Posted: 09 March 2014
By Asiya Shoot
Being a part of Acupuncture Relief Project (ARP) for seven weeks becomes your life so much that the day to day moments take a while to digest. As life is, when you are in it, it’s hard to see.
But, I have left there. Now, I am home, and everyone is asking me, “How was Nepal!? Tell me about your work and your time there?”. I think I am just now able to express a slice of all that has happened, all that I experienced there. There are quite a few things I have come to see now, and would like to share.
It is easy to hit everyone “right off the bat” with the most important part of why we join ARP, that is, the patients, the clinic work. In seven weeks I saw over 700 patient visits myself in the town of Bimphedi! This is huge, because as a new graduate of a Masters of Science degree in Acupuncture, this is more patient contacts than I treated in my entire program and it is more patients than most successful East Asian Medicine practitioners see in a year in the US. But really it’s not the number of patients as much as the experience itself, the health concerns we saw and treated, day in and day out. As you can imagine, it was good hard work. The work that is not just to keep you busy, but to make a real difference, and is truly productive. The work gave me back a sense of purpose, a sense of what is important, not just in my life but in the world. It’s that part — the sense of feeling alive and living so deeply in the present state — that I miss the most about Nepal.
I remember one night around 10:30 pm (which meant it was around 9 am back home in Seattle) I woke suddenly and couldn’t get back to sleep. This had never happened before, as every night we are all so dead tired post dinner, we crash so that we can meet another day. I remember realizing there in my bed, that this was the quietest it had been in my world at the time. I was actually able to be alone with my own thoughts and breath. I remember thinking about how holy the night was for those who did night vigils, and understood why. These times were very limited, especially in Nepal, as it is a place of community where you are always surrounded by people. Even then, in my bed, I wasn’t alone, for the other two practitioners, friends that were now my sisters, quietly slept there next to me. Ask anyone who has lived out in the land how beautifully quiet and still the night is, especially those times when you wake to use the outhouse, and look up into the dark night lit by stars. In Nepal, the only other sounds you hear at that time of the night, are insects and far-off howling jackals (which is quiet different from my life in Seattle.
We were living in the house of Auntie Krishna, our true house-mom, who hosts visitors like us, out of her three extra bedrooms in the town of Bimphedi. This district of Nepal, approximately a four hour drive south of Kathmandu, is a land of vast farms consisting mostly of corn and mustard fields, set among forested hills, valleys, and gorges. The word ‘phedi’ itself means a base of a hill.
Bhimphedi is mainly a one dirt-road bajaar (marketplace) that consists of small shops, an elementary school, a little post office, orphanage, jail, religious buildings, and (our favorite) the “internet/butcher’s shack”. Our clinic is also here on the main road, which runs full fledge with non stop action from Sunday morning to Friday noon. Bimphedi (being more of a town than a rural village like Kogate) is very populated and busy. All three practitioners at this clinic treated over twenty patients per day. This is why the middle of the night is literally the only time to be alone.
The clinic in Bimphedi is a two room concrete walled building with low ceilings and a thin mat covering the Earth floor. In the early morning you can hear music blasting from this same building, letting everyone in the town know that the daily yoga session has commenced. Our team of three practitioners and three interpreters used the largest room to treat patients. This way we were all close to each other. Every day upon arrival we set up 12 chairs in a big circle, each of us rotating around 4 chairs. On one end of the room near the front door (which is so low you have to bend down to enter), is our dispensary station. It consists of a table and shelves lined with Chinese herbs, some basic medication, medical supplies, needles, moxa and the like. Most of these supplies and herbs dwindle away as time goes on, which means we had to get creative. In this place, we measured out herbs into a scale, and placed them into brown bags with instructions. On that side of the room we also had a space where we piled cushions to make a makeshift bed for patients to lie down, as well as a massage chair for back treatments. On the other side of the room is a huge window where cold air flows in. This November and December time, the room tends to be colder than outside due to the lack of direct sunlight. It is actually quite amazing that in this mountainous region it is still sunny out. We try our best to keep our patients covered and to keep a balance between the warmth of the moxa, and the fresh air that is needed to clear the smoke that fills the room. The adjacent smaller room is where our much needed receptionist organized the patients files, and prepares the patients for treatment in an orderly fashion.
