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Circling back to Nepal:

How our ED found purpose returning to where it started

NEPAL THEN
I first went to Nepal in 2000 as an enthusiastic Family Medicine resident. I trekked half the Annapurnas, no road then so it was relatively arduous solo hiking, but the friendliness of locals made me feel so welcome. The beauty of these dusty stretches in Mustang with prayer flags draped over temples, the sheer drops off rope bridges between snow-capped cliffs, and the warm smiles of the Tibetans and Nepalis on that border were incredible. But there was change brewing; you could see the signs even then. I visited schools where the blackboard was commandeered by Maoist slogans which would result in often lethal consequences if erased. People were too afraid to push back. They were peaceful, often Buddhist (most of Nepal is Hindu), farmers and peasants who opened their small clay homes for the backpacking crowd. I gave away my hiking boots, worn to the metal, back in Pokhara and headed to my elective.
My first few weeks were in Emergency with Dr. Pratap Prasad at Tribhuvan Teaching University (he's now the WONCA chair for South Asia). Based in Kathmandu, he did his own Family Medicine training from 1990-93 in Calgary, who helped set up their first program. He attributes a lot of their success to UofC, now that there are hundreds of graduates, 1/3 of these posted in remote villages. Dr. David Allison (now based at Memorial) went back to Kathmandu with his wife Jill, who had already worked as a nurse in rural villages there. He worked with locals to create a Nepal-based training program. Now there are four Academies offering an MD-GP program, ensuring that good health care gets where it's needed most.
I recall struggling emotionally witnessing the hardships of life there, knowing that I would never fully understand the social determinants of health from these cases. Families whose mud-brick homes had fallen on them during their sleep, caving in parts of heads and chests. Teenagers attempting suicide - young girls promised to marry old men by their fathers who could no longer feed them - drinking insecticide, froth pouring from congested lungs. We would intubate and hand the bag-mask to their family members, "just push the bag to inflate their lungs every five seconds". Others had set themselves on fire, and I kept hoping they would die quicker. I didn't see a single survivor from the multiple cases we had each day. Even if we'd had a mechanical ventilator, such equipment often breaks down in countries where repair is not possible. Nepal has so few resources, even the tiny cost of lab tests were preclusive to many. I would walk back along the northern Ring Road through tuktuk clouds, tears waiting to fall until I sequestered in my room. We had no "global health mentoring" in those days, no Skype, and I felt unbearably hopeless.
My next posting was in Surkhet, a 19 hour bus west through precarious winding roads. Outside the Kathmandu valley, roads dropped sharply into terraced fields until we hit the terrai. I kept hoping a new bus driver would change shifts, but no one relieved him (or wide-eyed me). Surkhet then was a small rural hospital with a fantastic GP resident manning the show. Together, we saw end-stage wasting from TB, patients too poor or too far for attending clinics for medicine. A thin young baby dying from measles encephalitis, tell-tale dots spotting her mouth. The leprosy hospital, shadowy holes marking noses and digits. The final stages of things I had only expected to see in textbooks (Fournier's gangrene, Ludwig’s angina, and other such uncommon names), patients walking three days or more for care often wait until they must. Or they have to, like the woman who walked that distance to remove the baby who had tried to birth feet-first, his blackened feet still dangling as she walked, growing more septic with each step. She survived, and I could see that this hospital was doing everything it could in the harshest of circumstances. A good, comprehensive doctor with a primary care team made all the difference. A young Canadian who didn't now local context or resources could only do so much.
So I returned home shattered.
My career at MSF was unlikely. My sense of uselessness heightened. It was six years until hope returned. I kept traveling, engaging with people and cultures, learning and growing. Then I learned of the Laos project.
