Nepal - traffic nightmares & dream journeys.

Travelling from Kathmandu airport to the Malla Hotel was less than half an hour through the most amazing traffic I have seen anywhere. There are no rules of the road in KMD & it seems as if the total population of 4,000,000 is on the road in every conceivable method of transport known to man.

On the way to Samata school we pass through a road widening area where they are just slicing off the front of houses & shops - Seems a bit dodgy to me. The traffic is almost at gridlock on the bone shaking roads. The dust, rubbish & pollution is horrendous. It's all very hot & tiring & time wasting. One day we had a huge traffic jam with a faceless army of bikers in their helmets coming towards us from all directions & blocking our way. A policeman had to walk in front to get us through – not something to be done lightly I thought!

A journey to Bhaktapur took us along Nepal's only motorway the Araniko Highway – 7.1 k built by the Chinese along the main route to Tibet 115k away. Nepal is 17% mountains & 16% hills, the rest is terai. There seem to be hundreds of dogs, mainly sprawling asleep on the roadside, but I hadn't seen a single cat. Just before Bhaktapur we suddenly went from motorway to a rural tree lined road, from which we could see the city to our left through the trees.

On another hot and sunny day, when the monsoon had well and truly ended, we drove to Dhulikhel. After Bhaktapur the road is much more rural & we started going up into the foothills. There are lots of brickworks in the valley & terraced paddy fields on the hillsides. The number of Tata trucks on the roads is amazing, going in both directions. The roads here are truly dreadful in places, with very deep potholes & ruts. It isn't helped by the volume of very heavy vehicles. Climbing a hill we can see a huge sandstone statue of Shiva on the top of a ridge. Bizarrely it overlooks a new water park being built in the valley, supposedly to attract tourism. It really does look incongruous. People walking along the roads use umbrellas to shield them from the hot sun. Kavre district is very lush & green – lots of different shades. We passed through Banepa town which has a very wide main street to make into a motorway later. There are problems in this area because they remove the clay & then the buildings collapse.

Driving back from Pokhara all of life is on the roadside. Water buffalo stand in the river. We are following the range of mountains on our left. We reached Dulegaon, quite an industrial area producing concrete & stone with a huge quarry in the wide river valley. In contrast there are also rice paddies. So you get both coolie hats & hard hats. Irrigation channels follow the side of the road.

After an overnight stay at Bandipur we had a lovely drive back down to the main road. It's very clear so the twisty & precipitous road is even more hairy than it had been going up! The remnants of terracing are on hillsides everywhere. Wild orchids grow on the roadside. Oddly there is an Agricultural Research Station on the road with lovely flowering trees. Children are walking uphill to school. We pass little encampments of wooden huts with hay stooks & animals.

Almost all of the way from Pokhara we followed the river Mar Yang Nadi on our left which varies a lot in size & flow of water. Whole hillsides are clothed in jungly woodland. In flatter places it had been cleared & de-forested for farming. Charcoal makers use the plentiful wood. Steep cliffs rise vertically up from the road on the right in places. There are shanty dwellings all along the road where women are talking, squatting & going about their daily tasks. 

Dry river wadi's come down from the foothills. The drivers signals seem to be the reverse from ours. A right flashing rear light seems to mean overtake. At Abu Khaireni the road forks left to Gorkha. People routinely carry vast loads in Nepal in baskets on their backs supported by material round their foreheads. Sometimes they look just like walking bushes from the back. Goods are also transported by 3 wheeled bicycles pulling a wooden truck on the back.

We passed through Mugling where the road branches off to the right to go to Chitwan. Mugling is quite a big, bustling town. We had a couple of very near misses overtaking trucks or avoiding the potholes in the road. Quite a few trucks are carrying water buffalo in the back who seem to be roped in through their nostrils & tied by their tails. It seems very cruel packed tight in the jolting trucks.

 

In this area the steep river bank on the other side is dotted with sheer waterfalls. There is a cable car the only one in Nepal, to Manakamana Devi temple. You can toil up the mountain from the other side. The temple is on a ridge high above the confluence of two rivers & if you make the pilgrimage here you can expect your wish to be granted. (Seat belts seemed like a good wish to me).

