Why the MBBS docs are thinking twice about serving in earthquake zone May 29th


The truth

I know a doctor here in Nepal who once spent a month trekking from village to village in his district, working with every VDC, to examine women and find the ones who could benefit from a specialized surgical camp set up by a German charity group.  And for every doctor and nurse in Nepal, going on a “health camp” to a rural area is part of normal practice.

The innuendo

On May 26th, there was a short article in Republica newspaper bemoaning the fact that 300 doctors are needed in the earthquake-affected areas of Nepal,  and only about 19 responded to the government’s call to work in the earthquake zone. The writer was heaping shame on the young doctors of Nepal.

The response

I wrote a quick response, since the volunteer project I do here in Nepal involves working with those very same doctors, at the beginning of their career.

Today on Twitter I see that the original article has been retweeted more than a hundred times, and seemingly refuses to die. I replied to the retweets offering to give more info as to why young docs might be reluctant but – the writer of the original article did not call me.

Don’t pay  attention to Twitter?

I am aware that Twitter is a bit shadowy. Many of these people who tweet are seeking sensational stories and false outrage. Any twelve-year-old with a mobile can tweet. We don’t know who is “serious” – so, often it’s best to ignore them.

But this time I will be a bit more direct.

Here is what the young doctors are being asked to do, from what it sounds like.

1) go to work in a recent earthquake zone where the houses, schools and health posts have been destroyed.

2) live in the same kind of temporary structure that the people they serve are living in, just as exposed to the elements as the others;

3) Use a temporary structure as a clinic, just like the one that they are living in. There will be no guarantee of a recordkeeping system, no X-ray equipment, no lab equipment, not even a microscope. Not necessarily an examining table, no medical supplies accumulated from the past. There will be no way to dispense drugs if they write a prescription. If there were supplies at that location in the past, they now lie in a heap under rubble that used to be a health post.

4) there is no security personnel. There are reports that the aid now being delivered gets hijacked by village strongmen. Even before the earthquake, there has been a problem with aggressive behavior toward doctors when things don’t go well; the problem with “thrashing” has not gone away and will most likely get worse – the doctor’s physical safety is in doubt.

5) there will be no guarantee of a senior doctor of any kind to supervise or provide advice.

6) In many cases, the young doctor has never lived in a village – they grew up in Kathmandu.

Does this list help? Do you get the picture?

You can’t provide the kind of medical care you were trained to provide, on a picnic. You need tools.

You can’t do it while you are on a two-year’s long camping trip. How does the doctor get food and water and laundry?

The young doctors who signed a commitment to serve and repay loans, could not have known they would be asked to serve in an earthquake zone. Not even Albert Schweitzer would work under these conditions. Many of these young doctors are the same ones who rushed to the affected areas to provide immediate relief in the first weeks. They are not lacking in patriotism. In fact, a few of them did grow up in a village setting. In my teaching I met one  young doc from Makwanpur who was expert at handling oxen when it was time to plant paddy. But for most? Kathmandu.

The doctors need equipment, a roof over their head, and  somebody to prepare rice while they work.

The Nepal Army is in the affected area, doing the backbreaking work to help the residents prepare for monsoon. But while the Army guys were doing physical training everyday and camping while on maneuvers, the young doctors were in the library. All of a sudden, for all intents and purposes, they are asked to join the Army on deployment.

The government needs to  work on these issues and make an effective plan. The article in Republica resorts to shaming and namecalling. This is not the time to browbeat the twentytwo-year-old MBBS graduates, nor is it time to shame the Nepal Medical Council for bringing up the elements of an effective plan.  With a few more questions  the journalist could have gotten to the other issues and provided a service to the reader.

Alas, he did not.

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May 28 report of CCNEPal part three


Please read parts one and two. In part one, I summarized the numbers of sessions, the locations and the people who took the 2-day (MBBS) or 3-day (for nurses and nursing students) versions of the ACLS course. In part two, I  gave a narrative of MBBS education in Nepal, with some things that stood out after teaching this population.

CCNEPal and the Earthquake

CCNEPal trained 2,130 Nepali nurses and doctors since 2011, and 800 of them from Kathmandu Valley. I got a FaceBook message May 5th:

I was in thamel when the 11:56 happened. A 5 storeyed building. Glad it didnt give up. I survived. Came outside to see 2 houses collapsed. We dug out 2 people, husband and wife with local resources live shovel. The emergency protocols came spontaneously to me. I was able to stabilize them both physically and psychologically. Then in the late afternoon, I went to Bir hospital NAMS to see if i could contribute as a medical student. I performed half a dozen CPRs and assisted in many other emergency management. Could not save them all though. Saddened me of course. Wanted you to know all this because it is all thanks to you and your teaching approach that everything came to me spontaneously. You did save a lot of lives from dharahara quake through me. Thank you.

Even if that was the only guy we trained, it was all worth it.

to respond effectively in a crisis requires the ability to recall complicated protocols and choose the ones to apply. We use in-class exercises to reinforce the memory, and previous groups have told that

to respond effectively in a crisis requires the ability to recall complicated protocols and choose the ones to apply. We use in-class exercises to reinforce the memory, and previous groups have told that “Joe, you are turning us into Jombies!” – but – you need to be able to decide how to execute – and that’s the serious purpose.

The landscape of Cardiac Life Support in Nepal and the future.

CCNEPal is not the only entity that is trying to bring Advanced Cardiac Life Support education to a wider audience. There are other groups filling specific roles to teach nurses and doctors, mostly Medical Officers ( a few years older than the interns).

The hospitals and medical schools in Kathmandu. Bir Hospital has taught a course like ours to the post-graduate doctors seeking their M.D. (Master’s) degree. Man Mohan Cardiac Center and Shahid Gangalal Cardiac Center have recently started teaching this course to  their Medical Officers, as has Patan Academy of Health Sciences and Grande Hospital. It should be noted, however, that in these locations the interns are not included, nor are the nurses. None of the instructor groups from these locations has ever travelled outside the Kathmandu Valley to the fourteen medical schools located in the rest of Nepal, and CCNEPal often hears “You’re the only one who teaches this who comes to Terai!”

Man Mohan Cardiac Center worked with CCNEPal to train the nursing staff in 2014, the same way that SGNHC did in 2013. We did a training for thrity five nurses hosted by TUTH nursing school; then MMCVTC sent nurses to each session we held at LNC. They have a highly motivated and talented crew, and it was an honor to work with them. CCNEPal has trained nurses from each of the cath labs in Kathmandu as well.

