Leave Approved

We were fortunate enough to spend one night at Papa’s House with “Papa” (Michael Hess, who organized our volunteer placement) and his thirty odd gaggle of gorgeous children. They are orphans or children whose parents cannot afford to house and school them. Michael hails originally from the USA and has spent some three years building up the orphanage from its initial destitution to the joyous and well-run home we visited yesterday. 

Well, I think those children stole my heart and a big part of it is still there at Papa’s House. We have never met a more fantastic bunch of kids. I think I fell in love with each and every one of them, and how can you not, when they shower you, a stranger, with hugs and kisses, as though you are a long lost sister? They are the most affectionate, loving, open, friendly, well-behaved and selfless kids we have ever met! Our time with them was brief but incredibly precious, and even though we came bearing gifts from our friends in Australia, we felt as though they had given US so much more.

When we arrived, they were all engrossed in a movie. After about forty-five minutes, there was a curious crowd at our doorway, eyeing the three bags of toys in our room. Poor Vincent was trying to stem the tide by himself, as I was off having a shower! He told them to “Wait for sister” and they did, patiently, and when I came back and opened the first bag and beckoned for them to come in, the tide became a roar and then a feeding frenzy!

We sat completely overwhelmed and laughing as more than twenty children ripped through the toys like there was no tomorrow! Every child chose a few toys for him or herself, and we were completely amazed that there was no fighting, only the occasional excited shove. Everyone was delighted with what they got, even the ones who only managed to score a few pens. Many children came up to me to ask before they could lay claim to their chosen toy. All of them came up with beaming smiles and an emphatic “Thank you, sister!!” and a hug, kiss or maybe just a heartfelt squeeze of the hand. In ten minutes it was all over, and we sat there, two very stunned people, with three empty bags! Not a single toy or pen was left – each one went to a happy home. The older children probably didn’t stand a chance, but they were happy to watch the excitement of the younger ones.

Later, I was treated to a tour of the girl’s floor – as soon as they spotted me, I was surrounded by a group of little girls who took my hand and all wanted me to visit their rooms. Again, they melted my heart with hugs and kisses, and presented me with their drawings as a thankyou. (Many had drawn posters with their new crayons or colour pencils, with “Welcome to Australia Brother and Sister” in big letters or the like!) I could have happily spent all night with them, but bedtime came too soon. I saw plenty of Winnie the Poohs and other new soft toys sitting proudly on beds. I noticed that each child had perhaps one or two other toys only, so the gifts must have made them incredibly happy. The clothes went down a real treat as well, as were the balloons, and of course the pens and pencils and crayons.

We spent some time the next morning with them, and it was very hard to leave in the end. They went through a little photo album I had brought along, with snaps of family and our wedding, and each child wanted a photo from the album as a memento! I wrote a little message on the back for each one, and now there are some 17 photos of our family and our wedding day at Papa’s House!

I wasn’t sad when we left though – who could really be sad when there is so much joy around? Their comradeship, respect for others, joie de vivre and abundant love was simply palpable. We left knowing that in this part of the world, something is being done exactly right for once – Michael has done such a great job in providing a happy and secure home for these kids who came from incredibly unfortunate backgrounds.

If anyone is thinking about coming to the orphanage to volunteer (they always need English teachers at the school, and improving kids’ English is a key to a bright future – we saw the results of the volunteer teachers who have come in the past, as most of the children have excellent English) they will have an experience that cannot be equaled. If you stay at Papa’s House, you will be loved, cherished and appreciated as though you are a dear friend by thirty beautiful children. They ask for nothing apart from some time to talk, perhaps a written note as a memento, and the opportunity to thank you for being there. I thoroughly recommend this to anyone who is thinking about it, and they can view Michael’s website www.nepalorphanshome.org for more information. Donations for the kids are always welcome as well, and you can donate via the website.

The health post, and my interpreter, were labouring under the belief that the medications and donations that I brought were donated by the “Government of Australia”, and that I had been sent by the United Nations! They were quite non-plussed when I explained that kind family and friends had donated, and drug companies had provided the medications free of charge. They were even more puzzled by the fact that I wasn’t part of an organization, and that I was here “privately”.

