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. 

Arundhati Roy

"The things I've needed to say directly, I've said already. Now I feel like I would be repeating myself with different details," says Arundhati Roy in an article in NYT piece on her. I dearly hope and wish that Ms. Roy is not swayed away from the details by the apparent reiteration. We will be deprived of unparalleled clear narratives that has come with great personal risks to Ms. Roy, as the article makes it quite obvious.

"Titillating," is the word I attribute to the feelings her fiction "God of Small Things," had incited when I first read the book. The softness of her language cuddled a story that was not so kind. The woman so tender to her story has not been very delicate in her diagnoses of social ills ravaging India and in some cases the world. In the process, she has been a target, an outcast. Speaking truth to the power is a risky venture in these shores. The reactions tend to be visceral, personal, and defiant of logic and reasoning. But I hope we will continue to hear from Ms. Roy.

The Entitlement of Our Elites

An Indian diplomat to the US named Devyani Khobragade was arrested in New York on charges of forging visa documents for her house maid, making the maid work long hours, and not paying the agreed upon sum of money. The maid had filed the complaint. Ms. Kobragade lamented that she was handcuffed, strip-searched and treated like a "common criminal." The U.S. prosecutor involved in the case, Mr. Preet Bharara, defended that there was no violation of protocol. He asserted, "Is it for U.S. prosecutors to look the other way, ignore the law and the civil rights of victims or is it the responsibility of the diplomats and consular officers and their government to make sure the law is observed?"

The fury the arrest incited in India was astounding. The prime minister and the parliament expressed outrage against the arrest of the diplomat. They removed security barricade from the U.S. embassy, expelled a consular, blocked the flow of whiskey for the embassy staff (one has to wonder what incites creativity in Indians!). There were editorials condemning the U.S. There were enthusiastic flag burners in the street. Media reported that the maid's family was threatened. Even our own fierce proletariat Prachanda's foreign relations advisor penned an OpEd lamenting how was it possible for the poor diplomats to survive with a maid on meager USD 2000 per month if they pay the minimum wage demanded by the law of the land  (my simple advise to the advisor in such a profound dilemma would have been: not own a maid). 

I was flabbergasted by the Indian response. A person who had abused a vulnerable, powerless worker, lied to the authorities, was arrested following the law of the land following the complaint of the victim. And the whole country was vouching for the person who had committed the crime!

She howled, she was treated like a "common criminal." And the country said, "yes she is no common criminal, she needs to be treated special!" 

"It is a matter of our national pride, the pride of our mother country, the pride of our flag, the pride of our government and parliament, brothers and sisters!" said the Indians. "Yes!" everyone said. 

The crime vanquished from the conversation. Why bother what the grievances of the maid might be? The whole focus turned on: why was Ms. Khobragade treated like a "common criminal?" The turning of this beyond-common elite to a common was what hurt the conscience of the elite India. 

That is the entitlement of the elites of these regions. They have been so used to trampling over the rights, dignity and conscience of the powerless that if they are told otherwise they feel out of space. As if the reality has been distorted. I had learnt about it a little while back at smaller scales seeing our "Sirs" at public institutions. But I had never imagined that this can play out at the national scale as well. While at the smaller scales the tools of chauvinism are "insider"/"outsider", "senior"/"junior", "obedient"/"non-obedient", the tool at these national levels seem to be that of unreasoned nationalistic pride. 

In this perverse reality, countless of her citizens end up working in extreme conditions in middle east, her daughters and sisters raped and abused with none to voice the agony, her children denied basic dignity. Where is that diplomatic muscle where it is really needed? Where is that diplomatic muscle when it concerns the powerless? 

Dr. KC's Crusade

A paranoid schizophrenic man opened a fire in a public gathering of US congresswoman Gabrielle Giffords in Arizona in 2011. Six persons died, several were injured. Ms. Giffords was shot in the head; the bullet passed through her brain. She received immediate medical care and was operated emergently. She has made a remarkable functional recovery.

