An encouraging update from MCC friends, two years post-EQ:
As May draws to a close, and with it the season of spring catapulting us into summer, I find myself at a unique juncture. If it were a symphony, this would be one movement’s coda, lingering for a moment — drawing out a resolution incomplete by design — before flowing into the first notes and measures of the next.
It has been for me a season of fascinating juxtaposition — fresh beginnings nestled beside familiar patterns, the old and new coexisting alongside one another.
I’m now comfortably settled into my new home, thanks to the generous — not to mention exquisitely tasteful — help of my dear uncle John. I am so fortunate, and feel deeply cared for. This apartment *just happens* to be located directly across the street from the flat where I’d moved in as a medical student exactly a decade ago, and just a block down the street from the church and Tarrytown community I love so much. It’s a beautiful new space in a familiar old town, one to which I have longed to return. I’m thankful to be home.
I’ve also re-entered American medicine, in the form of an urgent care post in western Pennsylvania, the state in which I’ve maintained an active license. It’s a long commute to a short term assignment, but proved to be a true gift while my elusive New York medical license was filtering its way through the proverbial red tape. (Last week, it finally did!)
In another month, I look forward to joining the faculty of a tremendous new family medicine residency program at Phelps Memorial Hospital, one that’s affiliated with my alma mater, New York Medical College. Years ago, during my med student days, I would often go running along a ridge at the Rockefeller Estate Preserve that overlooks the hospital’s front gate. During those jogs, years before this residency program was formed — even before I had decided to pursue family medicine, and of course without any sense of that path that would ultimately led there — I’d say to myself, Someday I’m going to work at that hospital.
It has been a season, in short, of homecoming, the repotting of oft-transplanted roots in soil at once both familiar and fresh.
At the same time, it has been a season of near-perpetual motion, filled with the excitement and adventure of transition. That’s a familiar place for me, one that has always suited me well. Yet even as I write that, something stands out as different about this transition. For the first time in my life, I’m settling into a place and pursuit that doesn’t come with an expiration date. From grade school to grad school, from residency to fellowship to my years in Nepal, there was always a discrete timeframe, a specific endpoint in site after two, three or four years. What a different vantage point this long-range view now affords.
A new apartment in an old, familiar town; brand new NY plates on my road-worn Subaru; dear new friends meeting my dear old ones; a new job in the old and valued tradition of medical education; a new way to live out the same ancient calling to encounter our changeless God. And in the midst of it all, an important rounding out of one chapter, even as the first lines of the next are being written.
Speaking of which…
(And here you’ll have to excuse my being so thickly literal; I just couldn’t resist…)
The past few months have found me keeping up with a fair bit of writing on the side. For every word I post here, there must be close to a hundred that don’t make the cut, piling up on scraps of paper and collecting on looseleaf shuffled into countless notebooks and journals accumulated over the years. Now, having already made the transition from reader to writer through the course of this blog (and the profoundly formative fellowship year that preceded it), I’m cautiously exploring the critical next step — that of writer to author.
There, I said it.
We’ll see what comes of all this writing in time. If anything does evolve from the many piles of pages, you’ll eventually hear about it here. At the very least though, I plan to continue blogging now and again in the coming months, so stay tuned.
As a follow-up to my last post, I thought it might interest some of you to see a sampling of services and labs offered at Tansen, along with associated fees. This data was extracted from our most recent UMHT Price List (2015-2016):
|Service / Procedure||Fee, U.S. Dollars (approximate)|
|Outpatient visit, new patient||$0.70|
|Outpatient visit, returning patient||$0.60|
|Emergency Room visit||$3.50|
|Operation (minor to major)||$1.80 – $350.00|
|Surcharge for emergencies||$30.00 – $60.00|
|Admission fee (adult inpatient)||$5.00|
|Bed charge (general adult ward)||$4.50 per day|
|Extra fees: cardiac monitor||$1.00 per day|
|ICU-level care||$15.00 per day|
|Ventilator use & management||$42.00 per day|
|Normal vaginal delivery||$25.00|
|Amalgam dental filling||Starts at $3.60 per filling|
|Therapy (OT, PT, ST or neurorehab)||$2.30 (new visit, 30 min)|
|Lab / Diagnostic Test||Fee, U.S. Dollars (approximate)|
|CBC (complete blood count)||$4.50|
|HIV (quick test PCR)||$4.50|
|Cultures (urine, blood, body fluid)||$5.00 per culture|
|Sputum AFB (microscopy)||$0.65|
|Urinalysis with microscopy||$1.50|
|Lumbar puncture (procedure)||$14.00|
|bHCG (serum, quantitative)||$18.00|
If you’ve ever perused the price-list for services offered in an American medical clinic (or perhaps been shocked and appalled by the number of zeros at the end of your own hospital bill) then you might find these numbers surprisingly low.
