Reflecting on this experience in Nepal thus far is difficult because I have experienced so much. Looking back it feels like we left the United States months ago, but it has not been two weeks yet! Coming to Nepal after working for four years in healthcare through the pandemic and aftermath of such I did not know what to expect for the healthcare system here. What I did know was that there was and is a lot of things that I am unhappy about in the United States process of delivering healthcare. I think this jaded, burnt out attitude that I had towards the US assisted me in contrasting the two systems from a different angle. 

The cultural influence on healthcare in Nepal is striking. Although I had done some research on the system and hospital, I was still shocked by the shared room and small spaces that patients stayed in. The voices of US patients complaining about a curtain separating their double room from a neighbor rang in my ears. Instead of complaining, demanding, or yelling about the ten+ other patients and families being taken care of in the same room, I saw a community be formed. While there is a rare situation in the US where a double room creates a friendship, these mass rooms expected community. When a patient family member was out to get food, the next bed over would assist in helping the patient stand up. When doctors came to round on patients, other family members from the room would peek over the shoulders and listen into conversations.  While initially it was uncomfortable to discuss patients’ cases, administer medications, or change dressings with so many spectators; I was soon able to see them as not only onlookers but supporters in a way of their neighbor. I found they were willing and able to help if needed as a part of the room’s community. 

While it’s strange to initially understand why family members are so crucial to the bedside care of these patients, it becomes more clear when learning about resource poor healthcare settings. Because bills are truly itemized unlike in the states, families are expected to feed, bathe, assist in toileting, and grooming of the patients. They are also expected to supply the items necessary for these tasks, often from the shops outside the hospital gate selling different hygiene products. In this way, the hospital can lower costs and families can control the amount they spend on a variety of items. 

In shadowing the nurses I also saw them advocate for resource saving practices. On my first day in the hospital the nursing students were excited to see if I really knew how to do a dressing change. I assured them that I had done plenty back home but would love to watch them first. When my student pulled out a sterile tray I immediately shook my head affirming that maybe I had never done dressing before.

Instead of individually packaged gauze and cleanser, the process of a dressing change was delicately done with forceps and a hemostat, dunking cotton into sterile water to cleanse the area. Then delicately placing the previously counted gauze onto the wound. The students were diligent in the amount of gauze and cotton they used because each pair of gloves and additional dressings would be written in a charge book for the patient to pay for. 

While the hospital didn’t have resources to simply throw around either, I saw tests being ordered incredibly conservatively as well as diagnosis being made with minimal imaging results. While these providers may prefer a wider range of results and differential diagnosis to rely on- they have to consider what is available in the hospital and what the family can afford. It truly is a continuous ethical dilemma; balancing what the patient can afford with giving beneficent and honest care. Often patients were given the choice between paying “X” amount for a treatment that may or may not work or going home to an inevitable demise. The latter was often preferred. 

Working simply alongside the nurses, it was shocking to me to compare how much waste they produced in a day versus me in a day at work. While I may put on a pair of gloves one or more times per room, the Nepali nurses focused much more on proper hand washing between patients. Often if a bit of crumbs or water spills on a patient’s blanket, I throw it in the wash and get a new one while here, we dust the crumbs off or straighten the blanket; there’s no need to make extra laundry in those situations. While the intention behind this conservation of resources is cost and supply chain effectiveness, it is also good for the environment here that doesn’t have a developed waste services system. This process of saving and not overusing is a concept that I will be implementing into my practice back home and wish could be somehow reconciled with our system.

It has been prevalent the ways that spirituality and culture intersect with the way that the Nepali people work through the healthcare system. There are Christian staff members at the hospital and often foreigners are labeled as Christian. I think this is reflected in the way that people receive care. The system of contrasting the different spiritual beliefs and diverse culture sets is incredibly complex and I will not come close to understanding it at the end of this trip. For now I am working to recognize not only people’s actions but to ask about intention and try to learn where people’s heart is set.

I am incredibly grateful for this experience so far and the unmatched hospitality I have been shown. Reflecting on what I have seen and learned will be a months maybe years long process. Right now I am learning to slow down, conserve, see beyond my peripheral, and show endless respect.