Man Mohan Cardiac Center worked with CCNEPal to train the nursing staff in 2014, the same way that SGNHC did in 2013. We did a training for thrity five nurses hosted by TUTH nursing school; then MMCVTC sent nurses to each session we held at LNC. They have a highly motivated and talented crew, and it was an honor to work with them. CCNEPal has trained nurses from each of the cath labs in Kathmandu as well.

The Center for Medical Simulation deserves special praise and mention. Nepal’s only Official International Training Center from the American Heart Association. There is a lot to say about this Center. I was proud to consult with them as to proper policies and procedures, and the courses they offer are on par with the high standards of the American Heart Association.  The BLS or ACLS card you get from The Center is the Official AHA card. Any doc who wants to take USMLE will find that taking ACLS from The Center for Medical Simulation is considerably less expensive than going to Delhi or the USA. Having said that, the fee for the BLS/ACLS is about 20,000 nrs per person. They offer group discounts.

The Center for Medical Simulation owns a complete set of BLS manikins and awards the exact same course completion card that you would get in the USA.

The Center for Medical Simulation owns a complete set of BLS manikins and awards the exact same course completion card that you would get in the USA.

Videshi groups. It is not unusual for one or the other Kathmandu Valley entities to bring in a group of videshi instructors from an American Medical School to teach the “official” ACLS or PALS course, or one of the other courses such as ATLS or PHTLS. For some reason, every outside group always announces that “We were the first that ever did it.” – Um, no. You can think that way if you like, but – last year’s group from USA was also enticed to come here with that same pitch. And the group the year before that…… near as I can tell, groups of foreigners have come here to teach Nepali docs for more than twenty years. In 2014 I listened politely as a pediatric cardiologist from the Mayo Clinic announced to me that she was involved in the first ever ACLS course at a major hospital. Was it the official course? no. Well then, I’d already beaten them to it by thirty sessions with nurses. No big deal. (and for the record, CCNEPal has taught 70 sessions as of May 2015.)

Special note about foreigners coming to Nepal to teach or train:  study this blog and the CCNEPal FaceBook page; and read my two books. You can not simply transport an American course here and think it will work.

Note; if you are a qualified ACLS or BLS or PALS Instructor or Regional Faculty from USA, contact the Center for Medical Simulation. Send them your affiliation paper work as soon as you book the flight to Kathmandu. You no longer need to bring the required equipment, or improvise. You can now teach in Nepal and use state-of-the-art equipment from The Center – much more efficient than hauling stuff back and forth. The Center also has state-of-the-art simulation tools. They have a “3G Sim-Man” suite as well, which they are just starting to use.

Train-the-trainer is a sexy word in these sort of teaching ventures. In my view, it allows the teacher to rationalize doing the logistics for a session that only reaches twenty people at the max. My estimate is that about 30,000 doctors and nurses in Nepal need this. Train-the-trainer is a drop in the bucket; and since the logistics of setting up a course are daunting, none of the train-the-trainer people seem to actually turn around and teach after having just taken it once themselves. There needs to be a culture of ACLS.  I’ll expand on this in a future blog.

Furthermore, focusing on training the “Top Guys”  never seems to result in sharing the knowledge with the Junior Guys (and ladies). The knowledge of ACLS, and the practice of resuscitation, needs to be widely known at the level of the person who is working in a Casualty Room on an offshift, and not limited to the Senior Consultant from the Anesthesia Department.

Training Nurses Part One Any hospital or school that does not also train the nurses, simply does not have an effective ability to do resuscitation. And any person who disagrees with me is proving their ignorance.  I won’t be polite about this point.

Nurses need to learn how to do this. (don't try this at home. these are trained professionals under expert supervision)

Nurses need to learn how to do this. (don’t try this at home. these are trained professionals under expert supervision)

Training Nurses Part Two if your  hospital has an ICU or ER, every nurse in that area needs to have this training. If they do not, and especially if you do not value it, you don’t have a real ICU. The ability to do critical care is defined by training and teamwork, not by an inventory of equipment. Simple.

In May of 2013, CCNEPal started routinely including an anatomy lab in the 3-day session for nurses, to make up for gaps in science preparation ( something I had done in USA for years). For this we obtain en bloc heart-lug assemblies of mutton from local fresh shops. Here's a shot of the coronary arteries.

In May of 2013, CCNEPal started routinely including an anatomy lab in the 3-day session for nurses, to make up for gaps in science preparation ( something I had done in USA for years). For this we obtain en bloc heart-lug assemblies of mutton from local fresh shops. Here’s a shot of the coronary arteries.

Training Nurses Part Three I think CCNEPal should consider awarding a prize, or a Token of Love, or something, to any ICU that achieves 100% training of their nursing staff. Either certify the nurses with the AHA ACLS course or with something equivalent to the course CCNEPal teaches.

The American ACLS Course has it’s place but does not fit the needs of Nepal.

– The AHA has detailed requirements for “mandatory equipment” for each course. It leads to formidable start-up cost that makes it too expensive. With a bit of imagination,  you can do a course with improvised equipment that is not such a large investment.

This is the stuff  CCNEPal uses to teach the course. Another view of all the stuff, laid out so I won't forget something. note the

This is the stuff CCNEPal uses to teach the course. Another view of all the stuff, laid out so I won’t forget something. note the “CPR manikins” deflated in upper left corner :-)

– The protocols need to be adapted to reflect the clinical practices here, and what Nepal can afford.

– And most of all, the “English only for all discussions” requirement of AHA is not helpful. Click here for some examples of ACLS core case scenarios conducted in Nepal Bhasa. Let’s teach the stuff in the language it will be applied. A nurse or doc can be expert at this even if they speak no English. Because of the way the CCNEPal course is structured, every participant is able to get all their questions answered in the language with which they feel the most comfortable. Yes, most nurses and docs speak English. But – don’t underestimate the potency of this tool.

There needs to be a Nepali ACLS certification system. Sure, you can use the latest research-based findings of ILCOR, but the wallet card needs to have little Nepali flags on it, and scratch out the word  “American.” Click here to read about specific ways I adapt the course to fit Nepal.

Train Intern-level MBBS docs. In my view, the most important curriculum change that needs to take place in medical education is to require all interns to take an ACLS course before they complete their internship.  In USA, medical students take ACLS before they graduate. Nepal needs this.

MBBS interns at CMC in Bharatpur. These young docs were willing and enthusiastic. A bright spot for Nepal's future. In the recent exams, the aggregate scores for CMC were among the highest in the country.