While they may be relatively affordable compared to the costs associated with American medicine, they still represent a substantial burden for many of Nepal’s rural poor, who often struggle just to afford the four-dollar bus ticket that will bring them from villages a full day’s journey away.
In general, patients are asked to pay what they can for the care they receive. Fortunately, most of our patients are able to pay the full “fee-for-service” amounts like those noted above — fees that enable the hospital to cover most of the cost of providing care in Nepal. The MAF (Medical Assistance Fund) at Tansen, which I featured in my last post, is used only for direct free care, which accounts for roughly 5% of the hospital’s total patient charges.
The rationale behind asking even our poorest patients to contribute something, however minimal a token it may be, is that although paradoxical, it’s felt to actually encourage patient participation in their own care, fostering ownership of the role they each play in their healing. In light of the many-dimensioned aspects of poverty, it also provides an opportunity to empower our patients, affirming their dignity as people with agency and capability.
And that, I think, may be among the most valuable services we have to offer.
In a recent post, I alluded to the concept of multidimensional poverty when I shared the story of a grieving father, perceiving himself utterly disempowered to help his daughter get well. Perhaps you, like me, heard this man’s heart-cry and longed to solve it. However, in my previous post I did not jump there immediately, because merely throwing money at a complex and nuanced problem like systemic poverty doesn’t actually fix the deeper problem; worse, it can even create new ones.
That said, there is a very important role for partnering with organizations like Tansen Hospital, which depend to a large extent on donation funds in order to provide the services it does. (You may have noted that I avoid using this blog forum as a platform to reach out for donations on behalf of partner organizations; this post will be a rare exception.)
Unlike the majority of hospitals across Nepal, patients are never turned away from Tansen Hospital for inability to pay. Thus, a significant portion of Tansen’s care is provided at greatly reduced costs, or even entirely free, because of a reserve called the Medical Assistance Fund (MAF). In 2015 alone, the amount of free care at Tansen Hospital paid for by the MAF totaled $157,065 (USD), a sum that represents hundreds of patient stories.
One such story is that of Miya. Miya Sambu* was a young girl brought in by her family for treatment at Tansen Hospital one afternoon last September. She had previously been a happy, healthy nine-year old who attended the local village school with her three sisters, and lived with extended family in a remote village of Palpa — the same district in which Tansen is located.
On the morning of her hospitalization — a morning that would forever change the direction of her life — she and several friends were playing in a manual cement mixer they found near their home. (It may strike you as odd to think of small children using a piece of construction equipment as a jungle-gym; in Nepal that’s far from unusual.) Miya noticed the large cavernous structure in the back – the part that mixes clay, sand and gravel around to form cement – and thought it looked too tempting to pass up. She crawled inside, and her friends began to turn the handle, spinning the mixer with Miya inside. Suddenly, with a loud cry she was flung out. A group of village adults hurried over to find out what had happened, where they discovered her laying on the ground, unnaturally limp and hysterical with pain and fear. From there Miya endured a bumpy overland journey of several hours in a bus, eventually carried into our emergency room in her father’s arms, accompanied by a panicked group of family members.
