The air was the hot and heavy sort common just before the monsoon. It had a peculiar mixture of industrial strength antiseptic combined with the usual village smells of blossoming flowers and rotting waste.
A man lay on a bare metal stretcher in one of the open air rooms just inside the village's hospital entrance. He looked about sixty, skin, bones and sinewy tendons, very thin, but perhaps not more so than many, if not most, of Nepal's rural dwellers. An intravenous line hung from his arm and fluids were dripping in.
He had pneumonia and two days ago it would have been fair to wager that he was going to die. But now on this day he smiled from his bed and pressed his hands together in that familiar form of greeting here on the subcontinent. He actually looked quite vigourous.
His daughter stood dutifully beside the stretcher. She had brought him a plate of rice and lentils –dahl baat – the local dish of choice that nourishes the nation twice a day, apparently in perpetuity. I noticed that there was also a bowl of meat for him, a treat, no doubt, for a sick man, and I imagine this was also contributing to his good cheer. Not going to die and now some meat to boot.
I smiled and greeted him and walked on by and out into the sunlight. Off to the horizon it was still early enough for the massive Manaslu Himal to be visible before the haze enveloped it.
The old man would live. He looked happy. This was good.
I recently received an email from the health facility manager in the small, remote, and largely Aboriginal community where I live and work when I am in Canada. We frequently exchange emails; she updates me on the happenings in our town and I send her my observations and anecdotes about life in the Nepali countryside, medical and otherwise.
The last email she sent was of the more sombre variety. Her words bluntly describe a theme that emerges over and over and over again in many communities in remote parts of Canada. It is as confounding as it is sad.
"Very heavy mental health week. Nurses are tired, and everyone is a little testy, rounds were very uncomfortable. Everyone is feeling crappy and unhappy. I understand that staff are burnt out but there have been some negative attitudes. These patients have had the absolute worst things in life happen to them when they were children and they are simply doing the best that they can and I am amazed that other health care people can't see it. I think a change of attitude on our part is the only way we will be able to help these folks (patients) help themselves."
In some ways, the remote parts of Canada and Nepal are not dissimilar and many of the differences are of degree as opposed to kind. Both regions are under-resourced in terms of essential services, including health care, when compared with their urban counterparts. Like in much of Nepal, the topography in the Canadian hinterland presents tremendous logistical challenges for transportation. Road travel is impossible in many locations and treacherous in others, offset only by the shockingly unparalleled natural beauty that functions to create such conditions. In both countries, villagers feel forgotten by the larger population centres where power and resources are concentrated.
In both countries too, many people seem to cherish the isolation when things are good. But when ill-health arises, a certain desperation accompanies it, as I think anyone would find understandable.
Nevertheless, in these two settings I notice that this desperation is of two distinct forms. One is the desperation and fear of those and their loved ones critically unwell with meningitis or pneumonia or a bad leg bone break, any of which in the remote corners of Nepal and many other parts of the world, may well kill you.
The other is the kind Tennessee Williams is referring to in the searing opening of Menagerie which starts off this essay, the kind which is much harder to address, let alone change.
When I am the doctor-on-call in Canada in our town, it is not infrequent to have the phone ring in the middle of the night. It is invariably from the nursing station. I never really mind being woken up but if I am to be candid, I always find myself hoping that the call is regarding something organic. Meningitis or pneumonia I can manage. A desperately sad and emotionally damaged person pushed into crisis by factors I cannot begin to comprehend or even fathom is a whole different story.
No one in our town in Canada has died of meningitis since anyone can remember. Plenty of people have killed themselves or have died of the drink. Deaths of human desperation.
(As a counterpoint, I have witnessed plenty of meningitis-related deaths in Nepal since I have been here. There are undoubtedly countless more in the countryside, where health care is often non-existent).
Back in Canada, some years ago an intoxicated pre-teen got into a car and drove it into the river one dark and brutal night. The next morning a group of friends and classmates, all prepubescent kids, gathered at the hospital to pick up their friend to go party some more. They were all still wasted and wanted to continue partying, even though they knew that there had been an accident –the whole town knew and the mourning had begun for many. But these kids were too far gone to realize or to process that their friend's brain matter had been scraped up and lay in a body bag in the morgue.
The untimely and horrifically tragic death was one thing. The giggling raucous party atmosphere in the hospital the next morning as a number of staff and community members tried to explain what had happened and what that meant was another issue entirely.
I remember going home later that morning and sobbing within the protective walls of my bedroom. The reaction of those children, so distorted by their messed up world and then further fueled by drugs and alcohol, will always haunt me.
That story is one of many reflecting a torn social fabric that come through the doors of that remote hospital regularly. Moreover, many of the physical ailments that seem, at first glance, to be just that, are in fact strongly infused by a mental health component. The mind-body-spirit interface is far more powerful than I could ever have dreamed of.
Every day people come. Sad and angry.
Physical needs are met in Canada, at least to a great extent. But in some communities there is a lot of anger and a lot of sadness, and I would suggest that it is not resolving. In many cases, it appears to be getting worse.
Should medicine be looking after such issues? We have done and continue to do a terrible job of it. If health care is meant to produce measurable outcomes, on this front we are failing.
Don't get me wrong. I am not one of these anti-medicine maniacs. Vaccines save lives, as do hospitals, antibiotics, and surgeons. People in Nepal literally die every day without these things.
However we must accept our own limitations and dealing with messed up communities seems to be one of them.
Perhaps how we view wellness should change. Perhaps we should return this role to the healer and the shaman and the seer.
Perhaps conventional modern medicine, so strongly informed by modern society with all its trappings, is hardwired so as to be incapable of dealing with pain emanating from the soul, that part of our being that modernity has worked so hard to crush.
Perhaps this is a societal problem that requires a societal answer.
In Nepal, too many people die of preventable illnesses. This is tragic and entirely avoidable and should be shameful not only for Nepal's government, but for people everywhere in the world who have the luxury of not sharing in these struggles.
Equally, however, it is disgraceful that in a country as wealthy and as fortunate as Canada, we who are privileged have not found a way to walk alongside our neighbours within our own borders whose desperation continues day in and day out.