tertiary what? seriously where is public health?

There I was, all ready for the free food and great conversation. The CME (continued medical education) was about GERD (gastro-esophageal reflux disease), in Hotel Annapurna. Best minds of Nepal in the field of gastro-enterology (medicine about stomach and stuffs) would be there together with free-loaders like me (read – interns, medical officers and first year residents).

This was last Friday and I still have headache on what he ignored. “He” is a subjective grudge against this single speaker who as I found out later is also a third-degree-relative (father’s-mother’s-uncle’s-son-in-law or something) to me. My grudge is also directed toward the 50 or so bright minds that were invited there, to talk about GERD and their utmost loyalty to tertiary health care. A more of a vertical health approach twisted in the name of professionalism and wrong ethics.

so what did happen?

I went to attend this conference. The talk was wonderful and quite informative. The speaker had a Texas-Nepali accent mixed with periodic outburst of native tongue that just didn’t feel right. The 45 minutes of presentation had all sort of data and research citing from American, European and Indian Research Journals, which was then compared to Nepali citizens from Kathmandu and the periphery (in and around Kathmandu). He spoke of few clinical diagnostics procedures which are still not in Nepal, and then few Nepali medical culture/ethics regarding Gastric-Carcinoma (stomach cancer) with regards to Tripple-Therapy (medicines given to kill H. pylori bacteria). In the end there was a wonderful suggestion of making future CME in Nepal a little more responsive with written QnA sessions. With 30 minutes or so of good QnA sessions we went for the great Annapurna Dinner and liquor. Total number of participants were 50, out of which I had my wife (Dr Aditi) there with me, I knew one who taught me (Dr SL taught Medicine), his wife (don’t know her name) who’d come to our wedding. For obvious reasons, food was delicious, they even had the wonderful chat-dahi (curd thats like little too salty) and regular dahi (regular curd), with gulab-jamoon (lalmohan is what i call’em). During the dinner, we got a chance to talk with the speaker/presenter and raised some public health related inquiries. Five minutes into the talking, we being MBBS (the lowest ranked doctors in Nepal) were crushed and pushed aside with widely acclaimed speaker and his beliefs. Seventy Two hours later, as I recall the event and our little conversation, here is what he’d told us, and what we understood from the event as a whole.

why am I sad?

Here are some reasons that I think is a little off track from what should have been. Some may be genuine, some may be paths that I would/might also follow in future (knowingly/unknowingly) and some plain dumb reasons with no apparent thought process. For deliberate reason of being afraid I will not write the names of any other people.

1. The presenter is some one very reputed, has practiced medicine for nearly 35 years (his quote), has worked as a clinician and in management position of huge organizations in Nepal as well as in India. Is a professor of Medicine, must have given number of presentations, written number of papers (Journal papers that are scientific research). In his 45 minutes of presentation, there wasn’t a SINGLE NEPALI PAPER (research) QUOTED, let alone his personal findings. He talked of American standards, and then Indian data, and boasted a working of 35 years, and yet he had not accumulated any Nepali data. Post presentation, post QnA session, during the dinner, when we (Aditi and I) asked about his personal data and findings, he said

“Yes, I have my data, but they are with somebody else, in another hospital, and I don’t have it now”

Firstly shame on him, for being so ignorant about his own country, and speaking about foreign data. It would have been a passable excuse If there were no data of GERD related to Nepal. It would be better if he said that he did not know more on research, data mining, paper writing and stuffs. But the speaker, knew vert well of the research process, and yet after working for 35 years, he had nothing to present of his own, or others related to Nepali prevalence and outcome of GERD in Nepal.

2. Our second question to him was on why weren’t there proper research being conducted in Nepal? This is something we ask each and every one, and we do know some of the likely possibilities to this question. Its basically because we have a nascent research culture in Nepal, doctors are still learning, plus the lack of funding (Nepal is definitely poor to do bigger RCTs and all). However, we should be able to do surveys and cross-sectional studies and there are many small RCTs currently being conducted that I know of. To this small and pretty inconspicuous question he went and answered something like this.

“Nepal is poor, the best we can do is take others data and rely on this”

By “Others” he might have meant USA, EU, and or India. Against which we tried to argue whether smaller research were viable or not in Nepal. We questioned if smaller surveys and cross sectional studies should be pushed forward by this intellectual elite groups or not. To this he had to say –

“So you want me to carry a bag of endoscopy materials and go to villages conducting research and this age?”

A person at his caliber and experience may very well assign a group of person to calculate or collect data. We even offered to write up a paper on his behalf (this was the part where we were advertising ourselves) saying that we’d worked in KUMJ (www.kumj.org.np) and JAIM (www.aimjournal.org).

3. In a typical of the attitudes that we see in many Indian sub-continent (read Nepal, India, and the likes of SAARC countries) senior professors (not limiting to medicine only) there was a blatant ignorance of shortcoming one might have.Our last question is a little too private to be written here, but we were, in a way questioning of something that is right or wrong on an ethical level. The outcome of which might as well change the practice of many new doctors. Something I’d definitely would like to write, but now now, not associated here. Hint – Its associated with the Triple Drug Therapy and H. pylori treatment and its prevention for Gastric Carcinoma.

4. My last sadness (or grudge) was against all the elites present there, that day in the room. These were mostly tertiary care clinicians (as far as their looks and likes went). Again none of the post presentation QnA had public health related discussions. Almost all focussed on the high-profile cases of complex GERD. None talked about Nepali prevalence and outcomes of GERD. This was an Internal Medicine conference and well this should definitely means high profile cases and queries. But something inside me wanted to hear that public health aspect of GERD, and I was sad hearing so little.

There, I’ve all but summed about my Friday experience here except one. When we were leaving, at about nine, I met two of my friends from school. Intrigued and happy, I also found out that another program nearby was some sort of Fashion program by another of my friend from school. Damn the CME, I’d have (We’d have) love to go here instead of CME had we known beforehand. But then again, we did learn something new about GERD.

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