Dr. Peter Rhee, a trauma neurosurgeon who operated on Ms. Giffords took up the stage daily to update the press and the nation about her progress. However, he was an unconventional (almost exotic) character on the television news screen. Some people found his character to be even abrasive. Bottom line: this was a character not polished with the etiquettes of public speaking. He knew his trade; he had outcomes to support that but not the finesse of television talks.

We are also seeing our Nepali doctors on television screen on an almost regular basis now. There is a distinct difference of our doctors from Dr. Rhee. Their conversations on television screen are impeccable. They speak in language totally indistinguishable from that of our politicians or bureaucrats. There is a certain ease, smoothness and a natural flow. It is impressive!

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As a 16-year-old boy, when I first read “Satyagraha in South Africa” by Gandhi, a knot formed inside my throat, my stomach churned, and tears poured out ceaselessly from my eyes at some point in the book. A burly pathan had thrashed Gandhi, bloodying him, because he had made a compromise with the rulers. A heartbreaking agony seeped inside me upon learning this harmless creature being beaten senselessly. I wanted to rather receive the beating, if I could, to spare this saintly man.

Perhaps that was the power of Gandhi’s personal character that formed the foundation of his non-violent movement. People felt Gandhi’s pain as their own. The sheer passion evolved into a massive movement with means revolving around self-sacrifice. Indians succeeded in ending the imperial British rule.

Lately, we have seen revival of similar means in our region. In India, a saintly man named Anna Hazare challenged the central government to address corruption and a new party called Aam Admi Party (AAP) blessed by Mr. Hazare came into power in Delhi. In Nepal, an orthopedic surgeon Dr. Govinda KC has been using hunger strike to address political issues plaguing his institution- Institute of Medicine (IOM).  AAP is aiming to change Delhi government so that it serves the people. Dr. KC is aiming to change IOM so that it is a better institution. These movements gathered steam based on distinctive personal characters of their leaders, especially their demonstrated track record of self-sacrifice. Their personal characters have touched the chords of people’s heart. Perhaps similar to how Gandhi’s character had. However, I feel, there is a distinct difference in the struggles that Gandhi pursued and what these folks are pursuing. Gandhi’s was of justice, theirs is of building institutions. So we should ask: Is it likely to succeed?

AAP’s ascendency to the throne of Delhi government was dramatic and filled with drumbeats of radical change. But looking from surface now, their activity has turned into a circus.  We have no idea if the end result is going to make any difference in peoples’ lives the aspirations of which had buoyed AAP to the power. I have no in depth knowledge of Indian politics and I would like to leave it there. But I would like dwell a little bit more on Dr. KC.

Dr. KC is known to have a distinct personal character. He is single. He lives a very simple life sustained by sole salary from IOM. He abhors private practice and earning extra money. He spends long hours in patient care. He travels to remote areas of Nepal on his own to care for sick people. He even travels overseas in disaster struck areas to offer services for free. This compelling personality seems to have touched the hearts of people. When he staged hunger strike recently, the passion people had for him was apparent. The doctors closed outpatient services in majority of the public hospitals throughout the country, there were parallel hunger strikes in solidarity with Dr. KC, there were mass resignations from doctors, news channels had the hunger strike as top story for several days and the government heads had to scramble to address the demands this doctor had placed. After 14 days, the hunger strike ended with an agreement. It has been a few weeks since that agreement. Now, Dr. KC is back to hunger strike because the government has not implemented the agreement.

At the crux of Dr. KC’s struggle is the intent to have IOM as an autonomous institution protected from the savagery of political beasts that have incinerated a possibility of a decent society; although the language of his demands also includes many other issues pertaining to the overall health care of the country.  If the media reports are true, the extent of shameless savagery politicians, corrupt bureaucrats in government and officials at Tribhuvan University have exhibited in pursuing their interests is extraordinarily disgusting. In that light Dr. KC’s noble struggle is truly very welcome. And his means of using his moral connection with other people brought together by the influence of his extraordinary personal characteristic is praise worthy. However, before we get swept away with this inspiring movement, it is important that we ask if it is likely to achieve the end results.

What are those end results?

