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In What Soil Grows the Lotus Now

In What Soil Grows the Lotus Now

Five days ago, I physically arrived back to Portland. My mind is still on the job in Nepal. My spirit is still with the people there. Last time, it took almost eight months to feel that I had returned home (in as much as it s possible to return, when you love an entire community this strongly.)

I come down to my basement at one or two o’clock in the morning, so as not to wake my family with my jet-lagged schedule. While I’m down here, I practice clumsily writing the Devanagari script, I watch Nepali movies on Youtube and I scan my emails for high-priority stuff (like, we’ll shut off your electricity) but can’t seem to get to the rest of them. I text with my friends halfway around the world and have even taken to sending Snapchats to bring my mood up. I remember this feeling from last time. My teacher, who runs the program in Nepal, calls it “Soul Delay.” It can go on for months.

Right after I left, the people of Nepal celebrated the color festival, Holi. This festival rings in the vitality and energy of the springtime. As I see that same energy around me in Portland, I note that I always go to Nepal during the Winter. It is dry and bare while I am there, though I feel alive and creative in so many ways. It’s almost perfect that the gentle, generating aspect of the springtime receives me home to help nurture the part of me that brings my life forward.

Having just gotten back from the land where the Buddha was born, I am thinking about the meaning of all of this. I read a beautiful Nepali poem this morning: Deshko Parichaya by Mohan Koirala. This poem was published in 1951 in the journal Sharada and later translated to English by Michael Hutt (who writes all of the Nepali language guides I am using.) I found this to be a beautiful description of the spring. It also eludes to the lotus flower, which has long been a symbol of Buddhism. The flower is often the purest white possible, though it grows in some of the most disgusting filth possible. I have heard it said that the worse the filth, the more pure the flower. It was this concept, explained to King Ashoka by one of the monks in his torture chamber that ultimately converted him to Buddhism and stopped the violence he had committed himself to.

Now that I am hearing the first bell of Spring, the call to regeneration, how will I grow? I can try to plan my year, to take charge of it and to force it to be what it will. However, what is left of the ashes from last year? In what soil does my lotus grow?

This week off before I go back to work has given me time to spend with my children, especially my youngest, who will start kindergarten next year. We’ve drunk our fair share of hot cocoas and spent the morning rain-soaked and mud-covered on the Angel’s Rest trail. After the dry, dusty pollution of Kathmandu, I welcome all the moisture and even the clouded skies of the Pacific Northwest.

I’ll leave you with Mohan Koirala's poem now, as I continue to ponder it for myself, feeling a bit lost in the world I have returned to, and a bit lost in myself. I find so much of my experience represented in these words and I await the golden morning. 

This is the first bell,
and this is the first voice,
to our duties we are called
as the orchids flower on the precipice;
once the kumari has shared out the garlands,
every day will be the auspicious time:
very soon the light will come
on a golden morning.

An owl is weeping with open wings from its roost behind the cremation-ground,
another adds his song in fragments:
"in what soil grows the lotus now?
From which bough sings the nightingale?
In which forest do the peacocks dance?
what green plain will those eyes open,
which sleep now in deep emotion?”

Twisting its body, night attacks me,
black fangs glistening, it readies itself,
its arms are outstretched: I beat a drum,
to declare that the world still meditates and has yet to wake from its trance.
I picked up a firefly, held it up to the stars:
"It fears no one, it glows and dims,
it dims and glows, of its own accord,
Light  oh Light!" I cried,
and the eastern sky reddens:
very soon the light will come
On a golden morning.

The moonbird calls out to make me restless,
I stride out - the sound of voices is far away,
and the river sleeps between us;
it has rushed and roared,
washing vermillion from the Himalaya's hair.
Without the human hustle and bustle
which drags me along with this country's dreams
or knocks me up with its awakened martyrs,
my country grows cold
in a shroud of clouds. 

The sun hides under my pillow
and appears around midday,
when sunshine melts into the snow,
warming the hillsides,
re-opening every door:
very soon the light will come
on a golden morning.

The Buff Channel

The Buff Channel

We had a fried egg with channa and white bread this morning. As we sat at the table, enjoying our day off, we heard Bibek laughing out the window. We looked to see that the buffalo, nicknamed by Ritesh as "Momo," was running across the soccer field and the farmer couldn't catch him. A young girl with a sweeping brush of straw walked slowly towards him. He let her fan his nose for a moment before running off with a comical skip in his step. An older neighbor who had tried to help finally gave up and went walking home through the alley. When the buff saw this, he ran full boar towards where the man had gone, making it clear that this was a game for him. Through the laughter in the kitchen, somebody said, "It doesn't get better than the Buff Channel."

This went on for about twenty minutes before the animal was captured by his tail and ears. The four foot rope that tied him securely to the ground was wrapped around his neck again. We laughed at the playful spirit of this adolescent animal. Ritesh and Hong began talking about when he would be eaten. I thought about the simplicity of life here. I feel torn, wanting to see my children and wanting to stay here at the same time. We only have two more weeks of the clinic and I feel heavy at the thought of it. There is so much valuable work to do here. I want to keep working. I want to keep growing at the rate that I am growing here.

I went to the market today and bought a volleyball, a kick ball and some tubing to make two hula hoops. The kids gather in the field every night to play games. Anywhere between 20 and 30 kids are there and our cook and his wife play with them. I've started doing this too. Last night, Bibek took turns pushing them on the mountain bike and then we played a game of tag. They play with a little toy they make from piping or an old tire, with a wire wrapped loosely around the tube and then connected to a stick. I haven't gotten good at it, it takes quite a bit of coordination. Sometimes they have a wooden top. Every time, they are covered in dust with big bright smiles on their faces.

Part of me is wishing my children had this group to play with at night. I am wishing my children could be happily entertained with a wooden top and a filthy string to suck it back into their arms with. I am wishing that it felt safe in our US neighborhood for children as little as three to walk to the field and play with each other. This kind of wishing and comparing doesn't do anything for me or my children. It just takes me out of enjoying the present moment. In the present, I think that the Bajra children will love the hula hoops that I can make.

Some of the school children, their teachers and workers from the health post joined us yesterday afternoon to clean the temple grounds. The goddess, Bajrabarahi lives there. We spent an hour with our 60 or so helpers, picking up litter and burning it in a large pile by the river. Jessi deconstructed a huge garbage dam and the river flowed freely again. After this, our ARP team spent another hour sweeping and carrying water up from the stream to wash the floors of the small meeting houses. Some of the structures had been used to sacrifice animals, others for people partying at night and others were just filled with buffalo dung. The work was hard, but by the time we left, I was hoping that Bajrabarahi was smiling and she will continue to help us move Ignorance out of our paths.

When Andrew Schlabach first started this organization, ARP was housed in an area next to a different temple to Bajrabarahi. I don't believe that it's a coincidence that ARP was invited to this village, which not only has a temple dedicated to her, but is named after her. I don't believe it's a coincidence that that the Diamond-Sow Goddess who Vanquishes Ignorance is so intimately connected with us. We spend the days educating patients about their bodies and how to stay healthy, or at the very least, not let their diseases progress too quickly. We spend the evenings talking with each other so that we can increase our knowledge base as care providers, but also our wisdom as human beings.

I can see the gate to the temple from my bedroom window. I greet her every morning and look out at the full moon over her entrance in the evening. Rather than descending upwards, as with so many temples, her steps go down, as if deep into the Earth. At the bottom of the steps is a humble waterway, where one can listen to the days thoughts or reflect on the meaning of everything around. I look at my window, to these steps retreating into the metaphorical unconscious and I pray that she might show me a similar path that rides more deeply into a connection with myself and my own truth.

A walk down to the temple leads to a series of concrete slabs covered in chicken and buffalo blood, dried flowers and salt. The nethermost depths carry the most base aspects of our psyche. This is where, it seems, we would trade the blood of others for our own stability. If Joseph Campbell is to be believed, some time ago, this might have been pig's blood and before that, the blood of our most beautiful young person.

In this life, I've heard it said that the only constant is change. Everyday, we grow older, the Earth spins, the stars shift, our children mature, our parents die, the world becomes something we don't recognize from before. If I pray hard enough, if I am willing to spill the blood of another, if I make the most precious deal with something all-knowing, can I stop the changing nature? Can I prevent the Earth from shifting and bringing another quake? Can I stop myself from dying?

Ten days ago, I let the practitioners off work early and Ritesh and I treated a number of patients. A stroke patient came late in the afternoon. He lives in an area that would be a thirty minute walk for me to get to. Due to his hemiplegia, it takes him six hours to walk to our clinic for treatment and another six hours home. This man sat down in front of me and I immediately noted that he looked like a dusty, Nepali version of George Clooney. I told him he looked like one of our most handsome movie stars and he smiled.

He begged me to use electro-stimulation on his needles and complained that he hadn't gotten enough of this from his visits the previous week. I threaded two long needles through the belly of his brachioradialis and then two more through his extensor digitorum. I connected the tiny leads to each needle and turned the electro machine up until his hand slowly unwound from it's fist. His fingers spasmodically jumped into extension and he smiled wide.

"I will give you everything if you can fix me," came the translation from Ritesh. I jerked up with wide eyes and caught myself in my own surprise. I have heard this too many times to be surprised.

"Yes, I will give you all of my money, all of my things, everything I have," he said. In front of me sat a very strong, very determined man who was willing to give me all of his beautiful, human power. He was telling me that he was willing to accept that I, as a mere mortal in front of him, have more power to heal him than he has inside of his miraculously complex, self-healing body.

The Nepali Clooney will never be as he was before the stroke. We have impressive successes at our clinic: patients walk again, they are able to feed themselves again, they are able to participate in some of their farm chores again. What we do not have is the ability to restore someone's decade-younger, pre-stroke body to them. We do not have the ability to take anyone back in time, to stop this cycle that we are all a part of. We cannot make the change stop happening and neither can Bajrabarahi, yet somewhere in our unconscious, a belief that this is possible bubbles up in us and it makes us willing to give away everything we have.

In a couple more seasons, Momo will be walked down the temple stairs on a festival day. His happy neck will be slit open so that his blood can be spilled out to Bajrabarahi. Women will pour red and yellow tikka powder on top of the blood. Duck eggs, folded rupees, cups of river water, uncooked rice and salt will be sprinkled on top. The people will smear all of this into a red paste on their middle finger and mark the tikka on each other, offering a blessing for life as they do so. With this death and sacrifice, we wish each other happiness.

What is true Ignorance and how does it coincide with our inability to accept the world and it's changing cycles? Tonight, as the sun sets behind these beautiful hills, I say good night to the goddess at her gate. I feel bonded to her, held safely by her and so happy that many hours of my day were spent in her service. I must return to the U.S. and I hope that the spirit of this relationship I am forging with her will come with me. I pray that she fills me with the strength to know and accept what is inevitable.

Plan B

Plan B

It was an old, dirty, plastic bottle filled with water that sat on the patio table in front of me. Next to it, the stem of an umbrella rose up through a hole in the glass tabletop. I sat with three Nepalis, two of whom ate buffalo momo dumplings. I had a plate of chowmein (which here means egg noodles fried in mustard or soil oil with green onions and dried chilis.) Ritesh, our clinic manager, had this as well, though he got his with fried buffalo stomach and I taught him the English word tripe.

This was my third time at this Newari restaurant, and as such, the third plate of chowmein that I've had since coming here. This one was far saltier than the other two had been, and I was struggling to finish it. I coated it in hot achar sauce to try and take some of the salt out, but I was feeling parched. I usually have my water bottle with me, but I had been grieving about the interns and not thinking straight. I watched my companions drink repeatedly from the water bottle on the table and thought to myself, many times, not to do this. I did it anyway; two small sips were all I needed to feel a million times better.