NEXT STOP LAOS
A Calgary team had  been asked by the Laos Ministry of Health to work with the sole medical school around creating a more effective training program. Local leaders realized that the majority of their population was not benefitting from the existing health system; they simply lived too far away from centralized care. Educators from the University of Calgary worked with them and they determined to start a Family Medicine residency, with the government mandating the graduates to work more remotely. A needs assessment was done to ask health care workers and community leaders in rural areas what the priority health issues were for these populations, and the inaugural curriculum was designed around these topics.
I learned of the project during an evening presentation by two of its participants. This was it. I basically sat on somebody’s foot until they agreed I could join the project and made my first trip in 2007, when the third batch of residents were enrolled. So I had the opportunity to learn about the many innovative and inspiring measures that were implemented during the program’s creation. The needs assessment determining learning objectives, with multiple stakeholders’ input was the beginning. I participated in a “train the trainer” approach, where we encouraged Family Medicine residents to become the next teachers, and I watched them shine in leadership roles during my eight years on the project. They managed to shift from the first year training in the capital city to both years occurring in Provincial Hospital teaching centers, with these hardworking graduates on faculty. They assessed performance-based competency around the learning objectives through clinical rotations and exams with simulated patients. They created a plan for the Masters research project that involved living and engaging in a small rural village, which changed every year, on a public health project. Students would survey the health behaviours of the community, examine where an intervention might improve their health, and negotiated which of these to implement with community leaders. After participating in educational projects, or physically building hand washing or toileting stations, the residents surveyed the same people to examine whether their maneuver had changed the statistics. It invariably does, and this drives an awareness of how public health works on the ground. It also shows them about the quiet closeness of village life and how they can assimilate in a respected role to these communities.  And they graduated as extraordinary physicians, who serve these smaller Provincial and District Hospitals.
Spending four to six weeks a year on this project, I learned a great deal from these locally-driven successes. Living in a rural village at the Vientiane Provincial Hospital; it was so small I had to take an open-backed truck to the next town over to find a hotel. Not only did I observe the particular interventions and design of this program that aided its success, but I became engaged with the students myself in a similar way where they engaged with their village placement. I found a community.
In order to make myself more useful, I had enrolled in a Masters in Medical Education during my first year on the project. Being only six years out of residency at the time, I wanted to ensure that I could provide academic excellence with my contribution. Two years later, I spent a quarter of a year studying Tropical Disease at LSHTM in London, UK. This was exactly what I wanted to do with my international experiences. Work with local initiatives, build capacity, grow relationships.
It was hard to leave Laos, but I knew that it was time to find new opportunities, to impart these lessons I had learned as a participant by becoming a leader. While working in Laos, I had become involved with some wonderful Family Medicine programs in East Africa. Leveraging on existing collaborations through the University of Calgary, I was able to get involved in their work by facilitating a south-south network where they could share their stories. Since their programs were advanced, even if resources were scant, there was not as much of an academic role for me there. I yearned for partnerships where I could work with leaders creating or examining Family Medicine training. It brought me back to Nepal.
NEPAL AGAIN
One of the unique features of Family Medicine is that graduates can work in remote settings, since they can manage the majority of issues that arise. In most settings in Asia and Africa, they might work in a hospital environment. Sometimes incorporating public health into their roles, often learning surgeries (setting fractures, doing Cesarean sections), always learning what their community needs. Since in most of these emerging nations have a vast majority still residing in rural areas, they can serve the population that needs them the most.
In Nepal, despite shifting demographics around life in the Kathmandu valley, the majority still live rurally. Many had come into the central valley to escape the Maoist insurgency in the intervening years since I was first there. Makeshift tarp villages, new mud brick homes, overcrowded apartments were spilling over with families. But the valley has easier access to resources; remote villages in Nepal are often reached on long journeys over dangerous roads rendered impassable during the monsoon months. Life expectancy in rural areas is 20% less than in the Kathmandu valley.
