Hello from Arusha! I have finished my first 10 days into my second attempt here and so far I am anatomically intact. Mentally, however, it has been a whirlwind. My days begin with a beautiful 3.5 mile walk from my village of Il Boru to Selian Hospital. The walk itself summarizes life at the hospital such that I am able to see the wide economic divide first hand. From the playful smiles of poor young kids in tattered uniforms walking to school yelling muzungu (foreigner) and asking for fist bumps to the Land Rovers that careen by spraying dust over us, it is quite the experience. 

The days at Selian are generally similar to the structure of US internal medicine wards. We conduct rounds with two medical interns, one registrar (someone who has finished intern year and is working as a staff), and the nursing staff. The key difference lies at the end of every patient interaction when the medical team's plan to order tests and medications needs to be conveyed to the patient and their family. The difference in that conversation between the US and Selian lays plain the inability of the family to afford basic diagnostics that are taken for granted in the US (such as a urinalysis or a chest xray). This is somewhat complicated by an intermittent lack of resources at Selian to perform these diagnostics. 

Such difficulties make the practice of medicine very challenging and sometimes frustrating and this is evident among the interns and the rest of the medical team. However, the reliance on history, exam, and most importantly local epidemiological data make the practice both exciting and educational.
Selian Hospital is a major safety net for the Masai population and the poor around Arusha and the medical team truly cares about the patients and I am lucky to be here working with and learning from them!

A hungry baby goat on the walk to the hospital

Selian hospital

We Belong to Each Other

“If we have no peace, it is because we have forgotten that we belong to each other.” - Mother Teresa

I have spent a lot of time over the last few months learning about palliative care in global health. One of the projects I am working on this year is to create an online course in palliative care and medical ethics from a global health perspective for the residents and fellows here in Chiang Mai. I will admit that I knew very little about global health aspects of palliative care when I started, and even less about building a website! But now after immersing myself in this topic for a few months, I feel like I have a better understanding of what it takes to build a successful and sustainable palliative care system. If I had to summarize the most important component of a successful system in a single word it would be: community. 

The quote above comes from Mother Teresa, who might be considered one of the very first advocates of palliative care in global health. She was famous for her personal and organizational outreach to patients dying of diseases that carried great social stigma (HIV/AIDs, leprosy, TB) at the time. Instead of retreating from these patients, she reached out her hands to touch, her ears to listen and her heart to love them as best she could. In doing so, she resisted the strong currents of an increasingly modern society which preached a gospel of individualism, capitalism and distraction rather than service, compassion and presence.

Unfortunately, many healthcare systems around the world are based on individualism and capitalism. This can lead to a variety of problems when it comes to the equitable delivery of healthcare, but perhaps even more importantly, it obscures the truth of our interconnectedness as human beings and the incredible power of community. In the “Public Health Strategy for Palliative Care” promoted by the WHO there are four aspects to palliative care development: (1) policy (2) drug availability (3) education and (4) multi-level implementation. The model is visualized as a pyramid with community care as the base and with primary palliative care (all healthcare professionals) and specialized palliative care (palliative care experts) care at the top. 

At the heart of many palliative care initiatives in low and middle income countries are community volunteers. The Neighborhood Network in Palliative Care (NNPC) in Kerala, India is just one example of a successful community-owned program that is run largely by volunteers. Founded in the year 2000, it is based on a philosophy that problems associated with chronic and incurable illness are considered to be “social problems with a medical component”. Community volunteers complete a standardized training program that includes an introduction to palliative care, the role of the community, cancer basics, last hours, and others and use this knowledge in the community to help identify problems and intervene with support from physicians and nurses. 

As of 2014, this program has grown to have more than 15,000 trained community volunteers, 50 physicians and 100 nurses. It is almost entirely community-funded with most neighborhood groups (80%) managing to raise the money needed to deliver care locally through donations and local government support. I think it is important for Westerners to learn about programs like this because in the US people are often set in their ways of viewing healthcare as a commodity (i.e. something that can be bought and sold). But as Mother Teresa and the volunteers in the NNPC and countless other programs demonstrate, it can also be something that is freely given. At the very least, we need to realize that there are different ways of approaching medical care and that it might be beneficial to “think outside the box” (i.e. Western culture) sometimes. 

In order for a palliative care system to be successful, I would argue that it needs to be built around principles of inclusion and connection rather than individualism and consumerism, with the community serving as the foundation. Additionally, we need to improve our ability to conceptualize the end of life as simply another part of the life continuum, not something that is separate and needs to be hidden. I am reminded of a quote which I believe was initially intended for individual people, but I would argue that it also applies to the development of systems and institutions: 

“Watch your thoughts,

For they become words,

Watch your words,

For they become actions,

Watch your actions,

For they become habits,

Watch your habits,

For they become character,

Watch your character,

For it becomes your destiny.”  

Resources:

Sternsward J, Foley KM, Ferris FD. The Public Health Strategy for Palliative Care. Journal of Pain and Symptom Management (2007). 33(5): 486-494.

Kumar S, Numpeli M. Neighborhood network in palliative care. Indian Journal of Palliative Care (2005). 11(1): 6-9.

*Movie about Kerala program: https://www.youtube.com/watch?v=JBYS3h2EEg8

Photos: Around Chiang Mai

The Ping River at dusk (east of the Old City).

The city was decorated in lanterns for Loy Kratong Festival (November). 

Just another smiling life-size statue in Chiang Mai. We need more of these in the US.

Dinner with Thai family medicine residents and visiting resident from HCMC.