Our team quickly found the rhythm of the space and to the flow of treatment within the first week — even though the first couple days was extremely chaotic! In time, everyone supported each other, and was then able to give the best care to the patient sitting in front of them. Some of the patients needed more time and work than others, but over all, every patient is treated the same. It doesn’t matter what their background, wealth, caste, age, or status is. As such this is an exact image of true community acupuncture.
One by one the patients enter and take their seat, more often than not, knowing where to sit as they are regulars. Sometimes we say “Aunus” and “Basnus” “please come in” and “please sit”. We have come to learn little sayings like this, as it brings a smile to our patients faces and helps us connect. The most common ones are, “Tapailai kasto chha?” “how are you?”, “ke bhaiyo?” “what happened?”, “dhuksani” “painful”, “maaph ganuhos” “excuse me/sorry”, and of course a good old shivering of “dherai jaado!” “very cold!”. The Nepali people are very expressive, polite, and love to smile, laugh, and sing. Their clothes, their streets, their food, their homes are all filled with bright colors, traditional prints, jewels, and the smell of spices.
When we walk around this town, down the street to and from clinic, we hear many loud and direct “namaste!” (or “lhaso!”) greetings by fellow patients and neighbors as they sit with each other in front of stores or their homes. Sometimes they stop us to talk about their health, but more often, to invite us in for tea or to visit for a special occasion.
We also see the children as they wander to and from their way to school, dressed in their baby blue uniforms. It is such a delight to see many of the younger children following us down the roads when we are hiking, or in Bimphedi and Kogate. Some are shy but curious, peering from rooftops, hilltops, from behind trees, or into our rooms especially in Kogate. They make loud animal like sounds, howling to draw attention, and laugh hysterically with any little reply they get from us. Some of the more brave ones call out to us in the little English that they know, asking our name or where we are from. I think about my own childhood, riding bikes on the street and playing in the forest and creeks behind my grandparents house. This is something that all children in the world deserve.
Before the construction of highways, goods from India have been taken to Kathmandu from Bimphedi, and every day a bus runs through it, on to neighboring towns like Hetauda or Kogate. This is the same bus we have climbed onto the top of many Fridays, taking the trip to be with the rest of our team. It is a three hour curvy bumpy nauseating drive — unless you ride on the top. Come Sunday morning we travel back down to Bimphedi to do it all over again.
Even though the distance may be short, the journey is longer. The road is a perilous dirt track consisting of bends, twists, multiple switch-backs, that often cling to cliffs, sometimes with landslides and falling rocks. I honestly don’t know how the drivers round the corners, as they make their way up and down the mountains with confidence and precession. On the “himali tiger” bus that we take to and from Bimphedi on the weekends, I watch the bus driver as he pays more attention to the music dial above his head. Thankfully he has two other young teen boys who are working with him. They hang off the bus, banging on it as it rounds corners with distinct cues as if to say, “turn turn turn!” or “you are all good on this side!”. They signal for other cars, often getting off to check the scene (i.e., how close it is to the edge), or to help other vehicles maneuver
around it. In each stop they throw passengers luggage and goods up to the top and collect the bus fee. The bumps, the stop and go, the back and forth, for me, was the worst part about Nepal. It is nauseating. Many people get so sick they throw up out the windows. Which of course, makes it all worse.
The best place to sit in any vehicle, is up front, if at all possible. On the bus, the front seat is a three person seat that faces sideways toward the driver with the clutch in between. No seat belts, music blasting, sometimes the bus literally turning into a dance hall. This seat is often taken by the elderly or new mothers with their babies. 6 am, early Sunday mornings, this is where I sit for the journey back to Bimphedi. Since we are the first stop, we have first pick. But come half-way down the mountain, the seat, like the rest of the bus, is so overfilled, so cramped, that I am only half way sitting. On the next stop, when I can, I crawl over what seems like twenty people to the door, jump out and make my way climbing up the side of the bus to the top. The top of the bus, with the rest of the boxes, luggage, rice filled bags, my friends, young men and kids, is indeed the second best seat. Up on the roof of the bus is not nauseating at all, but your bum gets sore, it is 10 times more cold, and as people remove their luggage and goods, you tend to slide around with nothing to stop you. We find this all the more fun and can’t help but laugh and scream every time we hit a big bump, duck under branches or wires, and make our way over narrow cliffs. Safety aside, the freedom that is felt in this part of the world is so appreciated.
