by Britta Das
I grimace, thinking of our private sports clinic back home. We were six therapists working together in the same building with several orthopaedic surgeons. Our huge treatment room was bright and always spotless, with different types of gym equipment and twelve beds. Our patients were either athletes or very active students and professionals, mostly fit and trim, popping by for their treatments before or after work. Our equipment was state of the art, with distributors coming regularly, trying to sell us the very latest machines.
Again I look at the prehistoric ultrasound machine. Here, I cannot even count on steady electricity to make whatever we have work.
Yet the heavy reference textbook I have brought with me from Canada reminds me that the biggest difference will be my role as educator here. At home I was considered more of a junior therapist, having had only two years of work experience. During assessments and treatments, I used to confer regularly with my colleagues. Now I am the one who is supposed to be giving advice. Was I overconfident in coming?
Pema arrives at 9:30 a.m. with a shy, apologetic greeting.
“Good morning.” She smiles. “When did you reach?”
I have to chuckle. “At 9:00 a.m. when our duty time started.”
My innocent hint is gracefully overlooked, but Pema offers an explanation. “Nima is sick, and so I am late.” Obviously, the topic of tardiness is of little concern.
I decide to press a little about her son’s illness. “What is wrong with Nima?”
“I think he has a cough. He didn’t sleep last night.” Now I notice that Pema herself has dark rings under her eyes. “Actually, he never sleeps at night. He always wakes up, then I have to play with him. Otherwise he will cry. Sometimes, he doesn’t sleep until morning.”
“How old is Nima?”
“He is almost one,” Pema replies proudly, but then a shadow seems to settle on her face. “But he does not know how to crawl or stand. Sister, what do you think?”
“I—did any of the doctors look at him?” Thinking about Nima’s slow, writhing hand motions, the first thing that comes to mind is cerebral palsy, but I am afraid to pronounce the name of such a dire long-term prognosis. “Did something happen to him?” I ask instead.
“He was okay at birth, I am sure. But we had a very bad babysitter, you see. Maybe she let Nima fall. I am always so worried when I leave him at home.”
Absent-mindedly, Pema strokes the blue sheet on the treatment bed. “I want to take him to Vellore,” she says, turning to me with a desperate look in her eyes.
I nod. I have no idea where or what Vellore is, but it seems to mean a lot to Pema.
“Do you think he will walk?” Pema’s question is hesitant, yet lined with a trace of hope.
“I don’t know,” I answer honestly. “Why don’t you bring him here sometime?”
Pema seems to consider my question but then shakes her head. “Actually, I want to bring him. But Nima is so heavy. And now, in the rain, he will get wet. And who will look after him all day? I cannot take him back in the middle of the day.”
Now I feel guilty for my thoughtlessness, but Pema smiles at me. “I think now you are here, we will make many changes in physiotherapy. It will be good. So long I was asking for two rooms. Now you are here, and already we are getting an exercise room. That will be very good for patients, isn’t it?”
A couple of nurses stick their heads through the door and exchange a few words with Pema in a foreign tongue.
“Welcome, sister!” they greet me and immediately the now familiar question follows: “How do you like Mongar?”
I smile and nod, still searching for an appropriate answer. “Please come for tea, sister,” they invite, and in leaving call a few more words to Pema. Grateful for Pema’s fluent English, I turn to my new assistant and ally.
“How many languages do you speak?”
“Sharchhopkha, Dzongkha, Nepali, and Hindi. At home with my parents, I speak Sharchhopkha. Most of our patients also speak Sharchhopkha. I will teach you. And we will go to see my parents in Bargompa. You will like it there. It is like real village. But you must speak Sharchhopkha. You know ‘Kuzuzang po la,’ isn’t it?”
“Ku zoo zang poo la!” I repeat, and we both laugh.
Together we continue the survey of our room. The cupboard resists all attempts at opening until we fiercely bang against the sliding door. Once open, we are greeted by a wild mess of blankets, corset-shaped elastic back supports, various slings, a tub with black grease, a new white bed sheet, another supposedly temperamental ultrasound machine, a box with all kinds of screws, toothpicks, clasps, spare parts for machines that are long gone, and a pile of telltale mouse droppings. Most of the supplies look ancient and must date back to a time when Mongar Hospital was established and then run for twenty-odd years by the Norwegian leprosy mission.