The generous donations of money and medicines that I brought were both a blessing and a hindrance. On the one hand, I could dispense plenty of medication for symptomatic relief, treatment of infections, and rehydration. When certain medicines ran out I could then use the donations to purchase medications directly from the health post’s dispensary, and a little certainly went a long way – medicines cost about $0.50-$2 a course here. We also paid for a few Xrays that I felt were necessary, and offered to pay for an elderly man’s cataract operation (a bargain at under $100 for both eyes, but an astronomical sum for a poor elderly man! Incidentally, the ophthalmologists didn’t feel it was necessary right away, so I have left the appropriate amount with the health post for safekeeping for his future operation). At the end of my post we had used most of the medicines that I had brought, and spent $20 on medicines for some 25 patients. I was guided by my team at the health post as to who could and couldn’t afford to pay for medicines. Not everyone in Gundu is poor as there are many land-owners and people who don’t work in the fields.

On the other hand, some patients came in expecting a freebie or two or ten! Word certainly got around about this volunteer doctor from Australia who was paying for medicines and sending people home with pills and potions. Some patients insisted on having Xrays that were not necessary, and one woman spent part of her Xray money on her bus fare and afternoon tea! Fortunately there was only a handful of such cases, but it was irritating having to deal with them.

I don’t actually know a lot about the state of health care in Nepal. What I gleaned is that there are too few doctors – for a population of 23 million, there are a tiny 100 medical graduates a year (in comparison, I think Australia churns out more than 1000 doctors annually). I know that in the remote areas, like the Annapurna region we have just trekked through, the nearest doctor is usually at least three days WALK away, and there is no vehicular transport – we have often seen patients being piggy-backed by their family, or carried in a rudimentary stretcher formed by slinging a hammock around two bamboo posts. Up and down the rocky trails these “ambulances” go, walking for days before getting any medical care.

I know that patients have to pay for all consultations, even in hospitals, and for medications. Certain medicines are provided free, but these tend to be inferior choices.

It was difficult to know how much of an impact I made. I think that having seen a doctor gave a lot of people some comfort, and that we relieved symptoms in most of them (and the placebo effect probably had a lot to do with this). I directed a number of people with chronic and complex complaints to hospital outpatients or the nearest “polyclinic”, as they needed ongoing monitoring and care. This is one of the problems about being a volunteer – that it is a temporary post, and little opportunity for followup.

The biggest barrier to good health care in Nepal would have to be lack of education. Ignorance about good hygiene, nutrition and diet, smoking, and the need for regular checkups for chronic conditions impacts on the vast majority. It is perhaps a saving grace that most people work so hard physically that they don’t suffer from diseases of overabundance such as high blood pressure and diabetes.

The one thing I am sure of is that we have a stellar health care system in Australia. It’s accessible to all, it’s of an excellent standard, and it’s free. There are safety nets for those in need. I truly wish that doctors and patients would stop whingeing about the Australian medical system – they should spend a few days in Nepal to find out what life is like on the other side.

The most disturbing part of my volunteer placement was seeing first hand the stigma that faces patients with mental illness. We are only just beginning to overcome this in Australia, so it is unreasonable to expect any difference in Nepal (their health care system, in my rudimentary assessment, is some 30 years behind ours).

A 30 year old woman who had suffered depression for fifteen years came in to see me. She was chronically suicidal, and the tragedy was that she was not even on antidepressants. I suspect she can’t afford to pay for them, but I never quite found out why. She lived at home and was constantly being abused verbally (and possibly physically) by her family. There was little I could do for her except for to prescribe her some B complex syrup, in the hope that this helped her mood. My interpreter seemed quite keen on getting her out of the room as quickly as possible. Later, she admitted that she was “afraid of mental patients” because once she had “seen a madman and he had a brick in his hand”. This is a well-educated young woman we are talking about as well. She didn’t even understand that being “mad” was quite different to being depressed, and told me quite authoritatively that “there are no medicines to treat depression here”.

Later, a young man came in with epilepsy. He had seizures twice a month, said my interpreter, and she was under the impression that these coincided with the full moon and the new moon. “It is often the way with epilepsy”, she said. She told me that he had gone to the “mental hospital” to receive treatment for his epilepsy, and when I asked why (I would have sent a patient to a neurologist) she told me “It’s because epilepsy is a mental problem”.