On arrival at Tansen Hospital, Miya was found to have sustained facial lacerations, dental fractures, and a hyperextension fracture-dislocation of C3-4 with near-total quadraplegia. In
layman’s terms, her neck had been broken, leaving her paralyzed. Miya was admitted to the children’s orthopedic ward for further evaluation and management by our orthopedic and therapy teams, where she stayed for just over two months. She required a temporary feeding tube to help with nutrition during the first few weeks, while she worked intensively with our speech therapist, Sarah, re-learning how to swallow. Her hospital course was complicated by pneumonia, a consequence of weakened breathing & swallowing muscles and long weeks in a hospital bed, her head held rigidly immobile by a thick plastic neck-brace.
The journey that would ultimately link Miya’s story to Tansen Hospital actually began fifteen years earlier, when her family moved to Palpa from Jhapa in search of work. Jhapa is a district located along the Indian border of Nepal’s southeastern-most corner. They’d come in search of work for her father, who was eventually able to find a job in carpentry. However, the family has struggled for years to make ends meet on his irregular, weekly salary of 500 rupees (approximately $5). Her mother tends the home, occasionally taking on day labor jobs. Even so, virtually all of their income goes to rent and food for the family. They live in a simple mud home that they rent at a fee of 1000 rupees (about $10) per month. From records the family later provided, it was clear that school fees for all four girls were waived due to their extreme poverty. In addition to this, the family struggles under the weight of a debt of 150,000 rupees (about $1,500.00) incurred years earlier at another hospital, when Miya’s oldest sister was treated for severe meningitis.
The pastoral care team at Tansen Hospital does a tireless job working with patients in crisis, meeting each day with hundreds of patients who share stories like Miya’s. They see firsthand the multidimensional nature of poverty’s suffering – the lack of material goods and regular income; the poor standard of living that leads to disease; the social isolation that comes when you can’t afford to host your neighbors or reciprocate with house-gifts for friends who host you; the disempowerment, fear, hopelessness and despair that gradually creeps in over time, permeating deep within one’s being and sense of self. Such poverty is not fixed by money alone.
Our pastoral team met daily with Miya and her family during her hospitalization, spending hours at her bedside to provide prayer, encouragement, and presence. Over time, the team of doctors, nurses and staff got to know her and her family well. After reviewing their situation, a significant amount of charity care was allotted for Miya and her family to cover food and hospital costs during their stay. In this way, through spiritual support wedded to practical love, the Tansen team was able to share God’s love and healing in the midst of deep tragedy. After working with our therapy team for two months, she improved her swallowing function, regained some general movement on her left side, and was finally deemed ready for discharge back home to her village.
The road ahead of Miya is an arduous one, filled with dark days and a great deal of pain. Yet she left Tansen Hospital with the dignity-affirming care of a team of people present to her suffering. She left with the knowledge that her life and future are in the hands of a God who sees her and loves her. In the face of inexplicable tragedy, and in the midst of grief for which words fall woefully short, Tansen Hospital seeks to share this loving presence of Jesus by faithfully coming alongside those who suffer.
*Name changed for patient privacy
If you are interested in participating with the work being done at Tansen Hospital to bring healing and dignity to some of Nepal’s poorest members, prayerfully consider one of the routes below in order to donate to the Medical Assistance Fund:
FROM THE USA:
You can also give through the United Methodist Church. The full sum of money donated goes directly to Tansen, where it is then channeled into either MAF or capital items, if any are needed. Donations are tax deductible if given through this route.
Here’s an encouraging post from my friends the Dornons, especially for those of you following along with the border blockade crisis…
It has been a weekend for encouraging news! First, we heard on Friday that the main border crossing between Nepal and India (Birgunj – where 60% of goods cross over) was opened again. A day or two later some of the hardline protesters returned to close the border again but were chased away by the local people (especially the shop keepers!). All the barricades which had been built up there have been torn down. We pray that the entire border will re-open and remain that way! Hopefully supplies will start to come in and even though it will take awhile to catch up again, it should make a difference.
The other good news we literally just received. Many of you know that UMN has been in a dispute over the property where our headquarters is located in KTM. The case was waiting to be heard by the Supreme Court, but…
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“It was the best of times, it was the worst of times…”
Charles Dickens, A Tale of Two Cities
I’m writing this halfway through my week at D.A.R. (Debriefing and Renewal), a retreat sponsored by Mission Training International in Colorado Springs. It’s been a fantastic experience; I can’t recommend it highly enough for anyone making this sort of transition back. (Or forward, whatever you want to call it.)