You can imagine seeing over 20 patients a day how much you would change and grow personally and as a practitioner. I am reflecting about when I was applying to ARP and how I talked about three words that summed up my interest in being a part of it: self- exploration, commitment, and learning. It is interesting to reflect back on those words, and to see how much I was able to accomplish there.
I joined ARP post-graduation, so as you can imagine, after years of studying with focus on memorizing, test taking, clinical application, pulling out any bit of information from the depths of my brain (ok, or books), and an over-all disconnect from the world outside of the classrooms, self-exploration was essential. It helped me connect back to why I am in this field to begin with. That is, my calling to help heal and make a difference in people’s health.
In my blog, right before I flew out to Nepal, I wrote a passage about healing. I had been contemplating the word, the verb Heal which is defined as, “to make whole or to restore to health”, and it’s relationship to being whole, “free of defect or impairment, having all of it’s parts in entirety”. I was wondering if all of my passion, my intent, my calling, even going to Nepal itself was to help heal, how was I going to be able to do this? I mean, I wondered if healing completely and being whole is even attainable as a human? Is it attainable while we are alive?
I know that then, and still now, that I don't have the answer to these questions, but I think that the process of reaching wholeness, of becoming healthy, healing, and of being human itself on Earth, is almost one thing. It is as if healing and reaching wholeness is what we are living for. Being out here in Nepal I saw first hand how the human is holistically comprised of mind, body and spirit, and that the healing process needs the mental, physical, and spiritual work and can’t be separated.
In my intent to come to Nepal and be part of ARP I had also asked for a sign, possibly an answer to my questions and thoughts on healing and my role as a practitioner. Was I really capable of doing much? Could I really help with TCM? What if I don’t know what to do for my patients? What if someone dies in my care, and I am not able to help them!?
I was reading from Lao Tzu’s Tao Te Ching at the time and turned to a poem titled, Water and Stone:
“What’s softest in the world rushes and runs
over what’s hardest in the world. The immaterial enters
So I know the good in not doing. The wordless teaching,
the profit in not doing —
not many people understand it.”
To me this poem was a reminder when I was working in Nepal that I didn’t have to do anything, to do much. It was a lesson to learn and to practice of just being. It is not really about saving anyone, changing anyone, putting in needles correctly, dosing correctly or teaching through my mind as much as it was about being myself, transmitting love, and really taking time to connect from the heart, smile, and be present. This is always a hard lesson for me — balancing the mental and the heart. Even now I am not sure if I was able to do this as much as I wanted, but I hope I was able to; I think I was. I remember the last day when the ladies, a few of my patients, showed up at Auntie’s home to say goodbye. They showered us with gifts and flower necklaces called Malla. I think about patients, like the young girl nearly my age, that was crying on our last day at clinic, and I think of how much I was touched by their love too. I often think about all the friends I made, the interpreters, Auntie, our neighbor friend and how much I miss them and know that they miss me.
I think that there is healing in that knowing, but I also know that the next time I return to Nepal (if am blessed with that opportunity) there is more to give from my heart. More stretching to do. More connecting to do. I want to hear more of their stories. I want to spend more time with them in their homes and in the fields. I want to hold more babies hands. I want to touch more women through massage and craniosacral therapy that I am now studying, just because. I want to laugh more.
This is really the spirit part of being human; from here I think the most healing can take place.
At the same time I know and experienced how important knowledge of the mind is. Nepal is a country where education is passed vial oral transmission and the power of talking with our patients is something that will last for future generations. Preventative healthcare is one of the most important parts of what we do in this field. As Thomas Edison said, “The doctor of the future will give no medicine, but will interest his or her patients in the care of the human frame, in a proper diet, and in the cause and prevention of disease.”