Based on the demands set by Dr. KC, it seems to be achievement of autonomy of IOM, barring permit to open up new medical schools (where there is allegedly a huge bribery going on under the table to get approvals) and holding corrupt people in the system accountable. These are clear demands that are possibly achievable by the means Dr. KC is using.

However, it would be a mistake to pin too much hope on the dream of having a better IOM or national health care and health education system even if these demands were fulfilled. The real end results that the public institutions have to deliver is: accessible, quality health care and manpower trained to deliver such health care in responsible manner to dignified citizens.

I am afraid, the top-down structural change that Dr. KC is striving to bring about has to be met with bottom-up institutional changes to succeed in achieving the ultimate goal. And, I am afraid, his struggle hardly acknowledges that component. The political component can rile up passions because it is so dramatic. But the mundane day-to-day functioning of patient care where every patient interaction is weighed in terms of fairness, justice, appropriateness, quality and dignity is too banal, and too tying down. Holding everyone in the system accountable to high standards of ethics and integrity in patient care is too tedious. Our public institutions have considered those aspects dispensable. This was all too apparent in Dr. KC’s 14-day hunger strike. Outpatient clinics were closed, patients admitted to the hospital for surgery were discharged. The doctors conducted clinics in open tents in some public grounds. It was a mockery to the plight and dignity of sick individuals. They deprived sick patients of care or threw them out of their care and to top it off rounded up a drama under the tents. These doctors’ insensitivity to patients needs demonstrated during these protests speaks of a larger problem in everyday functioning of these institutions. That is how they are used to treating patients, that is how these institutions have allowed them to treat patients and it’s just natural for them to behave so. That is the component Dr. KC’s struggle will not address. And Dr. KC’s political achievement will be meaningless without the corresponding changes in the intrainstitutional behavior.  The same forces that are abusing the system now will find ways to corrupt the system in the new setup unless the institution has that corresponding bottom-up changes. It will just force them to use newer tactics.  Dr. KC will have to continue his hunger strike forever. Would it be more fruitful if the man of such integrity use more creative ways to build institutions that would care for patients than doggedly swim against the tide that will only be changed by collective transformation of this society at peoples’ level and perhaps at intra-institutional level?

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Being a doctor is a political job (Virchow would convince you on this). We want our doctors to be political. But there is succinct distinction we have to make. Using prevailing political language is not equal to the political cause that the doctors should pursue. Our political language concerns the interests of our patients that are connected to the larger society. This language has connection to issues like justice to our patients, fairness, ensured access to health care, dignity, and quality of care. The further our conversations go from these, we have to ask ourselves: are we embarking on a different turf? That turf might still be extremely valuable. But we have to get out of the illusion that it is the only thing holding up from building our institutions.

The Thud

It is a thud

That precedes a void,

perhaps silent,

perhaps empty.

Beyond the realm of quantification,

beyond the definition of a moment.

Detached from the senses,

and its languages.

Perhaps it was the cosmic darkness,

that filled the gap left by an event too nimble for the notion of time.

Senses overwhelm as he comes out of this void

What happened?

What’s happening?

What to do?

The questions churn around in his head,

at a singular moment before he lands to the asphalt-paved road.

“Head, head, head,”

He recalls telling himself as he descends to the ground,

tangled in the cross-bar of his bike.

The doctor in him has planted itself deep, 

later he tells of this reflex action. 

The thud knocks him down to the ground.

Its gallantry is no joke.

Days and weeks follow,

that attest to the mightiness of the thud.

Roaring from afar,

in unassailable commands,

the thud orders:

Dependence

Uncertainty

Fears

Helplessness

Pain

Restlessness

To which he bows in solemn obedience.

Try, it might,

to lull the world in the reverberations of its sound,

but the thud meets a more powerful resistance.

That of:

Kindness

Love

Selfless care

Of

Family, friends, colleagues and complete strangers.

Almost overwhelming.

Indebting

To be paid by comparable terms or heaps of guilt.

The soulless, mighty thud has no lessons to learn.

It has no mechanics to learn lessons.

This leaves the witness,

He,

to mop up the floor.

To be so deeply grateful to how much goodness exists in this world,

To be again indebted to the kindness and love people are capable of pouring out.