 

Red clay tandoor ovens are in almost all the buildings at the side of the road. There are a lot of very long thin deciduous trees – I have no idea what they are. The river bed obviously produces a lot of gravel for construction. On the hillsides the soils are red clay. The roads in Nepal are almost universally bad – but now the road is much worse & overtaking is very dangerous. There is evidence of landslides from the steep rock face on one side & stones & boulders litter the road as well as the potholes. Canna lillies grow wild on the verges. I actually think that Basanta, the driver, is driving faster than is safe & is overtaking where he shouldn't in his efforts to get to KMD by lunchtime. He is hooting his horn almost continuously & overtaking everything on the road including convoys of lorries. He either has a death wish or a pressing appointment with a woman!

 

We passed through some sort of army checkpoint where a convoy of vehicles was waiting. We were through quickly because we are a tourist vehicle & have precedence. There are a huge number of vehicles coming from KMD as well as going there.

 

We started to climb higher & diverge away from the river for the first time. This is apparently an “accident blackspot” which makes you wonder what the previous road is supposed to be. As we climb higher above the river gorge the traffic becomes worse & worse & so does the road. There are more & more huge, overloaded Tata trucks & buses which can only go very slowly and which are very obviously ruining the road. The ruts everywhere are unbelievably deep & dangerous.

 

The road became even more appalling as we went further into the foothills. Everything is now covered with a thick layer of dust & sand. You wouldn't know the vegetation is green. There is a choking pall over everything. Everything is grey. We are literally dicing with death in a vehicle with no seat belts. Vehicles drive on the wrong side of the road to avoid deep potholes. Their suspension must be shot. Motorbikes & scooters weave in & out of cars & lorries on both sides of the road, overtaking & undertaking all the time.

 

We are part of a very slow moving convoy uphill round hairpin bends with precipitous drops on the left side of the road & no barriers. The trucks belch out clouds of pitch black diesel smoke to add to the general pollution & discomfort. We have to have the windows closed despite the heat. There is a real danger of the heavily laden lorries tipping over as they negotiate the potholes & ruts. Unsurprisingly we passed a crash which had just happened between two lorries going in opposite directions. No one was giving way & there was lots of shouting. On our side of the road a truck had also collided with the tangled mess of electricity cables which is commonplace in Nepal. A huge amount of hawking & spitting was going on as the drivers tried to sort the mess out.

 

Reaching KMD & the Malla after the drive back from Pokhara seemed like coming home! I was almost relieved to be back in the pollution & dire roads that I knew so well! 

 

Is the NHS fit for purpose for dementia & chronic conditions?

"Increasing sub specialism & the decline of generalism..... can create a lack of co-ordination & oversight of patients multiple needs".

"Co-morbid mental health problems are particularly common among people with long term conditions".

"Supporting the psychological & mental health needs of people with long term conditions ...can lead to improvements in both mental & physical health. Existing provision fails to realise these opportunities. A separation of mental & physical health is hard wired into institutional arrangements, payment systems & professional training curricula".

"Physical illness makes the detection of mental health problems more difficult. The majority of depression among (this group) goes undetected & untreated (because of a) focus on physical symptoms".

"There are currently significant practical barriers that impede the effectiveness of liaison teams (often because they are) employed by a mental health trust, but working in a hospital run by an acute trust. Communication & co-ordination can be compromised by IT systems that are not inter-operable & a high degree of caution with regard to information sharing."

"Several policy barriers will need to be addressed. Potential savings associated with integrated services (are) challenging to achieve as a result of separation of budgets...and the incentive created by the Payment by Results system to maintain or increase activity in secondary (hospital) care."

The Kings Fund - Long Term Conditions & Mental Health - February 2012.

What we need is a complete review of interventions for elderly people with any chronic conditions. I found it amazing & unacceptable when I was involved with the Expert Patient Programme that many GP surgeries do not seem to collect data systematically on the number of patients with chronic conditions, those with multiple chronic conditions, what the prevalence of each condition is & what medications / treatments were being prescribed.

I have 5 chronic conditions. All are dealt with separately, no one looks at the whole person. The patient is passed like a parcel from specialist to specialist. Each medic only unwraps one layer of paper & no one gets to the core. My surgery specifies that patients only bring one illness / symptom to a consultation. I can well understand the time constraints on busy GP's, but it isn't good for patients.

