Posted by Rashmi Sharma
“Ke garney? This is my son, and I am his father.”
This is what the father of Rakesh, the 11-year old boy, said to me when I met him. He had just been told that his son may have rabies, an infection that may be exotic in other parts of the world, but is all too real in rural Nepal.
Rakesh had been bitten by a dog about a month ago. The dog had also bitten his dad, and their buffalo, which had recently calved. At that time nobody thought much of it because the wound had healed by itself. That is, until about three days ago, when Rakesh lost his appetite, and developed a horrible spasmodic twitch every time he tried to drink water. He was then brought to the hospital; a classic textbook case of rabies.
We all knew it was fatal–this infection. And here was this boy, calmly sitting on his hospital bed, chatting, talking, laughing, and demonstrating his oral twitch to whoever wanted to see it again and again.
The doctors present in the hospital, Dr. Payel, Bhibhusan, Roshan, and I scrambled to find the best treatment modalities. He received eight intra-dermal 0.1 ml doses of the Rabies vaccine, as it was deemed the most effective treatment protocol according to the World Health Organization (WHO) in post-exposure cases. The father was given two intra-dermal injections. And then we started negative counseling, but tried not to be too negative. A physician never gives up on hoping. Hope is all you can offer when you can’t offer anything else. Hence, when I wrote his discharge papers, we referred him to a hospital in Nepalgunj which is about 15 hours away by road for “further observation and treatment,” hoping he would receive exactly that and more.
This was my first day. I had just arrived that morning, after a 12 hour jeep ride from Dhangadi, to work as a staff physician at Bayalpata Hospital. My first sight as I entered the hospital was a woman quietly wiping away her tears. I must have asked for an explanation, because someone very discreetly whispered into my ear that her five year old daughter just died this morning of severe pneumonia. I peeked inside and saw a tiny corpse shrouded in a blue shawl. It suddenly dawned on me: I am in Achham, one of the poorest regions in South Asia, and one that shoulders some of the world’s highest mortality rates.
It all felt very surreal. Where am I? Until about a week ago, I was living very comfortably in the United States, among friends, eating barbeques on the Jersey shore, driving to downtown Philadelphia for a night out. And within a week, I was off on a flight to Kathmandu, and in Achham. The journey itself was a lesson in contrasts. Nepal and the United States are worlds apart, literally and figuratively. The flight on my way to Achham offered a panoramic view of the mountains. It looked as if a child drawing a picture had set his imaginations on fire. The mountains are randomly stacked one after another as far as the eye can see into the horizon. The rice, paddy, and maize terraces bind them in varying shades of green, blue and yellow. The beauty of the place contrasts sharply with the hardness of life here. The view from the hospital premises looks like a dream. Picture perfect. My first afternoon, I saw the biggest, most perfect rainbow I had ever seen in my life. Achham is breathtakingly beautiful, but its very ruggedness and remoteness means that its people do not have access to the commodities that should be available in the 21st century world.
Towards the end of the day, Dr. Payel asked if I had further news about Rakesh, the 11 year old boy with rabies. So I called his uncle on his mobile. He told me Rakesh passed away within 10 minutes of being discharged from the hospital. He didn’t even make it back home. He didn’t even have time to take the bus to Dhanghadi, and reach the medical college in Nepalgunj. I was stunned. Actually, we were all pretty stunned even though we all know that Rabies is almost always fatal. It is so much harder to hope than to despair…and there have been a few cases of patients with rabies surviving after all…wasn’t there a survival story in Milwaukee several years ago? The staff in the hospital talked about how amicable and stable Rakesh had been. I kept remembering the comment his father made to me. “Ke garney? This is my son, and I am his father.” The literal translation of “Ke garney” in Nepali, “What to do,” is a phrase I had heard multiple times within a few hours of arriving in Bayalpata. Be it in the emergency room, outpatient department, inpatient department, or pharmacy. What to do when you are living and working in one of the most resource-deprived regions in the world, and everything gets 100 times more difficult to carry out as you are 15-20 hours away from the rest of the world.
Well, at least the advantage of having followed-up on Rakesh was that we talked his entire family into coming in to get rabies vaccinations the very next day. We counseled the family regarding the importance of immediate treatment for animal bites, and convinced them to stop drinking milk from the buffalo that had been bitten by the same dog. It suddenly dawned on me how precious and fragile human life is. Here was this boy, demonstrating his twitches just that afternoon, and then he was gone. We lost an 11 year old boy who had his entire life ahead of him due to something as preventable as a rabies infection. Is there any sense in this kind of fatality in this day and age?
What a waste of life. Ke garney? However, I quickly learned that, as a physician in Achham, there is no time to waste. There is always another patient who needs medical help. Later in the evening one of the nurses called for me, and we delivered a healthy 2.8 kg baby girl that night. The lady in labor did not make a single sound. Not even when a quick episiotomy was made without giving her any local anesthetic. She never complained about the stifling heat in the labor room. The power had gone off. The fan wasn’t working overhead. She gritted her teeth, and pushed. Not a sound from her. It was an example of the sheer strength of the Achhami people, of their ability to survive and thrive despite some of the biggest odds against them.
It humbles me, being here. I am more appreciative of the education and the opportunities I have received having grown up in Kathmandu. I know a lot needs to be done in Achham in terms of infrastructure development, education, facilitating healthcare etc., but I feel that by being here, and caring for patients, I am at least doing my tiny bit to help improve healthcare in Achham. One patient at a time, one day at a time.
Dr. Rashmi Sharma graduated with an MBBS from Kathmandu Medical College. She is currently a staff physician for Nyaya Health and the first female physician working at Bayalpata hospital.