MBBS interns at CMC in Bharatpur. These young docs were willing and enthusiastic. A bright spot for Nepal’s future. In the recent exams, the aggregate scores for CMC were among the highest in the country.

Establish a national network to teach this. There are twenty medical schools in Nepal, and each should be teaching this. Every B Sc program in nursing needs to teach this.

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May 27th eye-witness report #2 by Nepali nurse from USA after earthquake relief expedition


Editor’s Note; Unita Magar, RN is a nurse who now lives in Omaha, Nebraska. She attended nursing graduate school in New York City but Unita is originally from Rukum district in western Nepal. She is active in NANA, the professional association for Nepali nurses in USA. With her colleagues, she flew to Kathmandu after the April 25th earthquake. Here is the story of her trip to the affected area.

On her FaceBook page she posted 150 pictures. I will cull those and add some to this blog. For now, the text is important enough to rush to print. The words are hers.

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For our first trip, our medical team consisted of 11 health care professionals in total: 4 NANA nurses, 3 NAN nurses, 3 medical doctors and 1 health assistant. Altogether, we were 29 of us with river rats (rafting brothers), a mouse (Frank), mountain cats brothers (Climbers) and a local’s team (Bobby dai and his team).

We were able to see 245 patients in about 9 villages in total. On the first day, all of us stayed at the base. On the second day, we divided the team into three groups. First team stayed at the base, second team went to Yangri and the surrounding villages and the third team went to Yarsa, Chunti, Bhotang Gumba, Thorbang, Meu Gau, Kuldi and Mane Gau. The roads to the villages had multiple landslides – some of them had huge rocks and fallen trees blocking the roads. The teams had to walk or crawl up the rubbles to get to the other side. Our team had one doctor, two nurses, one river rafting brother, one kitchen brother and two locals. Initially, when we left the base, we did not have any locals in the team. We were told by Bobby dai that we would find someone as we walked to the village. We found two locals who were very willing to take us around at Bhotang Gumba, our first stop. The hike to Bhotang Gumba was quite steep. From there, we moved from village to village stopping at a public school that had been badly damaged from the first earthquake for our lunch that consisted of chiura (beaten rice) and dalmot, roti (chapati) , boiled potato, small amount of salt wrapped inside a tissue paper to dip potato in and buffalo jerky. It tasted so good. It took me back to my childhood days, when I would go to fetch woods with group of women in the jungle during my summer visits to my grandparents in Rukum and we would rest to eat our lunch of bhuteko makai (popcorn), bhatmas (soybean seeds) and ussineko aloo (boiled potatoes). It made me nostalgic.

We went from door to door on that day, asking, “Yaha kohi birami hunuhuncha?” (Is anybody sick/ill here?). Sometimes, the answer would be “Yes,” and at other times “No.” If there was any sick person in the house, we would stop by, open our rucksack of medical and dressing supplies, examine the patient, treat, educate and then go to the next house. At some places, we would use the side of the road to place our rucksack and treat patients.

At one of the villages, we used our whistle to alert and call upon the villagers. This particular village sat lower on the same mountain to the village we were treating patients at. It was perhaps 10-15 minutes hike, but with rubbles of stones from fallen houses everywhere it may have taken us longer to reach there. When we blew the whistle and screamed at the top of our lungs – “Yaha kohi birami hunhuncha” (Is anybody sick and needs to see a doctor?), some of the villagers turned their heads around and screamed back, “chaina,” (No).

On the way to the villages, two of our team members slipped through the mud and fell on their backs. Thankfully, nobody got hurt. One of them had left behind her two young sons in the States to help with the relief work. Bless her heart for the sacrifice that she made for the people in Nepal. We also had another didi on our team who also left her young sons, one of them as young as three years old to help with relief work. Bless both of their hearts, only they know what it means to leave behind their young children for a cause.

It took us whole day to cover all the villages. At one of the villages, rice and noodles were being distributed by a local group. We purposefully chose to sit in between that particular village (which we had already covered) and the village that we had yet to see, to capture patients from the village we needed to see yet. The technique worked because the villagers stopped by with their ailments and we were able to see quite a few patients. It was already about 5.45 pm – getting dark and we needed to be at the base by 6 pm. We were tired and without any energy as we kept getting pages from the base camp asking us about our whereabouts. By then we were beyond exhaustion to even answer our walkie talkie. However, we knew and were conscientious about not leaving any patients behind without seeing them.

As we walked towards the base, we stopped by a hotel (only hotel in that village) to treat ourselves to wai wai soup (noodle soup). Oh boy, did it taste good! It had never tasted so good. I practically gulped down the whole bowl in two minutes and looked around to see that my team mates had only eaten few spoonfuls. I felt embarrassed. When the tab came, the total payment was very less than we had thought. Nima didi and I thought, the hotel owner probably gave us a big discount. Simple generous gestures like this was present everywhere.

We then made our way to the base camp joking amongst ourselves – feeling accomplished, although way too late than our curfew time of 6 pm. But, we were all so happy and well-satisfied that we had been able to cover all the villages even if it meant working till dark. Only at night in our tents did we realize about the aches in our bodies and feet.

We could not have done it without our 4 brothers – 2 brothers carrying our backpacks and 2 local volunteer brothers, who refused to be acknowledged for their time and effort. They literally held our hands to help us climb a steep hill, jump from a wall or go across to the other side through the narrow roads strewn with rubbles. Without their help we probably would have fallen and scraped ourselves numerous times. They also acted as our health educators during times when three of us got extremely busy treating patients. They taught the villagers to wash their hands before eating and after using toilets, to boil their water before drinking and not to eat meat of the dead animals.

On that day our team was able to see more than 50 patients. A young boy of about 9 years old was also referred to a hospital in KTM for hematoma on his lower back. He seemed to be in a lot of pain. It took us a while to convince his parents to send him to a hospital in KTM. The mother kept mentioning that they could not leave the next day because there was a “Ghewa,” a funeral ritual to attend to. It was a serious case and the boy could not wait to lose anymore time. We also communicated the need via our walkie talkie with the base. Next morning, two brothers had to run to the village to get the boy so that he would not miss the helicopter. He was airlifted the next morning to Kathmandu with other patients with critical conditions. Satish dai and Ang dai personally contributed money for the helicopter.

Next afternoon, we had to leave for KTM. Our initial plan was to stop by the village Dhap and distribute Phenyl liquid, dettol soap and few other supplies before heading to KTM. This is because Dhap was the only village that had a very bad odor – smelled of something rotten and we were concerned about the public health issues there. However, we could not do so because we had to take another way towards KTM as a vehicle had fallen down from the mountainous road we had initially intended to take.