Educating our patients about their medical conditions, be it diabetes, osteoarthritis, high blood pressure etc. changes their life. We teach them to make informed decisions about what they can do to help themselves, change lifestyle factors, and/or understanding the medications their on etc., even if we are no longer there. All three of these conditions were actually very common in Nepal. I can’t tell you how many patients we saw with a blood pressure reading of 130/90, so common that it wasn’t even a major concern anymore when we were seeing other patients with a BP reading of 180/100! I also had a patient whose blood glucose was so high that the machine actually read ‘HI’ and gave no number! I spent a lot of time educating this patient and his family about diabetes, and the need to go back to Hetauda to see an endocrinologist to get a correct insulin dosage, since it had been over 10 years. In this community clinic setting it was interesting to hear the other patients over time advising each other from what we had told them, specifically to drink more “pani” (water) which was a major issue. Now that they have this information, naturally they will continue to advise their family and children to do the same.
The commitment to this community was not only through educating the patients, but serving a roll, participating in building a clinic that can be sustainable for time to come, and helping other practitioners like myself do the best we can as health care providers. This means we had to step up to provide the primary care role that would normally be provided by physicians in developed nations. We had to do this to provide treatments that the patient’s needed. The patients recognized and trusted us as primary care medical practitioners as they would any “doctors in white coats”. They saw us as people who were there to help them with their health. They put themselves in our hands, literally, and this was definitely scary to start with. One of our main purposes there was to help treat the community through Traditional Chinese Medicine specifically Acupuncture, but was actually far more than that. We were the only medical practitioners (esp. in the remote village of Kogate) they had around, or had ever seen. Some of the conditions we were treating were so chronic and serious that if we didn’t help, the patient would quickly be in a critical condition. Many individuals needed to be referred, but out in Kogate which is at least a 6 hour trip to any other medical facility, any hope for an ambulance to take them to the hospital is limited. The patients often did not have money to travel, or get the care they needed, so we were their best hope. In other cases when we wanted to refer, the best care available would be from trained health workers that were more pharmacist than doctors. The patients would hardly receive the care they actually needed. It was up to us to make diagnosis, prescribe not only herbs but common pharmaceuticals, and monitor the patients. This is beyond our scope of practice in the US despite our study of pharmacology. Sometimes we actually needed to do minor surgery such as stitching up wounds or lancing an infected boil. More than anything though, being a health care provider meant really listening to our patients, spending the needed time with them, and connecting, which like most places in the world, is very rare especially in our Western health care model where physicians don’t have time to actually listen to their patients until they are expected to move on to the next patient. Taking care of their body, is just another (major) piece of the human experience toward healing.
In Bimphedi, I had a patient that I was seeing every day that came from a neighboring village with her son and daughter-in-law. They rented a room across from the clinic. She was an elderly women who had an ischemic stroke 10 days prior, and had almost complete left-sided paralysis of her arm and leg. Her facial/cranial nerves, hearing, and mental faculty were all fine, but she had been blind in both eyes since 2010. She had sensory ability in all dermatomes (of her leg and arm) but the motor function of her left arm and legs were affected. She was also bedridden. This was an amazing experience to have a patient that came in so soon after her stroke, and that I was able to see and treat her so frequently.
It definitely took commitment however to show up every day, especially after long days at the clinic or going over early mornings. There were days where her inability to feel or literally see the progress she was making, made it hard to continue. Of course, the progress was slow and subtle. In addition, both her and her son were depressed, and had a hard time being away from their home. There were days where both of them questioned if I was really helping, which was hard for me, and I had to remind her (and myself) how much she was improving, from being unable to grab my hand, to sitting up on her own within two weeks. There were days I had to remind the son how important it was to help her to get up and move, even if I wasn’t there to help. Still almost daily (besides Saturday), I would go and needle, do electroacupuncture, keep her company
and teach the son and daughter-in-law how to massage her, do moxa on her, and help them exercise her arms and legs. In one month, she was able to move her left arm with 80% full range of motion, and she was able to stand and walk with us holding her under her arms! This was amazing to witness.
Another patient I was seeing at least twice a week was a 26 year old male who had right sided paralysis of his face. He had facial twitching, facial nerve damage, loss of hearing to the right ear, and his right eye was crossed as a result of an occipital craniotomy surgery in 2010. He had fallen and fractured his occipital fossa and needed surgery to prevent hematoma or a hemorrhagic stroke. He came in for treatment of severe dizziness and vertigo, balance issues, and a heavy sensation to his head, all of which affected his ability to work. His right eye was also unable to close, and he had burning and itchiness that bothered him.