Some symptoms are common to many chronic conditions - pain, sleep disturbance, fatige, anxiety.....These symptoms can & should be managed by informed patients taking responsibility for themselves. But they need information & help from professionals or experienced lay people.

The NHS is too hierarchical with jealously guarded borders & fiefdoms. Until the whole patient & his / her needs are genuinely put at the centre of the NHS costs will escalate & waste will continue. Worse still the patients needs won't be met & they won't get the care they deserve.

Carers - a Ticking Timebomb.

Because of my personal experience & that of several close friends, I do think that any expectation that elderly people will silently bear the burden of caring for partners with dementia & chronic conditions is naive at best. This problem is a coming plague, which society has created for itself because of the development of interventions which prolong life. Women in particular did not sign up for lifelong caring for others, however needy & however much we love them. I wonder if the " me generation" who are used to instant gratification will consider it their role to be carers in the same way that my generation has.

The first thing that has to be recognised is that carers are not a homogenous group. Some children are carers, some carers are young people with demanding careers, some are from Ethnic minorities, some are single, some already have the huge demands of a family to care for, some have more than one elderly family member to care for on top of any of these. Sometimes many people share the burden of care, which brings it's own problems. Carers can be both men and women, with all the differences that involves. Deciding what we do & how we do it in terms of supporting carers & patients is very complex indeed & will need multiple options. Possibly something like a Menu in a restaurant.

Early diagnosis is an imperative so that the package of care can be implimented as soon as possible, before real problems arise. Similar services need to be available to everyone & expertise & good practice needs to be shared effectively & quickly. Effective communication is vital at all levels & involving everyone concerned. The Patient / Carer voice should be central to the process.The needs should be determined by the carers & patients. Patients, carers & service providers have to be actively involved in an ongoing process to constantly update & streamline available services.

Someone, at the very highest level, needs to be consulting & researching the development of strategies for carers & managing the care of elderly people with chronic conditions & dementia. There are charities with huge expertise in this area who should be closely involved.

This can't wait or it will be yet another poisoned chalice we leave for future generations. We need action. NOW.

Caring Women & Dementia

In many ways I was fortunate to be born a "baby boomer" immediately post the 2nd world war. I expected to have a career after college, not just a job. I considered marriage an equal partnership - (not sure I got that quite right - husband never did clean the bathroom, cook a meal or do the ironing!) I couldn't wait to get back to my career when my daughter was old enough to go to nursery & because I was a teacher the authority was desperate to have me back. I juggled all the plates in the air for years, so "had it all".

That all meant job security, a comfortable middle class lifestyle, a home of our own & ultimately a good pension.

But in one important way I don't think I was fortunate. I almost single handedly looked after my home & immediate family. Then when I retired on health grounds I had to look after my widowed father who became very ill & suffered from mild dementia. He finally died aged 89. After he died I looked after my widowed mother in law who also suffered from mild dementia & died aged 92. It could have been worse, it could have been all 4 parents. Life expectancy has risen over my lifetime. Had he lived, I might well have had to look after my husband who was older than me. I am currently trying to move closer to my daughter so I can play a part in caring for my grandchildren.

Women are, and have always been, "carers". Mostly we do what comes naturally & put ourselves last in the pecking order. Now, seemingly we are part of government policy because they have realised that we save them money - a huge amount of money. There is a movement afoot to avoid putting patients with dementia in care homes or hospitals. So lip service is being paid to "carers" needs.

I wonder how much thought the present young, predominantly male, leading politicians have given to this. Caring for your loved one with dementia is bad enough. Caring for someone who is no longer the person you married & has double incontinence in later stage dementia must be a living nightmare. The carers themselves are mostly elderly & many will have health issues of their own. Even if they don't, they probably don't have the physical strength or resiliance to care for someone 24 / 7. I doubt there should even be an expectation that they can / should be doing it. But they probably will go on trying, because they loved the person their partner once was & would feel guilty if they didn't. The burden of guilt & unreasonable expectations can be intolerable & unsustainable for women in particular.

So, we have an ageing population living a lot longer. This saga isn't going to get better. Dementia is progressive & incurable. We do need to look seriously at this as a society, because one day, the chances are, it will be each one of us in this situation. We need to look at the needs  of carers & the barriers to those needs being met.

