[Nb. One last Nepal post, originally posted on our class blog]
The patient lay back, anxious, her feet in the stirrups as we crowded into the examination room. Looking at her, I told the doctor “no, it’s ok,” meaning, I didn’t need to do a pelvic exam on her. But the words “its ok,” whether spoken in English or Nepali “tik-tsa” are decidedly affirmative, as is shaking one’s head from side to side, and a pair of re-sterilized gloves were held out to me with tongs. No one asked the patient if this was okay with her, and the patients never argue with doctors. Not knowing what to say, I suited up and examined her. She had a nabothian cyst, a benign but tender lump on her cervix caused by blocked mucosal glands.
The doctor sends her home with ceftriaxone and azithromycin. Wait, what? Now we’re treating Gonorrhea/Chlamydia? The doctor, who is in fact a medical officer, which means he has completed medical school and internship but no residency, explains that the clinic lacks the ability to test for STDs, so when in doubt, he prefers to treat. Also, patients have a tendency not to come back for follow ups, especially if they believe that nothing was done the first time.
It’s an interesting combination: the abject submissiveness in the clinic, and the disinterest in following instructions such as “come back if you feel worse.” It’s not trust, I realize, that makes patients so passive, just ingrained hierarchies.
I take a moment to imagine what this clinic would be like if it were part of a more egalitarian society, and I have a bit more appreciation for the feisty Israeli patients who regularly have to be shooed out from behind the nurses stations and from inside the doctors’ workrooms, and even for the angriest American patients, screaming and screaming in the Harlem ED until police are called, aware of where they fall in the deeply unequal American hierarchies, and unwilling to tolerate it.