepali airlines and banned them from flying in Euro zone. Yet, our shamelessness and complacence is unperturbed. We have adopted technology but mixed ruthless incompetency to the operational process. The result is devastating. I doubt the folks running Nepal's aviation industry have any inkling of insight.

This same risky adoption of technology is rampant in medical field that I am part of. In Nepali market-place you can find all the fancy new developments in global medical technology. For some of the medications which required crossing some hoops in North America, you find them here without much trouble. It is very easy to spot a neurosurgeon or for that matter any "specialist" in any field . A single person will claim himself to be an internist, gastroenterologist and endocrinologist without any structured training. With zero (0) fully-trained endocrinologist, a government institution runs an endocrinology fellowship. These poorly-trained "specialists" equipped with scopes, scalpels, injections and drugs experiment on lives; groping in the dark, unsupervised, unaware of how those trades/skills are supposed to be actually used. Unfortunately, there is no bang and fire of airplane crash in these nonchalances. Just voiceless and silent lost lives, sufferings, and hardships. Those who are so eager to adopt things that they don't have much idea about argue that it is a transition for the sake of future. But, in their recklessness, what they should realise is that poorly adopted technologies or authorities (in certain specialised skills) have grave consequences in medical field. Just like aviation industry, Nepali medical field has a lot of soul-searching in order. It is already a terrifying territory now.