Journal 5 – five: Third Clinic November 24, 2006
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Doing general med today with our Radiologist at the clinic near the airport. Our group often did 4 patients at a time – our group leader spoke Hindi, we often lucked out by having 2 translators, and a few of the patients spoke English. Wow!
One patient is an army guy with shaky hands. I think his 2 pot/day of coffee or tea may explain it. Lots of osteoarthritis and GERD, although not as much as previous days.
We hand out recommendations for sunscreen, hats, and sunglasses. The dusty winds and sun are hard on skin and eyes up here, and this is the best we can offer in terms of protection. Some cough suppressants and muscle relaxants doled out, like your every-day family practice. Another group has a patient with knobby outgrowths on his chest. Lipoma? Osteophytes? I don’t get to feel if they are mobile or not, but by the way they are distending his skin, I imagine they are quite painful. He also has a severe “hunch back” (not my most PC vocabulary); it’s probably due some nasty ankylosing spondylitis, or so I’m told.
What a long day. This time I jump in one of the first vehicles to get back for a refreshing shower. One of the residents gives a great talk on high altitude medicine. Pop another Diamox as we’ll be climbing in altitude again soon.
Another great dinner. Huge chunks of paneer in the palak paneer, which is served with pakoras and so on. All the fancy fixin’s. Rice pudding gets confused with mashed potatoes. I dream of buttery, garlic mashed potatos but the cheese-fanatic in me is still smiling from the generous portions of that soft goodness.
Into the village markets to check my e-mail. It tells me my parents have put an offer on a house in Campbell River, on Vancouver Island. I’m a bit surprised but also pleased. I hope they get it, if that’s what they really want. Messages from friends wishing me luck as the journey deepens.
Not feeling too well tonight. Pack light for the trip to Tangste and head to bed. The headache and nausea aren’t so bad and I wind up staying up to chat with my dentist pal and my roommate. There is a fuzzy channel on TV showing Dumb and Dumber. Really didn’t expect to have much more than a bed, but wound up with a well-equipped room and we take full advantage of the luxury and watch part of the horrible film. A nice abuse of modern living before tents and outhouses swallow us. I enjoy both styles and have traditionally felt “in my element” wherever I am, so long as I am exploring and enjoying everything to its fullest.
Sleep calls. I lay my head on the hard pillow and let it take me.
The Shape of the World November 21, 2006
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All those things you thought you knew about the shape of the world – like a bimodal distribution of wealth, Africa being uniformly poor, large families and short lifespans being a consistent feature of the third world, etc. – well, you might not really know them at all.
Check out this stimulating presentation: Myths About the Developing World (Hans Rosling, at the TED Talks series)
http://video.google.com/videoplay?docid=4237353244338529080&sourceid=searchfeed. This is courtesy of a skeptical, intelligent classmate. It is 20 minutes long, but well worth it.
Journal 4 – four: Second Clinic November 21, 2006
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Up for 6:30 yoga. It feels good but I’m so inflexible. Breakfast is carbs and eggs and usual, but somehow I manage to wnagle a chees, tomato, and onion omlet [I didn't know it then, but this was the best breakfast for a while...].
We drive off to clinic and set-up, this time having some understanding of what is going on. Not feeling as lost as before. I’m lucky to be inside again, having been placed with one of the less confident residents. The morning starts slowly and the patients back up as all the attention is focused on a chronic heart failure patient who is having some acute issues. A spontaneous lecture ensues. I’ve already heard it, but I feign interest to indulge the resident and because, frankly, there isn’t anything better to do.
My first patient is an omchi – a traditional healer. He’s got a cervical lipoma, pain and eye problems (following a goat horn stabbing his eye as a child). Some serious disconjugate eye movements and some extreme discomfort when he moves his neck. However, he’s a pretty relaxed guy. He takes a little nap while we wait for our Resident and the translator to be available. Ouch! Looks like under the dressing on the back of his neck, he’s done some moxibustion (i.e. applied a metal poker that has been heated in a fire of herbs). A lot of incoming patients have tried this for their painful, arthritic joints but this is a new one. Well, the wound is still pretty fresh and we want to dress the wound well. Topical antibiotic? Yep. Gauze? No… but a quick run to the dental tent and some help from a friend there resolves this. Medical tap? No. WhaT?! No medical tape? No bandages? No first aid kit on this medical trek? Bizarre. Outrageous! Frig. My partner and I dig in the boxes from our mobile pharmacy. Aha!
We have to suppress our shame while dressing his wound with what we found. Antibiotic cream on, gauze over-top, and secured with…. 5 Winnie-the-Pooh bandages! Yes, awesome! No wonder this 75+ traditional healer didn’t seek Western medicine earlier. Slapping children’s bandages on him like that! Ugh.
The pace quickens. We see apthous stomatitis (some sort of autoimmune-mediate white mouth sores), impetigo, lots of GERD [Gastroesophageal Reflux Disorder], and arthritic knees.