Since this lovely dinner, I had three days worth of abdominal cramping and diarrhea. I have learned something in coming to Nepal, and it's something I like very much about myself. First, I don't throw up when I have food poisoning. On one hand, this might be problematic in that I don't get the bacteria out fast and limit the duration of my illness. However, it means that I don't have to vomit, and that's definitely worth being sick longer. I don't think anyone likes to vomit, so I think it's just super cool that I usually don't. Secondly, I don't let it get me down. I manage to stay in a relatively good mood and with lots of energy to work, regardless of the cramping and diarrhea. I decided to give this bout three days before hitting my bottle of ciproflaxin and it appears that was all I needed. Whew!

Today I spent the morning cleaning, organizing and documenting our remaining herbal dispensary. I listened and watched the practitioners with their patients and interjected when asked (and a couple times, when not asked.) One woman this morning has been especially tough for two of our practitioners. She has liver function tests that show the beginning stages of liver disease. She has non-pitting edema. Her nails are starting to come off her fingers, but they aren't spooning and they aren't technically clubbing. What could it be? We talked about this case for thirty minutes the other night at dinner and once this woman was in front of me, the symptoms were all over the place. Finally, we asked about pesticide use and sure enough, she uses these on her crops everyday.

Three of our farmers this morning are suffering from the beginning stages of liver disease with shortness of breath and a number of organ problems that seem to be traced back to pesticide use. This is a tricky area, since it's hard to prove. An article in Environmental Health Perspectives talks about an analysis on farmers in developing countries who are suffering chronic pesticide poisoning with symptoms that include headache, dizziness, depression, limb weakness, poor balance, difficulty concentrating, and vision difficulties.

We're seeing far too much of this here. They often don't wear gloves or masks, don't wash their hands and then eat food. Of the three we talked to today, two wore gloves and one wore a surgical mask while applying the chemicals. None of them seemed to understand the detrimental effects these substances are having on them. In a country as beautiful as this, I have been quite surprised to find that the vast majority of the farmers here are using pesticides in high amount.

Strewn through this mix are a number of patients suffering from post-stroke hemiplegias, auto-immune conditions affecting the nervous system, the occasional lumbar disc lesion, cervical radiculopathy and a handful of other conditions that can mimic some of these symptoms. Our practitioners have twenty minutes with each patient to gather information, do objective testing, make an assessment and then treat with acupuncture or chiropractic. We see most patients 1-3 times per week, to continue gathering information and determining a diagnosis. We work with the pharmacist who runs the Healthpost here and the doctor at the Primary Healthcare Center in Palung to get blood tests and imaging to progress our cases. It can be hard to differentiate these things in the first few visits.

With chronic pesticide poisoning, I am still trying to determine our course of action. The results on the last few patients I have seen show the liver to be distressed, the lungs are severely affected (in a country where, after infectious disease, COPD is already taking the lives of over 40% of the folks left), and kidney function has been undermined. The testing and imaging add up for these farmers, who often carry many years worth of records through our doors when they come.

The organophosphates seem to cause irreversible toxicity to the nerve cells and deficits in cognitive function. I am still researching the possibilities and trying to figure out how we can educate people, with simple language, about avoiding these chemicals.

During lunch, Dr. Jessi and I took a patient up to the Healthpost to speak with the manager there about an orthopedic referral. The patient is  an 80-year old woman who is so osteoarthritic that it looks like she completely detached the head of her humerus. The humeral head appears, from x-rays, to have split into two pieces. The shaft of the humerus rises up into the shoulder girdle as this lady moves her arm.

From the paperwork, it looks like the government hospital recommended surgery, but the patient reported that they told her she was too old. After an hour of back and forth with three Nepali interpreters, the manager, the head midwife and two other staff members, we found out that it was the patient's children who had refused. They were worried about costs (which could be as little as $1500 US with the right connections or as high as $7000 US without) and the long-term recovery time for an older, osteoarthritic patient.

In the end, the manager of the healthpost has decided to call her children to come in so that he can talk with them, as he has been to their home before and thinks he can make some headway. The patient agreed to revisit the hospital in Kathmandu with her family so that she could get more details to make an educated choice. And, Dr. Jessi and I decided to create a non-surgical, Plan B solution, in case the family still decided not to do the surgery. At the very least, Jessi can create a molded cast/sling from Plaster of Paris, fitted to this woman, so at least if she stumbles a bit, she will have a minor degree of protection.

Lunch was delicious, as always. The afternoon was so stacked with patients that I ended up treating a few in the end to get everybody home. We are still working with reception to try and even the patient load between providers, though it was highly uneven today, with one of my practitioners treating 27 people in 7 hours. It was a good day, with a lot of great work done, but I'm hoping we can streamline the process a bit more this week.

Humeral head detachment

Holy Day

Holy Day

Yesterday morning, I walked down to the Bajrabarahi temple with one of our interpreters, Gunaraj, and his fiancé. I had been sitting at the table with Dr. Lucy, having a tea before breakfast, when Gunaraj brought in some fry bread that is eaten on holy days. He said he had to go to the temple before he had food and invited me to walk with him. I jumped at the chance.

January 14th is the Hindu holy day called Makar Sankranti. (It is also Felix’s birthday, though we are one day ahead, so I will not call him until the 15th here.) This is a very important day in the Nepalese calendar. It marks the start of Spring and it ends the time of darkness/winter in which sacred rituals cannot be performed. After this day, the Nepalese are free to perform their rituals with the good favor of the gods and the sun.

To celebrate this day, the Nepalese often take a bath in one of the holy rivers. However, in Bajrabarahi, we wake up to temperatures in the high 30’s, with no heating systems. Our living quarters have bedrooms whose doors open directly to the outside and our windows are not insulated. I sleep in a 15 degree, down sleeping bag wearing wool socks, two layers of wool long johns, my hooded down jacket and a merino wool hat. The last two days, I slept with my thick scarf on. The dry grass landscape looks white at 8am, due to a heavy layer of frost. The joints in my thirty-nine year old fingers feel stiff and painful for the first few hours after I am up. It’s unlikely that anyone would go for a dip in this.

The Bajra temple is across the street from the clinic. We walk through a white gate and down a spiral set of concrete steps. Small, covered porches are set along the sides near the bottom. On one of the walls, Shiva has been drawn with Nepali words underneath. I know that they say something to the effect of “Be it known to all, this is the temple of the Goddess, Bajrabaraji!” since I asked on an earlier day about this. He stares at me, with his trident held tightly in his right hand and I quietly acquiesce. Though Shiva both intrigues and frightens me, I have decided that Bajrabarahi might well be the god that has most of my attention on this trip. I am determined to let her know that I come in peace and that I only want to be here with her permission.

When we get to the bottom of the steps, Gunaraj opens the plastic sac he has brought. His fiancé pulls out a large, square metal plate. She arranges some small cedar boughs in the upper right corner as he hands her a fistful of sweet black incense sticks. They pull paper packages from the bag. One is bright red tikka powder and she carefully empties it into the left corner. The next is a yellow powder that she taps into the center. There is another pouch of rice and then some fennel seeds. These are carefully arranged as well. Lastly come two duck eggs. Gunaraj had carefully marked these as sacred with vertical yellow lines and then added small dots with the red tikka powder. These are set into the middle of the plate. She hands him a metal drinking cup and he runs down some steps to the river to fill it with the holy water.

We stand close to the altar, where many families have lined up with their own offerings. Though Gunaraj is cold and wants to light the incense sticks and get on with it, his fiancé tells him no. I can understand enough of their Nepali conversation to know that she wants to wait to light the sticks until they can have the center spot in front of the altar. I watch two young boys in cotton hoodies shivering in their flip flops as they wait for their families. To my left, a man slits the throat of a white chicken and removes it’s head. It’s neck continues to move and it’s wings continue to flap as he rips the feathers from the body and sprinkles the pieces on the various large rocks of the altar. He fills his cupped palm with blood and sprinkles it on top of the tikka powder, money and dried rice already on the altar.
Finally, it is our turn. We make our way in front of the altar and my friends begin sprinkling the items on their plate on top of the large rocks of the altar. Gunaraj sprinkles the holy water on top of everything. They leave some rupees amongst the offerings. A man rings a bell behind us to call the god and Gunaraj fills my hand with rice and tells me to sprinkle it. His fiancé dips her finger into the tikka powder of the altar, where river water, chicken blood and incense ash have been sprinkled. She asks me to bend down so that she can put a tikka between my eyes. She does the same to Gunaraj. They gently crack open the small end of the duck eggs, spilling the yolks and deciding that they do not like that. They put the eggs into a plastic bag and cinch it. I am unsure of what happened with the eggs, though I do know that they are proud they have brought duck eggs and not just chicken eggs like everyone else.

We walk towards the river to where the aged bronze bells hang. The bells are covered in red and yellow tikka powder and Gunaraj instructs me to walk around them with my right side towards the bells and ring each one to call the god. I do this, as instructed, but I am worried about whether or not I truly want to call the god. I feel unworthy of her attention. Perhaps I have not done as well as I could have. Perhaps my heart is not as pure as I would like it to be. Am I ready to meet her? I am more afraid of halting the procession behind us than I am of these things and so I decide I will take my chances and I ring the first bell, the second, the third and on, until I come to the last bell in the line of bells.

We proceed forward and stop many times to sprinkle rice and tikka powder. First we do this in the hollow of a small tree, where a prayer has been set. Then we do this on two small places at the foot of the stairs, also where prayers have been set. Halfway up the stairs, we do this again. We walk through a staircase and gateway in which prayers have been left in our path and we honor them with these powders and seeds.

As we make our way home for breakfast, I think to myself that I did not mean to see a chicken sacrificed this morning. I cannot reconcile it in my head. The colors at the temple were so vibrant, the bells so loud, the sugary incense so strong. What is it about the sacrifice that has been made? What is it about humans that we feel such a pull towards sacrifice?

I do not have a temple in my village where I go to pray in this way. The gods where I live are not so pronounced as this. I do not know a family in my home village who would sacrifice a chicken and sprinkle its blood onto an altar, though I do know of a family who kills their own chickens for food. Is there anything in my life, in my village, where we have these sensorial tributes to the spirit that we have together determined to be ruled by? Isn’t this what the god represents? A collaborative tribute to a shared spirit of protection and, in this case, the dissolution of ignorance?

Though I feel sick at the image of that bawking chicken, I also feel a grief for the communal sacrifice that I do not have and that I have never experienced. I feel a sense of loss for a shared value system that is honored in my community on specific holy days. I watch these feelings and they add to the visceral sensation that the whole temple experience has brought today.

This Morning I Put Some Footprints on the Wall

This Morning I Put Some Footprints on the Wall

It is Day 4 in Nepal.

I have written every day in my journal but have had a hard time putting together something coherent for a blog.

I feel a conflict as these two worlds mix in me…a titanic clash of mind as I’ve landed here. At first, I thought it was merely jet lag, but it feels like it’s taking longer this time. I go to bed shortly after dark and wake between 2 and 4am every day. I am up on the top floor, where there is no wireless and a beautiful rooftop to do Taichi, but if I descend, the hotel is dark and cold. The Nepali guys who work here sleep on the floor downstairs and I don’t want to bother them, though I want more than anything to have some hot water for a tea to sip while I write.

It was exhilarating when I first got here, knowing that I was about to see old friends. Mahesh Kumar Budah picked us up at the airport and lots of hugs ensued. Mahesh is a friend of Andrew Schlabach (our director) and in this capacity, helps with the Acupuncture Relief Project (ARP). He runs a trekking business here in Kathmandu and designs a huge range of trips for Westerners. On our second day here, when Jessie and I took a morning jaunt to the Monkey Temple and got lost in Thamel (the neighborhood where we are in Kathmandu), we serendipitously ran into Mahesh on his way to work. In the spirit of Nepali hospitality, he took us for a coffee and then walked us halfway back to the hotel to make sure we were okay.

My conversations with Mahesh have gone from his experiences on his treks to Buddhism to how we can be the best parents possible to our children. He has been helping me to pick up volunteers from the airport and I look forward to each excursion, knowing that it means another conversation with him. It also means that I feel very safe here (Mom, this is for you, ha!). In the haze of arrival and jet lag, I view him as an angel. I have no doubt I will see him in a relatively similar light when my head becomes clear.

