Learning to focus on measurable clinical outcomes is a skill that takes practitioners many patient touches to understand let alone master. Every year at our clinic in Nepal, Acupuncture Relief Project team leaders and I help practitioners learn to do better exam work, observe and record critical data and measure patient progression. My fellow colleagues, volunteers and teammates often reflect to me how tired they are of hearing me say “be objective.”, “how are you measuring that?”, “I know they are getting better but by how much?”, and finally “don’t rely on the patient to tell you how much they have improved... measure it! prove it!”. I certainly don’t mean to be a pest but I do want our practitioners to improve their diagnostic and prognostic skills. It is not enough to just treat hundreds of patients in Nepal... we have to be sure we are either getting them better or finding them someone who can.
This all seems like a straight forward process until you actually get into the treatment room. We are constantly confronted by the realities of the developing world: poverty, poor living conditions, lack of referral resources and hundreds of environmental factors like the absence of clean water, air pollution and poor sanitation. We also face many cultural and social obstacles like domestic violence, alcoholism, disenfranchised castes, disadvantaged ethnic groups and poor education. Then of course there are the human factors of old age, loneliness, depression and hopelessness. Even though most of our patients live a simple agrarian life, the day to day stress of basic survival for themselves and their families often weighs heavily on their well-being.
After months of balancing these many complexities it is easy to lose sight of our basic objectivity. On my recent return to the United States, I asked myself ”What did you accomplish”? The answer was so broad I wasn’t sure I could even grasp it. Hopefully I can illustrate some part of it in this story.
If you have seen our short documentary Compassion Connects you might remember seeing this young women (below right). Thirty-year-old Kanji Maya Tamang is one of three Tamang women who travel from the small village of Bhardev to our clinic in Chapagaon. Kanji Maya tells us in the video that she is coming to our clinic for menstrual pain. The full story is actually much more complex.
Kanji Maya was indeed coming to the clinic for menstrual pain, however, this pain was caused by a series of four miscarriages each followed by a curettage procedure. Her monthly cycles were now very irregular and painful. The bigger issue was that she was under enormous pressure from her family to become pregnant again. In Nepal, producing offspring is of critical importance to a families survival. In fact, at thirty-years-old and childless, Kanji Maya was at risk for her husband to take a second wife. While taking a second wife is a cultural norm in rural Nepal, the replaced wife is often shunned by the family and relegated to a life of hard labor, loneliness and poverty. We have treated many women of this status in Nepal and we have all seen how devastating this can be. Kanji Maya desperately needed more time and through many tearful sessions with our practitioners, she slowly began to have more confidence that we would be able to help her.
Personally, I rarely practice fertility medicine as it is not an interest for me and their are so many other practitioners for whom this is their passion. This case however had my attention and I could see so many implications as to how we were not just looking after this one young woman, but rather we were attending to the health of an entire family. As a team, we constructed what we thought would be an effective treatment plan. Then over the course of several months and several different volunteer practitioners, we went to work to implement that plan. Kanji Maya traveled several hours by bus twice a week to receive our treatment which at first focused on regulating her cycle, then later focused on building uterine blood, so that she could sustain a pregnancy. Towards the end of my stay in 2011 we had accomplished everything we had hoped to and I counseled Kanji Maya that the timing was right for her to try to get pregnant again. The team taking over for me continued her treatment for several weeks thereafter and in the Spring of 2012 we received the news that Kanji Maya was indeed pregnant. In early August she delivered a healthy son.
In the brisk mountain air of January, Satyamohan and I ride our small motorbike up the twisting road to the small village of Bhardev. A smattering of small white pines line the edges of the narrow road. At each bend a cathedral of Himalayan peaks pierce the horizon as my fingers burn from the cold. After reaching the pass we descend into a beautiful grassy valley littered by small clumps of thatched roof houses. A few minutes later we pull up in front of a squat, mud-and-brick building and as we dismount we are greeted by a small group of brightly dressed Tamang women. We are quickly escorted inside where the celebration is already long underway.
Pasni, the Weaning Ceremony, is one of the many hundreds of celebrations in Nepal. Relatives gather to witness and celebrate the child’s first taste of rice and for sons, this takes place when he is 6-months-old. We are escorted into a large smoke-filled room with mud floors. Dried corn and strips of meat hang from the low ceiling and a group of women attend an earthen hearth with a wood fire. They are busy preparing the meat of young water buffalo which was slaughtered just this morning. My eyes burn and the acid wood smoke causes my nose to run. I see many family members lining the inside of the small space, all drinking chhaang (rice beer) and talking all at once. One man gets up and entertains the group with a lively dance and everyone joins in by singing traditional folk songs.
Satyamohan and I are served heaping plates of spicy meat, rice and vegetables. One by one people come over to talk to us. They tell us how happy they are to have this new baby and how thankful they are for our clinic. Every story has the same theme. “I came to the clinic... then I sent my wife, she sent her brother, he brought his wife...” and on and on. It seems like pretty much everyone in Bhardev and the surrounding area had been touched by our clinic in one way or another. This new baby was just one tangible example. And who is to say really... Was it our medicine that brought to boy into this community? Perhaps it was just our kindness and support that allowed Kanji Maya the little more time she needed. Maybe it was just luck.
As I look though the smokey haze at the joy that is filling the hearts of so many people... let’s just call it an immeasurable success. --- Author: Andrew Schlabach