Pema explains that a few years ago the mission left, and Mongar Hospital was turned into a general hospital managed by the Bhutanese government. In January of this year, it was officially upgraded to become the Referral Hospital for Eastern Bhutan.
We examine a decrepit exercise bicycle and a pair of crutches with missing rubber tips.
“We have many more crutches, but I cannot use them. They are in storage room. When the mission goes, they leave us all crutches.” Pema points in the direction of a building above my classroom. She then proudly shows me her collection of bandages that have been given to her by the operating nurses. “I keep them here, just in case,” she explains.
Morning rounds on a typical day in Ward A at Mongar Hospital.
Our tour ends with a close inspection of the appointment book in which she records who the patient is, whether he was an inpatient or an outpatient, and what the diagnosis and treatment were. Overall, her records are meticulous and I am well satisfied.
One thing that begins to bother me immediately is the number of spectators that soon assemble in front of the physiotherapy rooms. Judging from the number of faces staring through the open windows into our physio room, I must be a rare breed of Homo sapiens. Feeling none too self-conscious, patients and visitors who are on their walkabouts of the courtyard stop and gawk at me intently. Every inch of me is scrutinized. They study my blond hair, my pale skin, my skirt, my shoes, my gestures, my speech. They nod in my direction or point at something. A few talk to Pema, others just silently stare. I would not be surprised if someone said that they were counting my breaths per minute.
Clusters of schoolgirls whisper and giggle, turning away shyly if I return their gaze. Occasionally, I hear the words phillingpa (“foreigner”) and doctor. Pema takes pity on me and asks them to leave. Still giggling they retreat, only to be replaced minutes later by another group of curious spectators.
After a couple of hours, I crave anonymity. I want to have black hair and dark skin. I promise myself that from now on I will wear only kiras. I will learn Sharchhopkha and I will fit in. Soon. Nevertheless, for now, I want to shut the doors and windows, and I want the patients in the hallway to stop staring. With much difficulty, I continue smiling.
By the end of the day, the room has received a facelift. All surplus furniture and equipment have been shoved into the hallway for removal, and the exercise room shines with a fresh coat of paint. The floor is swept and mopped, the dirt having been effectively wiped from one corner into a new one.
The windows remain open; I try not to notice. By three o’clock I am exhausted. Pema, in a hurry to get back to Nima, leaves me to close up the department. The crowds in the hallway have not yet dwindled, and without Pema I feel stripped of all self-confidence and fully conscious of my every move. Like a model on the runway, I slowly tiptoe home.
The next morning, when the monsoon rain pelts down in heavy downpours, and Pema again fails to arrive at nine o’clock, I join the doctors on their morning rounds. Dr. Lhendup, a general doctor in charge mostly of outpatients, seems like a jolly fellow. He looks sincere and is full of conversation. Reviewing the patient’s chart, he wrinkles his foreh
ead in concentration and then talks rapidly in Sharchhopkha.
Dr. Kalita, the orthopaedic surgeon, is a newcomer to Mongar, having been transferred here shortly before I arrived. Originally from the state of Assam in India, he completed his medical education in Scotland and is now one of the leading orthopaedic surgeons in Bhutan.
Dr. Shetri, the dentist, is a short, energetic man. His mastery of the local language seems to be in its infancy, but while constantly cracking jokes, he tries his best to communicate with his own mixture of Nepali, Dzongkha, and Sharchhopkha. Surprisingly, he also takes a very active role in the diagnosis and evaluation of the patients. Obviously, his medical knowledge is not limited to teeth alone.
The DMO is an eye specialist and, when not called away by administrative duties, joins our little team off and on.
Dr. Bikul, a young Indian general doctor, seems preoccupied with his cases and keeps disappearing to his outpatient chamber.
I am told that there is also a medical specialist, Dr. Pradhan, and a gynaecologist from Cameroon, Dr. Robert, both of whom are on leave at present.