The hotel is run by Asta Buddhachara who is a delight to see every day. He is full of laughter and great information about where to go for a meal or any item we might need to buy before we transport to the village. The neighborhood of Thamel is hard for me, it’s been one of the things that I have run my energy down with these last few days. I have averaged three hours of sleep each night but still find myself able to build up a barrage of negative self-talk about my ability to get around.

Prior to coming to Nepal in 2015, my range of travel included only Australia and Canada. I have never been to the developing world before and it’s hard for me to see the details necessary to find my way. Even as I type this, I can feel my eyes welling up a bit because it makes me feel inadequate already, at the beginning of this trip. It seems so easy and intuitive for all of these people who have travelled to South America, India and Asia many times before.

I feel that I cannot see what these others see and that I am so easily lost. Is this symbolic of the way I wander through life?  I walk past intersections where I should turn, I do not recognize basic things like bookstores until they are pointed out to me. Last night was the worst of it and it kept me tossing in bed for quite a while.

Ritesh Maharjan is the interpreter lead for our Bajrabarahi clinic. He calls me sister and this is true. I love him like one of my brothers and when we saw each other for the first time the other day, I hugged him and could not let him go. We had plans yesterday to meet up with the interpreters from our 2015 Camp but it was Ritesh’s birthday and we decided to try and squeeze in a trip to the botanical garden, which is one of his favorite places. This trip required a 30-minute cab ride to the bus depot and a 30-minute bus ride to the gardens, plus a 30 minute walk to get to the garden gate. In retrospect, it was a whole day trip and not something to be done for the morning.

Our group included Ritesh, our Bajra interpreter Milena, myself (three hours of sleep), Jessie (a few more hours of sleep) and Cami Hobbs, who literally arrived to the hotel at midnight from the epic trip from the US. She had gone for 30 hours without sleep. (This is a 16-hour flight to China, then a 5-hour flight to Nepal with layovers and all that other good stuff.)

The bus ride was beautiful, stuffed full of Nepalis young and old, the dashboard with a waving statue of Ganesh glued to it. The gear shift had ample layers of handkerchiefs rubber banded over it, for some reason unknown to me. A young Nepali man hung out of the side door whistling, clicking and yelling at potential passengers and collecting money. I quietly thanked our driver for each successful passing of other motorcycles and cars as we made our way up the hill and through the city.

Vendors on the pathway to the garden sold peanuts and MSG-coated fruits: the sour Chinese plum (called Lihimui in Hawaii, though I do not know it’s name here), small gummy squares coated in black Himalayan salt, dried pineapple and lemon rind and silver bowls with mounds of gooey fruit floating in gelatinous sugar.

We walked to the monastery and watched as people gathered inside the gate. The door to the temple was not open and we took pictures of the beautiful buildings. The monks sat quietly on the side lines of the cameras and children with balloons and I wondered at their experience, their perspective on this, which is something I will never know. I halted my mind from the judgements it wanted to make and shifted back to a curiosity.

Ritesh walked us to a building where water spouted from five or six lions head into a large pool with discarded one-use shampoo packets. Jess asked him if people bathed there. “Of course!” he answered. “This is a large bathtub for many.”

We went into the small building to see a shimmering square of water, filled with fish. Metal bars kept us from going nearby and a cleft in the rock at the corner was covered in the pink powder of Shiva, whose image sat nearby. More children with balloons made their way around the temple while tourists rang the bell next to the God and applied the pink tikka powder to their foreheads.

We found a rooftop where we could get noodles and momos and shared a tea. Satyamohan, one of the interpreters before my time who is now attending the acupuncture school in Kathmandu, walked by and our friends waved him up. We said hi, hugged and he departed as we made our way to the gardens. Ritesh tried to buy our tickets for the Nepali price, but the ticket handler saw us entering and made us come back to pay the extra $570 rupees for admission. Loud Hindi music wafted through the air from picnics in the background but it was not allowed in the garden itself.

The buildings were old colonial style greenhouses and it felt like stepping back an entire century. Unlike the rest of Kathmandu, the garbage had been picked up in the gardens. Though we went during the Winter, it was still quite beautiful. We visited the cactus and succulent nursery where a spidery web of cactus fur draped down from a metal pole in the ceiling. Unusual looking crepe paper ferns caught my attention in the next house. We eventually settled near a large greenhouse, closed to the public. Though a missing window at the uppermost section, I could see the rusted ceiling beams, cutting triangles through the greenery. We stretched and talked for a bit and I did a headstand in the grass which two curious children had to come see.

Time was short, our friends were calling us, but I could tell that I was already fading from a lack of sleep and so much travel. The other Westerners in our group, who were back at the hotel, were going to make their way to the large Bouda Stupa to meet our previous interpreters for a meal. I knew that the idea of this was more than I could handle and I asked Jessie and Cami who said they wanted to see Bouda and thought they would be ok. By the time we took the bus back and squeezed ourselves into the tiniest cab, the traffic to Bouda was unbearable. A Nepali song played on the radio over and over, “Sani-bar, Sani-bar, Saniiiiii-bar!” it exclaimed: Saturday, Saturday, Saturday. It went on and on for the forty minutes we spent in the cab. Jessie gasped at a pothole that she didn’t think our overloaded cab would make it through and I crossed my fingers and held more tightly to the young Melina, who was sitting on my lap. Cami’s eyes grew redder from the dust and she took turns leaning forward into numb feet and then back into the seatbelt that gouged her lower back so that her circulation could return.

We finally made it to the stupa, but I no longer had the blood sugar to hug and celebrate my old friends the way I wanted to. They rearranged the table for us and I ordered a dal bhat. When it came, I poured the dal over the rice, mixed everything together and didn’t come up for air until there was barely any left. By the time we got in the cab, I felt very sleepy, a little grumpy and mad at myself for doing more than I knew that I could do.

Cabs in Nepal are always precarious, but the cab that the three of us rode in seemed exceptionally so. Our driver continually passed the other cabs by making risky moves into the right lane and was clearly not afraid to hit pedestrians, one of whom only made it by jumping out of his way. I saw the Garden of Dreams to my right and then the cab stopped. The driver turned the engine off and leaned out his door. I was confused, I had no idea where I was…I knew that we could walk to the Garden of Dreams from our hotel, but I hadn’t done it and didn’t know how to get home.

I tried asking him what he was doing but he spoke no English. I didn’t think we were in Thamel, though it was merely due to my delirium with 12 hours of sleep over four days. He pointed to the cab behind us, I walked back and asked about Thamel and finally, the other Westerners in our group saw us and led us home. I felt like I had lost my mind and I was even more upset about not knowing my way around the city better. What would I have done if they hadn’t been there? I carry a compass and a map in my bag and I would have used them, but why is it that nobody else needs to use these things?

I took some herbs and other things before bed and was able to sleep for six hours last night. I woke up and did my Taichi, headstands and stretching for an hour. And then, at 5am, I decided to have a dance party with myself, hoping that I could stop being so mad at me for not knowing where everything in this city is. That felt better. I have spent all of 8 days of my life here and perhaps I don’t need to be so mean to myself about it. I can also work a little harder at it. I know myself and I know that I can. When I signed up for a physics degree, I did so because I was not good at it and I was determined to be. It took me four times longer to finish my Classical Mechanics homework than most of my classmates, but I always got a good grade. Determination and persistence is what works for me, not a magical intuition that will guide me into feeling my way around Kathmandu.

The other morning at breakfast, Mahesh told me about the time that he visited the cave of the Rinpoche. He said that on the left and right sides of the cave you could see the footprints of the Enlightened One, where he had gone mad fighting against his own demons. This morning, in an attempt at more self-love and acceptance, I put some metaphorical footprints on the walls of my room.

Today is a day that I have two airport pickups and not much else. In between these things, I will be studying a map and walking around the city, not for any other reason than to find my way out and back in, and hopefully in the process I will find a little bit more of myself.

Slow Down On Re-Entry

Slow Down On Re-Entry

I hold my arms in front of me and face the back of a man from Hong Kong. He stands on a small gravel pathway that runs between German and Roman chamomile and a waking Asian peony. He bends his knees to sink down and I follow the motion. His right hip pulls back as his left palm moves forward and he turns his torso towards the east. The students on either side of me move in unison as we begin the Yang Taichi long form. We side step and a whiff of something fragrant fills the air, but I know it's too early for the osmanthus to be blooming.

As I run through the exercise with Sifu Ko, I realize that practicing almost everyday in Nepal has started to make these movements inherent in me. I no longer have to be consciously thinking through each step to move my body. It's moving as if it was made to do this. As I try to engage my conscious brain, I feel myself lose the effortless action and my movement becomes clumsy again. I've done this with the medicine too. I practiced everyday until it started to become an effortless part of me.

I realize that this morning, I was really freaking out about all of the small parts I have to put together to make life work in America. I became overwhelmed as I entered insurance data and receipts. I started to wander off on thoughts about the scarcity of resources here and how I won't be able to practice medicine how I'd like. More thoughts about how I can't spend enough time with my kids; all kinds of thoughts that get loaded into the basket of "work-life balance," whatever that is. Once these gates of fear were open, my student loans showed up too. I felt panicky as I left the house. I cried as I navigated the freeway on the way to this class.

Though I promised myself on the way home from Nepal that I wouldn't do this, I see that I already started. My mind is beginning to take over again. It wants to calculate and plan out a course of action. It sees scarcity in the world around me and as it plans, things just don't add up quite right. I feel a little bit hopeless and a little bit frustrated because my mind has just come to the conclusion that I am not being practical in anything: the way I want to practice medicine, the way I want to mother my children or even the way I want to live.

It's ironic that in rural Nepal, with no heat and no hot shower, I felt as if the world were incredibly abundant. I ate the same dal bhat for every meal, drank the same four ounce milk tea at lunch and followed the exact same schedule for six days a week. In Nepal, my heart took the lead. When that happened, there were no coincidences. Everything in my day had a special meaning; whether it was a tree growing on the path I walked home or a puppy that showed up on the porch. I did not have to make a series of new decisions everyday. I had a set routine and the only job for my mind was to follow the lead of my heart.

It's been a culture shock these last couple of days, in the land of infinite choices. In Nepal, dinner means rice and lentils with a small amount of saag greens and vegetable. These are spiced with the same masala blend every time. After a few days, my mind stopped engaging in dinner and let my heart do the work. My heart found that my gratitude for a simple meal had been lost and it helped me to settle and take my time when I approached my plate. It helped me to enjoy more of each bite of my food. And, it engaged my mind to help it determine a solution. I decided not to do any snacking outside of my meals so that I could come to the table with my full appreciation.

In America, dinner means that I can go out to a multitude of places for food that comes from all around the world. Going to the grocery store brings an overwhelming amount of choices with novels of information for me to read so that I can make an informed choice about whatever I purchase. On top of this, I can choose to purchase more expensive items that will donate to a good cause. All of this is overwhelming and lets my mind take the lead around a choice that has traditionally been a heart-centered thing: a shared meal with family or friends where we connect around our day. In leaving the store, I wonder if I made the right choice for my family? Did I pick food that everyone will eat and that all of our bodies will benefit from? Do I know how to cook this food properly? Did I accidentally buy something from a company that didn't pay the farmer a living wage?

In my medical training, I learned that each yin organ has a virtue. Compassion is the virtue of the liver, justice that of the lung, wisdom that of the kidney and trust that of the spleen. It never made a great amount of sense to me that ritual was the virtue of the heart until I had the opportunity  to  feel it for myself. I had to be in a situation where everything was simplified for me. In ritual and healthy routine, the mind is allowed to fall back, in service to the heart's lead. When there are very few choices, we have the freedom to follow our joy. It is the mind that constantly craves new stimulus while the heart find pleasure and meaning in experiencing the same thing, over and over, at a deeper level each time; very much like walking around a mandala. Or, like doing the same Taichi form every day.

As we conclude the form with a bent side kick, I can feel that the integrity in my lumbar spine has been lost. I push down through my feet to root my body and correct this. No matter how many times I go through this form, there are so many opportunities to learn about myself. I can do each movement again and again, until my mind is screaming out of boredom and still, I would have an ocean to learn about such a small step in the whole.

