How to Measure Health Progress (when we are all going to die)

Getting out of the Silo

Something I liked about the medical community of Mission Hospital at Tansen was the accessibility of doctors and nurses to each other, something not common in Nepal, but for that matter, not common in most places in USA either. It seems as though there is a size limit for hospitals everywhere, and once that capacity is exceeded there is a natural tendency to start compartmentalizing the people you work with according to occupational category. In other words, doctors start to only hang out with doctors, nurses with nurses, and the like. In such places there will still be areas where the barriers are loose, such as in ICU or Labor and Delivery; but overall once the number of employees gets to a certain size you lose that gleeful sense of community. I tried to convey this sense of we’re-all-in-this-together in my book.

Skowhegan, Jewel of the Kennebec River Valley!

I spent many years working at a community hospital in the state of Maine and one thing I like about it (most of the time) was the “economy of scale” for interacting. At Redington-Fairview, if I felt like chatting with the CEO, I could do so, and the semi-retired pathologist whose office was in the lab in the basement was another wonderful person there. Likewise whenever I stopped by radiology, the radiologist would show me stuff on X-ray.

You can get that sense of community at a smaller hospital. The CEO’s office was right by the main entrance, and though he had a gatekeeper/secretary, you could still see what he was up to if you peered in at a certain angle. They made an addition while I was there, and the new “administrative suite” included the now-customary labyrinth before you could see into Ben’s office, but the first arrangement was something I enjoyed for eight years or so.

Dinner at Six, start with Thanks and Praise

At Mission Hospital, dinner at the Guest House was at six PM, and the table often included a mix of all the visiting videshis as well as docs on call and hangers-on. One of the Nepali doctors who worked at Mission Hospital in Tansen with me was a guy who had trained in Europe. He was the director of the Medical ward there in 2008 when I had my student group posted there each day. One day he diagnosed a case of Brucellosis in a patient on the Medical Ward, not a run-of-the-mill assessment even by the exotic standards of infectious disease in Nepal. Confirmed by lab test, no less.

And what do doctors talk about at dinner?

Shop, of course. He ate at the Guest House that same evening because he was on call, and so naturally, we were destined to discuss it over the “lasagna” made by the Guest House didi.

“ We have these unusual things here in Nepal. It is always difficult to measure how unusual they are or may be. People here don’t die of the same diseases that a similar population would succumb to in the West. We will know we are making progress when the people here start dying of the same profile of diseases that they do in New York”.

Which was a profound statement of course. Given the fact that we are all going to die, how do you know when you are dying of the “right’ thing? Apart from dying a the age of say, ninety five, what is the goal, the quota, for death?

“The Troubles”

Moving right along, that same doctor had done his residency in Belfast Northern Ireland during “the troubles” and on a different occasion I asked him whether he’d been worried about the violence.

“No. Of course, there were often checkpoints at which they would ask us whether we were Catholic or Protestant before we could cross”


“I would always say ‘I’m Hindu’, which made them stop and think. You could see them take a deep breath. The best reply I ever got was ‘are you a Catholic Hindu or a Protestant Hindu?’ ” Now there is a terrific punch line.

To attend medical school in Moscow he had learned Russian in a hurry, and in Belfast he once used his Russian when caring for a group of stranded Russian merchant mariners. You meet people with unusual skill sets, here in Nepal. The challenges faced by the health system in the country are not because the people lack talent. They mostly lack money and a few other things…..

Read Before you go!

Now, I recently was contacted by one of the other NGO groups that brings people to Nepal to volunteer. They were interested to host my training, but it will be a no-go for 2011 since I am booked up for the last few weeks. Maybe next year, and during that time we will get to know each other via email etc. This NGO sent me their pdf document of recommendations as to what a doctor or nurses should study prior to arrival. It’s been four years since I looked through something like this, and I thought it was worth revisiting. This last is something near and dear to my heart, since after all, my book is partly a compendium of how-to when the person wants to be a nurse in a Nepali Hospital. Often the books are directed at doctors who need to look at unusual medical problems. Nurses get short shrift. So, obviously, my own humble oevre would be the first course in this intellectual feast……

After Dinner Reading by the fire, with a cup of tea?

First and foremost, collect donated textbooks on general topics of nursing and medicine before you go, to bring with you. Leave them there when you depart. This is a “loaves and fishes” thing, a resource that will keep benefitting the locals long after you are gone. If you come to Kathmandu, donate to Lalitpur Nursing Campus library, best collection in the city.