The ride was bumpy as the vehicle jumped up and down on the gravels. The road was muddy, very narrow, winding and often perched on the steep mountains. This meant if the vehicle missed even an inch on the side of the road overlooking the river, we would all be tumbling and tumbling and then tumbling some more until we reached the bottom. What made me cringe and hold fastened to my seat was that the driver would look at the passengers instead of the road while talking and driving. At one time, I even pointed it to the driver dai ; perhaps it was rude but I couldn’t resist.

Just before we reached KTM, our tire got punctured. Perhaps, it happened for a reason. Fixing the tire took us about thirty minutes and this made us reach our destination thirty minutes late, but what we were met with on the way we could not believe our eyes. We were distressed to find a driver stuck inside the truck that had landed on its head on the side of the road as it slipped from the hill above. It was drizzling as well. The truck had slipped from the exact location our vehicle was parked. The skid marks from the tires were still visible – scary! It could have been us. The truck was vertically standing on its head with its tail in the air. Talk about disaster! Just then a van full of police also drove by and we directed them to the accident on the road below. The driver was finally rescued by Ang dai and the team after numerous attempts. The rafting brothers took care of the crowd control while the medical team attended to the driver. The conductor apparently did not get hurt. Initially, I was also made to hold hands with the rest of the crowd, while I struggled to explain to them in the dark that I was also part of the medical team and I needed to deliver supplies to them. The driver was conscious, however his face gave an expression that he was in shock. While we were still busy applying bandages to his visible injuries ambulance arrived and he was taken to the hospital.

By then I had sort of become numb after seeing so much in such little time. If I was feeling this way just by seeing them, what about the people who have experienced so much loss and in so little time? I cannot even imagine. But, such strong, resilient, generous, humble and content people filled with so much gratitude even with all their losses – offering you their tea, their limited food and resources even after knowing they may not have enough. What we were doing was very little compared to their gratitudes and generosity. May God bless them for eons and eons and give them strength to live through this. Bhotang VDC, you will always have a special place in my heart.

Thank you to our local volunteer brothers for bringing villagers in some villages. The villagers were ready for us to see them when we reached there.

Conditions we encountered most were URI – dry cough, stomach ache, GERD, headache r/t PTSD?, ankle pain, muscular pain, wounds, cuts & injuries r/t earthquake, I & D, diarrhea, a case of ascites, a case of CHF, and few other conditions.

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I will add some photos from her FB page. If anybody wishes to get in touch with Ms. Magar, send me a message and I will get it to her.

Also – in Kathmandu. I am told that the inpatient areas of most hospitals are having very low census right now because nobody is having elective surgery. Also, no patient seems willing to be admitted to a room on the second floor of any building, so the hospitals are reconfiguring to keep as many patient beds on ground floor as possible. Finally, the families are insisting to be with their loved on at all times. I know some will think this is a generalization. But – it’s what I have heard…..

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CCNEPal report may 26th, 2015 – part 2 – how MBBS medical education works


Update May 27th, 2015 – in Today’s news, an article about the Ministry of health and the difficulty faced in assigning young MBBS doctors to the quake zone. click here. I invite the government to learn more about my small project and what I have learned, that will help this problem. We have been working on a solution to this exact issue, since 2011.

Part two. There will be two more parts after this. 

note: I am an outsider to the system, and I know that there will be people to say this is not accurate etc. Any reader who wishes to complain is welcome to submit a comment. If you can help me make this better, I appreciate. I would love to “cloud source” this to make it the best possible. If you are not comfortable with commenting due to sharing your name, send an email to joeniemczura@gmail.com and I can incorporate your feedback anonymously.

This is the second part of wrapping up activities for CCNEPal in 2014-2015.

I am writing for an international audience, and I feel the need to take a detour in the report of activities. The medical education system in Nepal is not a one-to-one equivalent to USA. When I work with MBBS docs here, there are different needs than USA med students would have.

About the Medical Education system of Nepal

Here is the career path.

1) Go to school and pass SLC at the age of sixteen, then take two more years of science courses.

2) Enroll in Medical School as an undergraduate in Nepal. The degree is named “Medical Bachelor’s, Bachelors of Surgery ” – MBBS

MBBS is four years of school and one year of internship. during the school period, there are electives for various rotations.  There is no specific critical care rotation, it is included in the rotation for anesthesia. Note: most other rotations are two months but anesthesia is usually about two weeks – about long  enough to develop some practice managing an airway and performing endotracheal intubation. MBBS docs do not learn ecg in the format of an organized course- they are told to study that on their own. They typical MBBS graduate can not read an ecg rhythm strip.

3) On graduation from internship, the person is called a “Medical Officer.” If they do not have government loans, they are free to go anywhere. If they do have loans, they owe two years of service in a rural area to pay them back.

At some point after the two years, they can take a “Lok Sewa” exam ( civil service) and become a permanent government employee.

4) After a period of time, they can return to school for a “Master’s” – the post-graduate course- and become a Medical Doctor. Also known as a post-graduate doctor.

That’s the bare bones.

Government Policy Background

The government of Nepal has expanded the number of medical schools in the country over the past ten years or so, and now there are twenty.  Click here for a nifty infographic. Prior to the earthquake there was a big scandal in the country because the government was planning to award permission to open four more schools, and there were nationwide protests led by Dr Govinda GK. At that time, the news coverage focused on government corruption in the health sector. (that’s why the Kathmandu Post generated the infographic above.) The pool of senior doctors in Nepal to run all these schools is stretched thin due to rapid expansion.

Because of the lead-in time, only recently have larger numbers of MBBS grads come out of the pipeline. In some cases, the schools are specifically saying they wish to produce people who are prepared to serve in the rural areas.  The schools market the idea that they will help address the shortage of medical care in rural areas by setting up better-supervised placements in support of the recent MBBS grads doing this role. Read here for a description by a supporter of PAHS, one of the medical schools that markets this idea.

Key Points

There are key points I have learned from interview with students about their perception of the education at this point in their development.

The undergraduate degree is science-based, focused on book learning and reading, and does not presently use simulation learning or case-based learning.

The MBBS undergrads are allowed to tag along on clinical rounds but are “junior” to everyone and in many cases, are not allowed to speak.

Senior vs. Junior is an issue

MBBS interns in many cases, have never written “doctor’s order” or collaborated with a nurse. They are not allowed to participate in emergency response. They generally have not taken a BLS course. They can not reliably interpret an ECG.They have never given a “verbal order.”