How do I simplify my life so that my heart is allowed to be more fully present and conscious with everything I do? This is the question that has opened to me this weekend and it will be hard to answer from my chest and not my head.

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We Belong To Our Mountains

We Belong To Our Mountains

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I'm sitting in the last row of a Q400 passenger plane. I can see the Cascades through the window. The engine is grinding loudly compared to the large airplane that flew me into Vancouver, BC from Guangzhou. Below me, a trail of gigantic bear paws is printed in islands on the water. I see marinas carved into protected circles in some of them.

The seat next to me is empty. For the last thirty hours, I've been flying with Debbie Yu. When I left her at the Vancouver airport, I put a thick, powdery tikka on her forehead and wrapped a white cloth around her neck. She did the same to me. We hugged goodbye for the first time in nine weeks. I no longer have anyone with me who understands exactly what it feels like to be going home after this experience. Nobody is here with me to have rudimentary Nepalese conversations. She's not here with me to share the stomach pain from leaving so many patients and friends behind. But, Seattle is not too far away. We reminded ourselves often of this fact. I also reminded myself of the blessing in finding another human being who I could connect with so deeply around a shared act of courage. This is special and it will not be lost or forgotten.

I look up to see the flight attendant offering to take a photo for a group of young Canadians while she hands out angel pins for people who are afraid to be going up in the air. I have a dorje hanging around my neck and four Nepalese amulets in my checked baggage below my seat. I don't feel afraid to be flying today.

The powder peaks of Mount Rainier write a history out the window to my left. My favorite place on the earth. Mixing with the memories of this place and my culture are fresh memories of the patients I love, the monasteries, the communal sink in Nepal. All of these come together into my canvas of the present to produce colorful thoughts, inspiring and painful at the same time. I look forward to seeing my children at the airport.

Nine weeks ago, I set out on a journey that required me to do a number of things I was terrified of. After all of it, I didn't die. I didn't get sick and I didn't fail at helping people. Did I do what I set out to do? Did I make a difference? I know there is a difference for me. I am changed, but when I look at my hands folded in my lap, they still look like the same hands. My face looks like the same face reflecting back from the small square window.

The plane floats over Mount Saint Helens and people get out of their seats to take pictures through the window. Though she is scarred, she is so very beautiful. She is recognizable. They discuss which mountain is Mount Adams and which is Mount Rainier, but everyone knows who Saint Helens is. She is a survivor. She reminds me of so many of my patients. Maybe she reminds me of myself. I suppose she is a symbol of the human experience. _______________________________ Tonight, my husband and children have gone to bed. I'm sitting in front of a fire, watching a television show. My three-year old wakes up and calls out for his mama. I go in and he asks me to lay with him. I kiss his hands and wait for him to fall back to sleep.

As I make my way back out to the couch, I think about Auntie and my dal bhat plates. The airline lost my baggage. Will they be able to return the things I was bringing home from Nepal or is it all lost? What about my memories? Will they fade? Will I forget the people that I spent the last two months loving as I reconnect and focus on my family and friends here in Portland again?

As much as I love Nepal and even fantasized about staying and living there, and as much as I want to go back, I know that I belong to these mountains. I am home here, in the Pacific Northwest: temperate rainforest, sweet smelling moss, dark salty seal water. It takes courage for me to invest in what is right before me, in the present moment. It means I have to let go of what has been and what will be. I have to risk losing my memories in order to make new ones.

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Oracle Part II

Oracle Part II

Continued...

Today, the rain started on the way to work. By the time we got there, the thunder rolled loudly over the mountains while the lighting cracked the sky apart in horizontal waves. It is our second-to-last day in the clinic and we expected to be busy. Even so, the monster puddles and epic downpour had emptied the streets and the buses held far less passengers than we are used to. We spent more time with our patients, massaging them and saying goodbye to those that we will not see tomorrow.

I put needles in a patient and then ran home to get our headlamps when the power started going in and out. I borrowed Erin's jacket and got drenched before I'd even run a block. I saw one Nepali woman with an umbrella and a few children huddled under an awning. Otherwise, the normally bustling marketplace was happening behind the closed doors of the shops. I got to Auntie's house dripping wet and in soggy shoes. She was in the back, under the coverof the kitchen, cutting red onions with a Nepali floor knife. She sent me back with her lantern and an umbrella that I didn't use because I was scared that the metal pole at the top might attract some of the biggest lightning bolts I've ever seen.

Back at work, I changed out of my wet pants, threw a skirt over my soaked base layer and went in to find my patient. It's her fourth treatment in four days and she's been coming regularly to try and fit half a treatment plan in before we leave. Like many of the patients here, money is the limiting factor around their healthcare. When given the opportunity to have affordable treatment, they travel great distances to come every day or every other day and are compliant in following our directions.

When I first met her, she complained of large and painful breast lumps, burning and smelly leukorrhea and lower abdominal pain. She looked very tired and her pulses agreed that she had no energy. I palpated her breasts to find long, fibrous lumps. When she brought her medical records to me, her ultrasound verified my diagnosis of fibrocystic breast changes.

Like most of my female patients with reproductive complaints, the gynecologist at the hospital did not perform a pelvic exam but instead, just gave her a round of multiple antibiotics and anti-fungals. After four years with these symptoms, it's likely that she has pelvic inflammatory disease or chlamydia. These things are hard to get diagnoses for. Only one doctor followed through with my written referral to do an actual pelvic exam and even with that, he didn't culture what he found. Instead, he diagnosed chlamydia and prescribed the same round of antibiotics and anti-fungals.

My current patient never had the money to buy the medications, since she spent everything she had on the ultrasound and "gynecological exam." No one at the hospital took the time to sit with her and talk about what was going on with her body. Nobody explained to her that she has had a pelvic infection for five years. Four days ago, as she sat in front of me, she thought she had breast cancer because the ultrasound tech never explained to her that the breast lumps were not malignant.

In the first thirty minutes that I had with her, I found as many working metaphors as I could to explain what an infection is. I hope that I was able to help her understand the importance of taking the antibiotics. After this, I worked with the translator to explain fibrocystic breast changes to this patient and help her to understand that she does not have cancer. So much of the patient care here revolves around educating people about their own bodies and their health. They are often confused and scared after having been to any healthcare provider in this country.

Today, the patient reports that almost 100% of the pain in her breasts has been resolved and her lower abdominal pain is 50% better. With the herbal antibiotics we gave her to take until she can afford a round of Western meds, she reports less burning and leukorrhea. But, the pain in her left hip bone, something she's never mentioned before, hasn't been resolved. The clinic is slow, so I lay her on a thin mat on the floor and massage some herbal oil into her back. I do some cranial sacral work and then send her out into the cold and wind to catch the bus. She tells me that she will come back for our last day tomorrow.

Tomorrow.

I've been here for eight and a half weeks and it barely feels like two. There are so many patients and so much left to do. Yet, tomorrow is our last day. ARP won't have another camp here until September. We leave our patients for six months without the healthcare that they are used to. We leave them in a medical system where very few doctors are willing to take responsibility for coordinating their care. I don't blame them. I know that it takes a lot of courage to take a patient's case on. I've had to dig deep inside to do it myself, but that's what I promised to do when I signed up for this trip.

I haven't been incinerated here. And I haven't run into the wilderness when I was forced to face myself. In fact, as I have spent this time with myself, I am starting to think that it's not so bad to be me. I am made of shadow and light, as we all are. I have my night and day, my sun, stars and moon...and I hope that in going home I have learned not to take so much of that beauty, that is inside of me, for granted.

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Oracle, Part I

Oracle, Part I

Before I got on the plane in Portland, I had an image from the NeverEnding Story in my head. I saw Atreyu, standing before the Southern Oracle. In order to pass through the gate of the Oracle, first one has to feel their own worth. If the person is doubtful of their worth, they are incinerated. At the second gate, there is a mirror that reflects the true nature of the observer. Many people go mad looking into the heart of themselves and run into the snowy wilderness to die.

This image became a symbol of my participation in this trip. I had a severe fear of flying on planes. I was convinced that I was unworthy of volunteering in Nepal. I had no idea how I would be able to help a single person here. And, I would be spending nine weeks away from my family, in the company of strangers, most of whom don't speak English. I made myself come anyway and I decided that if it wasn't worth the risk of incinerating myself that it wasn't worth the risk of living.

With three more days of clinic left, the the six of us had a closing circle last night to reflect on our trip. Reflect was exactly what I did, as it's been the crux of my experience here. Every patient, every translator and every other practitioner here has been the mirror in the wilderness for me. I have seen the essence of myself shone back at me with each and every interaction that's occurred here.

Most notably, Lal Bahadur Lama, my patient and my friend, held up a looking glass that required the most courage for me to look at. Of course, it was difficult to watch an extended and painful death. It was hard to see the injustice of a under-regulated system that manages to over-regulate morphine. I cried and I isolated myself on some nights, knowing that his pain could have been managed with one of the cheapest drugs available in the world; a drug that is recommended for this exact use by the World Health Organization. While I slept, I knew that only 150 meters away, he was slowly suffocating in his bed. It was heart-breaking to know that he did not need to experience a slow drowning. It was an outrage for me to see that the huge oxygen tank he was hooked to tied him into an unnecessary bedrest and that the bedrest ultimately killed him. But, Lal showed me that I could find the courage to watch this process instead of running away from it. I saw that if I ever had to die this way that I could do it with the same dignity that he did it with. He taught me how to die with strength in the worst way that I could imagine.

More than this though, he held up another reflective glass for me. So many times, while Debbie and I sat with him, he told us how he wished he could draw or paint or sculpt a beautiful piece of artwork for us. He frequently apologized for not being able to give us anything for our service to him. He told us about the photography shop he started in Bhimphedi years ago. It quickly went out business because he gave everything away to his friends for free. I realized that I too, have a hard time receiving from people and that it is far more comfortable for me to be giving.

When I give, it feels good, but it also puts me in a place of power. I have something and I have chosen to give it to another person. The giving is happening on my terms. Receiving is a position of vulnerability. It requires a great deal of trust in the relationship to relax into that role. I don't know that I've ever been able to do it. Last night, Maggie Shao gave us a quote about generosity:

"True generosity is the willingness to plant a tree whose shade you will never enjoy sitting under."

If that's generosity, what does it mean to be on the receiving end of that? To be the one who did not plant the tree, but only enjoys the shade given by it? It brings up some serious issues around worthiness for me. I am only worth the enjoyment of the shade if I planted the tree myself.

I expect others around me to openly receive my generosity when I would not be able to receive it from them if the roles were reversed.

In the two months that I knew him, Lal Bahadur Lama spent his entire existence in a twin-sized bed in an 8x10 mud room, hooked to a 5-foot oxygen tank. I brought him charcoal pencils and drawing paper. I made sure that he had hot water to drink and codeine for his sleep. I gently massaged his shoulders and did cranial sacral work at his occiput. I took his pulses and gave him acupuncture. I listened to every lobe of his lungs as he inhaled and exhaled. I quieted the room so that I could hear every beat of his heart through my stethoscope for a full minute. I squinted at the curving script of his medical records and copied everything down. I researched and thought about him for hours of every day.

For all of this, Lal told me that he gave me nothing. My heart knows that's not true. My heart knows that I have  enjoyed the shade of the tree that was planted with Lal Lama. At his funeral, I cried for his passing, but I also cried with joy for an inclusion that I've never felt. His daughters called me, sister, in English when they handed me roses for his coffin. They took my hands and cupped them and filled them with dirt to throw into his grave. They honored me and gave me the most memorable experience I've had in Nepal. For Lal, buried at the river, I hope he knows all of this.

To be continued after work....

