Trust, submissiveness, and ingrained hierarchies: more adventures in feeling cervices

[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.




Oh I’m blessed but greedy.

With a slice of warm apple pie

on my plate, I worry

it won’t be apple-y enough.

I watch the sunrise over Annapurna,

over the Fishtail and Machhapuchhare,

and worry they won’t turn pink and gold.

Expectations leave me begging for scraps.

Looming over my left shoulder, and the town,

Machhapuchhare remains rock and ice.

The sun keeps on shining.

The apple pie is gone from my plate.

Cow Trails

Leaving the pagoda

I strayed onto a herd trail,

blazed by the cows themselves

(I stepped in it) it led,

of course, past chittering

monkeys to bulls, they stood

placidly chewing their cud.

I often lose the trail

and follow cows, seeking God

in all the wrong places.  


We’ve given up on the propane-fueled space heater that came with our flat (here in Patan, Nepal), not because of the semi-open flames, but because our propane tank leaks and we decided to put it outside the flat, and our landlord is having trouble getting us a new one- he says there is a propane shortage in Nepal.

But we’ve adjusted, and it’s only dropping into the forties at night. We wear socks and sweaters, and drink tea, and I purchased a “hot water bag,” which, in other parts of the world, you might call a hot water bottle.

While browsing Indian County Today, which I’ve followed sporadically since getting back from Alaska, I learned that the propane shortage isn’t limited to Nepal (which relies on India for imports). The price per gallon has doubled in the US. The first headline I saw on ICT readStanding Rock Sioux Woman Dies During Propane Shortage in Sub-Zero Temperatures.” And lest we think our propane space heaters, or the propane gadget on our shower that ignites with a “FOOM” sound we want hot water, are anything exotic, the article continues, “Nearly 90 percent of the Standing Rock Sioux Reservation’s residents use propane to heat their homes.”

I’m halfway around the world, learning how little I know about my own country. 

So, Nepal . . .

There are privileges I’ve always known I had, like white skin, english as a first language, education, a stable and financially comfortable family, and there are privileges where it never occurred to me to know that I had them. Like being warm in the winter. I wear my coat and hat and thick fleece-lined slippers indoors, and the tips of my fingers and toes are still icy cold. Only the most luxurious of luxurious buildings are heated in Nepal, and as the hospital librarian said today, laughing, “in the winter, we just suffer.” I’ve never spent a winter without heat before, or reliable hot water, and no, snarky-pants reader, Israel doesn’t count. Could I get a space heater? Not that easy in a city with scheduled rolling black-outs.
Like, we saw a patient who had had a stroke. I asked the Attending physician about tPA, one of the best treatments for stroke. He said it’s not used in Nepal; patients never get to the hospital within the time window (4 hours) for giving it. Anyway, the price is exorbitant. So there’s a technology challenge, of how to bring down the price of these medicines, and the transportation problem, of how to bring patients to the medicine. Alaska used airplanes, but, cost.
Like, I’ve seen my first tuberculosis patients here. The skin testing we use in the US is useless, everyone’s been exposed. A patient coughing blood is presumed to have TB, then double-checked by X-ray. I should ask tomorrow if there’s a national TB control program; I know there’s a national HIV treatment program not unlike the erstwhile pre-Obamacare Ryan White Fund, except using Indian drugs with busted patents. Technology problems, solved, sometimes. I’m supposed to buy a facemask, both for the TB and for the thick smog that erupts out of hundreds and thousands of tailpipes each morning and is hemmed in by the mountain ranges one can barely see through the smog.
And the mountains. Rising jagged and higher in the horizon than I’ve ever seen mountains before.