The MBBS grad has read about psychiatric counseling, but the curriculum does not include opportunities to personally apply the skills. Mental health is a very new field in Nepal, land of Saddhus.

Specific education for rural practice is not included.

In this article, the author makes a point to describe the educational needs of students before they go to the rural area.

There is no support from post-graduate doctors to the Medical Officers in the rural postings in most cases. There is no structured program of professional development.

The threat of physical violence from family members of patients is real.  This last statement may be a shock to people who wish to believe that Nepalis are a kind, hospitable, loving family-oriented people.  To say otherwise would hurt Nepal’s marketing as a tourist destination. And so – nobody talks about it. It is hidden from the tourists. The threats of violence, and the actual violence, is not something the average 22 year old geeky med student kid from Nepal is prepared to deal with.

There is presently a pent -up demand among MBBS Medical Officers to take USMLE and continue their studies in USA. The young docs have heard that the USA system is different and they want to see for themselves. Maybe they will return to Nepal;  they all have an attachment to the culture here. But, Nepal is not immune from the “Brain Drain.” Click here for an article that describes a study about Nepali MBBS practicing abroad. The link is to a newspaper article describing a study published in the British Medical Journal. In that study, it gives the statistic that one-third of graduates in the sample from one medical school, are practicing abroad.

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CCNEPal Preliminary report for 2015, late May, part one, just the facts…..


note: I will depart Nepal for 2015 on May 30th. It’s a slow day and I thought I’d start this.

The calendar year 2014 was summarized in a previous blog. Considerable detailed notes have been published here on a frequent basis.

Year-end totals for previous years were:

2011 -198

2013 – 534

2014 – 708

Add to this the tentative year-end total for 2015 – 690 – and the grand total is 2,130.

Since 2011, CCNEPal has awarded training certificates to 2,130 nurses and doctors. About 800 of these were in Kathmandu and the rest were in locations including Dulikhel, Biratnagar, Pokhara, Bhairawaha, Butwal, Palpa, and Bharatpur.

The list included MBBS students or interns from Lumbini Medical College, College of Medical Sciences, Universal College of Medical Science, and Chitwan Medical College. When the course was given at Nepal Medical College in Jorpati, the anesthesia staff got trained in the teaching methods as well.

Nursing staff from the two national heart hospitals (2013 for Shahid Gangalal National Heart Center and 2014 for Man Mohan Cardiovascular, Thoracic and Transplant Center), received this training, as did nurses from all four cath labs in Kathmandu.  It is fair to say that there is somebody I trained, working in every ICU and ER in Kathmandu.

The Center for Medical Simulation received their official Approval as an International Training center for ACLS and BLS with the American Heart Association in January 2015. The four nurses on their staff worked with me to learn how to conduct the megacode small-group work of ACLS, the heart and soul of the course.

The Center for Medical Simulation received their official Approval as an International Training center for ACLS and BLS with the American Heart Association in January 2015. The four nurses on their staff worked with me to learn how to conduct the megacode small-group work of ACLS, the heart and soul of the course.

CCNEPal was pleased to train the teaching staff of the Center for Medical Simulation in Kathmandu. CCNEPal also served in an unpaid consultant role with Center for Medical Simulation to obtain their authorization as an International Training Center for BLS and ACLS via the American Heart Association – the only such in Nepal.

CCNEPal continues to partner with Lalitpur Nursing Campus in Sanepa to maintain the Library. LNC has an inclusive policy of sharing their books with other nursing schools and nurses. One donation was the most recent

CCNEPal continues to partner with Lalitpur Nursing Campus in Sanepa to maintain the Library. LNC has an inclusive policy of sharing their books with other nursing schools and nurses. One donation was the most recent “Procedure Manual for Critical Care Nursing” from AACN. Probably the only copy of this important resource, in the country of Nepal.

CCNEPal shared all our teaching materials and resources with any person who brought a pen drive, and at the fall meeting of the Nepal Cardiology Society. Specific textbooks were donated to Lalitpur Nursing Campus, which has an open-access policy for nurses in Kathmandu. Click here.  CCNEPal has developed a variety of inexpensive pieces of equipment that allows the course to be portable.

The collection of books from the American Heart Association were donated to Lalitpur Nursing Campus. LNC has a policy to share their texts with students from other nursing schools, as well as nurses.

The collection of books from the American Heart Association were donated to Lalitpur Nursing Campus. LNC has a policy to share their texts with students from other nursing schools, as well as nurses.

Chitwan Medical College

The critical care teaching crew at Chitwant Medical College Teaching Hospital is excellent. Their combination of teaching ability and clinical experience makes them the top critical care nursing education team in the country of Nepal, in my opinion.

The critical care teaching crew at Chitwant Medical College Teaching Hospital is excellent. Their combination of teaching ability and clinical experience makes them the top critical care nursing education team in the country of Nepal, in my opinion.

Also, in Bharatpur, the teaching staff of Chitwan Medical College worked with me for the four-session series; it is my considered opinion that CMC is able to teach this independently to a high standard, and I think they have proven themselves to be a resource for training for all of the Terai where fifty percent of the population resides.

Specific subtotals for 2015 were:

Lumbini Medical College – 4 sessions – 37, 37, 28 and 22.

Kathmandu University , Dulikhel (physio dept) 32

Global Hospital, Gwarko – 34

Lalitpur Nursing Campus – 4 sessions – 32,28,36 and 32

Spring Road Trip April 8th to May 27th

Due to my bus accident in January, I decided to make the travel schedule as efficient and compact as it could be. CCNEPal has historically spent 50% of time outside the Kathmandu Valley.

Purbanchal University, Biratnagar, 37

Chitwan Medical College interns – 4 sessions – 30, 29, 30 and 30.

Universal College of Medical Science, Bhairawaha – 5 sessions – 30, 16, 24, 26, 18.

Crimson Hospital, Butwal, 27 and 33

Gautam Buddha Community Heart Hospital, Butwal, 28 and 11

final tally – 690.

Mentoring “Assistants” and growing future leaders of critical care

At each location I identified local clinical leaders who would serve as “assistants” in the course session, and I mentored them as they conducted the small group sessions in Nepal language. In some cases in 2015, these were persons who previously took the class and now were becoming more comfortable with teaching technique. There is now a cadre of about a hundred such persons, and they will be leaders in the future.

Role Play and scenario-based education methods

One feature of CCNEPal’s approach which has garnered enthusiastic reviews has been the imaginative use of use of role play and simulation. As Joe says “I didn’t invent the role play, I’m just the person who brought it here.”