Most of all we need to stop assuming that elderly women will do it for us on their own.

Getting to know Samata "Bamboo" School

Samata1Bamboo school is 6 years old & was founded by Uttam Sanjel. The original Samata school was destroyed by parents & teachers because they didn't understand what he was trying to achieve, which is education for very poor children. There are about 3,000 children here. A big rectangular courtyard / playground is surrounded by bamboo huts roofed with corrugated iron. We didn't teach there as volunteers. We worked in the newer 2 year old school run by Laxmi the wife of the pricipal of Samata 1,Sushil. The layout is very similar though – each hut is a fairly dark classroom, the only lighting coming from unglazed windows covered with bamboo latticework & a doorless doorway. Currently Uttam, the founder, has 14 schools in districts of Nepal. Women teach the younger children, men teach the 14 – 16 year olds. Some older children teach younger children.

When we arrived the children were doing the National Exams which they work very hard to pass. It is common for children to get up very early in the morning to do chores & homework, come to school & then do more homework when they go home. A high percentage get good pass marks in the exams. The family pays 100R a month for the school, which is very low. Some children who come from villages away from KMD don't see their families for months, which must be very hard for all of them. We talked to Uttam, Sushil & some of the older children, who were a delight. Sushil prides himself on being so strict that the children are frightened to talk in front of him. Corporal punishment is commonplace, which was quite difficult for Western volunteers to see.

We visited the other Samata school 5 minutes away & met the lovely Laxmi. Each classroom has a wall painted with black paint as a blackboard, a dirt floor & old fashioned metal & wood bench / desks which can seat 6 children. They are all arranged in rows facing the blackboard, girls on one side, boys on the other. Unfortunately the timetables we had been sent were for Samata 1 and organisation of this school is different to the older one. Contrary to what I had been told, I discovered that Samata 2 does actually have electricity, but it isn't connected up to the classrooms so doesn't benefit the children.

Class Groups are quite mixed in age according to ability. Older students with poor English are kept down. They use the Oxford Reading Circle. Children provide their own paper, pencils etc, there are no central supplies. The school takes children from Nursery to Stage 7. There are 20 classrooms on each side, but only 21 are in use at the moment. Laxmi took us to look in some of the classrooms & introduced us to her deputy Binod who is 17 & has come through Samata school himself. It's all learning by rote by repeating what is written on the blackboard in the younger classes – (A – L / 1 – 10 / + 10 Nepali symbols. Also A is for apple etc). Bizzarely a teacher who can't speak English is teaching English in one class. Another teacher was really lovely with the children & did singing games with actions. The classrooms are completely bare with no charts, pictures or children's work displayed.

We overlapped with two of the previous volunteers Roger & Pauline which is very unusual, but very helpful. They obviously have great reservations about the whole scheme, including the money aspect, and gave us quite a bit of info. They suggested we should spend the £150 Saga money which comes out of what we pay for the trip while we are here. Pauline wanted us to let her know when / if the stuff they had “bought” actually arrived!

All would be revealed once we started teaching.

Saga Nepal Volunteering - pros & cons.

Firstly, having had seven very different volunteering jobs since I got medical retirement, I have to say that I think anyone who volunteers gets more out of volunteering than they put in. The contact with different people in different circumstances, often worse than your own, is always stimulating & challenging. Your perspective & experience is broadened & you learn so much.

But, I have real doubts about what I have just done in Nepal. There are too many organisations with different agendas & levels of competence involved. I travelled with Saga Volunteer Travel, the land agents in Nepal were Social Tours in Kathmandu, the founder of Samata Bamboo Schools is Uttam Sanjel, the organisation which ran the Naxal Orphanage is OCCED, and finally the accommodation & transport was provided by Malla Hotel & Tours. Too many fingers in the pie resulting in a somewhat frustrating & less than satisfying experience for volunteers. Communication & demarcation lines of responsibility was poor throughout. We wasted a lot of time getting to understand how the set up worked, both in terms of the school or orphanage & in terms of the wider areas of responsibility between the various agencies. Someone really needs to get to grips with this & make very clear to volunteers who does what.