I met him on his fifth treatment. By that time the weakness in his right arm and leg were 80% improved with electroacupuncture. I worked with him doing facial electroacupuncture, and other body points, as well as put him on herbs. By the 10th treatment he was able to move his right eye lid up and down and feel it, there was no longer burning or itchiness, and his eyelid could close 60%. He also no longer had nausea, dizziness or feeling off balance, or heaviness in his occiput. His right arm and leg were 100% better and he was back at work. By the 15th treatment he was able to puff out his cheek, wrinkle his forehead, and close his eye 80%. Since his injury was over 3 years ago, this was also amazing results, beyond what we had discussed for prognosis, and it was an important lesson in keeping the patients chief complaint in mind as you treat, which was all 100% resolved.
Other cases I dealt with were a lot of ear and lung infections. I seemed to get all the ear infection patients, I mean, at least five a day! Those were some of the hardest cases I dealt with because some of the patients were children or elderly, which always increases concern. Some of the patients did fine with Pu Ji Xiao Du Yin, or Chuan Xin Lian Pian which are internal Chinese herb formulas, but some would get better and then get worse again, or it would be a week with no improvement and so I would have to start them on one of the antibiotics we had access to: amoxicillin. In these cases you hope that you are making the right choice. It is always based on doing your best with the knowledge you have, but there were definitely times I was looking into ears thinking, “I don’t know what I am looking at” or “this isn’t getting better, I don’t why, what should I do?”. The thing with antibiotics is that you have to educate the patients on taking the full dose, because the infection needs to be fully gone before they stop taking it. This was the worst part because there were patients that were not compliant, or come to find out, had been on amoxicillin for long periods of time, taking it when they didn’t need it. This means that the amoxicillin was not strong enough for them any more. Sadly, we have this overuse in developed nations as well. There were many patients I saw with blown out tympanic membranes, and yet were given ear drops by local pharmacies or the health-post. Many other patients were given amoxicillin when they didn’t even have any infection to begin with! So these patient’s would be susceptible to further infection since their healthy gut flora was decimated. Luckily in Bimphedi we had access to Probiotics.
Besides the plenty of back and knee pain, other common cases included multiple fungal and dermatitis infections, some harder to treat than others. In these cases I also had to educate the patients to continue taking meds or applying topical creams/ointment until it was all gone, enforcing that it often takes a lot of time before it clears. Again, there were times when I had to give fungal creams, topical antibiotics, internal herbs and acupuncture just to “hit them with everything I had”. And there were times when I personally had to buy these medicines for them knowing that they, or their parents, grandparents etc., didn’t have the money to get it themselves. When it starts to visibly clear up, it was such a relief and such a feeling of success.
I joined ARP with the commitment to serve these patients, with the medical training and wisdom I have, but it went far beyond the clinic walls.
One of the most important parts of this program is that ARP hires locals to help with all the other ground work. One of the most important local workers is Tsering, officially the “Nepali liaison”, the best bridge APR has, that is continuously working on establishing long term clinic projects. Unofficially we called him “our Nepali Santa” because he always made sure we were comfortable in our home away from home, bringing us honey, peanut butter, holiday cakes and all the supplies we needed for the clinic that could be found from Hetauda to Kathmandu. He is also a musician, has been working with APR from the beginning, and is an amazing interpreter who also knows Chinese Medicine because of his passion and self-studies. Other team members include all the wonderful youth interpreters (and neighbors) who quickly became our friends and siblings here, who made us feel at home, shared stories, meals, hikes, bus rides, songs, camp fires, tree planting, holidays and birthdays, laughter, and worked so hard in the clinic with us every day. We truly couldn’t do any of it without them! I miss you all!! Training them in various subject of this medicine, and learning from them about Nepal, was one of the best part of ARP for me. All the drivers, cooks, house mom, secretaries are all Nepali. Helping to offer these various jobs and educating these brilliant interpreters, establishes sustainability in the time to come. I hope each one of them will continue to study this medicine and in time be able to run the clinics on their own. This is important for me because I truly believe all people everywhere have the potential to solve their problems, increase availability, create long-term solutions, develop skills within their own communities, and know that every one of us already have within us amazing skills, ideas, and gifts. We share by helping each other, rather than this notion of, “we are here to save you”. Honestly, I have never seen such an intelligent group of individuals, who are so proud of their country as our Nepali ARP team. It is for this exact reason I find that we need to do relief work in our own backyards as well. Due to my experience with ARP, I find myself wanting to study even more, especially in Western medicine now that I am home. “Ours is not the task of fixing the entire world at once, but of stretching out to mend the part of the world that is within our reach.” (Clarissa Pinkola Estés)
With all of these experiences that I have mentioned, accelerated learning that takes place here for the practitioner, is the aspect of volunteering that I would highlight for anyone who is considering ARP. Again, seeing over 700 patient visits in 7 weeks quickly teaches you what works and what doesn’t as far as TCM is concerned. More importantly, I also learned about myself in this intensive setting. With all my comforts set to the back burner, I learned how much I can be challenged and how much I can grow. Traveling is uncomfortable because it opens up your mind, it creates situations that push you to meet new people, sometimes it means you have to get around where no one speaks your native language, eat different foods, live without hot water! It teaches you clearly how much you take for granted.
