Education has not enjoyed the value in this culture which we enjoy in ours. A person who changes tires on motorbikes, who does the laundry, or drives a tuk-tuk will make much more money than will a doctor. One physician we know here is able to manage his administrative position because his wife is a street vendor. The difference in education requirements and sacrifice to be a physician is staggering in this economy.
Medical care is costly for these people. People buy the intravenous fluids and tubing, the IV catheters, and the drugs. When the money runs out, there is no more - and sometimes people die.
There is little medical infrastructure in the villages - usually a small building staffed by a volunteer without education. When a group of medical students visited 2 villages, they found the infection rate with diarrhea to be 80% in one of the villages. Villagers collected water from the river -- a 6 km walk in the dry season. The water was used to bathe, to cook, and then to consume - because you cannot use it once it is consumed. These young doctors helped find a Non Government Organization (NGO) to fund a water pipe from the hills to a reservoir in the town, and the diarrhea problem was reduced to 5%. In another village, simply keeping the animals out of the water supply, and providing them with their own was sufficient to reduce the disease burden.
By putting final year students in a district hospital, the pattern of care has changed. In a district hospital 20 km from town, they increased the patient volume to 45 per morning from 5 per day by talking to the villagers, and using the following approach;
• Be kind to people,
• Try to fix one or two things that are fixable, and
• Tell them to come back if they do not get better.
When we pour money in, when we build edifices to our glory, these people do not help themselves. When we pay them big salaries from our short term funding, we alienate them from their peers. Infusion of funds to lift the burdens, education to help them see the problems and find their own solutions, and treating others with dignity is respected and valued.
Jaelene was teaching physical diagnosis to her group. During the abdominal exam of the kidney, one of her group said, "My colleague here has a large kidney." The colleague said, "I have a kidney stone." He had an IVP, and brought it in to show her - he had a very large (about 7 cm) kidney stone, like the ones we had seen. This problem is common here, because of dehydration (who would want to drink water processed by washing and cooking) and diet. This 32 year old man must have chronic pyelonephritis, he has frequent pain, and he drove 30 km each way every day to come in for the physical diagnosis course.
Jaelene put him in touch with the surgeon, and arranged personal funding from colleagues on this trip to cover the expense for extracting the stone.
Even if we train the best doctors, even if we provide the best hospital, people cannot pay. When a family brings a child to hospital, they are given a list of things that are needed, and they go across the street and buy it. They pay for every lab test. When the money runs out, they ask for no more lab tests, they stop the drugs or they take the child home, sometimes to die, and sometimes to come back for more care two weeks later. This economy is 80% agrarian, and it does not sustain medical care of our standard. There are no "rights to medical care" and there are no "rights to live". This is why Beat Richner in Cambodia has addressed the ongoing problem of illness in children in a different way - by funding free care for mothers and families, using current medications and current investigations. Every time we address a problem, we come back to looking at culture and economy, and there is no solution, because the problem is not defined.
This place is so far from what we do and who we are as a culture. Expectations for medical care are different. Expectations for income are different. Expectations for life are different.
For many of us, we cannot help but weep at where we have arrived in our lives and in our culture - with such a strong sense of entitlement for what we think we need. Our wants have become transformed into our needs, we value our contribution to society by the income we make, and we blame others for what we do not have. We live in excess and what we have is never enough. Ours seems to be a culture with instincts run rampant. Going back to Calgary is all about "culture shock".
This is a competent and interesting crew, with a few "old farts" providing balance and solace. Using the measuring stick today - the biggest change in the medical school has been generated by an IT person who has abandoned the "money chase", and invested himself into helping people use more effectively what they have. Other changes will take more time. The teaching of clinical skills here is needed and the long term impact of a good clinical examination process is inestimable. For today, there is positive change, and there is a measure of respect for what we have done here.