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Nepal Newsletter

posted:
October 2, 2007
Mark and Deirdre Zimmerman
NSI, EPC 1813,
PO Box 8975,
Kathmandu, Nepal

“Whatever you do, work at it with all your heart, as working for the Lord, not for men.” Col. 3:23

2 October, 2007

Dear Friends,

In 1988, my second year in Nepal , I hiked with two friends into the mountains of Gorkha District.  I was working as a doctor in a hospital there, and for vacation we set off to trek around the Manaslu Himal, on whose majestic faces we gazed every day.

About a week into the journey, we crossed the Larke Pass in waist-deep snow and in the evening finally came down to a hut used by shepherds.  We were hungry and cold, and the local Tibetan man who’d guided us over the pass chopped chunks of wood from the rafters of the shed in order to build a fire to warm us and cook soup.

Further on, we walked above the Buri Gandaki River and one day stopped for lunch in a small village called Prok.  While waiting for our meal to be cooked we chatted with a man, and when he learned I was a doctor he insisted we come see his friend.   We walked a short distance across a sunny courtyard, to where he led a man out of a house.  The fellow was thin and moved with slow, deliberate steps, as if to not break something inside himself, and he carried a small container.  He looked about 40 years old.

“What’s wrong, friend?” I asked.

“Coughing up blood.”

“How much?”

He slid the quart-size copper pot across the stone towards me. It was half full of frothy blood.

“How long have you been sick?”

“Three or four months.”

“Can’t you get medicine around here?”

“In these mountains?!  There’s neither medicine nor doctor within a week’s walk of here.”

I thought the man probably had TB and I told him he was seriously ill, that he might die unless he got treatment soon.  I told him I was sorry that none of the tablets we were carrying would help him.  I tore out a page from my notebook, and wrote my name and “ Amp Pipal Hospital .”  He’d heard of the place.

Though we’d walked down and out of the snow, our path remained difficult.  I’ll never forget walking precariously over 20-foot sections that were suspended from the cliff face.  Where the path could not be carved into the rock, it jutted out on logs laid haphazardly on scaffolding socked into cracks in the sheer cliff walls.  I forced myself to walk sideways over wobbly sections of wood, my hands pressed against the rock as I looked down through gaps at the river 300 feet below.

Upon returning to Amp Pipal, I completely forgot about the man from Prok – until about a month later when someone brought him into our outpatient department.  I was shocked.  His family had carried him down for 10 days over those difficult paths, and now he lay on my exam table.   He looked worse, and he could barely speak.  I examined him and ordered a chest X-ray.  Expecting to see TB, I was surprised that there was no sign of it but could see that he probably had amebic parasites in his liver.  An abscess had burrowed up into his chest, and that was the cause of his hemorrhaging.  The treatment was simple enough: I drained 2 liters of bloody pus from his liver and gave him some inexpensive metronidazole tablets.  Within five days, he was markedly better and able to head home.

Twenty years later, last April, I rode out again to Gorkha District as part of my work with the Nick Simons Institute (NSI), of which I am executive director.  NSI supports rural health care in Nepal , the “backbone” of which is the “mid-level worker.”  Nepal ’s mid-level workers, called medical assistants, are similar to the physicians’ assistants or nurse practitioners of developed countries – classified below doctors in the medical hierarchy, they often do the work of the absent physician.  One of NSI’s goals is to improve the care that these mid-level health care workers provide.

I was coming to Gorkha to check on our NSI Assessment Team.  We had a team of eight health care professionals who were conducting a week-long program to determine the skills of health care workers.  Our team tested 10 workers each day, eventually covering every government mid-level worker in that district.  We put the health workers through a series of stations where they had to demonstrate their competency on mock patients: They had to deliver a baby from its mannequin mother, treat a simulated arm fracture, care for a child with diarrhea, go through the steps of inserting an intravenous line – basic skills.

Unfortunately, most of the health care workers did poorly on our assessment.  Even on these basic skills, they scored in the 30-60% range.  Some had no idea how to examine a patient and had only rudimentary (or no) skills in delivering babies.  Nepal ’s maternal mortality ratio is one of the highest in the world.  Some of the workers we tested didn’t even know how to open the set of delivery instruments.  In one sense the assessment was a success: we identified specific skill gaps of these vital workers.

All this took place in the Gorkha District Health building.  I walked along the corridor and went into each of the six testing rooms, watching for 15-20 minutes at a time.  Out in the hallway the workers stood waiting their turn to be tested.  In the afternoon I spoke with one young worker.

“How does the test seem to you?”

“Good.  We’re glad someone cares enough about us to try to help.”

“Where are you working?”

“Health post way up the Buri Gandaki River .  It took me 4 days to walk down.”

“Are you anywhere near the village of Prok ?”

“Yes, right below there.”

I left Gorkha that day last April reflecting on the passage of time.  In 20 years there had been some progress.  Government workers had moved into areas where they had not been before.  There was even a manned health post high in the mountains near Prok.  Unfortunately, that worker languished in his remote post, all but forgotten.  And his skills showed it: he couldn’t perform even the most basic tasks required of a competent health care worker.   There was expanded health care for the rural people, but the progress was incomplete.

Still, there is reason to be hopeful.  The Health Ministry knows that it must continue to improve the skills of its 5000 mid-level workers, many of whom work in remote locations across the breadth of the country.  Following our assessment of 163 workers in 4 remote districts, the government has given approval to develop a new course to upgrade the skills of existing government health care workers.  Our NSI team is putting this new program together.  We hope that by mid-2008 this course will join other NSI trainings for rural health care workers.

Please continue to pray for the NSI team and for me.  The beginning stages involve a lot of planning, discussion, negotiation, and waiting.  I feel a long way from the action – the place where doctor meets patient – and sometimes wonder if I’m the right person for this job.  Still, Deirdre and I believe that God opened this unusual opportunity for us, so persistence is called for.  When we were home on furlough in 2004, we asked churches to pray for the idea of a new medical college in Nepal .  Little did we expect that some months later this path would appear before us.

This summer after work I frequently changed my route home and stopped by the swimming pool where our family has a membership.  In past years I didn’t do much swimming, but this year there was a new attraction.  Zachary and Benjamin are beginning to swim.  Zach can doggy paddle across the pool and Benjamin has gotten over his fear and is right behind in arm bands.  They are both doing ballet this year too.  There’s a lady from New York ’s Joffrey Ballet who teaches kids here in Kathmandu .

With Zach going to school every day, Deirdre’s routine becomes slightly less home-bound.  She still has a pot pourri of activities – with Benjamin, Nutrition Program, another NGO, giving a bit of support at school – and probably won’t move fully into outside work until Benjamin is off to school in two years.  Personally, it’s great to have someone looking after our home front and the nutrition side there. (And she still looks dashing around the pool.)

We’re thankful for your prayers,
Deirdre, Mark, Zachary and Benjamin

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