Patan Academy of Health Sciences (PAHS) lies in the valley; Patan is one of three cities nestled in this crater. This school was designed to graduate health care workers who would be able to work in these rural settings. They partnered with Patan Hospital so there would be an attached training site, and are working to make this a center of clinical excellence. The feasibility study for this institution was spearheaded by Dr. Bob Woollard acting as an international consultant, and he has become a mentor in my career. I accompanied him to PAHS in October of 2014 to learn about where I might forge relationships at this extraordinary school.
As of 2015, PAHS is about to graduate their first batch of medical students. They will need to do a required year of clinical internment before they could decide if they want to specialize. Many will simply work where the are posted, not studying beyond the five years of medical school. But others have begun to recognize that GP training will enhance their ability to manage the depth and variety of illness that they will be managing. Patan Hospital has been running a GP training program even before its merge with PAHS, but they will soon be running this under the auspices of their own academy.
During both of these recent trips back to Nepal, in October 2014 and April 2015, it was instantly apparent that I would again learn a lot from the work already accomplished. When PAHS determined their mandate, which heartwarmingly includes the word “love”, they wanted each step to reinforce the mission. Students are chosen through a rigorous selection process that would make them more likely to retain in remote settings; many from these rural villages are given scholarships to attend in the hopes they will return. Those with experience as health care workers in villages, with a desire to pursue GP studies, or who have demonstrated social accountability are given priority. It makes for a wonderful group of people. I met some fantastic medical students, most from wealthier families in the villages, since the cost of smart phones with uploaded textbooks or the hostel would be preclusive to many. But they informed me that one boy’s father broke rocks with a sledgehammer so that his boy could attend. Another girl is from the “untouchable” caste, and the students relay this news to me with pride and awe.
Some of these students are keen to study GP medicine, since they are committed to working in a village. Many of them on scholarship have a bond (or contract) to do so, but others see this as important work, the most significant way they could serve the country’s highest need. This was not lip-service, it was their life plan. I have been so impressed by these students.
Life will not be easy, some will be separate from the rest of their family while their children attend private school in the valley. One described his home-town hospital with no electricity, so the citizens had set up solar links. They would often have minimal administrative supports, a constant undersupply of medicine, and impossibly long days as the sole physician in town. Even the surgeries they might be trained to perform would be impossible due to lack of instruments and trained assistants, so they would have to watch patients, their community, die a death they could have prevented.
They become prepared and more confident for this life through PAHS training. During my recent visits, I have learned that the medical school curriculum focus’ on marginalized populations, both urban and rural. For 17 weeks of their final year, they study both clinical medicine and public health in four remote training sites. It costs the equivalent of a physician’s monthly salary to get these students to these villages, but PAHS recognizes this as imperative to their mandate. Students who learn in these environments, especially those who grew up in remote regions, are the most likely to stay. There is good research proving this, and it is so foundational to PAHS’s mandate that they must give them the best chance of success. Global Familymed Foundation has now chosen this expense as a fundraising effort; PAHS leaders describe it as a necessary operating cost that is
The project as an academic consultant with the GP faculty at PAHS will be exciting co-learning. Already I have seen some innovative ideas in practice: a half-day each week set aside for teaching around the non-clinical aspects of their learning objectives (ethics, policies, communication). GP faculty assigned as mentors to work one-on-one with each resident, monitoring progress and checking on personal issues. Large involvement of these GP faculty in many aspects of undergraduate education, from heading their virtual classrooms to teaching Family Medicine principles. There will be ways in which I can contribute, based on conversations with these leaders. I have begun interviewing some of their residents, and they also had creative and thoughtful ideas on how the program could be improved.
So it seems that I have a lot to learn on an ongoing basis here in Nepal. From my initial encounters with a sense of hopelessness and inability to contribute to returning with a purpose. By working on capacity building, engaging with local leadership, designing learning around the community needs, and measuring success, there is an opportunity to leverage up the success I am seeing. Building capacity in an area with such great need and finding sustainable solutions to rural health inequities will be the dream I hadn’t yet conceived of during my first visit here.