The scenarios we use are adapted from the “Ten Core Cases” of AHA ( published elsewhere on this blog) It’s important to know that the course teaches more than just the resuscitation protocols; it allows the participant to learn about their own level of confidence, decisionmaking and clinical leadership. We have a heavy emphasis on Chapter three of the ACLS manual that goes over teamwork; We teach role development when we have an MBBS audience. It should be noted that we are not an official ACLS course from the American Heart Association and – we like it that way!

Yes, we use

Yes, we use “props” – it makes the role play more fun but it has a serious purpose of helping explore decision-making and teamwork when there are well-defined hierarchical roles. and – I have about fifty photos of this-or-that person wearing the puggri – it’s “bindass!”

Nepali bhasa

CCNEPal’s policy is to conduct the smallgroup portion of each session in Nepali to the greatest extent possible. In this way, even though my own Nepali is limited, the participants got their questions answered in their best-understood language.  personnel.

I kept a blog (this one!) and made regular updates to it on subjects of critical care in Nepal, nursing education, and pedagogy of South Asia.

This is part one. Because I have University-level teaching experience in USA, I build in a system of “praxis” to improve the course as I go along. You could call it “tweaking” I suppose but that does not capture the full thought process. I have analyzed the learning style of the students and  the clinical needs.

I will analyze impact and future directions in blog entries to follow.

The short summary is, it is critically important for this skill set to become as widely adopted throughout Nepal as possible, and all strategies that  bring it to a wide audience in the entire country, need to be considered. I would humbly suggest that CCNEPal has led the way in Nepal and that no other group has trained more personnel.

I learned a lot about the Big Picture while doing this, and I have some very specific policy recommendations for any person or group that wishes to build on this work.

Thousands of lives lost in the April 26th earthquake. Please pray for Nepal.

Thousands of lives lost in the April 26th earthquake. Please pray for Nepal.

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How a doctor or nurse can prepare for a medical volunteer trip to Nepal since the April 2015 earthquake.


There is a surge of interest among nurses and doctors to volunteer in Nepal since the earthquake. I’ve been coming here since 2007 and I have some advice.

UPDATE MAY 30th – the aftershocks are still happening but they have subsided. If you ask me, now is the time to think about coming ( I was among those who said “stay away!” before). Some of the monuments have tumbled; but Nepal is still a beautiful country and the culture here is fascinating and wonderful. There are many reasons to come – but – touristy stuff is at a bargain price!

Specifically for Doctors: The Nepal Medical Council is still working. You absolutely must be credentialed to work in this country, earthquake or no earthquake.

First – Nepal is still an active disaster zone. The aftershock of May 12th   reminded the people of Kathmandu that it’s not over. Do you really want to do this?

I originally wrote this under the title “Twelve Steps to Prepare for Global Health Nursing” in May, 2011 and that version was published in the online version of Imprint, a publication of the National Student Nurses Association.

Your nursing skills are your gift to the world. 

This blog usually gets a hundred hits a day, but the stats zoomed off into the 800-hits-per-day region in the weeks following the quake. The drama and heroism of the earthquake captured the attention of the world. Relief workers and supplies poured in to Nepal.  As “Professional do-gooders,” it’s understandable that you want to help. No matter where you go, you need to prepare. Despite the urgency, there is no urgency – it will still be a disaster months from now.  These simple steps will guide you to make the most of your experience.

Learn about the “bubble.”

We all exist in an invisible “bubble” – an insulating set of comforts and expectations to make daily life easier and predictable.  The “bubble” consists of familiar routines and objects that make our daily life easy. It’s also a set of cultural assumptions, most of which are taken for granted. For example, whether the cars drive on the left side of the road or the right; the way a toilet operates; table manners; or the proper greeting when you meet a stranger.

Clever tourism promoters go out of their way to present a predictable packaged experience – “the bubble” – to insulate the traveler from the sometimes-unpleasant reality of life in other parts of the world. A trip to Nepal is off-the-beaten-path, and qualifies as “adventure travel” with unpredictable elements. When you combine travel and medical or nursing practice, you are going behind the scenes, to the places the usual tourist does not go, and meeting people in their turf, in settings not in the guidebooks. You will need to learn a whole new set of travel skills and it takes courage. Less than four percent of all travelers engage in adventure travel.

To use your nursing skills in Nepal requires a new set of skills to navigate daily life. If you have never visited any foreign country, you will be in for a surprise in Kathmandu.  The toilets are different and there is not always toilet paper. The food is not the same.  People don’t generally use washing machines (they wash by hand), and they certainly don’t drink the water. In a separate blog I described how the hospitals work. Things you take for granted, such as intravenous line setup, are not the same.

Here’s a list of things to do before you come.

Get the shots. Go to a travel clinic and get immunized. make sure you tell that that you will be working with sick people.

Choose an NGO. NGO stands for “Non-Governmental Organization.”  In Nepal, for a nurse, the very best is NurseTeachReach from Australia. They were here prior to the quake. Don’t go with a group that has never been to Nepal or that is vague about what you will do. Before the quake, there were some tours billed as “village health care” which essentially turned out to be trekking trip that handed out toothbrushes. Frankly, there were some groups that showed up in Nepal, claiming to their volunteers that they knew the country – that didn’t.

Backfill

The role of the foreign volunteer is mainly to “backfill” the less complicated care needs so the Nepali staff can focus on what they need to do. Be advised, the unemployment rate among “passed out” nurses in Kathmandu hovers at about forty per cent. Every volunteer nurse that comes here to do direct patient care is taking the place of a qualified Nepali nurse. The Army and Police got overtime pay for their work; the nurses did not.

An NGO will pave the way for you to use your skills to the maximum. Often, they will plug you into an existing program that will fit your needs, and also help you with in-country travel and such things as food shopping.

The W.H.O. has a longstanding embrace of the idea that USA is the “big brother country” of Central America and Africa. There aren’t that many Americans with experience here, by comparison. The Peace Corps pulled out during the Civil War and only recently returned.

Learn the language.  Take language lessons. This is the single most important long-range skill required for most global health experiences. Nursing depends on making a person-to-person connection and dealing with the patients face-to-face. If you are a doctor, they will often give you an interpreter; nurses don’t get that same perk. Your transition will be easier if you can  say hello, navigate the local bus system, and  order at a restaurant.

