August 9 – Powerful Deterrents

So today, we went back to Patan Hospital to sign Dr. Bishnu’s training agreement. I also found out that Director Shrestha, while the Patan Birthing Center undergoes renovation, is working as coordinator of the night shift nurses. Unfortunately, that means that I have to show up either really late at night or really early in the morning. (I’ll be going at night, since there’s no way I’m waking up at 5AM).

To finally put some closure to the MDGP scholarships, I also went to NSI (The Nick Simons Institute) to sign our agreement with Dr. Zimmerman (and pick his brain about some clinic legal issues). One of the issues we discussed was medicolegal aspects of the clinic: how to deal with malpractice suits. Personally, I was curious about this as well, since I knew that Nepal was not a sue-happy place like America. Dr. Z enlightened me about the way things are done here: no doctors have malpractice insurance. The Nepalese don’t really sue in this department, and the law is somewhat loose as well. Apparently, until 15 years ago, medical malpractice had to be tried under assault and battery statutes. Even now, cases are seen more in the sense of consumer protection laws.

On the other hand, the Nepalese are more willing to take matters into their own hands. Should an egregious case of malpractice occur, threats, vigilante action, and out-of-court monetary demands are common. A more powerful deterrent is the press: families with connections can publish articles defaming physicians for their negligence. On top of being completely in the hands of the writers, such measures ensure humiliation and the fact that the doctor will probably be unable to practice in that city again.

That’s some scary stuff.

August 8 – Back in the Groove

After spending a day finalizing the agenda for my last week in Kathmandu, I got back in the swing of administrative duties, which was rather tough after the somewhat slow pace of life in Achham. Today’s agenda, however, took me through some areas that made me realize that there was inequity in the cities as well.

My first stop was the Nepal Medical Council, found all the way across town in Bansibar, Maharajgunj. For some reason, there was a massive traffic jam in central Kathmandu, so my cabbie made me a deal: he would work for a flat fee if he were allowed to take the side streets to save time. One of the rules of Nepalese city life (for foreigners, at least) is to go by taxi meter, but given the circumstances, I agreed. Doing so, he took the backroad (road is a relative term here—it was basically an unpaved rock path) that followed on the banks of the muddiest, brownest river I had ever seen. Trash literally made of several of the banks, and an overwhelming stench of waste (both industrial and human) hit me full-on. Nevertheless, hundreds of people were still making a living here. Young men waded in the shallows with nets, trying to catch something (I couldn’t believe anything could possibly survive in that river), while old women washed their clothes in the putrid water. Children splashed each other on the banks, shadowed by tin-and-cardboard shanties that looked like they may fall over at any moment.

“I asked to come this way because you told me you’d been in Nepal for a while,” said the cabbie, noticing that I was staring. “I usually don’t take foreigners this route.”

We then veered back onto the main road through a winding alleyway, and I was amazed by the sudden transformation. Bansibar is where many of the major embassies (French, Australian, Japanese) and organizational centers (Councils of Medicine, Nursing, Water) are, and the neat row of houses, sparkling government buildings, and shops were a stark contrast to the poverty omnipresent less than half a kilometer away.

Anyways, after doing some business at the Nepal Medical Council (okay, okay, I was getting documentation and applications so that we could bring in several expatriate doctors to work at the clinic) I took another cab to Patan Hospital to track down Rachanal Shretha, the director of the birthing center there (which is famous for reasons I’ve enumerated in a previous post). Nobody seemed to know where she was, so I took a stroll down the pediatric wards (for some reason, if you drop by in the afternoon, the security doesn’t seem to care if you just wander around the patient wards). In the words of Sachin, my pediatrician ex-housemate, “there were a lot of sick kids.” Many seemed quite cheerful though, and two with casts were actually playing with a ball in the courtyard.

This made me think that sometimes, I wish I could go back to being a small child. There’s a pure optimism kids have that we don’t anymore. Granted, as a young person, I’m still overly a glass-half-full person, but I can’t always believe that the best will come around. Bless them for it, I suppose.

July 26 – This is for you, Nick Simons

Working in a developing country is interesting since you routinely encounter folks involved in a variety of development NGOs. We met today with Dr. Zimmerman (a *gasp* American) with the Nick Simons Institute. NSI is offering MD-GP (Medical Doctor-General Practitioner) scholarships for eligible MBBS doctors (Medical Bachelor/ Bachelor in Surgery). Though our current medical director is not interested, we hope this will be a sufficient incentive to attract future doctors to the Nyaya Health clinic. The problem with the program is that in the current Nepali system, a bachelor in medicine is usually sufficient to allow a doctor to enter the field. An MD-GP is nice, but unnecessary. In fact, most MD-GPs work in rural areas (with charitable intentions), since their additional training enables them to become proficient family doctors.