I learned to trust myself more in Nepal, to follow my intuition. Now I have more confidence and commitment to bring back all that I learned to my home, in hopes of building and working in many more communities, and in my own practice. I honestly see that it is possible to change the world, by offering health care to those in need, building sustainable clinics here in Nepal is do-able, and therefore it is do-able everywhere else in the world.
I know that there are neighborhoods in my own city that call for involvement, be it in education, medicine, feeding and housing those in need, or any volunteering we can do. There are Native American reservations next door to us, asking for our participation especially in the cold months. There are beautiful landscapes in this country maybe you have never visited, beaches that need to be cleaned up, farms that need work, and forests that are calling you to come and discover life.
The first stop I had coming home was Dubai. As you can imagine, it was worlds away from where I had been the last 7 weeks. Besides the differences in culture, gaudiness, over the top buildings and highways, it was the first place I was truly all alone. No roommates, no loud speaking neighbors, no singing or laughing heard between the thin walls, no animals, not even the crazy beeping horns and noise of Kathmandu. Just quiet.
I realized then that this was the first of many days I now would be alone, and it was overwhelmingly sad. I know I’m not really alone though, I have so many friends and family and lovely people surrounding me like my beautiful husband. But the day to day existence in most of America, even being surrounded by so many, is just isolating; I had forgotten that. Here in Seattle, I see so many people rushing to somewhere, separated, on their phones, standing in lines, hardly engaging, hardly making time for each other. It is a consumer-driven culture that focuses on material possessions (or the illusion of it), and we all know it, but may not be aware of it. It was honestly culture shock coming back. I must say here that I had been traveling in Asia for almost 5 months.
I remember laying there in the three star hotel room of Dubai (which is like a 10 star), thinking about all the Nepali men on the plane with me, also traveling to Dubai. All the men who are now there for work, probably some sort of labor construction. I think about if they are being cheated, if they are happy there, if they are finding whatever it is they are looking for. Because being in Nepal, I had never been somewhere that has such a sense of peace, with people so welcoming, so happy despite their conditions. When you slow down enough to see what matters, to embrace nature and the immaterial, you feel alive. I want that feeling to last forever. I want everyone to know it, I want my children to experience it — to feel so blessed.
I know that all over the world, even in our neighborhoods, there are people who are struggling and having hardships, family problems, money problems, or major health issues. When you look at this culture so put together by community — where everyone knows each other and looks out for each other — I really struggle being without it, and I really know that out of everything I learned the most, is that community is essential now. I know that there is work to do; we all have to move towards Unity. It is the only way to become sustainable, to make a difference, to raise our children up, to learn from our failures and what is not working any longer for the masses. It is all attainable, I witnessed that in Nepal. Slowly but surely. I know that I am fortunate to be able to have knowledge of this medicine, and to use it to be a conductor, to do my part in the world. I know that I am fortunate to have been able to travel, learn, and work in Nepal, and I hope that I can continue to be part of many more projects around the world. I don’t know when or where. All I know is that my whole being, from deep in my core, is yelling out, “WE ARE MEANT TO BE TOGETHER!!” –Asiya Mahdiyah Shoot MSA, LAc