The original article appeared in the Wilderness Medicine Society Magazine Fall 06 Vol 4. www.wms.org This describes my experience building the Nangi Clinic and learning the truer meaning of being a teacher and pupil.
Your travels take you out of your own community but the teaching doesn’t need to be left behind. Wherever you go bring your teaching mind and look for an opportunity to share your wilderness medicine knowledge and experiences. My travels to Nepal gave me the opportunity to help a community open a clinic and provide continuing medical education for the health care workers, Lila and Rupa.
“Sharing the Knowledge”
I was glad I remembered to bring the little pieces of cotton as I stuffed them in each ear. Past experience at Shaman ceremonies had left me with yet another language handicap; that of diminished hearing from hours of loud drumming. I could still hear the Shaman’s chants and rhythmic banging on the pan but at least my ears wouldn’t be ringing all night. The pungent incense wafted by my nose and I breathed deeply, taking in all the sights, sounds and smells around me. The clinic looked different at night, gone was the commotion of people coming and going. Everyone was settling in on the floor and along the walls with the same quieting hush before any performance. I sat down with the Shamans, as they prepared to bless the clinic, and remembered back to the first time I had stepped into the building that would one day become Nangi Clinic…..
In 2002 I went to western Nepal for trekking and to live in Nangi village for seven weeks. I had made arrangements through Himanchal Educational Foundation (HEF) to be a volunteer physician, teaching the health care workers and working in Nangi Clinic. HEF is a grass roots Nepali supervised educational NGO sponsored through the University of Nebraska.
The health care workers, Lila and Rupa rarely used the Nangi Clinic building. Instead they worked out of their homes treating everything from TB to lacerations needing sutured. Those too sick to walk or giving birth were seen in their own homes. Lila Pun trained for two years in Pokhara and Kathmandu as a community health care worker. Rupa Pun trained for two years in Baglung and Pokhara as a community midwife and together they cared for the health needs of Nangi village and surrounding areas with a population of 2000 villagers. They had finished their training six years ago and came back to their village to work. There was little opportunity for continuing medical education over the past years. They had occasional contact with other village health care workers, but they had no access to new books, publications, training sessions or Nepali health professionals. They lived in a village which is a one day walk to the nearest clinic or hospital and therefore worked in the wilderness day in and day out. When I began to grasp what they did given the limitations I realized I had a lot to learn from them.
The clinic was housed in a mud and stone building with broken windows, leaking roof and no water or electricity. We had two rooms, one measuring 8×6 feet to store the supplies and the other 6×4 feet to see the patients. We stocked supplies on make shift shelves, put a bucket with water on the table and opened the doors to dozens of villagers patiently waiting outside.
So began my journey as teacher and student. We saw patients together in the clinic. With Lila and Rupa speaking haltingly in English far better then my Nepali we diagnosed and treated a spectrum of diseases from impetigo to GI bleeding. We poured over the books and information I brought with me after closing the clinic doors each day. We each wanted to know how the other treated medical conditions and injuries. These impromptu teaching sessions brought us together as practitioners and educators. They were helping me understand not only their educational needs but the health needs of the village. They taught me about diseases I didn’t see in my everyday practice such as TB and Hanson’s Disease. They introduced me to Moti who healed with plants and the Shamans who invoked the spirits. Most importantly we became colleagues with a common goal of improving the health services to the villagers and providing continuous medical education for Lila and Rupa. And so, our friendship and practice gave birth to the Nangi Village Health Plan .
Lila, Rupa and I met with the mother’s group “Aama Suma”, village development committee, plant healers, Shamans and HEF project director, Mahabir Pun, to develop a comprehensive plan. The Nangi Village Health Plan was designed as a long term plan addressing issues such as rebuilding the clinic, providing continuing medical education for the health care workers, developing a Telemedicine program, building community composting toilets and developing clean water sources. It wasn’t about what “I thought’ they needed but about what “they knew” they needed. Keeping in mind Dr. Stephen Bezruchka’s infinite wisdom; “Development teaches poverty”, our project vision is summarized in the statement:
Nangi Village, while preserving the cultural and environmental integrity of the community, will develop and implement a plan for improved health for the population utilizing a multi-disciplined approach combining the skills of allopathic health care practitioners, traditional plant healers and spiritual healers; developing a potable water supply and improving the waste management system for all villagers.
