In my last post, I mentioned Greg Mortenson, a modern-day hero to the people of northern Pakistan, whose story has been widely publicized. I cannot fail to also tell the story of the Pakistani doctor who is responsible for medical care in the Shigar Valley, where one of Mortenson’s schools for girls is located.
My friend, Debbie, and I walked into the local clinic on a Saturday morning. We visited because, as medical providers, we were curious about the services offered in this very remote area of the mountains of Pakistan, where there are no modern conveniences. Women wash clothes in the river, there is no running water or sewage and electricity is dependent on generators, which means the overwhelming majority of those who live there have no electricity.
We were warmly welcomed in the clinic’s outer waiting area, and an attendant, who spoke no English, hurried off to get the doctor. The physician, probably in his late 30s, invited us into his office and offered us tea. I am ashamed to say I do not remember his name, because it deserves remembering. We explained who we were and he cordially told us—his English was quite good—about his life. Notice, I didn’t say he told us about his practice. That’s because we quickly learned that the practice of medicine is his life—it is clearly not a job.
This man, the government-stationed physician, is responsible for the 15,000 people of his area and the only formally educated medical person in the Shigar Valley. His staff consisted of local people who had received on-the-job training to assist him in caring for his patient load. His wife and children live at the clinic with him, and he works every day of the year!
While we talked, his assistant brought in patients, who were totally accommodating of our presence. In their language, they told the doctor their complaints. After briefly examining them, he wrote notes on small pieces of paper, which he handed to the assistant. He explained that he was writing down what treatment to give or medicine to dispense. There was a steady stream of people of all ages coming through the door to his office. The nearest hospital is 2 1/2 hours away and inaccessible four to five months of the year, when the roads and mountain passes are closed by heavy snowfall. This doctor takes care of what he can and comforts the patients and families when all he can offer is compassion.
He kindly offered us a tour of the clinic. There were women’s and men’s inpatient wards and treatment rooms for minor surgical procedures or deliveries. There was a small pharmacy and a very basic laboratory. Furnishings were old and meager, but the place was amazingly clean. We asked him if the clinic accepted donations of medicine or medical supplies. No, he said. Needs of government clinics were provided for by the Ministry of Health, and they were specifically forbidden to accept any outside assistance.
Undoubtedly, there will never be a book written about this man, but he is also a hero to the people of northern Pakistan and another fine example of what one person can do. I really wish I could remember his name.
For Reflections on Nursing Leadership, published by the Honor Society of Nursing, Sigma Theta Tau International.
For diplomats, travel within Pakistan is severely limited. However, the far north region remains secure and, outside of the snow months—November to March, visiting is entirely possible, though not entirely reliable.
It is a one-hour flight from Islamabad to either the northern side of the Karakoram mountain range of the Himalayas and the green Hunza Valley, or to the eastern side of the range and the stark gray beauty of the Skardu and Shigar Valleys, and the raging Indus River. Booking a flight in either direction is easy. Getting on the flight, or getting on a flight back, is the challenge. The planes fly into and out of these valleys by visual means only and, in these high mountains, visibility changes from one hour to the next. I’ve had many colleagues who were stuck on one side or the other for several days, unable to return until the weather cleared. I was never that fortunate.
Both of these areas draw mountain climbers from all over the world, although the security situation in Pakistan has hurt the sport tremendously since 2001. These are not classic tourist areas. There are comfortable—though basic—places to lodge, the air is crystal clear and the food is hearty, although it would not be termed cuisine. Hikers can safely backpack to remote locations and camp and, while very little English is spoken, local people are adept at understanding what a visitor needs and are always willing to assist.
It was on a visit to the eastern side and Shigar Valley that my friend Debbie and I came upon a little school building with a yard full of happy, giggling girls. This tiny village doesn’t see many visitors and the girls were extremely excited by our presence. The head teacher welcomed us to the school and offered a tour. So, in and out of the neat little classrooms we went, looking at artwork and taking note of writing exercises on the blackboards and completed math pages. One young girl offered to read to me from her English book, so we sat on the steps as she expertly read a story. I noticed a photo on the desk of a Western-looking family who, the teacher explained, was the school’s benefactor. It was only later that I understood the significance of that photo.
If you have not read the book, Three Cups of Tea, please do. It is the story of Greg Mortenson, an American RN and former mountain climber who saw a need in the mountains of Pakistan and made it his life’s work to educate the illiterate children, especially girls, of the northern regions. It was one of Mortenson’s schools that my friend and I visited that day, and it is one of the most meaningful memories of my time in Pakistan.
