Feb 22nd Update
My February 19th Nursing Grand Rounds appearance at DHMC in Hanover, NH – is now a warm memory. I enjoyed meeting the nurses. If you found this location because of the links, below is the key reading for purposes of my talk with nurses and doctors. This piece got cluttered with a bunch of updates; today I moved them all to the end. I have also created a “top ten” list for the Feb 18th event. Click here to get a longer list of links!
So you want to serve?
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). SEE ABOVE UPDATE! 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.
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.
Here is a person you might be meeting:
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.
Jan 6th 2016 update
Jan 30, 2016 Update:
The political situation in Nepal is in flux, and evolves day-to-day. As of Jan 30th, 2016, there has been a petrol blockade since more than four months. It that has severely affected all manner of activity in Nepal, especially Kathmandu. I have more than one blog, and now that I am in USA, I have blogged on the nitty-gritty of this historic event, at another location. Go to DailyKOS for a sample. if you click on This link, you can see a summary of all my blogs on the Siege of Kathmandu and the Petrol Blockade.
Summary: Read the US state Department Advisory. Kathmandu is not an easy “First Asian City,” even before all this.