I returned in 2003 and helped renovate the Nangi Clinic building working with a plan devised by Lila, Rupa and the village carpenters. Windows and roof were replaced. Plank flooring was installed topped with sheets of linoleum. The inside was gutted and then partitioned with plywood into a waiting room, two exam rooms and a work room. Wired for electricity we had light from the water powered generator. In our work room we stored supplies and equipment in cupboards, put in a desk for reading and teaching, built a sink with gravity fed water and used a two burner propane stove to clean equipment. It also provided hot water for our daily afternoon tea during our didactic sessions after clinic closed. Within two weeks, helped by students, volunteers and villagers, we had painted, stocked and cleaned up opening our doors to both the sick and curious.
Based on what Lila and Rupa outlined as needed equipment I brought instruments and supplies packed into kits for labor and delivery, suturing, OB/Gyn and EENT treatments. They had given me a list of topics they wanted to cover and each day we either reviewed a case seen in the clinic that day or reviewed one of the topics. I used texts with pictures, diagrams, anatomy books, anatomical models and pictorial posters as teaching tools. We walked the hills and visited the village nursery as they and Moti taught me about local plant therapy. We visited patients in their homes so I could understand the practicality of our medical care and recommendations. Lila and Rupa welcomed me into the homes and hearts of their families so I could begin to understand a small part of Nepali culture. I can picture Nupesh, Lila’s four year old son, plopping down in my lap to share a plate of fried potato slices with “Auntie Devi”.
Over the next several weeks Lila, Rupa and I worked in the clinic and held a week long class for health care workers from surrounding villages. Together we taught didactics and skills workshops for cleaning wounds, suturing, splinting and fracture management, pelvic exams, rectal exams, removing eye and wound foreign bodies, complications of labor and delivery, management of respiratory and GI complications along with general health topics.
As the weeks went by they saw more patients and I saw fewer. They presented fewer cases for my advice as their confidence in the diagnosis and treatment grew exponentially. I lingered in the clinic as a security blanket which towards the end they had little need of. I was silently walking away in mind, body and spirit as they steered the course of the Nangi Village health plan.
It is over two years since the Shamans came to the clinic for the cleansing and blessing ceremony. At the end of the ceremony they drove a nail part way into the door frame and broke it off. This signified the helping and healing spirit of the clinic could not easily be removed. Since then Lila and Rupa have run the clinic despite the threats from government and Maoists during the Peoples War. They have networked with Nepali physicians in Pokhara for continuing medical education and once a year they go to work side by side with the doctors and other health professionals for two weeks. The clinic has a computer and webcam which allows them to Telemedicine with other rural health care workers or the two physicians in Pokhara for advice on difficult cases or referrals via an ingenious wireless network http://nepalwireless.net Via the internet, journals and the Pokhara connection they have access to medical information on new treatment guidelines for diseases such as TB and HIV.
Nangi Village Health Plan moves forward with the building of three composting toilets, improvements made to the gravity fed water supply to reduce surface contamination, establishment of a health education curriculum for students taught by Lila and establishment of a teaching center for CME in rural and wilderness medicine for Nepalese health care workers taught by Lila, Rupa, visiting Nepali physicians and occasionally western practitioners.
Talk with others who have experience before venturing into foreign community education. Know your motives, remember for every action there is a reaction and develop staying power. Once there start with support of the existing medical system so as not to destroy confidence in the local health providers. President Jimmy Carter said in his 2002 Nobel Peace Prize speech; “the most serious and universal problem is the growing chasm between the richest and poorest people on earth”. Economic support of non medical projects such as composting toilets in a community can help close the gap.
This health project was designed to use renewable and readily available resources. It was designed to be self sufficient relying on Nepalese helping Nepalese. It was designed to work independent of western support and influence. It was designed to work with the village goals for economic self sufficiency and improved education.
Like the nail in the doorframe that is difficult to remove Lila and Rupa carry on with their work by “sharing the knowledge” with their community.
Debra Stoner MD FACEP
Medical Advisor and Executive Board Member
Himancahl Educational Foundation