Mortenson’s foundation, Central Asia Institute, strives to promote peace through education and by improving the place of girls in society. In November 2009, Mortenson was awarded the Archon Award by the Honor Society of Nursing, Sigma Theta Tau International at its 40th Biennial Convention. I have read that he has twice been nominated for the Nobel Peace Prize, an honor he surely deserves, as he has more than answered the age-old question, “What can one person do?” As one person, Greg Mortenson has created miracles and changed lives, and is an American hero in Pakistan.
Additional resources:
Convention highlights—Monday, 2 November. (2009). Reflections on Nursing Leadership, 35(4). Retrieved 15 March 2009 from http://www.reflectionsonnursingleadership.org/Pages/Vol35_4_FTS_Convention_day3.aspx
Today was a beautiful, sunny day—a real treat during this mostly gray-skies time of year in Prague. I took the opportunity to hop a tram, followed by the metro, to go to a distant shopping area and explore that vicinity of the city.
Before I joined the Foreign Service, I spent my entire life in southern United States. Mass transit really doesn’t exist in the South, other than a rather limited system in Atlanta, so being involved with some of the world’s largest and most sophisticated mass-transit systems has been of real interest to me, both in technology and in the culture of mass travel.
Most of my metro/tram experience has been in Europe, but I was also a frequent rider of the Mexico City metro, while serving in that post. Frankly, most of my colleagues wouldn’t ride the Mexico City metro, for fear of pickpockets or of being squashed to death. The latter was a real possibility, as I quickly discovered one rush hour when I witnessed a young woman trying to exit the train and be literally picked up by the oncoming rush of people and pushed back into the car. I hoped she was able to get off at the following stop.
My favorite thing about living in Moscow was the metro system. This system is HUGE! It is dependable, inexpensive and has the most artistic stations I’ve ever seen. I spent many weekends just traveling the metro and taking pictures of station decorations, which was strictly forbidden but not enforced. There are tours of the Moscow subway stations—I took one just to learn more about the history—and coffee-table picture books of the most ornate.
The culture of mass transit in Moscow is interesting. There is a set etiquette for travel, and it includes being straight-faced and, preferably, quiet. If one must speak to another passenger, it is to be done at a whisper and as quickly as possible. And one should never ever smile, nod or make eye contact with other travelers.
In contrast is travel on the Rome metro, where jabbering travelers might be entertained by a fellow commuter(s) who breaks out in song—usually opera—for a few minutes, and then finishes to raucous clapping. While Rome stations are not particularly ornate, in comparison to Moscow stations, their displays of Roman antiquities are a real plus.
In Bucharest, I sometimes traveled on the new and modern metro, usually with only a few other passengers. The line is rather limited, but so expensive that most people couldn’t afford to travel. Sure kept those cars clean and shiny, though.
In Budapest, the stations were underground shopping malls with food courts, stores, flower shops and travel agencies—sort of one-stop shopping while going to or from home. I mostly used the trams in Budapest, and I don’t think I was ever on one that wasn’t standing-room-only, which became an issue when tram police jumped on to check tickets. People without tickets would start pushing to the other end of the car, hoping to get off at the next stop before getting caught and fined. It was great entertainment, if I could get out of the way.
The metro and trams in Prague are modern and quite utilitarian, and the system is widespread. The most important thing is, they are punctual with a great frequency schedule. Unlike our neighbors to the far northeast, people happily chat and smile at each other, though not so much to strangers. On my tram ride back home today, our car was serenaded by a group of three young men—visiting Italians!
For Reflections on Nursing Leadership, published by the Honor Society of Nursing, Sigma Theta Tau International.
I continue to visit medical and dental clinics in Prague, as required by my Washington superiors. The purpose is to know options for care that are most in line with our American medical philosophy. This information benefits Americans who work here in an official capacity as well as visiting Americans who call the consular office for our list of medical consultants. I’ve had the opportunity to hear interesting stories along the way, and I frequently find the unexpected.
From 1948 to 1989, the Czechs were under a communist political system. One practitioner I know completed his medical education in Prague in the late 1960s and then defected to the west, eventually ending up in Canada, where he practiced for more than 20 years. He returned to Prague a few years ago to work and reclaim the home of his youth. His story is fascinating as he tells of his struggle to learn English, pass the medical examinations required in Canada and begin a life completely cut off from the rest of his family, who remained in what was then Czechoslovakia. He made huge sacrifices to live a life free of political domination.
