Philosophy in Nepal
Early last century, philosopher Bertrand Russell advocated a distinction between “knowledge by description”, what we indirectly know through second-hand reports, and “knowledge by acquaintance”, that which is acquired only through direct experience1. I had been aware for some time that Nepal was one of the poorest countries in the world, one of the ‘bottom billion’2. I knew it was a country where the majority of nearly 30 million inhabitants live on less than $2 a day, and are separated from health care by rough terrain3. My desire was to move forward from “knowledge by description” to personal “acquaintance”.
I started at Tilganga Eye Hospital in Gaushala, an outer district of Kathmandu, in December 2010. It is one of several tertiary eye hospitals in Nepal, most of which are based in Kathmandu Valley and all of which are heavily reliant on overseas aid. Tilganga, for example, is supported by the Himalayan Cataract Project (US) and our own Fred Hollows Foundation4-6.
Pedestrians, bicycles and cars share the busy streets of Kathmandu
The days started at approximately 7.30am with a ride through the chaotic streets of central Kathmandu on the hospital bus. I say approximately because schedules work differently in Nepal – the bus could arrive anytime between 7.15-8am and could be coming from either direction on the major four-lane artery called Kantipath, so you had to keep your eyes peeled. We would have teaching or research presentations most mornings, when the normally very friendly consultants would grill to the residents to a degree I have not yet seen in Melbourne. We then divided the day between clinics, operating theatres and emergency.
As a student, I assisted the residents in the general clinics and emergency department, by directing the flow of patients (hundreds a day!) through the clinics, taking histories from those that could speak English and examining many beautiful pairs of eyes. I assisted the consultants in the operating theatre when a resident was not present, and learnt refraction from the orthoptists. I am particularly interested in women’s health and produced a report with their research department called ‘Gender Inequity in Eye Care in Nepal: A Hospital-Based Study’, which has been submitted for publication.
Learning to use an indirect ophthalmoscope in clinic
Professionally, my time in Nepal was most productive in terms of improving my clinical examination skills using the slit lamp, direct and indirect ophthalmoscopes. However the personal gains were so much more valuable.
I was absolutely inspired by what I saw at Tilganga. People who were very poor could access quality eye care for free and others who could afford to pay were billed via a tiered payment system that was income-dependent. I shed the ‘compassion fatigue’ that had built up over the years when I saw where the money that we donate to non-government organisations, such as Fred Hollows, goes.
The work ethic that the doctors modeled has galvanised me for my final year of medical school. Despite limitations, what they have the resources to do, they do very well – we had visiting ophthalmologists from the US and North Korea (yes, North!) who had come especially to learn the technique of Small-Incision Cataract Surgery (SICS) from the Nepalese surgeons7 8. The ‘brain drain’ of medical staff away from developing countries is well-documented9 10 and I was impressed that the consultants, many of whom had completed fellowships in Australia and the US, decided every day to stay and work in a country of six-day working weeks, constant power cuts and volatile politics.
The most challenging aspect of my time was thinking through the ethical dilemmas that presented themselves daily. As a young person from a rich country, it was difficult knowing how to respond to the blatant inequality. But I learnt that despite feeling overwhelmed, it is possible to go about your day with a sense of ethics and an eye for the small ways in which you can help begin to redress the balance, whether that is treating patients in the hospital during the day or choosing fair-trade shops and restaurants at night.
By our standards, the care at Tilganga lacked confidentiality and seemed paternalistic. However I came to understand that this was due not only to the need to see so many patients in a day, but also to the cultural framework in which the Nepalese live and access care – patients expected a communal experience and for the doctor to provide very specific guidance as to what should be done. So though there are many opportunities to improve care at Tilganga, there were also many of my own preconceptions that needed to change.
My worlds collided when the issue of medical tourism presented itself. An opinion piece was published in Sydney Morning Herald just before Christmas and caused some excitement11 – “Rather than endure a three-year public hospital waiting list” and “determined not to pay for more Gucci bags for a Mosman mansion”, an Australian woman flew to Tilganga for bilateral cataract removal. She reported that she “didn't suffer any ill effects - not even a headache… the hospital was cleaner than many I've seen in Sydney... the staff were plentiful, kind and well trained”. Though my personal feelings remain against the concept of medical tourism, I could see that the staff’s enthusiastic response to this article was simply one way to express pride in their work – work which is increasingly aligned with world’s best practice.
In summary, my Nepalese sojourn has made me more “knowledgeable by acquaintance” with professional and personal situations that have extended me. Our philosopher Russell had a protégé, Wittgenstein, who is famous in his own right for his aphorism, “Whereof one cannot speak, thereof one must remain silent”. Aside from the excitement of new experiences, my elective in Nepal has opened up a new conversation for me, that of the possibility of an ongoing professional relationship with this part of the world. Medicine is universal and transportable – it is just as possible to perform cataract surgery in a tent in rural Nepal, as it is in a multi-million dollar surgicentre in Melbourne – and I am excited to see where it will take me!
Painted “Buddha’s eyes” are watching all over Kathmandu Valley
Russell B. The basic writings of Bertrand Russell. Abingdon, Oxon, England ; New York: Routledge, 2009.
Collier P. The bottom billion : why the poorest countries are failing and what can be done about it. Oxford ; New York: Oxford University Press, 2007.
The Fred Hollows Foundation. Nepal Facts, 2010. <www.hollows.org/Nepal/Facts>
Tilganga Institute of Ophthalmology. 2010. <www.tilganga.org/index.php>
The Fred Hollows Foundation. Our Programs, 2010. <www.hollows.org/Nepal/Program>
Himalayan Cataract Project. Tilganga Eye Centre, 2010. <www.cureblindness.org/what/infrastructure/specialty-hospitals/tilganga>
Ruit S, Tabin G, Chang D, Bajracharya L, Kline DC, Richheimer W, et al. A prospective randomized clinical trial of phacoemulsification vs manual sutureless small-incision extracapsular cataract surgery in Nepal. Am J Ophthalmol 2007;143(1):32-38.
Tabin G. Safety and efficacy of manual small incision cataract surgery for phacolytic glaucoma. Br J Ophthalmol 2007;91(3):269-70.
Pang T, Lansang MA, Haines A. Brain drain and health professionals. BMJ 2002;324(7336):499-500.
Mullan F. The metrics of the physician brain drain. N Engl J Med 2005;353(17):1810-8.
Smith J. Seeing the light after 40 years. Sydney Morning Herald, 2010.