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.