I met a physician born in the United States to Czech parents, who defected from communism. He completed his medical education around the time the Czech Communist Party was abolished and decided to come to the Czech Republic to help build the new medical system. He has spent the last 20 years with his foot in both societies. He has a practice in Prague and maintains an attending staff position at an Ivy League teaching hospital in the United States, working at the U.S. location several times a year. Medical residents from the U.S. program have the opportunity to rotate through a linked curriculum he administers in Prague for an overseas study semester.
My young dentist in Prague is an American who married a Czech woman. They met in the United States, where they married, lived and worked but, when their child was born, they decided to move to the Czech Republic to be near her parents. His story is equally interesting because it is the reverse tale. Although he wasn’t escaping a totalitarian government, he did have to learn Czech—a very difficult language—to pass the certifying and licensing examinations. In fact, he was the first English-speaking dentist to achieve licensing in the Czech Republic. And, of course, he had to adapt to a very different medical environment. He has great stories to tell about his experiences; in fact, they all do. Meeting these interesting people and hearing their histories is one of the most interesting parts of my job.
For Reflections on Nursing Leadership, published by the Honor Society of Nursing, Sigma Theta Tau International.
I live in a computer. At least, that’s what my 18-month-old grandson, Price, thinks. Yesterday, my daughter in Orlando sent me a precious video of Price standing in front of the computer monitor, pointing and saying, “Nana!” It is there, in that small square, that he sees me the most. I play tickle with him by waving my fingers at the webcam and blowing kisses his way. He leans in to hug the monitor and then looks confused that it looks like me, but isn’t me. I want to reach out and grab him, but we aren’t at the “Scotty, beam me up” phase of our scientific progress yet. Webcam is definitely the next best thing.
Living overseas has many challenges. Maintaining a family life with those in the United States is one of them. When I joined the Foreign Service in the late 1990s, technology—especially communication technology—was still very basic. There was email, of course, but no Facebook, blogs, webcam or Voice over Internet Protocal (VoIP). The special-occasion phone calls were very expensive and mail (via the U.S. diplomatic pouch system) was slow. The only thing that has remained the same is the pouch.Another significant change for me is my family framework. During the early years, my four older children were all single and in university. They didn’t have much time to communicate and, frankly, not a lot of interest. If I managed to talk to them every other month and saw them once a year, that was OK. We were all busy with our individual lives and, because my youngest child was with me overseas, I still had a family core.
Then, in quick succession came the weddings, followed by the change that rocked my world—grandchildren. The birth of each little boy—there are seven now—tugged my heart a bit more and, I believe, gave my grown children a different perspective about staying in closer touch with me, too. The difficulties of frequent communication became more apparent to us all, and while webcams had become available by then, I didn’t have computer access that could support one.
When I moved to Islamabad in 2006, I could finally sign up for VoIP and use a webcam. My then youngest grandson, Trevor, who previously would have nothing to do with me on home visits because I was a stranger to him, learned who I was and would happily babble to me over the Internet. Now, when I would visit, he came to me easily. When my next grandson, Caden, was born, he grew up seeing me on webcam and never viewed me as a stranger at all. His mother would announce as I was leaving from a visit, “Nana is going back into her box!” and the transition was smooth. Little ones are amazing like that.
I fully understand how much this advance in technology has helped me stay satisfied with my Foreign Service career and life out of the United States. I feel like I am part of my children and grandchildren’s lives on a more personal level and, as a result, any guilt I might have of choosing to be so far away is largely assuaged. It is a tough choice to move to the other side of the world from one’s family and friends. I am very grateful to have the benefit of technology to bridge the distance.
For Reflections on Nursing Leadership, published by the Honor Society of Nursing, Sigma Theta Tau International.
The snow has been falling intermittently in Prague for two months. The streets and sidewalks are rife with patches of ice that threaten all who trod there. I’ve been doing quite a bit of slippin’ and slidin’ myself, and I’ve had a number of patients come to the medical unit that have been injured from falls. Some have been referred to our local emergency departments or orthopedists for treatment.
This brings me to the topic of pain and, more precisely, pain control. Americans, probably more than any other society on earth, are interested in pain control. We don’t like to hurt, and we believe that unnecessary pain is a violation of our human rights. We have laws that govern pain control measures, and we have developed pain measurement scales to assist providers in properly assessing the level of pain or pain relief.
Many other societies accept pain as incidental to injury and, while they may offer measures of relief, they are not committed to pain eradication whenever possible. Of course, there are many areas of the world where pain medication just doesn’t exist, or it is reserved for the truly severe cases, so pain tolerance is expected.