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Brilliance Across Mountains

Brilliance Across Mountains

We are standing in the middle of the road while the new rain hits the dried gravel. As the dust is stirred by the falling water, the air is filled with a smell almost as good as puppy breath. Down here in the valley, we can see the lighting flashing over the mountains on either side of us. The thunder claps, garungarung, over the ridge to the west. Everyone else is in the dark house sleeping. The power has gone out twice and the second time, it didn't come back on. Debbie and I are just arriving home from a small fire in the soccer field. We prayed to Shiva and watched the lights of the prison sparkle in the foreground as the brilliant sky moved closer and closer.

My down jacket is soaked and my hair is dripping with Nepali rain. I feel like I could stand here in the road, forever, being showered at the top of the world. The cold is invigorating and I feel pleasantly uncomfortable; worried that Auntie will wake up from the rain pounding her roof and unknowingly lock us out. The downpour comes heavier now and we can't hear each other shouting, even though we huddled together, with our faces only inches away. The other practitioners in the house are sure to wake up now. We run, screaming with delight, through the gate, grabbing at our water bottles, tooth brushes and my ipad, sitting mildly protected under the patio cover.

Nothing can be heard in the house over the screaming tapping of the droplets as the thunder spits them out of his angry mouth. Our roommate wakes up as we come into the room, but she hears nothing we say to her as she winces into our headlamps. W are changing our wet clothes, and Auntie slides into our door, her tired eyes looking for the outlets. She is unplugging everything so that the power surge doesn't fry our electronics. I sit on my bed to write and realize that this is the first time I've felt anything move me to do so in three days. I look out the window and a flash of lighting squeals across the sky. This storm feels good in me.

Lal Bahadur Lama died two days ago. I was at his house for four hours of his struggle but I didn't see him take his last breath. I knew it was coming, but there were too many people keeping him from sleeping and I couldn't stand to watch. I was so very tired myself. His vitals were so low that even my pulse oximeter refused to wake up and take them. As he lay in his daughters arms, it's little red lines stared back at me saying, "Let's go home. There's nothing more to be done here. I'm tired. It will all be over when we wake up."

It was over when I woke up and I stopped by in the morning to see his wife. She sat against the side of the house, watching her daughter wash her face at the spigot. "Ama, have you eaten?" I asked her.

"Just a little milk tea. He's gone and I didn't go with him."

I hugged her while she stayed stiff in my arms. I knew it wasn't super appropriate, but I couldn't help myself. I went to clinic for two hours before she called, asking for Debbie and I to come to her house since they were moving the body. I walked down the street, not knowing what to expect since this family was Christian. I'd seen the marigold cremations at Pashnupatinath and another under the bridge a short walk from Aunties. I assumed his body would be cremated to release the soul, but with some sort of Nepali Christian flair.

Instead, I walked into a room with a wooden coffin. The box was painted white and had a red cross brushed on either side. It tapered at the top and the lid was partially opened. Two rings of marigolds encircled the lid but the fragrance in the room came from the wild roses that everyone held. "Sister," I heard Lal's daughter say. She handed me a bunch of wild roses and I walked toward the coffin. I was stoic until I looked inside and saw his face. There was cotton stuffed into his nostrils and his eyes were closed. He had a white cloth covering his body and his head floated in roses.

I used to be an artist. I'd walk to the Monkey Temple and paint the mountains. I sculpted animals too. I made a life sized, spring-loaded elephant for the king; when it was wheeled in front of him, it's trunk swung up in a salute. Now I don't do anything. I can't draw or sculpt anything for you because of my asthma. When I get better, I will make you the most beautiful drawing of an elephant. I would make you something beautiful now, if my life wasn't over.

Then the tears came. The women wailed and some fell over. I sat on the floor and held a grandmother as she moaned at the sky for her baby. "Babu! Babu!"

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It was time to go and Lal's son and nephew took the head of the coffin while a few other men helped. It was carried out to the road and we walked in a procession down to the dry riverbed. A line of us, like ants carrying a huge piece of bounty back to the hill; we crossed the riverbed and landed on a small ridge, just large enough to fit a six-foot-deep hole. A few men jumped inside and others handed the box down to them. On top of the box, they placed his folded comforter and a suitcase of his things.

A pastor stood at the head of the grave, next to a woman with a stick-cross ringed with marigolds. He led the circle of people in Nepali versions of Christian songs while I sat on the edge of the ridge by myself. When they were done, another daughter called me over and put a scoop of dirt into my hands. "Throw it in," she instructed.

Six Buddhist monks and their teacher were back at the house. Lal's son and nephew are Buddhist and another ceremony was setup to honor him in that way as well. The monks read chants in Lama language, from old books, while their teacher painted incense sticks with creamy fat and burned them. A foam mat was laid next to the setup and Debbie and I sat there, cross-legged with our hands in prayer and meditated on the chant. A daughter served milk tea around the patio and in the various rooms of the house. The Christians gathered by the goat and chicken house.

It was late and we needed to get back to work. We excused ourselves and left. The afternoon was busy, but wonderful as random bursts of laughter kept breaking out between our patients. I found myself laughing and enjoying the time at the clinic and my brain occasionally wondered if that was okay to do. The evening brought the Shivaratri festival, with a bonfire and folksongs in front of the house. Auntie kept us all laughing by stealing wood from the neighbors and when that ran out, she threw dead thorn bushes on top.

I didn't realize it until just now, but I have been in need of a good storm. The world outside is matching the way that I feel. So much beauty. So much tragedy. This is the life that we all share together. My hair is wet and I cannot sleep. And I love it all.

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Annoyed or Grateful?

Annoyed or Grateful?

Andrew Schlabach left today. I thought he was coming back for one more visit before flying back to the States, but as I hugged him goodbye, he said that he's probably not.

I'm thinking about this as I needle my side-lying patient in the sun. Flies are landing on his exposed hip and I insert a seven inch needle into huantiao, "the jumping circle." I move the needle gently until he does jump and then move on to the next point. The flies are irritating me. For days, I have been trying to figure out how flies make the world a better place. I haven't come up with anything yet, but I'm sure they feed something I like. In a conversation last night, Debbie said she couldn't tell if she was annoyed or grateful about the wind as she meditated. I replied, "Not being able to decide if I'm annoyed or grateful describes so much of my experience here." We laughed. As I shoo the flies from this man's legs, I remember it and smile.

We had the conversation last night around the dinner table with Andrew. We were able to ask about our cases and get input from him. He knows this place so well, from years of researching his patients in Nepal. It's a blessing when he can quickly shine a light on a troubling presentation or help us navigate the politics around the local health post. It's changing the way I practice to have his instruction in the various classes that we've attended here: orthopedics, infectious disease, diagnostics, measurements of efficacy, case management and the progression of patients.

rest
rest

I turn back to this man and cover him with a light towel so that the flies won't bother him while he rests. I think about how far I've come in the past six weeks as I walk towards my next patient. While I was treating the other man's hip pain, Milan built a fire at the teahouse next door and boiled some water. He is just walking into the yard with it. We pour some into a bowl and I swirl a bar of soap around in it. I don some gloves and sit in front of the old man in front of me. I wash the wound between his fourth and fifth toe with the water. It's hurting him, so Ritesh and I use a cotton applicator to put some lidocaine into the deep, centimeter wide crevice. The wound is filled with some dried flower that a friend recommended for flesh generation. It's black and hard to remove from the two-month old hole.

tb
tb

I hear Andrew's voice in my head: If you've got a pus-filled wound that isn't healing but there's no inflammation around it, think about skin tuberculosis. Refer the patient for a Mantoux test.

Every time I see a case that has the potential for TB, I try to talk myself out of it. Especially this extra-pulmonary TB, which is something that isn't a big part of my reality back home. Yet, how could I be so surprised or doubtful? One in three people in the world have tuberculosis. Considering that the rates of TB in the US and other developed countries is so low, it's got to be pretty high in other places. India had the highest total number of TB cases in 2010 and we aren't far from there. In world medicine, it's considered a pandemic, with 1.5 million deaths per year, mostly in developing countries.

The diagnostic tests we've got aren't great, and I mean we as in The World And Those Of Us In It. The sputum test is definitive for pulmonary TB, but it's not always an accurate test for this extra-pulmonary stuff. When I suspected spinal TB in a patient last week, I sent her in for the Mantoux skin test and she had a positive reading, yet that test is highly inaccurate. She is unlikely to have a positive skin test, especially without a respiratory infection. I had to send her for a spinal biopsy in Kathmandu to get a more accurate result. The WHO and United States are currently subsidizing a new, fast-acting test, but it's yet to be released and who knows when it will be (no pun intended.)

Right now, the five of us on our healthcare team are looking at a handful of cases that look like extra-pulmonary TB and trying to navigate the governmental system and politics here that go with this. After the skin test, we've got to run a sputum culture before the local Health Post will write a government letter to enroll the patient in the WHO Directly Observed Treatment Short-Course (DOTS) program. We don't treat TB at our clinic. Patients must be quarantined and observed for the strong antibiotic regimen. However, getting them to that place is something we're finding hard to navigate....

I write a referral letter for my patient to take to the Health Post in the village where he lives. I pack the wound with clean gauge and tell him that he can't be walking around in flip flops anymore. I give him instructions on how to wash and care for the wound until Monday, when he can bring me the unreliable results of the test. Unfortunately, I've only got 3.5 weeks left in Nepal. If his skin test is positive, will I have time to go through the process with him? Who will manage his case when we're gone? Much of the problem with healthcare here has to do with a shortage of doctors - but so much of it also has to do with the inability of the doctors who are here to take responsibility for a case.

ARP can't use the community center in Bhimphedi from March until September so these people will go for six months without our clinic. Andrew and Tsering have bought land down the road but they are waiting for the Nepalese government to approve their proposal to build on that land. If they can get it, they can setup a year-round clinic here. A clinic staffed with health care providers who are being trained to take responsibility; to take charge of a patient's case and follow it through to the end. I am sad to see Andrew go today, but I am so proud that I got to be a small part of the beautiful work he is doing here.

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Running With Needles

Running With Needles

Suddenly, he stood up in the chair and lurched forward. I was inserting needles at the vertex of his head and took a step back before I realized what was happening. I grabbed his left arm and his mother his right, but it didn't matter. He had a focused momentum that propelled him forward to jump off the two-foot high porch. He fell into a brusk walk through the yard, his mother running after him, and quickly exited the gate to the street. As he did this, I looked at Milan who shrugged and then made eye contact with Ritesh, who was working at the reception table. The two of us let out a giggle.

"What the hell?" I raised an eyebrow in confusion.

"I need to pee! I need to pee!" Milan shouted as he laughed and washed his face under the water bucket.

Twenty-four year old Anil was my last patient before lunch. Three translators were hanging out and waiting for me to finish up with him so we could go eat. Since he'd just run down the street with acupuncture needles in, I figured it would be a while until we would get to go home and have some dal bhat.

The morning had been busy and I was feeling pretty tired. I started taking my supplies back into the clinic, where Anil had been too fearful to be treated. He suffers from autism and is pretty high on the spectrum. He can't speak and his hands are almost permanently formed into fists. When he gets scared, he bites his hands. While I worked with him, massaging his arms and relaxing his fingers, I exposed a number of large wounds there.

His mother rarely takes him on the bus because he gets far too scared and can get very violent. I saw from his file that he had lashed out at some of his previous treatments, breaking some items and biting himself at the clinic. Even so, his parents kept bringing him because after he started acupuncture last September, he started trying to speak for the first time in his twenty-four years on Earth. In December, the traveling got to be too hard and they said they would discontinue treatment. Today was the first time that Anil has been to the clinic to see this set of doctors that I'm with.

As I touched Anil, I kept contact with his eyes, whether or not he would make eye contact with me. Emotions moved across his face like erratic weather patterns and I tried to stay with him. I was checking in to see if it would be safe enough to use needles with him.

"Anil, I'm so proud of you for riding the bus today."

Smile. Laugh and head bounce. Attention out to the street. Fear. Big eyes, something scary out there.

"Anil, here's a tickle," as I pressed into his medial elbow and palm and slowly stretched his arm.

Eyes back to me. Smile. Recognition of safety.

I looked at his mother. She was smiling at him and trying to help me keep his attention. My translator entertained him while I put eight needles into his scalp and after the last one was inserted, he ran off.