These patients have nothing. They have no family support, as they are shunned by society and their family is greatly ashamed of them. They have little or no access to counseling or psychological treatment. They don’t even have access to proper psychiatric care. They languish as pariahs and have no future. The suicide rate is high here. What I saw was tragic and I felt completely impotent in my inability to help.

One Saturday we went to a nearby village populated by a caste of people known as Tamangs. It was one hour’s walk away, situated in a serene hillside setting with neat rows of terraced fields and picturesque terracotta cottages. This scene was less than idyllic close up, though, as the people who lived there were extremely poor and had little education. We went from house to house spreading the word that I was consulting at the health post, and dispensing any required medications.

Mobile medicine

 Checking a wound on child’s ear in Tamang village

We came across a young mother with her one-month-old baby. She told us everything was fine, and the babe appeared to be sleeping quite peacefully. Two days later the mother brought the baby, Puja, to see me. She said Puja was not feeding well and had turned “wrinkly”. I took one look at the tiny, grey, dehydrated and incredibly weak baby in front of me, and directed her to the nearest hospital for immediate rehydration. We tried to stress that this was a dire case, so I hope that they did go and that little Puja made it. She had weighed only 2kg at birth, and over the past month had put on only 100g. Her mother was eighteen years old.

I have heard that infant mortality is very high in Nepal, and most babies are born without any trained staff attending. I suspect that there is also little in the way of antenatal or postnatal care here. Seeing Puja almost broke my heart. We take so much for granted in Australia – a baby weighing 2kg would never have been allowed to go home straight away, and perhaps with good antenatal care and good nutrition, babies would be unlikely to be born at 2kg (very low birth weight) anyway.

I never did find out what happened to her, despite asking around. Nobody seemed to know.

There was great excitement one afternoon when a young woman came in with a 5cm cut to her forearm from a scythe used to cut wheat. It was a simple task to sew it up really, with the equipment that was donated by Monbulk Family Clinic, apart from the fact that I needed one assistant just to swat flies away (this was DEFINITELY not a truly sterile procedure!!) It seemed to be healing beautifully, amazingly with no signs of infection, and everyone watched intently as I removed the first few stitches a week later. To my dismay, the wound slowly started to gape, and all I could do was to Elastoplast it back together and hope for the best. I’ve never seen this happen before to this extent, and I’m not sure why – we suspect she may have gone back to work, stressing the wound, against my advice. I’m wondering if nutrition or lack of had something to do with it. Hopefully it will continue to heal over the next few days.

When we first arrived in Gundu, no-one seemed to know who we were and why we were there apart from our small welcoming party. Word of mouth works quickly there, though – a reasonably sized crowd had assembled within ten minutes of a few villagers getting wind of the doctor at the health post. They have never had a doctor here before, so everyone seemed to come in with a lifetime of health complaints.

I saw 181 patients in ten days. It may not seem like a huge number, but it took  time for the history to be translated from Nepali to English and then advice and instructions from English to Nepali again! Plus each patient had an average of four health complaints. The opening line was usually something like “She has back pain, dizziness, a vision problem and burning pain in the stomach”.

My very first patient had some unusual tingling in the back of the right arm (which I soon discovered was an extremely common complaint in Gundu) and, trying to be a good doctor, I tried to examine his arm thoroughly, causing a small riot in the waiting room because I was taking far too long! (Villagers burst in, demanding to know when they would be seen, as they had to return to the fields to work!)

So, I had to proceed with great speed and efficiency, but without abandoning good medicine. The expectations of the villagers are for a quick fix - “a pill for every ill” would be an accurate description. My ideals of preventive medicine and health advice were torn to shreds – gentle advice on stopping smoking simply fell on deaf ears. Patients wanted to walk out the door with magic pills in their hands, and these pills better work straight away! (A few came back after two days of being on iron tablets, wanting to know why they still felt tired). At times I did feel like a medical vending machine, but I think my greatest impact (hopefully) were the times when I was assertive in giving health advice – prescribing exercise for overweight diabetics, for example!