I’m discovering that the philosophy in the Czech Republic, as in much of Europe, is that pain is to be dampened by using the most moderate means available. That usually means no narcotics. Europeans love NSAIDS (ibuprofen-type medications) and are really slow to suggest narcotics. They also rely on nonpharmacological methods such as ice, heat, breathing techniques, muscle relaxation, music, massage therapy, and the list continues. These important adjuvant measures are used in the United States, too, but usually not for short-term or immediate pain control.
In West Africa, I took a patient with an injured leg to the local emergency department. The X-ray showed a displaced fracture and the orthopedist was called to do a closed reduction. I asked the doc, “What are you going to give her for pain?” He looked puzzled for a moment, then turned to the nurse and said, “Please prepare some tea!”
A very quick and tense conversation followed regarding pain control in this patient, who was now terrified as well as hurting. It was finally decided that I would scurry to my clinic to bring an appropriate pain medication to the hospital for my patient, as all the doc could provide was an NSAID. My patient had pain medication prior to the closed reduction and casting and, while the procedure was still a bit uncomfortable, she did quite well. Oh, yes. She also had tea!
For Reflections on Nursing Leadership, published by the Honor Society of Nursing, Sigma Theta Tau International.
How, you might wonder, do I manage a patient with a medical problem that can’t be handled at my post? This is actually quite common at many embassies and not just those with poor, local medical care. Some very modern places in the world do have a medical viewpoint that is culturally different from Americans and, when necessary, we medevac to a location more in keeping with our standards or expectations. Of course, the majority of medevacs are for conditions that cannot be medically treated due to lack of appropriate local resources.
The type of medevac depends on the patient and the problem. Sometimes, the patient travels on commercial transportation alone, sometimes with a non-medical or medical attendant and, in the most severe circumstances, we call in an air ambulance. During my career, I’ve had patients who have required each kind.
You might think that the person who is able to travel alone would cause me the least angst, but that isn’t a given. Consider the mid-40s gentleman who, after six months of feeling not quite right, was evaluated by his family doctor while in the United States on leave. A chest X-ray was suspicious and a CT was ordered but, before the report was sent, he returned to post in Kabul, Afghanistan. This gentleman brought a letter into my clinic that had arrived via DHL.
The letter started with “Take this to your medical provider immediately” and, as I read, I saw the term “dissecting, ascending aortic aneurysm.” These are not words a nurse practitioner wants to read, ever, but particularly not in the middle of a war zone with limited options for emergency care. After many phone calls of consultation, the decision was made to fly the patient back to the U.S. for surgery—on regular transport. Imagine both my surprise and relief when I received a message some 30 hours later that the patient was at Duke University Hospital prepping for surgery after an uneventful flight.
The only case of Guillain-Barre I’ve ever seen occurred when I was serving in Conakry, Guinea. While my patient’s ascending paralysis was making its way up his torso, I was calling in the air ambulance. Unfortunately, air ambulance support to a remote place like Conakry can take a lot of time and, in this case, more than 24 hours. I moved the patient to the hospital nearest the airport where there were people—but precious little else—to help me take care of him. The internist overseeing the patient’s care moved the anesthesia machine into the room in case he required respiratory support, as there was no ventilator in the hospital. But, much of the time there was no electricity in the hospital either, so an Ambu bag was brought in as well!
After we settled the patient in the room, the internist brought in a candle and a tape measure. He proceeded to measure 18 inches out from the patient’s mouth, then lit the candle and asked the man to blow out the flame. He did. This, the internist said, was proof that his pulmonary function was adequate. As long as our patient could blow out the candle each hour, we would not have to intubate (put in a breathing tube). Every hour, for the next 20-plus hours, either the internist or I dutifully lit the candle and our patient dutifully blew it out. By the time the air ambulance arrived, my patient only had use of his head, neck, shoulders and upper arms, but he could still blow out the candle! I have no idea if this procedure is actually founded in good science, but I can tell you that this hourly exercise was immensely calming both to my patient and me during an otherwise very scary situation.
When the flight crew arrived and I reported off, I couldn’t help but notice the confusion on the face of the attending physician when I explained that our patient had been able to extinguish a candle flame at 18 inches throughout our wait for the air ambulance. I’ve tucked this little pearl of information into the recesses of my brain, in case I’m ever in a similar circumstance and need a rudimentary means of assessing respiratory effort. I’m happy to wait.
For Reflections on Nursing Leadership, published by the Honor Society of Nursing, Sigma Theta Tau International.
In my last post, I mentioned Greg Mortenson, a modern-day hero to the people of northern Pakistan, whose story has been widely publicized. I cannot fail to also tell the story of the Pakistani doctor who is responsible for medical care in the Shigar Valley, where one of Mortenson’s schools for girls is located.