Second; don’t get the American CDC guide to travel medicine. It focuses on immunizations. all well and good, but you’ll be treating people who didn’t get the shot.

Unless you are specifically doing primary care in a jungle, don’t bother with “Where There is No Doctor”; it’s a fine book but hospital practice is waaaay beyond that. The same group has a book on care of handicapped children in the village setting – this one is highly worthwhile…

The Oxford book of Tropical Diseases is the ultimate resource, but I think it costs $500 or so; and it’s heavy.

The best all-around book is the one by C.R. Shull “Common Medical Problems in the Tropics” referenced in the Amazon list below. It’s old and may be out of print. It gives the basic of malaria, diarrhea, TB, etc and is very practical.

There s a company called INMED in USA which covers similar ground in one of their books.

On the internet, be sure to find TALCUK, “Training Aids at Low Cost” and browse what they have. It’s a division of London-based MacMillan Publishing, and they have worthwhile stuff.

For my own self, I ransacked the internet for Nepal books prior to coming, and one thing I did was to make a “listmania” list on Amazon. Here I compiled two lists of my reviews of books that were useful.

The link to the first list is: 

I also made a listmania list of books on short-term medical missions. The URL for that one is:

And of course, read up on “Culture Shock” – also known as “Re-entry shock.” the best single web-based resource for this is from The University of the Pacific, and the URL is:

If you don’t read this, you will be sorreeeeeee!

Converting the Nations all at once?

The book by Thomas Hale is a sort of management text for how to run an NGO that uses volunteers from around the world, it is full of management advice and has some wonderful gems in it, such as the priceless story about the zealous Christian Volunteer who arrived in Nepal from the UK with a simple plan for converting the entire nation in just one day. An understated account of a confounding episode, which could serve as a cautionary tale for us all. You will need to buy Dr. Hale’s book, i will not give a spoiler here.

That’s all for today, I have been dawdling. Happy Fourth to all expats, everywhere!

Joe Sar


About Joe Niemczura, RN, MS

These blogs, and my books, and videos are written on the principle that any person embarking on something similar to what I do will gain more preparation than I first had, by reading them. I have fifteen years of USA nursing faculty background. Add to it fifteen more devoted to adult critical care. In Nepal, I started teaching critical care skills in 2011. I figure out what they need to know in a Nepali practice setting. Then I teach it in a culturally appropriate way so that the boots-on-the-ground people will use it. One theme of my work has been collective culture and how it manifests itself in anger. Because this was a problem I incorporated elements of "situational awareness" training from the beginning, in 2011.
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5 Responses to How to Measure Health Progress (when we are all going to die)

  1. Eric says:

    great to see that you’re there now! keep up the meaningful work/life example!


  2. I think the idea of donating textbooks is a good one, but I am convinced it is more valuable to send laptops or tablets. These can be purchased, new, for under $200 Cdn, and can be loaded with hundreds of resources, if internet independence is required. Computers mean resources can include videos, sounds (ie auscultation), and interactive cases. And computers are helpful, simply because they are computers!

    Netbooks and tablets are also very energy efficient, and a simple solar array plus battery means they could be used even where power is an issue….

    • says:

      Good thought. I’m sticking with textbooks though.

      I can get them free, they will last forty years, very little maintenance, and they can be photocopied.

      There is no question about the digital revolution, I am not denying that it’s a fact. With our harsh climate here though, I have seen one server-based piece of biomedical equipment after another, go down and stay down for lack of repair.

      Watch they way the people study now. Maybe it is different in the cultures where you visit, with more individualistic traits. Here, the norm is group work. Not so easy with a tablet.

      From may until August 2nd I am in Nepal.

      email is the besy way to reach me – but my mobile is


  3. gaynor says:

    When asking for donated textbooks Joe, what’s your limit in terms of when the book was published? I know some books, like on anatomy and physiology, can be older to some extent, but in critical care what the oldest book you’d be willing to take? What’s your view on nursing magazine subscriptions to say LNC or TMH libraries? Are they likely to get read do you think? Maybe by faculty if not students?

    • anything less than ten years old. Remember, these are replacing books from the 1960s in some cases. whatever is donated will likely still be in use thirty years from now.

      There is a nice nook in the LNC library where people congregate to read the Kathmandu newspapers or periodicals, a panoramic view of Kathmandu in the distance and I bet when the weatehr is right the Himalayas will loom in the distance. They don’t have that many periodicals right now, but i am sure they woudl devour them, especially if they came from Oz.

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