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. 

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.