The most common ailments were a “burning pain in the heart” (meaning the stomach region), most probably caused by the Nepali habit of eating a spicy meal twice a day, with twelve hours in between meals, and going to bed soon after dinner. The first medicines to run out was Omeprazole which treats gastritis and similar problems! Respiratory problems were also common, most probably related to the high rates of smoking here. But the most common complaint of all must have been “back pain and knee pain”, which is not surprising when you know how hard the women work here. Almost every patient walked out with a strip of Paracetamol tablets for this. Diarrhoea wasn’t as common as I though it would be, and I didn’t see much that was exotic – it was usually run-of-the-mill stuff that I might have seen in Melbourne in a normal GP practice (but with different causes!) Most patients had had their problem for many years, and many had never consulted a doctor about them, although a proportion of them could afford seeing doctors (or received free treatment at the nearby Army Hospital, if they were eligible) and came in for a second opinion, or because of curiosity, or because they heard that free medication was available. Sometimes I felt as though they were hoping for a magic new cure from Australia – they were usually sent away disappointed!

My team at Gundu Health Post - From left to right - Me, Pabitra (interpreter), Head of the Health post committee, Admin staff member (I never quite got his name), Sunder (health assistant), Suntali (midwife, tea maker, and health assistant)

Before I came to Gundu I was expecting to arrive finding a small hut to serve as my clinic, and no staff. I was pleasantly surprised to find a well-run and newly built health post with several health assistants and administration staff as well as a well-stocked dispensary with commonly used antibiotics and other basic medications. The health post itself actually consisted of a room to do dressings in, an administration room and dispensary, a “family planning” room, and two consultation rooms.

It was really enjoyable working with such a great team – they were always smiling, their energy never flagged even when patients overran the waiting room, and they brought me sustaining cups of tea when my energy flagged! The main health assistant, a gentle giant called Sunder, was really knowledgeable and and a great help to me.

My assistant was the lovely Pabitra, a college student who spoke good English. Pabitra had the advantage of youth, with boundless energy and enthusiasm. It wasn’t an easy task being a medical interpreter, especially without any formal training, but with some direction from my end she came through like a trouper.

On my last day, the health post presented me with a certificate of thanks, which I found really touching. It was really simple for me to fit in as the doctor here – things ran very smoothly after we ironed out a few issues on the first day. The nearest doctor is at least an hour’s walk away, so I hope that in a small way my being there for ten days made some kind of a difference.

Gundu is a sprawling agricultural village of some 5000 people, one hours walk from the city of Bhakthapur and only twenty kilometres from the nation’s capital Kathmandu. It is an idyllic scene with neat little fields of golden wheat, corn, cucumbers and tomatoes in orderly rows, and lovely hills in the background. It’s a very clean village compared to the ones we have trekked through in the mountains - mainly because the livestock is kept penned up and not allowed to roam around. There are goats, a few cows, and even some geese.

Every morning the women head out at sunrise to work in the fields. The wheat was ripe, so each day we saw fields of wheat being cut (which is performed with a very dangerous looking scythe) and tied into neat bundles. The women all wear the same thing - a type of jacket, called a chollo, and a long skirt, and a very long strip of cloth wrapped many times around their middle, which apparently acts as a bit of a back brace. They also wrap a large cloth around their heads. The predominant colour is red or various shades of red. They work until sundown - I saw women carrying bundles of wheat and picking their way back across the fields even when it was almost dark.

(The men apparently do “nothing” apart from sit around, chat, and drink tea).

Women carrying wheat in Gundu

At sunset, the distant hills are a dusky lavender colour, and the stars start to come out. The insects start their nightly orchestra, and fireflies dance in the cornfields. It’s quite an amazing sight.

Gundu’s surroundings are pure jungle, on one of our hikes up to the surrounding hills of Tamang-Gou (HIll of the Tamangs), the livestock started going crazy from the howls of a nearby jackal. A woman related how a jaguar had attacked her in her home at night, and local kids swear that they have heard, some even swearing they have seen tigers. This might be explained by parents using the tiger as a boogeyman effect on their kids to scare them into eating their dal bhat. The other day, the town drunk (villagers like to gossip) paraded a snake he had beaten to death, 8 feet from tounge to tail.