The matron of the hospital, a short, compact woman with a determined attitude, pushes a little yellow cart containing all of the patient charts through the wards. There are other nurses as well, all dressed in white kiras with little caps on their heads. They take off bandages, comment on the patients’ condition, and get the necessary charts ready. One round of the hospital includes five main wards and a few private or semi-private cabins. Wards A and B are for females and children, C and D for males, and there is a separate ward for patients with active TB and leprosy. In total there must be about sixty beds, give or take a few; overflow patients are bedded on mattresses on the floor as needed.
Quietly, I follow the little procession of doctors as they make their way through the wards. Most of the diseases presented here are unknown to me, and I am unsure of the patients’ source of suffering. In addition, none of the patients are addressed in English, and my grasp of the local language is far too sparse to understand anything. Yesterday I learned that lekpu means “good” or “better”; mangi or mala are forms of “no”; phaiga means “at your home”; and pholang means “abdomen”, a word I hear frequently used. It seems that a large number of patients suffer from some sort of stomach trouble. On the charts, I read other foreign-sounding diagnoses: osteomyelitis, viral encephalitis, chronic malaria, typhoid, abdominal tuberculosis, leprotic ulcers, grade three malnourished. I have entered a world of medicine unknown to me.
In the wards, I have difficulty separating patients from attending family members. More often than not, two or three people sit on one bed. Like their attendants, patients are dressed in everyday clothes. There is no sign of pyjamas or hospital gowns.
The thick hair of both men and women is short, at times spiky, dust and oil turning into a natural hairspray. Everyone wears a certain amount of grease and grime. Many lips and teeth look as if they are bleeding, permanently stained by the juices of betelnuts mixed with lime. Clothes are smudged and tied carelessly, often well worn to the point where the material is hanging on by merely a few thin threads. By far the most remarkable attribute is the patients’ feet. Disproportionate to their short stature, their feet are huge, with round stubby toes and unkempt nails. The soles are covered by a thick layer of dirt that has grown deep into the chaps and cracks of a lifetime of barefoot walking.
The general lack of cleanliness has rubbed off onto the surroundings. The blue hospital sheets are stained, and often a kira is used instead of a blanket. The yellow and white walls are spotted with mud and mildew, and the windows are faintly tinted by a covering of dust. Despite the screens, thousands of flies populate the hospital, crawling over beds, people, and food. Although I had mentally prepared myself for a certain lack of hygiene, what I see worries me deeply. Garbage litters the corners, and patients readily dispose of bloodied bandages, plastic bags, or food scraps under the beds. I think of the flies crawling over everything and then looking for a hatching place for their eggs. As we continue along the rows of beds, my stomach twists into a tight knot and my knees begin to wobble. Shocked, I try hard not to avert my eyes.
Privacy is not a concept practised or valued, and the metre of space between beds is hardly enough to keep neighbours from actively observing every detail of an examination. Many patients wear a look of dull surrender, a blank stare that seems to reach beyond the hospital walls, yearning for the world outside in the hills. Yet it is not an expression of suffering, but rather of resignation or disbelief. There is no questioning and often no response. What goes on inside their minds is hidden to me.
How would I feel if I had to lie in one these beds, lined up in a row, with no curtains and no dividers? What would it be like? A nightmare, no doubt. Everyone in his or her street clothes, looking dirty and smelling accordingly. As we continue our rounds, I feel a mixture of pity, sadness, and anger. The patients’ obvious lack of education and often innocent ignorance tug at my heartstrings.
A few people are introduced to me as my patients. A girl with a severe burn scar and a damaged knee is disabled and confined to her bed. An old man who is in the hospital for the treatment of his eye infection complains of a painful, stiff shoulder. A boy in a coma with malarial encephalitis has been paralyzed for several days. An old diabetic woman who has recently undergone a below-the-knee amputation for a gangrenous leg needs to get out of bed.
