Saturday, March 5, 2016

Turkey Dinner


On Christmas eve, we decided to cook turkey dinner. Late after work we headed to the grocery store bustling with last minute shoppers. Not finding the 12 lbs turkey that Ina Garten's recipe called for, my wife and I were weighing in our options, picking up a few frozen turkeys in the horizontal freezer,  to see if there was anything close to the recommended weight.

"Good luck with getting turkey ready for tomorrow," said a woman, leaning towards us from the opposite end of the freezer.

"Yeah? Why?" I asked.

"You won't be able to thaw the turkey on time," she replied. I proffered that we could leave it out at room temperature overnight. She countered that it will destroy the turkey. She was right. They generally recommend thawing the frozen turkey in the refrigerator compartment allowing 24 hours for each 4-5 lbs. We were stuck.

"You could thaw it in cold water, changing water frequently, or you could get a fresh turkey that should be in that area," she pointed to another area in the meat section. We had no idea that there were fresh turkeys in the store. We thanked her  and got our fresh turkey. It cooked well and we had a gratifying dinner. 

She must have felt a pity for a mixed race Asian couple, in the heart of rural Maine, trying to cook a quintessential American dinner but at the verge of utter failure.  In this society where people live a very individualistic life, value privacy of other people, and avoid gazes, stares at public places, her silence would have gone unnoticed.  Rather, it would be the norm. Instead, she decided to break the norm and save a stranger's turkey dinner.

If we watch or read current American public debates portrayed in the news and in the conversations of demagogues vying for power, it is very easy to get wound up. It is easy to identify with one side or the other and start huffing and puffing. But I am afraid, these are 
exercises born of desires to simplify reality, to create heroes and villains for writing history. In the lives we live, however, kindness is born in non-reasoned goodwill, outside the usual norms, and across the superficial distinctions of identities, in mundane everyday spontaneous interactions. Heroism is not what is pursued but a spontaneous majestic, abstract excellence.

Fortunately, human history favors excellence in us. It favors kindness in us and not cruelty. It favors creation and not destruction. Yes, our cruelty and destructive tendencies can do great damages and suffering but they are not our triumphant attributes.

Hope more of us, and more often, we have the courage like the lady across the freezer, to have kind intentions, and kinder feelings.

Sunday, November 1, 2015

National Pride and Sentimental Affiliation

On June 17th this year, a young man joined several others gathered for an evening Bible study at a South Carolina church. He stayed for almost an hour while they read their scripture. Then he stood up, pulled out a gun and started shooting them, reloading the gun several times, and killing a total of nine of them.

The young man was a white man. Those killed were black. His rage was borne of cold-blooded racial hatred. He targeted people of a specific color.

The horror shook the country. If you just watched one of the YouTube speech videos of one of its victim, state senator Rev. Clementa Pinckney, it is not hard to share the despair. Of the senselessness of the act. His politeness of speech alone, in the crude world of American politics, imbues antithesis of violence. "Why" that reverberates in ceaseless expanse of darkness, echoing, bouncing, feeds this anguish. 

This despair collided with a particular history of this country: of the race relations between the whites and the blacks. I certainly bear no depth of understanding of this country's history of race relations. My understanding is rather simple: black people were forcefully dragged out of their native countries, enslaved, dehumanized and traded as commodities in more barbaric times of this country. This country has come a long way from that disgrace. But it is not a transformation that has happened overnight. There has always been sides, and people have struggled, suffered, to come to the stage it is now. They have made improvements in slow, painful steps. There have been violent oppositions to each of these changes. 

Confederate flag represents one of those opposing sides to the American black people. Reminding them of those times when several states fought, claiming their rights to own slaves. South Carolina was one of those states. And its state house proudly displayed the flag on its grounds claiming legacy of their past. Multiple attempts over decades by more fair-minded people to have it removed had proved futile.

After the racist massacre in the Church, slowly a call started burgeoning, touching on the wrongs of racial past: to remove confederate flag from South Carolina state ground. This was opposed by many, who probably aligned themselves to the white racial supremacy of the past. But the mainstream politics, media was rather unified in calling for the removal. The state government ultimately bowed to the call. The confederate flag, that symbolized atrocities of more barbaric past for many, that fluttered in glory for decades against the cringe it incited on many, was removed.

It was a humble moment for me. I thought, better instincts of human beings had prevailed. And to collectively attain that better state, I suspected, if you were a citizen of this country, you would be proud. That would be a form of a national moment where I could, for that instance, claim the pride of national identity.

As an immigrant, I know, I will never share that sense of nationalism in this country. I have no claims to the sufferings of their past to share their joys. But more than that, nationalistic feelings have not been particularly appealing in general.

Interacting with fellow immigrants from Nepal to this country, I sense that many find the question of national identity particularly acute. Perhaps it is aggravated by the difficulty of assimilating to the new culture and place. Perhaps it is realization of a difference of national identity that introduces a certain sense of insecurity in a foreign land. Regardless, many appear to have developed a sharpened sense of affiliation to Nepal.