After I had packed my things, I wandered out to the street and started walking the way that they'd gone. I saw Anil and his mother walking back and I went to meet him. I saw his right hand in a fist again and I picked it up, softly opened his fingers and touched his palm to mine. His mother held his other hand and we walked him back to the clinic. No other patients were inside and I sat him down and removed everything from his scalp.

Anil's mother thanked us and walked to the bus with her son. She was courageous enough to try it again for the trip home. The translators and I headed home, where we ate and were surprised to share a birthday cake for "Andrew Sir." The chocolate and whipped cream had been motorbiked in from Hetauda by the amazing Tsering Sherpa. I am constantly in awe of all he does for our team and as the director of Good Health Nepal - the NGO that we are partnered with here.

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Ringing Bells

Ringing Bells

Okay, Uncle.  I'm going to take your case. For real this time. I think I am the best you have. And while I'm sorry for you that I am not a better person and a better healer, I'll do it. G.K. Chesterton said, "If a thing is worth doing, it is worth doing badly." I think that I might understand what that means. You're worth the risk of doing it badly.

I've brought you paper and pencils and even some charcoal today. I know you want to draw and paint and sculpt. I know you want to be the young man that you once were and I know that's impossible. I think that I will feel the same way when I come to the end of my life. But, I have hope that you can be the man that you are today, for however long that lasts. And I wish that when I reach the point where you are, somebody is willing to witness for me, to sit with me, to love me unconditionally and to make it a little less scary.

"Do you have something for my cough?"

You ask me this every time I visit and every time I tell you, I have something for your sleep. It will help a bit with the cough too, but it's not made for the cough.

I've answered this way from the beginning, from the point at which I took your case on. I've answered this way because you refused to go back to the hospital when we asked you to. But, in the beginning, I didn't know that the hospital told you there was nothing else they could do. In the beginning, I didn't know what the hospitals were like here. All I knew is that I couldn't be responsible for your case: Late stage emphysema, respiratory failure and an inability to breathe without an oxygen tank. I thought that there was a great answer out there for you. I thought you had access to better technology, like the kind of technology my family back home can access. I thought there would be somebody better for you than me. I couldn't offer you the wisp of smoke that is me when there was some solid, tangible foundation that I was imagining being available to you.

I am not good enough.

There's that thought again. It haunts me and in the last couple of weeks, it has hurt us both. I hear you saying it too: We both believe that about ourselves. How did that happen to us? I know it's not true about you so there is a good chance it's not true about me either.

What are we doing together, Uncle? Am I a healer? A doctor? Because right now, I don't know what that means. I sit with you on your bed. I hold your hand when you let me. I listen to your stories. Sometimes I give you acupuncture, sometimes codeine, but nothing I do lets you get off the tank and walk outside. Nothing I do will reverse the emphysema that is killing you. I can't get you out on your land, where you can watch your beautiful wife watering the bright green saag in the sunshine.

I said I couldn't help you because I've been trying to communicate to you that I couldn't take your case. I said that all I can do is monitor your vital signs because I haven't wanted the responsibility of your death. I haven't wanted to risk that responsibility for anyone on my team. This is what we decided that first night when we came to your emergency call. We decided that we did not have the resources to help you fight such an advanced disease. It's true. I have nothing in my toolbox to cure emphysema. So I've been clear with you about that from the beginning, even when it took so long for me to explain your disease to you because nobody ever did.

Today, I brought another practitioner with me. She was seeing you for the second time and she had her boundaries straight. When you asked for cough medicine, she told the interpreter, "Make sure he understands that we do not have medicine for his cough. We never will. He needs to understand that we will not ever be giving him a medicine for his cough."

Well, Uncle, that was just enough of a mirror to help me understand that something here just isn't quite right. So, I decided to go pray for some answers. I walked out to the cliff by the soccer field and found a temple. I rang the bell and walked around it clockwise. I rang it again and walked the circle again. I did this eight times, asking for help, ringing it louder and louder. Did anybody hear me?

I sat on the edge of the cliff, waiting for an answer. The mountains were covered in mist and I saw that any answer I was getting was just about as clear. A fog of confusion came over me, I started writing in my journal: Why can't we give him medicine for his cough? Am I a Western practitioner or a Chinese medicine physician?

Well Uncle, I've been confused here for a while. I've been checking blood pressures and looking for tuberculosis and trying to make sure that really sick people can get help if they need it. And because this is a bit different than I'm used to, I've been forgetting about the kind of doctor that I am. I've forgotten that I practice natural medicine and that I honor the body as an inherent part of this constantly changing ecosystem. I've said that here, in Nepal, I have to use medicine that works. What does "works" mean? What works for you, Uncle?

What is death, Uncle? How do we know when it's happening? At what point do we stop providing care? What is hope? Does hope have to disappear so that we can die? What do I do for you now? Am I an observer? Am I good enough to be with you right now? Do I have the courage to look into your eyes? Do I have the courage to stand up and take your case when no one else has done it or will do it?

I turned to go back home with nothing but questions in my book. No answer from a god or goddess. No answer from the earth or the mountains. Just a verification of my aloneness, of my lack of help. On the path, a woman held a carrot up while a dog jumped at it. He jumped and jumped and every time she raised the carrot above his reach. She had no intention of giving it to him but I could see that he trusted that she would. He even believed that he might like that carrot, perhaps imagining it to be a piece of meat. There's your answer, I heard in my brain.

I sat down on a pile of rocks. I feel so much pain and I don't know whose pain it is. Yours? Mine? The dogs? What do I do? I know I have everything I need for the answers. I am the one who gets in my own way.

Yesterday, our director told us, "I can't make you care. You either care or you don't. You can be the kind of practitioner that just pops in needles and charges for it as long as the patient will come back. You'll make money that way. Or, you can be the kind of practitioner who says, 'When you're under my care, I DO CARE. I care about you and I'm going to manage your case."

Well, Uncle, I do care about you. I really do. And I don't want to be holding carrots for you to jump at. I've got herbs at the clinic that I can give you for your cough. They won't make it go away and they won't cure your emphysema. But, when I give them to you, I think you will know that I care.

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Home to Bhimphedi and Momos!!

Home to Bhimphedi and Momos!!

I woke yesterday at 7am. Terry and Ritesh were up washing their faces. We'd already missed the sunset but we walked up to "Taichi Hill" to see if we could see any of the mountains of the Himal. Terry pointed a white tip out to me and named a peak that I'd never heard of. Otherwise, she said that we couldn't see much.

I did a few minutes of standing meditation and then ran through the Yang long form. I thought about my teacher, PikShan Ko. Though I was standing on a hill with a beautiful view of the surrounding mountain range, I had to imagine that I was in his garden. I have a hard time orienting myself without his osmanthus to my left, the peony directly in front of me and the witch hazel and cherry trees to the right.

Suman's mother brought us a breakfast of pressure-cooked garbanzo beans, fried roti and a hard boiled egg. We sat next to each other on the small bench outside our bedrooms and ate. I always peel my egg and break it apart in my garbanzo beans. I noticed that Terry and Ritesh just ate their egg whole. We grabbed our things and began the walk to the clinic.

I had seen pictures of the clinic on the ARP site but it looked different to me now that we were here. I could see it clustered in with a few other small buildings as we approached from the road. Once inside, I saw that it had two front rooms and a larger back room. John Timm, a volunteer from the earliest camp of the year, had put plastic over the windows to try and keep the back room warmer. There were blue handprints and trees painted on the walls back there and a few things had been written next to them.

I looked closer: People Change Feelings Change Things Change. Underneath the handprints, someone had written in a black marker, To Make a Difference in Someone's Life You Don't Have To Be Brilliant Rich Beautiful or Perfect You Just Have To Care Enough And Be There. Another set of blue hands with a strip of blue paint under it. Nepali script ran across the top of the strip in black marker. Underneath, the marker declared in English: You Are Not Alone.

I tried the light but it didn't work. Terry and Ritesh were setting the chairs up outside. I set my bag down in the small front room that served as a medicinary. I grabbed a clean stainless steel tray and started selecting needles, cotton balls, hand sanitizer. I grabbed a moxa stick and a box of matches, threw on a white coat with my name tag and went to join them. A woman with back pain handed me her booklet of patient notes and I took her inside to the small front room with a massage table. I inserted needles into her back, legs, arms and scalp.

An older man on crutches came into the room and laid down on the bed. He had deep scars over his hip that were attached to the bone from a surgery to remove cysts there. He'd been getting treated by our group since September and was showing a lot of improvement in the range of motion in his hip. I wished that I had more time to spend with him and the ability to look over his case in greater detail. It looked like a practitioner in the camp before me had done a case study on him and she put a lot of time into accurately charting all of her objective data.

We treated more back pain, knee pain and stomach pain and then it was time to walk back up for lunch. We ate our dal bhat and returned to the clinic to find a few adults and a number of teenagers who had just gotten out of school. Almost everyone was there to be treated for a cough. Terry and I took turns with my thermometer, pulse oximeter and stethoscope. We listened for clear lungs and made sure that everyone with a low-grade fever knew what to watch for. We ladled loquat syrup into their mouths using the bottle cap and handed out paper envelopes of Chinese herbs. The young girls giggled at the acupuncture needles and the boys watched intently as we inserted them into their hands.

fire
fire

Twenty-patients later, we were invited by one of the boys to go to his grandmother's house and have a tikka. The full-moon was coming up and it's a special month that ends in the Holi color festival. We followed him home and took our shoes off and came inside the house. The family was sitting against the walls of the room eating dal bhat. Grandma was cooking over the small hearth and the room was filling with smoke as they stoked the fire. The three of us sat under the window and tried to get a breath of air as we could.

A woman came around with a thick mixture of rice powder and red paint. She slathered a dab on Terry's head, put a yellow dot on top and then stuck a marigold in Terry's hair. She did the same thing to me. They gave us a small dish with two slices of banana, a couple of wedges of tangerine, a sliver of coconut and an inch-long piece of fresh sugarcane. Shortly afterwards, three plates of dal bhat were passed to us with dried rice, garbanzo beans and fried roti.

"Raksi?" the old woman asked?

Terry answered, "A little bit," and two 8-ounce cups were filled to the brim.

I tasted the distilled corn alcohol and it made me cringe. Somehow, I had to find a way to swallow it down. A few minutes later, two mugs of hot tea were set in front of us and I followed Terry's lead as she mixed the raksi into the tastier decoction. As soon as we were done, we made our way out of the smoke-filled room back onto the porch. My eyes were burning and I searched around for my headlamp. I got my shoes on and we hiked up to Suman's house. His parents were there with food waiting for us. We sat down on the floor and ate another plate of dal bhat.

As we walked back to our room, my stomach was far too full. I hadn't felt hungry at any point in the night but out of politeness, I'd eaten all the food that was offered. We sat down on the bed and started watching a movie on my ipad. Twenty minutes into the movie, Suman's mom shuffled his little sister, Rista, into the room. She had a sprained ankle and Ama wanted her to be treated.

We set her up on the extra bed and I put some needles in. Ritesh found some herbal patches and Terry dug out a sheet of ibuprofen caps. As we were doing this, it started hailing outside and I went to see the commotion. The wind was whipping brutally at the scarce sprinkling of trees where we stayed. I came back inside and finished the treatment. Ama and Rista stayed and talked with us for a while. We started the movie back up when they left but the wind started blowing the windows and door open and Ritesh scared us with talk about demons coming in.

I woke up with a stomach bug. I managed to pack my bag and get it on top of the bus before it left at 7am. Ritesh and I took the three-hour walk back to Bhimphedi, getting in around 11. I tossed my things on the floor near my bed, unpacked my sleeping bag and crawled inside for an hour. I woke up and tried to drink a little water. I took a cold sponge bath and changed my clothes. I grabbed my lab coat and headed over to the Bhimphedi clinic to treat patients for the afternoon.