Meet somebody who is from Nepal. In the largest American cities nowadays, there’s always a South Asian grocery store, or one that sells Tibetan stuff. You can find small pockets of people from nearly every society on earth – this is an amazing resource. Use the internet or go to your local college and you can find somebody who is from Nepal. They can become a source of valuable information in all sorts of ways.  Before I left for my first trip to Nepal I found a Nepali language tutor by posting a small flyer on the wall of the only South Asian grocery store in Honolulu. She taught me about language and customs such as table manners and greetings.  Befriending a person from a different culture is a two-way street and has many advantages.  It is something we can all do even if we have no intention of leaving home.

Go camping.  Learn how to get by with fewer creature comforts than the typical American. If you have never prepared food using primitive equipment over a woodfire, or used a privy, this skill will open your eyes to the daily challenges faced by rural people all over the world. Start to walk or hike regularly – if the transportation system is poor, you may find yourself walking a lot more than usual. In some cultures, coffee is not a daily menu item; If you simply must have coffee every day, learn how to make it using a wire mesh filter.

Eat the food. This starts with going to a Nepali restaurant in USA if there is one nearby; but in many countries where cooking is the role of women, you can experience the role of women by familiarizing yourself with food preparation and the time it takes.

Read the literature of the country. Don’t bother with “Where There is No Doctor” – it’s a fine book but tells you nothing about hospital care. My favorite is Common Medical Problems of the Tropics. Start with the Lonely Planet tourist guidebook; even though the iconic temples will be closed for repair, these still include useful cultural tips and the elementary rules of etiquette. You can learn about religion, politics, gender roles, customs such as those surrounding funerals, and body language. I once met a nurse from USA that wanted to teach a hospice and bereavement course here – but she didn’t know anything about Hindu customs such as same-day cremation. She needed more homework.

Dress Modestly. This is a conservative country, and you need to respect the values. In Kathmandu, women may wear a short skirt, but in the rural areas (such as the epicenter zone) they will be very conservative. Do not show cleavage or anything tight that shows off your butt. The typical outfit of a relief worker these days is jeans and a T-shirt. See photo.

This called a

This called a “Kurtha Surual” and the front and back apron conceal the wearer’s curves. This photo was taken in January in Palpa; in Summer it’s cooler but the principle of modesty is the same. Also, you are less likely to get leeches in one of these outfits.

Here is a person you might be meeting:

Here is a person you may be meeting. (photo b a friend of mine who was in the earthquake-affected rural area.) She has a fascinating and wonderful cultural background. But she's more likely to trust and respect you if you dress modestly and respect her culture.

Here is a person you may be meeting. (photo b a friend of mine who was in the earthquake-affected rural area.) She has a fascinating and wonderful cultural background. But she’s more likely to trust and respect you if you dress modestly and respect her culture.

Read my two books about Nepal hospitals, The Hospital at the End of the World and The Sacrament of the Goddess.

Don’t bring toothbrushes. You can get them here, cheaper than in USA. Do bring textbooks. The language of instruction in nursing schools is English. Click here to read about donating books.

Read Nepal Newspapers on-line. MyRepublika is a personal favorite; Nepali Times has also gained respect for their excellent earthquake coverage.

Are you  an ACLS, BLS or PALS Instructor (or Regional Faculty?) there is one AHA ITC in Kathmandu and you should affiliate with them.

Use Social Media. Everyone in Nepal is on FaceBook. Every hospital and Medical School has a FaceBook page. Two groups with more than 10,000 “likes” each, are Nepalese Nurses and Nurses of Nepal. CCNEPal and NurseTeachReach are also on FaceBook.

YouTube. Here’s a playlist I made from all my odd videos of Nursing Education in Nepal.

Here is a truly excellent twentythree minute documentary about childbirth in Nepal.

Here is a playlist of hospital videos, mostly from Mission Hospital in Tansen

Plan for culture shock and re-entry shock. Study this link to University of the Pacific. Culture Shock arises from the inevitable comparison to your home. Re-entry shock is something that sneaks up on you – it happens when you return, expecting to take up your life where it left off, but realize that you have changed in unexpected ways. It is not unusual after a global health experience to feel disconnected from your home culture.  It is worse when you do some kind of hard-core medical thing in a Low Income Country. Every nurse needs to be aware of this phenomenon.

Minimize your baggage. I have friend who has led ten trips to rural Nicaragua. She blushingly confessed to me that she brought a blowdryer with her the first time. On each subsequent trip she learned what she did not need. Nowadays, she travels very lightly, with only as much as she can fit in a daypack, for a three week trip.

About students? This is not the place to bring students if they have never travelled outside the USA before. A newbie does better in some sort of cultural trip, such a Habitat for Humanity. Yes, they have to start somewhere; but – Costa Rica would be a better trip for a first-timer. Or maybe Ireland.

Plan to share from the beginning. We owe it to our fellow Americans to educate them about global health, and a firsthand account is powerful. Get a camera and practice with it before you go. Be advised, Nepal has strict rules about photographing patients these days without their consent. No matter how much you tell people, they will never understand what it was like unless you have photos when you return. If you buy souvenirs or artifacts, choose ones which tell a story about the daily life of the people. Keep a journal.

Learn about hospital and clinic standards. Many of the health problems are directly traceable to lack of public health infrastructure. There will likely be more problems with infectious diseases; and you may need to learn how the local providers deliver care even though disposable supplies may be limited or they may not have new equipment.

Skip the “Pearls” A common approach among young medical students is to focus on learning diagnostic zebras, such as leprosy or malaria. Medical care in Nepal is more than just being able to say you saw a case of visceral Leishmaniasis.  Learn about the social context of illness. Study poverty and malnutrition. Many hospitals operate a “feeding station” for malnourished people. Learn about the health  practices and about the health system.

No alcohol. We are still having aftershocks. This is not a party destination. If you disable yourself by getting snockered here, your team will be unable to respond appropriately to a challenging situation. You are a liability. Kathmandu is not a place where women go out at night unaccompanied. You can stay home in USA if you need to drink.

Practice “water discipline” and food sanitation. Clean water is something we take for granted. Food- and water-borne illnesses are the single biggest problem encountered in foreign adventure travel. In Nepal the water from the tap is unreliable. It is helpful to practice safe ways to use water which will become firmly engrained habits prior to the trip.

Are you going somewhere else? Even if the primary purpose of foreign travel is vacation and you are not planning to use your nursing skills, there are some things you can do. For example, if you go to the Caribbean, you can get “out of the bubble” by spending a half-day touring a local hospital. Often, somebody will gladly show you around even if you give limited notice. In Low Income Countries, up-to-date nursing textbooks are beyond the reach of local health care workers. Pack one with your luggage as a gift for the hospital library and you will contribute to local health care even if it in is a small way.   This sort of person-to-person experience does not need to be planned in advance.

