CHRONICLE. Three times Henrik Sjövall has had the privilege of visiting the Patan Academy of Health Sciences, a faculty of medicine founded by Dr Arjun Karki, which hopefully will provide the Nepalese countryside with doctors. When Arjun recently made a quick visit to Gothenburg, Henrik took the chance to show him a hospital, university and an island community to which he is proud to belong.
Many years ago, I was invited to a dinner engagement at the Himalaya restaurant in Östra Nordstan. The reason for this was because a Nepalese group was visiting to organize student exchanges with Nepal, and since I have ultimate responsibility for the degree project work of our medical students, I thought I should go over and say hello. It was getting late, and I was sat with one of the Nepalese party who spoke fairly poor English. He asked me a bit about my family, that kind of thing, and I explained that I lived on Donsö in the Gothenburg South archipelago, and about life out there. I didn’t think he understood that well, but I noticed that another man in the group was listening intensively. When I finished, the other man joined in the conversation, saying in much clearer English: “This community you describe reminds me a lot of my homeland, Nepal. I think you should come and visit us!”. The man was Arjun Karki.
Who is Arjun Karki? He grew up in a poor farmhouse up in the mountains, and his parents did all they could to give him a good education. The farm didn’t make a lot of money, so his father enlisted in the army, sending him money home from Burma, where he was posted. Arjun worked hard at school and gained entry into medical school, but he would never have been able to manage financially without the support of a patron, a Swiss benefactor who he had got to know. One day, he decided he wanted to become a researcher, which included spending a short period of time as a PhD student in Lund, but he decided he want to become a clinician, and so with the help of his patron, and scholarships, he was able to train as a pulmonary physician in the USA. He then returned to Nepal, establishing two faculties of medicine; most recently the Patan Academy of Health Sciences which I wrote about previously in Akademiliv. He currently fulfills two distinct roles, spending half of his time as an intensive care physician in a private hospital, and the remainder as an advisor on medical issues for the Nepalese government.
Arjun Karki liked what I told him about our community and just six months later I was invited to visit Nepal, an unforgettable visit, about which I wrote previously in Akademilivskrönika. I subsequently returned twice more, once in a private capacity, and once in order to review their examination system for entry into medicine. After these visits, I understood what Arjun had meant when he saw similarities between the community in Nepal, and the local community out on Donsö. The uniting factor, in fact, is a special type of resistance to stress, which was demonstrated, among other things, in how his community managed the earthquake disaster.They have a well-functioning social framework, parents usually take care of their children, most marriages last, despite the fact that many people are forced to go abroad to work, the children try to take care of their elderly parents who often remain up in the villages in the mountains, and people work or potter around, trying to do that which needs to be done. And the religion, a variant of Hinduism, is still taken very seriously; the people take part in various events, including countless festivals. A striking example of this was a procession, where the villagers mourned for those who died during the earthquake.
During my visit, I also had the opportunity to gain an insight into the medical faculty founded by Arjun, Patan Academy, a medical school explicitly intended to train doctors to serve in small hospitals up in the mountains. I also had the privilege of visiting one of them – Amppipal – and was greatly impressed over the high level of care they were able to provide for an apparently low cost.
I was also entrusted to review their examination system. The examination system was approved with significant plaudits – I concluded that only a minority of our own medical students would have been able to pass the very tough final examination.
Back to Sweden: A few months ago, Arjun got back in touch. He was going to Berlin to attend a WHO meeting, would be able to stop by for a few days, and wanted to see Sahlgrenska Hospital, but also the island about which I had spoken in such glowing terms. Of course I told him he was welcome, but he turned out to be engaged with other commitments, so all he had left was two days. How do you show someone a university hospital and an island community in two days? There was also a condition: he absolutely insisted on seeing our intensive care unit, since that was where he himself worked.
Here I thought: a uniquely Swedish phenomenon is our personal ID system, our registers and our system for managing dangerous infectious diseases. We’re also really skilled in management of antibiotics. And we also have a brand-new Imaging and Intervention Centre (BOIC), to show him. After a few emails, this was organized.
Leif Dotevall responsible for Infection Control talked about our infection-tracking system; we talked about management of all imported cases of TB, and he described how we work systematically to reduce prescription of antibiotics. In Nepal, anyone can go to a pharmacy and buy non-prescription antibiotics; consequently, consumption is extremely high. MRSA (multi-resistant staphylococcus) is the rule, rather than the exception, and in principle, infection tracking does not take place. In this arena, we have a great deal of knowledge to pass on.
Next – intensive care. Christian Rylander, one of our most experienced intensive care physicians, talked about staffing, where our intensive care nurses play a key role. Nepalese nurses have a significantly lower educational level, and large elements of their role in Sweden are performed by doctors in Nepal. The care team is also smaller in Sweden. In Nepal, generally speaking one consultant runs an entire intensive care unit. Arjun works at a private hospital, which in principle has roughly the same equipment to which we have access. We also discussed the importance of contact with relatives, and in Nepal they have the ubiquitous problem of economic considerations, which thankfully we can avoid. In publicly funded care, in Nepal, urgent treatment often has to be discontinued where the patient does not have the means to pay, while in the private healthcare sector, providers are often forced to undertake futile treatment at the behest of relatives, who are willing to pay.