I try to smile at everyone, although my rebelling gut has sucked out my confidence. How will I ever treat these patients in our little two-room department with the fancy title “Physiotherapy”? I look at the faces and see only tragedy. I reach out to greet a patient and meet the eyes of accepted suffering. The poverty, the dirt, and the diseases overwhelm me. My heart cries, and my boldness plummets. If I can help any of these patients even a little bit, it will be a small miracle.
6
Lhamo
At first, I see only a small, wrinkled face with a lovely smile peeking around the corner. My desk in the physiotherapy room is set back beside the door frame, and so the next thing I can see from this vantage point is a pair of thin, bony legs floating a few inches above the ground. Then the figure of a tiny lady, and lastly Lhamo, who is being carried by piggyback into the treatment room.
Baffled, I stare at the surprising appearance of mother and daughter. Though Lhamo is as thin as a beanstalk, she dwarfs her mother, who stands at no more than four and a bit feet tall. At thirteen, Lhamo’s shoulders are several inches wider than the ones carrying her. It seems impossible that the petite lady does not buckle underneath her heavy load. Yet there she stands, steadily balancing Lhamo on her back. She even manages to untangle one of her arms to point at the bed beside me.
I snap out of my stupor and quickly pilot them inside the room. We manoeuvre Lhamo onto the bed, and there she stays lying in a fetal position, nervously staring at me. I try to make her feel comfortable by talking to her in English as soothingly as I can. My efforts are rewarded with a shy, uncomprehending smile.
A few moments later, Pema enters and tells me that she has called Lhamo for treatment. Confused, I ask if they do not have a wheelchair. Pema explains that Lhamo’s mother is used to carrying her daughter, and it really is no problem. Of course this is a problem, I think, but for now I keep my thoughts to myself and take out an assessment sheet.
Pema pulls up a stool beside me. The main goal of my stay in Mongar is to teach Pema as many of my physiotherapy skills as possible. Through her training as an assistant, she already has some basic knowledge of anatomy as well as physiology, but her treatments are based solely on a cookbook approach of using a diagnosis made by the doctors as her prescription. During my year in Mongar, I will try to help her become more independent in assessing and treating patients. For the first week, we have agreed that she will act as a translator and watch what I do.
My pen and paper poised, I am ready to take Lhamo’s history. Lhamo’s mother, however, is not ready to give it. In an unin
terrupted torrent of words, she talks to Pema in Sharchhopkha. When she finally finishes, I ask Pema the meaning of her outburst.
“She wants to know will Lhamo walk again.”
A little exasperated, I ask what else she said.
“Nothing,” Pema replies and turns back to Lhamo.
Over the better part of an hour, we patch together Lhamo’s history. Lhamo’s family comes from the district of Trashi-Yangtse, from a small village two days’ walk from the main road. Like most villagers, her family has lived on the same farm for generations and produces a small crop on a bit of land. Lhamo herself has never attended school.
According to her mother, five or six years ago Lhamo fell over a pot of boiling water and burned the back of her left leg. It healed, but since then she has had a severe scar from the buttock right down to below her knee. One year ago, a knife injury damaged her right knee, and now it is stuck in its present position and hurts.
The details and dates of this story vary from what the nurses told me, and on further repeated questioning of Lhamo’s mother, the injuries now range anywhere from eight years ago for the left leg, and three years to a few months back for the right. It seems pointless to harp on a detail that obviously does not hold priority in their lives, and we move on, marking the category “Time of onset of injury” with a big question mark.
What does become apparent, though, is that this second injury has caused much hardship for Lhamo and her family. Since the trauma, Lhamo has not stood or walked. Confined to her bed all day, Lhamo is carried outside by her mother only to urinate or defecate, or, occasionally, to have a wash.
They have tried several “treatments.” The village lama has come to hold many a religious ceremony called a puja. Her family has prayed and made offerings for a quick recovery. No result. They brought her to the hospital, and the surgeon at the time tried to lengthen her burn scar to allow the leg to extend completely, thereby making weight-bearing possible. No help. Different doctors subsequently tried the same operation. Unfortunately, the resulting fibrosis and immobility in bed only made her stiffer and, in the end, the leg seemed the same. A team of Australian plastic surgeons came for a visit, but they too shook their heads in regret. There was nothing to be done.