Something to think about

Nepal has twentyeight million people, twice as much as the six-state New England region. If it were a US State, it would be #2, second only to California.

In summary, an experience in Nepal can be very rewarding, but to have the best success will require intensive preparation, and the time to start is now. We can benefit from adopting a global attitude, even if we never leave home.

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First-hand eye-witness description of nursing needs in earthquake-ravaged area of Nepal by a Nepali-American nurse


A #Nepal -American nurse reports from #Sindupalchowk after #Nepalquake

Firsthand assessment

This was on the FaceBook page of a friend and I thought it was newsworthy. Generally, the people doing actual earthquake relief are too busy to send reports back, and there is limited teleconnectivity in the rural area.

Note; Unita Magar, RN, MS is a nurse from Nepal who went to school in USA and now is in graduate school in New York City. I met her when I was on book tour for The Hospital at the End of the World in 2009.  (she rode the train for two hours to hear me speak). She is active in NANA – the professional nurses association for Nepali nurses in North America. Click here for their FaceBook page. There you will also find pictures.

In November, I met with NANA members in Jackson Heights, Queens New York ( the epicenter of Nepali neighborhoods in USA!)  and Unita brought me “panipuri take-out” – a very hospitable gesture.

NANA could not stay in USA

When the earthquake hit, NANA members did not hesitate. They spent some time gathering equipment, and got on the plane. Normally, it is not a good idea for Americans to just jump on a plane and go to a disaster area. NANA knew they had specific skills to offer.  ( the current President, for example, got her PCL nursing education from Bir Hospital) As you might imagine, their language skills are flawless and they come to Nepal with perfect cultural understanding as well as nursing background.  Nepal is not an easy country for foreign nurses. They invited me to join them on their relief mission, but I decided to continue my teaching.

Here is what Unita Magar, RN,  wrote ( I did not edit it, but added some formatting):

Our team went to thulo bhotang, sindhupalchowk and kalleri, dhading. All the villages in sindhupalchowk have been very much damaged, most of them down to rubbles – sad. We were able to see many patients in both regions. My heart breaks to see so many people losing their loved ones – orphans, widows, mothers who have lost their child/children …

My assessment so far:

1. Eating utensils: One of the young girls from dalit community who lost her mom and sister mentioned not having utensils to eat food, as they are buried in rubbles. So while distributing rice bags and other foods that is one area to keep in mind.

2. Schools and health posts have been badly damaged in most of these villages. That is another area of need. With no proper health posts, patients are not able to f/u with the the medical professional re: their wounds, upper respiratory problems and other health issues – wounds can get infected if not followed up. Medical teams come and leave in 3-4 days that is not good enough for continuity of care.

3. Most people have been displaced from their homes – educating public re: what type of houses to build is important. People were asking me what type of houses to build. Educating public on this will be very helpful.

4. Houses: so far people are using tarps for temp housing. Monsoon season is coming soon. This means people especially in mountains will need more stronger houses – jasta pata type to keep them dry.

5. Many kids are orphaned – putting them in schools will be important. It is so sad frown emoticon I wanted to adopt them all. At one instance I was trying to counsel one baini (young girl) who lost her mom and lil sister in earthquake and I could not hold up my tears. Tears rolled down my cheeks. Instead of me comforting her, she was telling me “please don’t cry, things like this happen.” One of the dai (young Nepali guy) said he will educate those 3 kids. Bless his heart. There are many young needy kids displaced by earthquake like this baini and her siblings. Many might get dragged into bad direction if not guided, so kids, especially girls will be important to focus on.

5. Elderly people: who are living alone by themselves. More chances of being malnourished due to lack of proper help and resources due to current situation in Nepal.

6. Women and dalit community – important to distribute food/shelter to them first when distributing goods. As they may stand behind allowing others to get the goods first due to Nepal’s cultural practices. Sometimes, they may not get anything because of that.

7. Important to use the locals from the region when doing any projects or distributing foods.

8. Going from house to house may mean everyone will get the medical tx and supplies. Some ppl maybe too weak, busy or disabled to even walk 15 minutes to use the available services. Going door to door is beneficial if u want to be more effective in your effort. We were able to reach out to more people when we went from door to door from village to village.

8. Counseling and psychological services – will be very much needed in Nepal. We saw many patients with c/o headache. This may indicate post traumatic stress disorder. One baini said to me she felt relieved after talking to me. She was afraid of sharing her thoughts with her neighbors as she was afraid they may gossip. Some people may feel comfortable sharing their thoughts with an unknown face to known face.

Everyone in the city and villages continue to live with some lingering fear of earthquake recurring again. It will take a while to overcome this fear.

9. Men in Nepal may have difficulty sharing their concerns and thoughts with others, thus holding their worries and loss/losses locked inside their minds. They may instead resort to drinking to forget their worries. This is another area of concern.

10. Some patients are in hospitals with no family members visiting them. We saw some volunteer bhais acting as a companion and advocates for these patients. There are quite a few patients like these in hospitals.

11. Hard hand gloves in villages for villagers trying to take out their belongings from the rubbles.

There is lot to be done. However, everyone is doing their best here in Nepal and abroad in any way they are able from taxi driver brothers to students to professionals, army, police to the general people in Nepal despite the fact that their families are also suffering. Salute to all of these kind souls

for foreign response teams

It is critically important, for all foreign response teams, to have somebody like Ms Magar  with them. She understands the cultural nuances of Nepal and can guide decisions. For example, the truly vulnerable persons do not always appear in public, at the front of the line, demanding help – they suffer alone and in silence. In the above, she is an articulate link between the ongoing social issues of  human trafficking, the depopulation of rural Nepal’s young men, and the coming famine.

The reconstruction needs are extensive. I am sure that NANA will continue to send money.  go to their site.

Prior to the earthquake, it was difficult to get young doctors and nurses to serve in these areas, and the Nepal government was actively supporting various schemes to do so. Since the earthquake, I have read various USA editorials about “rebuilding Nepal’s health system” and frankly, some of these were by International NGOs that had only a minor presence in this country before the quake. I have worked with Nepali people since 2007 and in a future blog I will throw in my two cents. Briefly, Nepal has twentyeight million people with about twenty medical schools, hundreds of nursing schools, and a system of hospitals in the private sector, some of which are quite new and modern. Most of the hospitals in Kathmandu survived intact; click here for more info on hospital damage assessment. The health sector has a history of extensive collaboration, and any International NGO that comes here, needs to know this. Resist sloganeering.

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