However that isn't the only problem. There seems to be little in the way of selection criteria for volunteers. Is it really reasonable, from anyone's point of view, to send middle aged people with no experience whatsoever of teaching primary & secondary children English as a second language, to teach anywhere without any preparation or training whatsoever? I wasn't expecting to have to mentor the other teaching volunteers & do all the lesson planning for them. What would have happened if they were on their own with no one who was experienced? Is it reasonable to send a volunteer to the orphanage, a very challenging environment, on their own with almost no back up?

I was also frustrated & infuriated not to be able to get  a proper professional briefing before I went out, so I knew what materials & equipment to take to maximise what I could achieve for the children. In fact we weren't even teaching in the school we had been given a lesson schedule for, so it bore no resemblance to the timetable in Samata 2! I was experienced enough to organise children who spoke good English as monitors for each volunteer & determine which periods we taught & what we taught, so the initial time wasting waiting for children to arrive was cut to a minimum. The one really good thing was Laxmi, the young woman in charge of Samata 2. She was a delight to work with, helped in every way she could & was always open to suggestions.

The initial grandiose ideas outlined by Saga of me training teachers, teaching music & art or computing were utterly ridiculous. There were no art materials, instruments or computers, (not to mention electricity in the classrooms!) & the teachers were teaching their classes of 50 plus!

Finally there is the question of the cash. I was left feeling that it was far too easy for it to go adrift. There was little evidence of the money from previous volunteers being spent directly for the benefit of the children, as opposed to paying salaries for instance. In theory each volunteer brings a paltry £150 from the £3.200 cost. There is no apparent accountability or transparency for this money though & I was aware of differences of opinion between the various bodies involved in Nepal. Often volunteers are sponsored by friends & also take out large sums of money as well. That money has to be given on trust. Given the huge & endemic corruption in Nepal, I didn't feel inclined to do that.

This was undoubtedly a great experience. Living and working in a country is not the same as having a holiday. I would love to go back & really use my skills & expertise to help these wonderful children & teachers.The children are a delight - very underprivileged & hard working. Full of drive & personality & a will to succeed. They deserve better & I could have done so much more. I know other volunteers have felt the same from their emails & blogs. So why haven't the issues been tackled? Is it all just a box ticking exercise?

Back Home

Home to the "season of mists & mellow fruitfulness" having been away for a month in the heat, dust & pollution of Kathmandu. It's really odd, in one way it's as if I've never been away, and in another I feel that things have changed completely.

I am now beginning to be able to talk properly after two and a half weeks of barely being able to speak. We do all take for granted the ability to communicate. It is deeply frustrating not to be able to participate in conversation & it was a bit worrying not knowing whether I was right, that it was simply a combination of external stresses on the voice - teaching, dust, pollution etc. Interestingly if you have to make a huge effort to communicate you tend to stop trying & listen more. Really listening to other peoples conversation without thinking of what you want to respond is fascinating. We can't have deep & philosophical conversations all the time, but it is amazing how the trivia of life plays a very repetitive part in general conversation.

Physically I have paid a price I didn't expect to pay. I thought I would be more or less bound to have a dreadful tummy bug - luckily it didn't happen. (I could have done with losing some weight!) But I wasn't expecting the daily hour & a half horrendous journey to and from school in a 4WD or taxi on the most unbelievably bad roads I have ever been on in my life. (That includes India, rural China & developing countries in the Middle East). Getting in & out of the vehicles, holding on for dear life in the absence of seat belts sometimes, & bracing my legs against the seat in front has all  left me limping with a much worse left knee & right hip. Not bad enough to be bionic yet according to the GP, so just have to adjust to more difficulties with hills & stairs & getting in & out of chairs & beds.

I certainly appreciate everything I have even more than I did before I went, if that's possible. Seeing how the orphans live in the orphanage we visited - spending a month in the delightful company of the children I taught in Samata school - seeing the street children living round the corner from my hotel, sleeping on the pavement curled up together like puppies on a rug on a main road, it is impossible not to be moved to real anger & despair at the unfairness of the world we live in.

We all actually know what the problems are - the solutions are the problem. Especially in a country as corrupt as Nepal. "Better to have a monarchy than anarchy" as one Nepali said to me about the current shambles of a government. More on this subject when I have had chance to reflect & assimilate the experience. But I loved it.