Lunch is unexpectedly elaborate, again. Annoj is fantastic and there is no end to his spoiling! The pharmacy crew do a great job but they are swamped at times and I sneak over to help. I like the quiet process of pill pushing. The calm in the center of a storm of people.
One of our translators has been an amazing help. He really wants glasses but we aren’t giving them out today – I manage to get a favour from the friendly Southern student who brought all the glasses along in the first place, and it turns out we actually can’t help the translator. At least we tried!
We dispensed a lot of Tylenol/Nizantadine combinations for pain and GERD. I stay late again to help pack the pharmacy. I’ve been and uninterested this year at school; I leave school as soon as possible, not lingering to chat. At home, I do what is required but no more. Sure I volunteer, but only as it fits my schedule or suits me. A friend needs help to move and I can’t find the time? Not like me and yet it is what I’ve become. It feels good to reprise my role – even in such a small capacity – as someone willing to help, for the simple pleasure of helping someone. No ulterior motives. No restrictive schedule. No excuses. Just helping. Heck, it’s just shoving some bottles into boxes and loading them onto the truck, but I haven’t felt this much like myself in ages.
We have an excellently short lecture on Remote Health Care and the unique challenges it presents, starting just about 5 minutes after we get back to HQ. In our discussion, I mention my frustration as it relates to the lack of first aid kit. I also had a patient today who had GERD, came to the clinic last year, got some medication, got better [while on medication], and got worse [when he ran out of the medication]. What could we do? Again, prescribe a limited amount o the medication. I tried my best at lifestyle/diet counselling, but it will have little effect even if followed religiously. This is a problem that won’t be solved.
Dinner is awesome. Paneer this-and-that, aloo-something, chapati with some cauliflower yummyness inside. MMMM!
Capacity Building Reflection November 3, 2006
Posted by jaotte in Ethics, Healthcare, Human Rights, Medical School, Medicine, Nepal.2 comments
This is a copy of my Doctor, Patient and Society (DPAS) journal entry from a recent plenary:
When I think of “capacity building,” I think of the clinic that I briefly worked at during my time in Nepal. Although not yet self-sustaining, the Chapagoan Primary Health and Resource center (PHRC) has been making moves to involve the community, generate revenue, upgrade workers skills, and create infrastructure, which should enable it to follow a sustainable development path in the future.
Firstly, community members are invited to sit on the board of directors for the clinic. Their role is to speak for the needs of the population at large, such that the clinic can develop programs that correspond to actual rather than perceived need. Those who attend the clinic are the clinic’s best advertisers, sharing their experiences with peers and building trust in the health care system. Many women are hired as community health promoters, venturing into communities to educate them about hygiene, nutrition, and safe child birth, as well as recruiting malnourished and pregnant women as patients. When a child is found malnourished, he or she and his or her mother is brought to the clinic; the mother is educated about nutrition and hygeine and is allowed to return home only when she can demonstrate competency in these areas; this technique has proved much more successful in maintaining long-term health than would merely providing rations.
Secondly, the clinic operates a micro-insurance scheme. While most funding for salaries and operative costs comes from foreign NGO support, there is somewhat of a short-fall when it comes to providing services and medications. Consequently, the clinic has developed a scheme wherein patients may a very small annual fee which entitles them to free or heavily-subsidized medications and services. Safe delivery services are offered at a rate that is much more accessible than a hospital, and yet can help generate some funds for the continued operation of the clinic. By operating a strong training program in health management and offering a few places for observerships and electives, the clinic can earn a small profit from students, especially foreigners (such as myself!). The clinic also sells “super-flour,” a complete nutritional source that was designed for dietary rehabilitation in times of famine.
Thirdly, the clinic is constantly working to educate its workers and others in the health care field from the surrounding areas. There is much interdisciplinary cooperation; once a week, one member of the health team will lecture about his or her role (eg. dentistry) or new developments in their field (eg. a new diagnostic criteria for enteric fever). By having a constant flux of training workers, a lot of new ideas and techniques are brought to the clinic and can be incorporated into its practices.
Lastly, the PHRC has made a big investment in developing their physical site, equipment, and so on, so as to be able to expand and create a wider range of services. The purchase of an ambulance, more observation beds, a library, etc. will help them to deliver a wider range of services and thus be able to adequately serve the needs of their community. Likewise, an investment in pre-natal care, well-baby checkups, vaccines, and diet counselling are measures in preventative care which should yield an increase in the health index of their target population.
I think this serves as an excellent example of capacity building in action.
New South Wales Health in Australia defines capacity building as “the development of sustainable skills, organisational structures, resources and commitment to health improvement in health and other sectors, to prolong and multiply health gains many times over”. I think that this statement, however broad, illustrates the importance of development of multiple aspects of a health initiative in order to make it a long-term success. I’d like to incorporate these notions and a case study on the Chapagoan PHRC into my independent project, which is aimed at creating a criteria for evaluating the quality of health initiatives.