This was reflected in an acute form when earthquake rattled Nepal recently. They exhibited an extraordinary generosity; they reached for their pockets, some made journeys to Nepal to volunteer, many penned their love for the country in their social media pages; the affection was palpable. The connection to the nation was visible. Even in less extra-ordinary times, their longing is visible-- in their daura surwals and dhaka topis in dashain (I do not see many doing the same in Nepal itself), exaggerated glitters of Teej, serene landscapes of Nepal (rather enhanced by extraordinary photography skills) on their Facebook pages affixed with nostalgic expressions.

It is a sentimental affiliation. But it is a mistake to think of this as a national identification that gives a claim to moments of pride akin to the lowering of confederate flag in South Carolina state grounds.

As immigrants, ours is an identification of convenience. We can mostly choose what we like about Nepal, polish it with imageries and mold the affiliation to our liking. On rare occasions when we are forced to face the inescability of national identity -renewing passport, being harrassed in the airport for one thing or other- we seek the most convenient solutions to patch the hiccup. We find relatives in power and bypass the procedure, or in worst case scenario bear the burden of the procedure in silence saying it is only this time I have to endure this. We don't even protest if we found the processes unfair. Why take the unnecessary burden when I will be away in another country in a day?

But the burden imposed by boundaries of the nation called Nepal is inescapable to many who live in that country. It is not with longing they think of their nation. But daily struggles in navigating a collective society. It expresses itself in violent forms in their daily life: public officials who ask for bribes to carry the official process of selling your property, political cadres who threaten your life for your beliefs, justice system which answers to calls of bribes than arguments of reasons, tax payer funded public officials who see the service seekers as slaves and find every reason to impose hardship. The weakest among them suffer the worst of the imposition.

Are we willing to take up that burden?

That is why it is best if we recognized our romance with the notion of nationalism as what it is: a sentimental affiliation. The claims to glory of nationhood belongs to those who toil in that inescapability against all odds, to elevate the collective society to a mass of better human beings. It belongs to the weak who suffer just based on the fact that they happen to be born there and have no escape. It also does not belong to those who live in the confines of the nation but prey upon the weak ones to feed their needs.  

Saturday, April 25, 2015

Earthquake

Hope we find comfort and courage to deal with the suffering brought along by this devastating earthquake. 

Saturday, January 24, 2015

Questions

Hospital internist called asking for help. "He is about to leave, perhaps in next half an hour, but I need your help."

We endocrinologists tend to get exasperated with such last minute calls. For the types of problems we deal with, most of which are longer-term diseases, time of hospital discharge is not a very opportune moment. Yet I held my patience. And the internist was no cavalier soul trying to cover up her incompetence at the last minute of patient care. She was a genuinely concerned doctor.

The patient was a young man with type 1 diabetes and required insulin to sustain life. He was brought into the hospital after he collapsed following heroin injection. Just a few days ago, apparently, he was released from prison. He was unemployed, did not have health insurance, and did not have money to buy insulin.

This doctor was concerned about what would happen with his need for insulin once he left the hospital.

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The patient was a huge mess. His problem was a product of addiction, poverty, social-politico factors beyond the comprehension of a doctor who cared for patients with hormonal disorders. I can recommend and adjust medication dose but enable access to a medication? That is beyond me. What did she expect me to do?

That was my first reaction.

But she had reached out in desperation. So we talked to each other for a while to see if there was any way out. At the end, we came up with a plan. We decided to switch him to a cheaper form of insulin that would be injected just twice a day. Hospital pharmacy would dispense a vial that would last him at least 2 weeks. I would schedule a follow-up for the patient at my clinic with diabetes educator within a week and with myself in 2 weeks. My clinic would provide him some free insulin samples that the pharmaceutical companies gave us and enroll him in drug assistance program offered by these companies.

He did not show up to the appointment with the diabetes educator. But showed much later to see me. Having had type 1 diabetes for most of his life, he had a good knowledge about diabetes self-management. He was living in couches of his relatives: ex-wife, father and brother. He had been getting insulin samples from one clinic or another and sometimes using friends' insulin.

I talked to my clinic staff. They immediately arranged for insulin that would last at least 2 months and started paper-work for patient assitance program for providing long-term insulin.

At the end, he said, "I really appreciate the thing you guys do."

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That is the nature of this profession. We deal with the failures: failures of normal physiology and failures of persons, society. A patient should not be foraging for insulin in the most wealthy and powerful nation on earth. But that happens. Why is a different question. And it is at the receiving end of these failures that we, doctors, are positioned.
It is a good position to be. Especially if you have support to be able to make things happen. To have opportunity to tell yourself, I helped another individual in need, in pain, and in suffering. That opportunity to assertion of a meaningful life is what motivates many of us to seek or pursue this profession.

Yet, I know, there is now a constant variable whose shadow will follow me in all my interpretations: that of an immigrant. After starting my professional practice at the country I was born, experiencing being a doctor there for a few years, I am now back to practice in the country I was trained at. How much a claim an immigrant doctor has to meaningfulness of his vocation? Is loyalty to individuals in pain, suffering any different when you are an immigrant doctor? How and why, if the answers are different? These are some of the questions. 

Saturday, November 22, 2014

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.  

Saturday, August 16, 2014

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!

Wednesday, August 13, 2014

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.