When I got to the clinic, I saw an older man on crutches making his way around the building next to us. I see this man everyday. He barely touches the toes of his left foot to the ground and his leg is atrophied. His clothes are dirty and his crutches look too small for him, they are making his back look humped. Milan walked over to the barbed wire fence with me and I shouted at the man to come over. I asked him if he would come to the clinic and let me treat him. He told me that he is hopeless, untreatable, not worth it.

I talked with this man for 20 minutes, making one of my regular patients wait. He told me that he is 60 years old and that he fell through a door sixteen years ago when the power went out one night. He broke his ankle and because he couldn't afford to go get it set, he ended up crippled. He fell a short time after this and broke his hip. They feed him a lunchtime meal at the army barracks. He told me again that he is hopeless and old and will die soon. I told him that I see him everyday and I will continue to bother him until he comes through the gate for some treatment.

I treated a few patients and then walked to Uncle Lal's house to check his vitals. (I wrote about Lal a couple of weeks back on the ARP blog: http://www.acupuncturereliefproject.org/news-blog/227-mirrors) His pulse oxygen was low and I recommended to him that it might be time to go to the hospital if he wants some morphine to help ease his discomfort. He refused the hospital again and I told him to call if he needs somebody to come and sit with him.

momos
momos

At home, Debbie and Tiffany were rolling buffalo momos with Auntie. We always have dal bhat here and so having momos is a huge treat. They are very similar to Chinese steamed potstickers and served with a spicy tomato sauce. Andrew was back from his trip with his dad, so I was excited that we get to spend some more time talking about cases with him. We all had dinner together and did just that. Tomorrow, after work, we will present summaries for our potential case studies.

I have three patient cases that I need to write up for the team to look at....but I am slow to get there. I can't stop writing!!

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Getting to Kogate

Getting to Kogate

"Namaste." She puts her hands together at her heart as we pass each other on the road. It's the same word but very different than the ending to my Portland yoga class. It's also a bit different than the word and gesture spoken in Bhimphedi, where the children clap their hands together, shout "Namaste!" and laugh. Many of the younger children are made to do this by their parents, or grandparents, when we pass by. Here, on the road to Kogate, this woman smiles sincerely, pyramiding her hands three times for each one of us. She smiles and I smile back.

I have my heavy hiking boots on but I'm only carrying a small bag with filtered water, gloves, a headlamp, my camera, a few rupees and some hand sanitizer. My bigger bag, with everything I need to stay two nights in Kogate, is atop the big bus called The Himal Tiger. Terry's bag is riding with mine, but Ritesh has the few things that he needs on his back. It takes about three and a half hours to hike up to the village and if we don't take a break, we'll beat the bus.

We start talking about kids and it turns to babies and eventually I start on the long story of my labor with Jasper. I don't forget any of the minor details: the grilled cheese sandwich I vomited, watching my favorite surfing movie, In Gods Hands, or the painter's plastic-lined cattle bathing tub that I eventually gave birth in. By the time I've finished the story, we have cleared the ridge and can see the parked bus with our bags resting on top. It beat us because we stopped to share a 65% dark chocolate bar (my last one and we still have four weeks!) and a lychee drink that Ritesh got in town.

I've heard a lot about Kogate from Tiffany, Maggie and Debbie when they returned from their service there. Each week, one of us goes up to the village with a translator/assistant. We work at the Bhimphedi clinic on Monday and then walk or ride up to Kogate after lunch. Tuesday, we work at the small clinic in Kogate and then come back down on Wednesday morning and treat patients in Bhimphedi that afternoon.

house
house

One of our translators, who is also apprenticing in acupuncture, Suman Magar, lives with his family in Kogate. They have a beautiful, two-story mud home where they share meals with us. We sleep in a second mud and rock building that has two bedrooms, a small eating area and a storage area upstairs. One of these bedrooms is Suman's, but the translators rotate with the practitioners each week and he has already come up to work. It's Ritesh who comes with us this time.

Terry and I put our things in Suman's room and each of us picks a bed. It's odd that he's down in Bhimphedi working and we are here with his family, staying in his room. The walls are covered with the Kathmandu Times, an English newspaper. Terry points to an article on one of the pages about a Nepali man drowning in a river near our home in Portland. "How weird is that?" she asks.

I find a pair of flip flops on the porch that I can wear so that I don't have to tie the laces on my heavy boots each time I go in or out of a doorway here. I sit on a bench on the porch and watch Terry and Ritesh wash their faces with cold water at the spigot across from our doorway. Suman's father comes out. "Namaste!" he says, as their two black dogs wrestle near his legs.

We are invited into their home for dinner. The floor is pressed mud and there is a small square in the corner that was shaped into the floor and wall to serve as the hearth. Suman's mother stokes a tiny fire inside and heats water over it. She sets three metal plates on the floor, each plate is sectioned into four parts. She heaps rice into the larger area and then puts saag (greens) into one section, aloo (roasted potatoes) into the second section and a cucumber pickle into the third. We are sitting together on a mat at the wall and she sets a plate in front of each of us. She returns with a small bowl of dal (lentil soup). We pour the soup over the rice and then heap each bit of vegetable on top and mix it all together. Terry and I eat ours with a spoon. The family watches us while we eat and Suman's mother brings each item over and asks if we'd like more.

"Bhayou," Terry and I say. We're finished. Ritesh motions for more saag. We finish and bring our dishes towards the door and put them in the wash bin. We don't linger or talk too much since the family is waiting for us to finish before they will start eating. We go back to our bedrooms, fill our bottles with the tato pani (hot water) that they've left for us and head off to bed.

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Sunday Moonlight

Sunday Moonlight

I'm standing here tonight, brushing my teeth under the almost-full moon. There is a shared sink on the road. It makes me think of a spigot in a campground. This sink is used for everything: washing dishes, laundry, weekly hair treatments and most of our hygiene. All of the neighbors on the street use it and any passerby who feels like washing his face. We fill our tea kettle here and it's where we refill the shower drum. It's made of a concrete pad with a small drain in it and some concrete edging to make it into a little square. An iron pipe comes from the ground, ending in a faucet about three feet from the pad. A small piece of hose hangs down to direct the flow.

Part of me is turned off by the large pool of stagnating water that the sink drains into. It's where we spit our toothpaste out and where all of the animals drink from. Another part of me thinks about how beautiful it is that all of us, ARP volunteers and neighbors, are out here in the cold, brushing our teeth together. The sky tonight is cloudy and the stars can't be seen, but there is enough of a break for the big chunk of white moon to shine down on us. I don't go out into the moonlight enough at home. I brush my teeth in my bathroom, in socks and pajamas. In the US, I am too comfortable to spend this beautiful time underneath the night sky. In the US, a lot of things are different.

I'm thinking over my day and I am exhausted and relieved. I met my 22-year old patient at the local health depot where her Mantoux skin test showed a positive result for tuberculosis. With a high erythrocyte sedimentation rate (ESR) and total lymphocyte count (TLC), I was able to send her on to a hospital in Kathmandu for a spinal biopsy. The skin test is not a conclusive result that she has spinal tuberculosis, but it is now a possibility. A treatable possibility. The treatment is awful, much like chemotherapy, but it is treatment and she would have a chance at living a normal life afterwards.

When the government official measured the swollen red mark on her arm and pronounced a positive result, Ranjana and I smiled at each other. In the back of my mind I thought: How odd is it that we are happy that she may have spinal tuberculosis? I felt a pang of guilt at that, but compared to the other things on the list, it would give her the best outcome. Ankylosing spondylitis, cancer, multiple sclerosis...these are all diseases that are managed. Not cured. They are diseases for life. So we smiled and hugged each other with hope at a positive TB test.

Writing a referral note for her took an hour, as we had to get our letterhead from the clinic, type it out and then walk to the other side of town to have it printed up at one of the shops. She and her father met us. It took them less than an hour to pack all of their things so that they could skip town and head back towards the city hospitals. I was sad to see her go, particularly because it was the first time I'd seen her so happy and hopeful since I'd met her. I had her write down her email for me, though I knew that it would be impossible for us to write since neither of us speaks the other language.

Debbie and I headed back and grabbed our water bottles. Milan, our translator, headed out with us, to cross the scary metal bridge on the way to Kogate. Instead of heading left at the other side, we veered right. We decided to go see the village of Suping, a town only thirty minutes away. Though Milan has lived here his whole life, he's never ventured up into those hills. We arrived to find some mud homes and a large group of goats tended by a sleeping dog. Laundry was hung out near the street, as always, and Debbie pointed out a beautiful banana flower.

As we made our way through the simple houses and appreciated the clean air, we heard a boy calling to us. "Hello!! Hello!! What is your name?!" He was thirteen years old and excited to have some Westerners to practice his English with. We invited him to walk with us and he showed us the hills and terraces near his home. We watched a wedding party cross a deep ravine near us and took pictures of them on the suspension bridge. The cold was too much and we returned the way we came. The boy invited us for some milk tea at his house and his mother was kind enough to serve us masala on their porch. We sat on mudas and the boy told us about his little puppy and how he hopes to save enough money to take her to Hetauda and learn how to train her.

"She is so naughty! She bites the cows. But, she doesn't bite me. I feed her little bits of my food and she is very nice to me."

We said our goodbyes and made our way back to Bhimphedi. Auntie was here cooking dal bhat when we returned and we ate together with the team. I snuck a big spoonful of the chocolate hazelnut butter that's under my bed, virtually all I have left from the large duffle of snacks I brought. In the morning, I'll work at the clinic and leave for Kogate in the afternoon. I'll stay there for two nights to work in the clinic there and return Wednesday. I am excited to go but sad to leave my friends and patients here for two full days....

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Seventy Two Hours

Seventy Two Hours

I load an acupuncture needle into a small tube and touch the plastic to her skin. I haven't even inserted the needle yet and she starts sobbing into the head cradle of the massage chair.

"I'm scared." The interpreter translates.

"I know," I say back. "Are you sure that you want to be needled? We can just do the moxa."

"Yes, I want the acupuncture. I want to get better." I tap the needle in and don't bother manipulating it. I know she can't handle anymore sensation than this without starting to scream.

I would like her to get better too. It's her first treatment and we have no idea what's wrong. This 22-year old woman showed up with a thick packet full of medical records. She requested a female translator and Urmila quickly volunteered. We helped her disrobe, cover her breasts with a sarong and sit into the massage chair. This was only possible because we were working through our lunch and so we had the privacy of an empty room.

She told me her story as I leafed through the medical records. About a year an a half ago, she got a high fever that turned into an excruciating headache with back pain, nausea, vomiting and photosensitivity. She went into the hospital, where they found an erosive lesion at her T12 vertebra. They put her on high doses of multiple antibiotics and referred her to a spinal surgeon for an exam and radiography. The surgeon wrote that the lesion was most likely infective, possibly an eosinophilic granuloma. He reported that his findings showed that the lesion was not infecting the soft tissue around the vertebra and that it was most likely not malignant (the spine is the third most common place for metastasis, behind the lung and the liver.)

For the last year and a half, she has been put on a myriad of antibiotics and drugs and she has been scanned, poked and prodded as doctors have tried to find the answer to her illness. She carries her medical records with her to these various places, but she does not have any of her radiographic scans for me to look at. She tells me that she has incredible pain in her neck and back, but as I examine her, she is able to turn her head from side to side, only reporting dizziness when she laterally extends. Her right side is subjectively numb and weak in comparison to the left. I find that the deep tendon reflex at her patella is hyper-reflexive, meaning that the signals at that tendon are not getting to her brain for some reason.

I can't get a needle anywhere near her spine or on her back. I tap two 36-gauge needles into the skin near her occiput and she screams at both of them, while asking me to put them there. The full treatment ends with a needle in each hand, each foot and two at the back of the neck. We spend forty minutes with moxa down her spine and at a point on her leg to help rejuvenate her immune system. I don't know if her nervous system is hyper-responsive because of her illness or from the trauma of being tested and examined over and over again, by strangers, over the last 18 months.

We get her off the table and she gives us her records to bring home while the rest of the team is finishing lunch. I quickly go over them with the team of doctors while I inhale the warm dal bhat that Auntie gives me.