There is something deeply affirming in the opportunity to share your story with others who have “been there” and can relate to various stresses of cross-cultural living – the relentless discomfort of being different, the vague uncertainty of political unrest, the ground-note of fear following a natural disaster. These are people who have lived it firsthand. They know that feeling of anger tightening in their chest over injustice and abuse run rampant. They have wept over the ravaging effects of poverty, disease and death that grievously burden our neighbors and friends.
These are folks who can also laugh with you over the adventure of “daily life” throughout most of the world – bathroom creepie-crawlies; air pollution; deafening truck horns; language foibles. An unscheduled electricity black-out when dinner is still only halfway cooked. Or the discovery of furry green mildew – yes, this really happened – transforming your shoes into a pair of creatures that could possibly walk out the door on their own.
As I reflect on these memories, there’s an enormous feeling of gratitude. I now enjoy the gift of reliable electricity and hot running water at the turn of every tap in the house. My clothes always smell freshly laundered. And I am perfectly, effortlessly understood by any customer service rep at the end of an 800-number. I’ve had a chance to reconnect with many family and friends, and have plans to see more dear ones in the coming weeks.
Yet at the same time – at exactly the same time – there is also a longing within me to return to my life in Nepal. I miss the simplicity of patient encounters – but not the overwhelming numbers. I miss the joys of living alongside amazing people that you looked up to as mentors, and loved as friends – but not the burden of being constantly different, forever an outsider to the Nepali culture. Mostly, I miss the singleness of vision that exists when you live and work, serve and worship within a community whose sights are set on the beauty of a world that Christ is presently healing – but not the frustrations and heartache that can so easily cloud that vision.
In short, I loved – and very much struggled with – the intense, demanding pace of work and life that is the reality at rural mission hospitals like Tansen.
One of many powerful insights from this week came on Day One: the encouragement to “talk in paradox.” According to Webster, a paradox is “a statement or proposition seemingly self-contradictory or absurd, and yet expressing a truth.” If paradox is at the heart of cross-cultural living, it’s also the achilles heel of re-entry, complicating an already confusing panoply of emotion and memory.
Enter: A PairOfDucks (get it? Paradox?). Two yellow rubber duckies, aptly named Yay Duck and Yuck Duck. The kid’s team at DAR uses this fantastic (and oh so clever!) model to help children process the paradox of loving and loathing the very same places in the transition between two starkly different worlds.
Here’s how one missionary couple describes this PairOfDucks:
During our time at MTI, we learned about some ducks. The first duck was clean and happy with a permanent smile on his face. His name was Yay Duck, and he loved life and all it had to offer. He couldn’t help but see the bright side of things, and he enjoyed pointing them out. The second duck was dirty, sad, and altogether depressing. His name was Yuck Duck, and for the life of him, he couldn’t find one thing to be happy about. Both ducks were content where they were, and sometimes they had a hard time understanding the other.
When Yay Duck was having a great day, which honestly was every day, Yuck Duck couldn’t stand being around him. And when Yuck Duck was having a particularly disgusting day, Yay Duck would spend hours trying to pull him out of the sad pit he was living in. Neither duck could understand why the other one was the way he was, and it was starting to affect their friendship.
One day, Yuck Duck fell in a mud puddle for the third time, and instead of pointing out that at least it wasn’t the fourth time, Yay Duck simply said, “I’m sorry. That’s no fun.” Suddenly, Yuck Duck felt heard, understood, and cared about. Yay Duck didn’t need to try to make him happy, he just needed to meet him where he was. And when Yay Duck had something to celebrate, Yuck Duck didn’t need to point out the fact that pretty soon something was going to crush it. He just needed to celebrate with Yay Duck.
See, we live in a constant paradox, or “pair-of-ducks.” There is always something imperfect, and always something to rejoice in. We can feel happy and sad simultaneously. We can feel scared and excited. And it’s ok.
