The enormous destruction caused by the earthquake in Nepal was recently at the center of the conversation for four friends in a restaurant in Gothenburg. Henrik Sjövall lets us take part in the meeting.
Nepal is back in the news, this time for unfortunate reasons. If you have a good memory, you might recall that I fell in love with the country during an official trip last year (www.akademiliv.se/2014/10/21418/). Ever since then, I have tried to stay up to date on developments there. Last week’s media storm was very hard to sift through and it wasn’t until last evening that I got together and discussed strategy with a few colleagues who share my enthusiasm.
Most of them come back more broadminded people
As the person in charge of the project for 10th semester medical students, I see it as a unique opportunity to spend an extended period of time in a country that faces its own challenges and has a different kind of healthcare system than they are used to. Currently fewer than one-third of the students go to low and middle income countries. I think we can do better than that. We expect a great deal of these students—they must possess a decent familiarity, much of it counterintuitive, with the host societies. But we are firmly convinced that most of them come back more broadminded people. At least that’s what happened to me after visiting Amp Pipal, a little mountain hospital.
We met at the Namaste Nepal restaurant in Gothenburg. Namaste is a greeting that literally means “I bow to you”.
The reason for choosing that particular restaurant was that I had wound up there by chance a while back and chatted with the owner. He told me that he had grown up in a little mountain village of western Nepal and had never heard the word money until he was 15. His brother had wended his way down the tortuous path to a law degree and gone to London, where he arranged for other family members to join him. I don’t remember how my new acquaintance had finally ended up in Sweden. We hit it off so I asked him to prepare dal bhat, one of the most popular traditional Nepalese dishes.
Who else was there? Three other gentlemen who are no longer wet behind the ears—Göran Kurlberg, Leif Dotevall and Mats Sandberg—each with a special relationship to Nepal. Göran is a surgeon who has spent decades at Amp Pipal and other hospitals. He speaks Nepali and is “Mr. Goran” to friend and acquaintance alike. Leif is an infectious and communicable disease specialist who has been heavily involved in projects with low and middle income countries. Mats, who is the resident Sahlgrenska Academy ecology guru, teaches neurophysiology at Patan Academy in Kathmandu with his environmental fervor in tow. And yours truly—a bit more enthusiastic than knowledgeable about global health issues but with a rapidly expanding network of academicians and care professionals.
It wasn’t long before we started talking about news coverage of the earthquake. “By the way, do you know why it was called the Spanish flu?” Lars asked. “The epidemic also struck Germany, France and the UK, but they didn’t want the world to know about it. Conditions were no worse in Spain than anywhere else.”
That got us going on the subject of epidemics. “It’s only a matter of time,” said Lars with a worried look on his face. “Initial reports of acute hepatitis have already arrived. Most people have had hepatitis A and hepatitis B doesn’t usually behave this way. Who knows, a hepatitis E outbreak may be around the corner.”
Lars is an expert on epidemics that occur as the result of natural disasters and occasionally lectures about their role in history. I flashed on Jared Diamond’s Guns, Germs and Steel about that very subject.
Tuberculosis was the next topic of conversation. Leif talked about the multidrug-resistant strain that poses a genuine threat in Sweden and elsewhere, as well as the fact that people with the disease are still stigmatized even in countries where it is very common. The medications are free but patients frequently fail to realize that they should keep taking them even when they are feeling fine.
I couldn’t help it—I just had to bring up leprosy at that point. Over the Easter holiday, my wife and I had visited the Green Pastures Hospital and Rehabilitation Center in Pokhara, affiliated with the International Nepal Fellowship.
Officially nobody has leprosy but the nurse receives 5-6 new cases each month from six districts alone. It is a hard diagnosis to confirm—the disease usually starts with difficult-to-interpret pigment changes and vague local neurological symptoms. Some type of local autoimmune response is apparently involved. Treatment is available free of charge, but the damage that arises before it starts is irreversible. Green Pastures focuses on rehabilitation, which is far from free. Nevertheless, it has impressive medical stores, an exercise center and an obstacle course for wheelchairs.
The nurse related to us that obtaining financial support for this kind of institution is extremely difficult. It was Good Friday, and we felt as though we were back in biblical times.
Just imagine if the Göta Älvbron bridge in Gothenburg collapsed and our authorities were caught with their pants down
Next on the agenda: how well had the Nepal government dealt with the crisis?
Göran: “Just imagine if the Göta Älvbron bridge in Gothenburg collapsed and our authorities were caught with their pants down. It’s all over the front pages and American freighters suddenly apply for permission to land at Landvetter airport. Carloads of aid workers arrive and demand that we get their baggage to the hotel. What would be our reaction?”