On the third visit, the new jewel in our crown, the Imaging and Intervention Centre, BoiC. This visit was masterfully guided by Martin Rösman, Monika Holmbom and Peter Gjertsson, in the magnificent, light and harmoniously coloured premises, where we saw a selection of the equipment, which is at the cutting edge of international medical-technical design.
Arjun was impressed, explaining that they have also have some of the medical devices displayed, including at the large, private hospital where he works, but there just the one machine where we had three. And they had no PET-CT, or mobile CT scanner. We also talked a lot about working methods: radiology rounds, multidisciplinary team rounds and quality of referrals. Nepal has more of a linear ordering system, where most things can be done, providing that you have the means to pay. Our system, whereby all members of the MDT become involved in a patient’s case, and decide on care matters in consensus, was unfamiliar to Arjun.
Time to play the SA-card. Arjun had heard mention of our quality-control system. We proudly presented our national quality-control registers, which in principle enables monitoring of quality with a resolution down to the level of individual doctors, and whereby we can follow-up our own results over time – the most recent example being the dramatic improvement in cardiovascular disease among diabetic patients. No similar service exists in Nepal – if patients are dissatisfied, they simply go to another doctor.
Next SA card, the clinical research. I may have romanticized it a little, but when recruiting doctors it’s made clear that your research activity is expected at Sahlgrenska, and if you do not like that, you are recommended to work somewhere else. A majority of our interns are registered PhD students, in keeping with this approach, and in most cases they also get their PhDs. I also explained about the different combined positions available in the hinterland between healthcare and universities. None of this is available in Nepal.If doctors for some reason have no active research, they are instead expected to actively contribute towards QC work, and of course also participate in educational assignments. The latter, by the way, also works well in Nepal. Their research system, however, is significantly weaker, the threshold for tenure as a professor is, in our judgement, very low, and nor is there any system for quality-assured PhD training. .
We left SU, to take a look at the island community on Donsö. Showing someone an island community in just one day is a massive challenge. I tried to describe the history, how tough it used to be out there, and among other things, showed him the memorial to drowned fishermen.
I showed him the books about the houses and families, about how during the 1800s, alcohol abuse threatening to tear apart the community; I told him about the religious revival, the emergence of shipping companies, and the decline of the number of fishingboats. . We also introduced him to the Syrians who rent our old house. Atiya had the opportunity to practice a little English. I described the house’s history, who had lived there and what life had been like. And how pleased we are that the old house is once again being lived in.
After visiting the old house, we pottered around the island without any concrete plan, chatting with anyone we happened to bump into. We went up to Nordön and I showed him our excellent sports hall, as well as the old quarry from the days of mica quarrying at the beginning of the century. Then we took a walk – by chance heading out on the scouts’ spring hike.
There is a sign in the gymnasium at Eton, which says: : ”This is where Empire was built!”. You might well say something similar about the role of the Donsö scouts in the so-called “Donsö spirit”, a term within shipping. The organisation is run by the Mission Church, with a focus on ethics and manners, rather than absolute religious education. The scout leaders are islanders, and one of the most appreciated is Tomas Larsson, who built our house.
In the scouts, the children learn basic rules of conduct: everyone is welcome, but people are expected to get to know the rules. Help if you can (even if it’s raining) and finish what you start. If you are on fire watch, the fire should still be going when you come off watch. It all sounds very militaristic, but the children learn to take responsibility and “to be seen”. Clearly, it’s also okay to fail at what you’re trying to do, most of us do that sooner or later. The children take these simple rules with them for the rest of their lives. It all came out: among other things, we had a look at the story of Joseph and his brothers, and on the way back met some girls who had been hauling a canoe.
I had told Arjun that we have a spry 103-year-old on the island, and Arjun wanted to meet him. Bror-Nils is a practical- rather than verbal man, and he answered most questions with stories from his rich life. In answer to the question: “What difference do you see between how it is now, and how it was in the past?”, Bror-Nils answered bluntly: “Hate. We had no hate!”
When we returned from this conversation, reports started coming in about how the Swedes had reacted to the terror incident in Stockholm, of children hugging- and giving flowers to the police to thank them for doing their job, and how people gave up their homes and cars, and how the cafes offered tea and coffee, and how the hotels offered people rooms for free. I was struck by the thought that the same had happened in Nepal during the earthquake: people had all mucked in, instead of complaining.
Thanks for the visit, Arjun, and we hope that our two countries have the sense and wisdom to appreciate and be proud of the good things we have. On the medical side, Nepal can teach us clinical breadth and remind us of “the good enough level”, while we can teach you about infection tracking, antibiotic management, and to expand on clinical research. There is so much that unites our countries, and we have to continue working on promoting student exchange.
I really believe that most of our students would absolutely love to visit a Nepalese mountain hospital.
Henrik Sjövall