From Kimballs In Kenya, Dec 2014
If this is true of life in general, I’m finding it far moreso as I reflect back on my two years in Nepal, an experience of life lived out in the constant tension of deep joy and overwhelming grief.
Plenty of areas where Yay Duck and Yuck Duck clamor to have their say.
A few weeks ago, I spent an afternoon with a dear couple from my parents’ church. Last year they celebrated their sixtieth wedding anniversary, and with the advance of years and experience, their hope in Jesus has grown deeper, more solid. They pray regularly for me, as they do for countless others around the world – faithful each day to remember people whose names they’ve jotted down on a slip of yellow legal paper tucked into their Bible. Even as they deal with increasing frailty that can frustrate plans and limit mobility, these two dear ones have an incredible imagination for what God is doing in distant lands. For more than an hour, they asked me question after question about Nepal, utterly absorbed in a world far from the rural Pennsylvania cul-de-sac neighborhood where we sat.
At one point, I shared with them a story from Tansen Hospital about a teenaged girl dying of kidney failure and rheumatic heart disease. Sadly, this was a fairly typical story, something I was already learning by that early point in my time at Tansen. I remember bringing this girl’s father out into the hospital’s corridor (our most secluded space) to discuss her poor prognosis. She clearly had very little time left, mere hours to days, and there was nothing more that we – or anyone – could do to reverse her disease. Although there’s a huge role for palliative care in such situations, families will often instead choose to bring their loved one home before death, for pragmatic reasons as well as cultural and religious ones.
How clearly I recall him standing there, this humble man trying to grasp news that no human should have to fully absorb. Yet it was what he said next that I remember most: “I am such a poor man; oh, if only I were not so poor, she would live!” In his poverty, he felt utterly powerless to help his dearly beloved daughter. It’s a memory that haunts me – one of many that point not only to the wrenching pathos of grief, but also to the vicious toll poverty takes – physically, psychologically and spiritually.
At that moment, it struck me that above all, this man needed to hear that his daughter’s death was not his fault. She was not dying, as he seemed to indicate, because of something he’d failed to provide. This young woman was indeed very ill; I felt confident to say that nowhere else in the world, even with the most sophisticated care, could things have gone any differently for her at that point. I wanted him to hear that message from me, a doctor whose words carry a degree of authority – words that might mean something when he recalled them down the road. I wanted to ensure that, of all the burdens of grief he would carry home with him that night, the weight of guilt would not be among them.
As I shared all this with my friends, a tsunami-wave of emotion surged forth, entirely unexpectedly. Caught completely off guard, I barely maintained my composure, struggling to avoid sobbing right there in the living room. At Tansen, this sort of “case” was so typical, really – anything but unusual. It’s a story that continues to play out day after day across Nepal and around the world. It hadn’t even been a particularly emotional experience for me at the time; with the pressure of the day’s tasks shuttling you from one thing to the next, there’s rarely an inch even to pause and breathe. Not until that wintry afternoon, with a chance to see their story through the lens of time, ample rest, and the norms of my own affluent culture, did the tragedy of it fully hit me.
I’m told that these waves of emotion are a normal thing, that re-entry is not all that different from other forms of grief. I’m told that I should expect that sort of thing, and more. (This post from the blog Velvet Ashes already resonates deeply with my own experience of return, and is worth at least a quick glance.) In the midst of all the busy-ness of the holidays, the fun and laughter, the times spent with family and catching up with friends, I’d failed to recognize that a turbulent sea swells beneath this experience, a vast ocean of thoughts & feelings that still remain to be “processed.” (How sterile and mechanical that word sounds!)
In a few days I head to Colorado to do exactly that, through a week-long “Debriefing and Renewal” program held periodically for those returning from cross-cultural missions work of a year or more. I’m looking forward to this dedicated space of reflection, in which to give focused thought to the past few years alongside a small group of others who share a similar story. Yet at the same time, I wouldn’t want you to think that you should stop asking questions! As best I can, I want to share this world with those willing to enter it. And, time and again over these past few weeks, I’ve deeply appreciated your making room for me to do just that.