Göran says that Nepali hospitals stage disaster management exercises, particularly earthquake scenarios, on a regular basis. The last major tremor was 80 years ago, but nobody had forgotten and they were prepared. Still the authorities were caught off guard and didn’t know what to do when a bunch of aid workers showed up with all their equipment. A decree, fortunately unenforced as far as he could tell, was issued to the effect that all new “small accounts” for earthquake victims would be consolidated under the Prime Minister’s Relief Fund, leading to suspicions that the money would end up in the wrong hands. The first announcement suggested that the decree would also apply to Save the Children, Doctors Without Borders, Mission to Nepal and other previous partners. Media exposure may have led to the retreat—I know that I alerted Swedish Public Radio to the situation. In any case, the donations appear to be coming in through established channels.
Leif: “But they must be giving the wrong signal by sending volunteers back home.”
Göran: “Both yes and no. The zealots don’t want to cooperate with others but do their own thing. Not only that, they require major financial resources because they are accustomed to a different standard of living. So sending them packing is not completely out of line.”
Still safe for students to go there?
We talked about whether it was still safe for students to go there. My spontaneous thought: “The likelihood of second earthquake following one this big, including aftershocks, is very low, right? From that point of view, this might be the perfect time to go.” Yes, but parts of the country are in ruins and local supervisors have more important tasks than looking after the needs of Swedish project managers. Meanwhile, a lot of fascinating issues remain to be explored. We agreed to proceed with the projects that have already been planned, provided that the local supervisors are willing.
I wanted to have a more general discussion about ways of enabling students to see that part of the world. I mentioned that a delegation had just visited from Rwanda and that they were also interested in long-term collaboration. The country fell apart while the genocide was being carried out, but the situation is relatively stable now and the students will be well provided for. My ultimate vision is to find a half dozen or more partners in low and middle income countries, preferably both with and without good public health care, social insurance systems, etc. Leif seemed to like the idea but was skeptical about its feasibility. We’ll have to keep our eyes open—but Nepal and Rwanda are good places to start.
Sahlgrenska Academy now has a Master’s program in Global Health
I took the opportunity to mention to my dinner partners that Sahlgrenska Academy now has a Master’s program in Global Health, which has set the stage for recruiting graduate students. The program will also give our project students a chance to gain a more in-depth understanding of the ground rules in low and middle-income countries. The news was received with great enthusiasm.
The last topic for the evening was which projects to prioritize. I expressed interest in sending students to Green Pastures and Leif promised to help with supervision. Mats brought up asphyxia injuries during childbirth, evidently a huge problem in Nepal. He is a biochemist and conducts research in the field. I was a physiologist once upon a time—when I was there last, I saw a woman carrying a pack of reinforcement bars up a steep staircase without visible difficulty. How is that possible? How do the lungs and circulatory systems handle it? Many physiological mysteries remain to be solved.
How is that possible? How do the lungs and circulatory systems handle it?
Last but not least, the Patan Academy of Health Sciences (PAHS) offers a unique medical program. They recruit students from mountain villages and give them a relatively heavy battery of tests for both personal qualities and cognition. Admission to most other medical programs proceeds strictly from previous grades, though wealthy parents can grease the wheels. PAHS uses problem-based teaching and learning, whereas the others are more traditional. What an interesting project it would be to compare the knowledge and skills of these students with ours. My impression is that they are at least as well-read and probably better at physical diagnosis, but a reality check would be in order.
We squeezed in a word or two about ethics while waiting for the check. I will be taking over the ethics module of the internal medicine course this fall—end-of-life care will certainly be on the agenda. The doctor at Amp Pipal told us about a farmer whose son developed kidney failure and faced the prospect of dialysis for the rest of his life. The family would have to sell the farm and be left with nothing to live on. If he let his son die, who would perform his own burial rites? His wife was too old to have any more children. Just imagine if we could arrange a joint ethics lecture on Skype with students from both countries.
We divided up the modest check and said goodbye to our hosts. Rising from our seats, we all agreed that with a team like this, we can’t fail. Namaste, Nepal, until we meet again.
P.S.
Patan Hospital would be very grateful for any donations you are able to spare
Bank: Nabil Bank Limited
Account: Patan Academy of Health Sciences
Account number: 0203217500593
SWIFT Code: NARBNPKA
Branch: Kupondol, Lalitpur
Please specify: Patan Hospital earthquake disaster relief