Anyways, you may ask “why a funny name like Nick Simons?”

The story gets interesting: According to Chris, Nick Simons was a wealthy young man who lacked a goal in life but enjoyed traveling to exotic places. During one such visit, he was trekking through rural Nepal. Somehow, something he saw here touched him so much that he decided to become a doctor and devote his life to serving the people of Nepal. Unfortunately, on the trip home, he stopped by in Indonesia, where he drowned while swimming in an atoll.

His parents, in his memory, decided to continue his work and have thus created the huge institute in Nepal to improve health in rural areas via MD-GP scholarships, nurse/midwife training, and improved clinical research methods.

With this in mind, Chris, Bibhav, and I went to the NSI offices—and were amazed. Though tucked away in a residential area, the NSI building is immaculate, A/Ced in every room, computer-enabled in every office (with wireless internet too!), and full of massive furniture. We actually joked with Dr. Z that we may consider working for him on account of the impressive setup. That aside, negotiations went well with NSI, and we’re well on track for signing a number of scholarships each year with the organization.

Upon leaving the building, Bibhav let us know that he had done his research. Apparently, Mr. Simons (father of the late Nick) is among the 60 wealthiest people in the world. NSI is actually just one part of the great charitable projects they’ve financed in this country. Patan Hospital’s birthing center (the model for all Nepali birthing centers and a fully-independent [no doctors] program that has seen only 2 technical complications out of the last 600 births) was built (and now being renovated) by a million-dollar gift from the Simonses. Sadly, the family has not been similarly blessed. Nick, the eldest, met his untimely end in Indonesia. The second son was killed in a car accident while riding his bike outside his home. The third son is apparently autistic. Though I haven’t had time to confirm these facts, they’re a grim, but encouraging reminder that philanthropy is an important and powerful factor in global development.

On a lighter note, Bibhav and I had pizza today. Chris is from Connecticut, so he remained a skeptical of Nepalese pizza-making, but I thought it was okay. Definitely no Peppe’s or even Papa John’s, but it was recognizable as pizza.

July 16, 2007 – Earning My Keep

This morning, I woke up to loud shouting of Nepali over a megaphone. When I poked my head out the window, I saw a government vehicle rolling down the street, loudspeakers blaring. A man was throwing pamphlets out the window. A closer look at a sign on the front of the car read “HERPES”. My grasp of the language is terrible, so it may have been something other than an STD campaign, but it remains an intriguing possibility of a pretty frank method of public health education.

Anyways, today was my first day of official duties, and Chris has been amazing in helping me get used to the work. First, we visited Patan Hospital (one of the best state-run hospitals) to request special Peds/Obs training for our MBBS doctor. We next dropped by the National Center for AIDS and STD Control and spoke with the Deputy Director there. Dr. Pant (who did his MPH at Johns Hopkins) seemed quite optimistic about providing our clinic with both documentation and supplies to help us set up a Prevention of Mother to Child HIV Transmission (PTMCT) program, something both exciting and encouraging.

As part of the “detective work” involved in securing medical resources, Chris and I went to Teku in search of the elusive Dr. Upreti, Chief of Immunization and Health Services in the Dept. of Health Services in Nepal. We had originally believed that he worked for the Ministry of Health, but that search proved fruitless, as the main office informed us he wasn’t under their direct organization. Since UNICEF is one of major provider of vaccines, we then attempted to locate him there, but that was a false lead as well. Finally, after wandering about the government buildings in town, we found his signature on a form in the Child Health Division. A quick meeting with him then provided us with more good news: all the vaccines for the major diseases are already present at the district hospital; we just need to talk to the local District Health Officer to procure them. Mission success!

To end a long day of trekking, we went to check out a big mall in a central plaza—and almost forgot we were in Nepal. The complex looks like a shopping center in the US (complete with glass elevators and AC) albeit a bit smaller. Puma and Nike sneakers cram storefront windows, while Beckham soccer jerseys and Armani slacks hang by the rackful. Young people with Ray Bans and iPods shuffled past in the consumer paradise we Americans know so well. Sometimes you realize what a small world it is.