"What do you think it is?" the team lead asks me.

"Spinal tuberculosis. It's the only thing I can think of, but it's just a feeling. It's impractical. And it wouldn't make sense that they didn't test her for it yet. What else can we add to the differential?" I am confused as I go through the mass of paperwork. She's been looked at by a dozen doctors and during this whole time, they haven't listed any real diagnostic options. In the last month, they've decided to test her for lupus and autoimmune disease. I don't understand why there is no clear direction of diagnostic possibilities listed early on in the disease. It seems like these doctors have been blindly running tests but none of the tests adds up to anything we can understand and they haven't charted their thought process or plan.

We decide to send her to the local Health Post for a Mantoux test (to check for tuberculosis). It's a simple test that costs 50 rupees. I'm not sure why this wasn't done in the first place. In addition, we check her rheumatoid factor and erythrocyte sedimentation rate. I am worried about auto-immune conditions, especially Ankylosing spondylitis, since an earlier Camp found an undiagnosed instance of AS here a few months ago. Regardless, I am hoping for something infectious that is treatable. If she can be treated, she can go on with a relatively normal life. If she has an auto-immune condition, it can be managed but her prognosis will not look so great.

______ Four treatments later and I am still putting together the differential. The patient and her family are on their way to India right now, just passing through Bhimphedi. They are searching for answers for her illness and are not sure where they will go once they get to India, but they think they can find better doctors there.

I have asked her to stay for 10 days while we go over her case and try to put together some clear goals for the doctors she finds. I am treating her symptoms and she is getting some relief, but the bigger job is to offer her some direction around the kind of care that she needs. I find that the greatest thing I can give her right now is compassion and empathy. Though we rarely have the privacy that she would like, we are often able to treat her in a room full of only women and with a female translator. Three times now, I have simply held onto her while she cries into my dusty lab coat about her situation.

I worry about her when I am not at the clinic and I know I have taken too much of her pain onto myself. For now, I am waiting until we can have the Mantoux test read and get some idea of the direction that she needs to go. I have a feeling that this is spinal TB but feelings don't mean much in this arena. I've got to be objective about her case and make sure that I am able to provide her with some directions when she gets to the hospital.

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Nepal Times

Nepal Times

It's been twenty-three days since I arrived in Kathmandu and sixteen days since we opened the clinic in Bhimphedi again. I've been posting photos to Facebook, as the internet allows, so that my family knows I'm okay. I've been wanting to write some of my own blog posts but the work days are long and trying to fit in house calls, get laundry washed, do some exercise and occasionally talk with my kids hasn't left me a lot of time. I also needed to get a blog post to ARP so they could put it up on their site. As I'm writing this, the internet has been down for three days and I don't know when it will come back again so that I can post this. I have been keeping a journal about my experience here, but I will try to be better about blogging over the next five weeks that I'm here. Pictures are near impossible to post anywhere but Facebook (why is that?) so I'll try and keep TLH page updated with those as I  caan.

Hetauda
Hetauda

I'm writing this post on the porch where we eat before work. It's Monday for us, the start of a new week, and I'm due at clinic in an hour. Yesterday was our day "off" and Terry okayed Debbie and I to take a trip to Hetauda. This is a bit of a bigger town than we are staying in and we wanted to go there to try and find charcoal pencils for a patient we see on hospice. He has been asking for drawing tools since he is confined to his bed. One of the interpreters was kind enough to chaperone us and so after finishing the tasks that have to be done on our day off, we ventured out to the main road to catch the bus.

The bus was running on Nepali time (so it was 50 minutes late). We didn't know that there was a mela (like a state fair) in Hetauda until we got on the bus and as we ventured down the mountain road, we stopped frequently to pick up passengers. We were packed inside like sardines, I had my arm over Debbie's shoulders to try and give us some extra room as we squished against the windows. The kids piled up by the windshield and stacked themselves on each other. What is usually an hour bus ride took us almost two hours. When we arrived in the town, we were really excited to see a variety of shops and we were hopeful we could find some charcoal.

Laundry
Laundry

The town of Bhimphedi, where we are living, was once the end of the road coming in from India. Some of the folks who lived here would walk these goods into Kathmandu where they would sell them. Now, the road continues all the way there, though it is long and indirect and India is offering to build a new road that would get to the big city in a fraction of the time.

The electricity that comes to Bhimphedi from the dam (about two hours away) is more reliable than it is in Kathmandu. We have only had one power outage since we've been here. The ARP teams last year didn't have internet at Auntie's house, where we stay, but the interpreters found an old router and hooked it up in the bedroom. Though the internet goes out a lot and the router is slow, we are able to get online at least a couple of times a week. I can't upload photos to Flickr or Picasa, but I am able to upload them to Facebook if I set it up before I go to bed and let it upload while I'm sleeping.

Aunties house is four rooms with a hallway between them. She sleeps in one, Terry (our lead) sleeps in another and we use it for a meeting and teaching space and then the five of us split the other two rooms. Erin and I sleep on cots, Tiffany, Debbie and Maggie sleep on wooden beds with thin foam mattresses laid on top of them. We all sleep in our sleeping bags and try to organize our clothing and supplies under the beds or on the window sills. There is no heat in the house, but we've all learned to sleep in sweaters or down jackets. I wear my scarf and sometimes my hat to bed and I find it pretty comfortable. There is a small back yard where Auntie cooks. She makes everything in pressure cookers on a camp-style stove and we boil water in a plug-in kettle. There is a small fridge out there, though I've never looked inside. The eggs and milk are kept in a curio cabinet - I think the milk is raw, it curdles a bit on top but never goes bad. There is a table by the kitchen where the translators eat. There is a small brick structure with two doors and on one side is a squat toilet and on the other is a new shower. There is a large container of water on top of the structure that we have to haul into the front yard and fill up from the main, shared faucet. Gravity pulls the water down and through a low-pressure water heater so we can take a very low-pressure shower. It is heated by a propane tank that is a little fussy but I've learned how to get it between 39 and 43 degrees Celsius and that seems to work out well. We are careful not to take many showers, or to stay in the shower too long because filling the tank can be a huge operation.

The clinic is about ten minutes walk from Auntie's house. We have to be there by 8:30am to get setup and our first patients are scheduled at 9. We are working out of an old community center that the town has loaned to us for this purpose, from September until March. This is comprised of a building with two small, and pretty cold, rooms. We setup plastic yard chairs around the rooms with small foot stools. Each practitioner's area has two mudas to squat on, one for the doc and one for the medical assistant/translator. ARP gave us each a medical kit that we carry to work each day. This kit includes our stethoscope, otoscope, blood pressure cuff, glucose test kit, Babinski hammer, electrical stimulation machine, thermometer and various other medical supplies. The clinic itself is where we keep our needles, herbs, medications, bandages and clean field materials.

We are setup to see four patients an hour, though the clinic has been unusually slow since we've been here. We have been seeing 10-15 patients a day, rather than 20-25 patients. Much of this is due to the fighting over the ratification of the constitution. This has caused a number of outbreaks in Kathmandu and the strikes that have followed have shut down the busses, which prohibits a number of people from reaching us. Most patients who are coming to the clinic right now are walking 15 minutes to four hours to get to us. This is ironic, considering that majority of our patients suffer from debilitating knee and back pain, due to over-stressing these load bearing joints through their daily work.

Patient
Patient

Unlike Portland State University, where I work on a group acupuncture shift - providing acupuncture treatments, ARP runs a primary care clinic. This means that for each patient, we need to be monitoring their vitals, checking for red flags and coordinating care for them. Our Director, Andrew Schlabach, has repeatedly talked to us about the difference between providing care and treatment. We provide care at this clinic, which does not always mean that we are providing acupuncture for our patients. We only do the latter if it is part of the care that they need for their overall health picture. The majority of our patients do not have primary care providers and it is our job to know what is available (in terms of medications, hospitals, etc) and get the patients the treatment that they need. We followup with our patients and monitor their progress and we communicate with their care providers to make sure that they are receiving the medications and treatment that is appropriate for them.

We work Monday through Saturday and sometimes have Sundays off. So far, we have had classes each Sunday we've been here, but this last Sunday was ours! So, Debbie and I trekked to Hetauda and checked out a little bit more of Nepal. Right now, she is in Kogate with our medical assistant/translator, Pawan Thapa. I am missing her, as we've become good friends and partners in crime, but she will be home on Wednesday afternoon. We are rotating through the Kogate clinic. One of us works Monday morning and then takes the 3 hour hike or bus ride up into the mountains. We work there until Wednesday morning and then come back down. Kogate has no electricity or internet, but the translators have cell phones and we can communicate with Terry and the team that way if we have an emergency while we are up there.

It sounds like Auntie is bringing breakfast out to the front porch, where the practitioners eat, so I've got to go, but I will try to be better about updates with our progress now that I've filled you in on the basic details!

Two Days on a Plane

Two Days on a Plane

I am above the clouds at the 34th hour after leaving Portland. I am told that soon I will be able to see the Himalayas below us and I'm excited to take a photograph through the two layers of greasy airplane glass. This plane from Guangzhou to Kathmandu is much smaller than the gigantic international flight my companions and I took into China. It shakes up here and I let my neck go a little limp as it sways side to side. I was getting the hang of taking the flights but still couldn't sleep on them. I was pretty delirious in China. Once we arrived on this flight, Maggie found three empty rows for she, Debbie and I to lay down in. I took a milliram of lorazepam, turned on my Passenger CD and finally fell asleep for two hours. The shaking woke me up and I felt relaxed and a little excited by it. Nobody here seems to mind as they walk up and down the aisles and speak softly to one another in Mandarin and other languages whose names I don't yet know. There is a monk in a grey robe who occasionally walks to the bathroom, and unlike the other passengers, he returns my goofy smile with one of his own. I decide that I like him well.

So far, flying above this sea of white is my favorite part of the trip. I imagined it as we flew over Mt. Hood and back then, those many hours ago, I hoped the the Himalayas woud look just as beautiful. When I landed in L.A., I found the international terminal was very under construction. I couldn't check in to China Southerrn because the kiosks wouldn't be open for another three hours. I walked back to find Debbie, who had just disembarked on her plane. We passed each other outside multiple times before we figured out that I was on the departures level and she was on the arrivals platform. Ha!

An old friend with a brand new baby came and picked us up and took us out to dinner. We ate steak and salmon and salads with rich dressings. I attempted a hot toddy for the cold I came down with the day before I left. It just made my throat more sore and the dehydration from the forced air a little worse. My friend brought us back to the airport, full and happy, and we were finally able to check-in through the international terminal. Inside, we found a myriad of fancy restaurants, including a caviar and champagne bar with glowing gold orbs over each seat. We forked out the $3 for water bottles and tissues and then went to plug in our electronics.

The flight disembarked late, a little after 11pm. We were hoping to sleep, but they kept the lights on and served beverages and shrimp with rice, rolls and potato salad. I covered my head with a blanket and tried to sleep before they finally turned off the lights around 2am. The whole plane slept, my companions next to me finding ways to adjust their bodies for at least 20 or 30 minutes before some random pain woke them up. They would shift and go back to sleep. I couldn't seem to find this rhythm with them so I stayed up, knitting, watching The Dawn of the Planet of the Apes. The gigantic plane landed with a thud so hard that I grabbed Debbie's arm before realizing that all was okay.

We wandered through the next International terminal, finding dim sum with warm black sesame soy milk. We paid in cash, at a questionable conversion rate and moved on to the most wonderful experience since the whole trip started: a long, drawn out time in front of the bathroom sink with a toothbrush. At least one part of me no longer stunk. Some yoga stretches at the gate with essential oils on my smelly feet got us aboard doing a little bit better after the 16 hour flight.

And now we're here, over the clouds, shaking and swaying, looking for signs of the mountains peeking through. We are twenty-five minutes from landing in the country that birthed the Buddha, the country that holds the largest mountain on Earth. There is a greatness I feel measured against when I think about that and I wonder how it will feel in my heart when my feet touch that soil and hear the languages that are sung around me.