On Change, Culture, and Tradition

As my time here in Laos approaches its conclusion, I find myself continually struck by how much things change and how much things stay the same, both inside and outside of the hospital setting. There are aspects of hospital life and Luang Prabang life that are still exactly the same as when I first arrived: the drum beats each morning at 5:30am to signal a call to almsgiving, the monks are chanting in the temple and older and middle-aged women dance for exercise in the schoolyard near my guesthouse every evening at 6:30pm, the fruit, vegetable, sandwich, and meat stalls are always stocked along the roadsides, the stray dogs and cats are always looking for food, the motorbikes, bicycles, and trucks are always weaving around each other and the potholes at a speed of 20 miles per hour or less, there is always a constant flow of patients, families, and staff coming in and out of the hospital, grand rounds are Monday morning, developmental clinic is on Tuesdays, Thalassemia clinic happens on Wednesdays and Thursdays, and the staff meeting is on Friday. This past week, I have neglected writing this blog, wrapped up in tying up the loose ends of projects I have begun during my time here and in trying to bid farewell to other volunteers whose time has ended or will end in the next few days and weeks. As I anticipate my own farewells, I find myself reflecting on the unique aspects of life and of volunteering here.

The role of culture and tradition and the acceptance of cultural practices within the hospital setting has been an aspect of volunteering in Laos that I have treasured. From unknown substances lurking beneath beds in bowls, knives under mattresses in the NICU to protect newborns’ souls from dabs (evil spirits who would steal the soul away), black or brown pigment on the soles of patients’ feet and Baci strings wrapped around their wrists, to sacrificed mice in bags on the edge of a crib and tales of sacrificed chickens in the street outside, there is a recognition and validation of the practice of cultural traditions within this rather Western medical setting. Witnessing the effect on the patient and family of making space for cultural practice within the international medical team’s care planning has been a continually heartwarming and humbling part of volunteering in Laos.

For over a month, an adolescent girl was admitted to our inpatient unit with severe headaches, fever, and, as time went on, various other symptoms. Diagnosing her was a difficult task for both the Lao doctors in training and the extremely well experienced international doctors. For the first month, she passed from queried diagnosis to diagnosis: migraines, different types of meningitis, encephalitis, conversion disorder, and many others. The medical team tried countless medications, treatments, and tests, trying to alleviate her pain and identify her illness. It was difficult to find a way to reach her from a child life perspective, as her struggle with pain limited her desire to engage with anyone. The death of another patient she knew from school on the unit affected her strongly and it was her fear and grief from witnessing her passing that catalyzed her eventual opening up to my child life coworker and I. Even so, she frequently declined our bedside interactions and pain management and grief interventions. It wasn’t until about a month after she had been admitted that she was able to be diagnosed with an extremely rare form of meningitis, one which usually only affects HIV positive individuals despite her HIV negative condition. Treatment for this rare form of meningitis consisted of frequent lumbar punctures to remove cerebrospinal fluid and alleviate pressure on the brain as well as a very potent medication with side effects similar to chemotherapy. Given that we had to wait for such a medication to be flown in and it would be over a month of continuous, arduous inpatient treatment before she could be discharged on oral medications, the decision was made that she could be discharged for a few days to go home for culture.

When patients are discharged to go home for culture here in Laos, as far as my understanding goes, it usually means going home for a Baci ceremony. Baci ceremonies are celebrations of good luck (as in marriages, births, and entering monkhood), celebrations of recovery from an illness, or ceremonies seeking a cure from any ill health. As I have been told, they involve the whole family and community and, at some point during the ceremony, Baci strings are tied around the wrists of the honored individual in a spiritually significant manner. When Baci ceremonies take place to seek a cure for an illness, the Baci strings are meant to tether the individual’s soul and prevent their death. Some ceremonies take multiple days. When a patient is discharged for a Baci, they usually come back within a week. Some patients who are discharged for culture, however, do not come back.

The adolescent girl with the rare form of meningitis did come back. Her family rented a van of some sort and my child life coworker and I met them on the road outside the hospital ramp. While the days at home were good for her and for her family spiritually and her wrists and arms were tethered with Baci strings, she did not look well. Her uncle, my coworker, and I lifted her into a wheelchair and wheeled her straight into the ED, supporting her tall frame as she writhed in the wheelchair in pain and then nearly off of the ED bed, too disoriented and in too much pain to know where her body was and where the bed ended despite the bedrails. She was inpatient again for a few days and made a bit of a recovery, frequent lumbar punctures, pain medication, an NG tube, and medications helping her body while we waited for the more effective drugs to arrive. My coworker and I did a diagnostic teaching on cryptococcal meningitis, helping her to understand what was making her sick, what would make her better, and trying to come up with more coping techniques. She celebrated her birthday inpatient, getting a lovely pampering from the nursing staff and a full spa treatment including hair, nails, and a facemask. As the medication had still not arrived, the decision was made to let her return home for a second ceremony. The medication arrived at the hospital Wednesday night. Thursday afternoon, the hospital managed to make phone contact with the chief of her village only to learn that sometime between Wednesday night and Thursday morning, she had died in her sleep. While the inability to cure her and her unanticipated death are extremely tragic, the fact that she died at home and her family is thus able to practice their ideal death rituals and traditions free from any cultural taboos around dead body transport is comforting.

There are many things that are possible here in the hospital and many things that are not. For what resources are available, the care here is nothing short of miraculous. The nurses and doctors in training are excellent and the volunteer nurses and doctors are incredible teachers and resources.

This past Tuesday, I was taking a break from developmental clinic to eat lunch with coworkers on a bench in the stairwell above the entrance to the hospital when an ambulance pulled up. There is no real emergency medical response system here in Laos. The vehicles referred to as ambulances here are vans with questionable medical support equipment that are predominantly used to transfer patients between hospitals or to transport dead bodies back to villages when possible at exorbitant prices. Two teenage parents and a slightly older woman exited the vehicle and began to wander aimlessly around the foliage at the entrance, the woman holding a tiny bundle in her arms. My coworker and I stood up and went down the stairs to meet them and help them inside. As we approached, it was immediately apparent that the infant in the teenage mother’s arms was very blue. I smiled at her and said a quick “Sabaidee, this way” so as not to scare her as I put my arm around her shoulder and forcefully navigated the two of them into the ED, summoning help as we entered and stepping back to allow the medical team to descend and begin their lifesaving interventions. Despite the incredibly high-quality NICU care available here, I found myself back in the ED with the same parents and the same infant this past Friday evening, helping them to create painted handprints and footprints in the culturally significant, life-giving color green of their infant whose cardiac malformations were not anticipated to be survivable. The fact that the baby lived as long as she did and the space that is made for families in such a time is a testament to the level of care and compassion in this hospital.

Though many things change at the hospital, many things stay the same. There is a constant turnover of volunteers and the Lao staff are constantly learning and developing as clinicians. For every patient death, there are so very many who survive and thrive. As I sat in the back of the temple this evening, listening to the monks chanting and the rain falling outside, I found myself reflecting on how pervasive cultural traditions have been in my clinical experiences here in Laos. In the rituals, traditions, and taboos surrounding death and in the acute illnesses and injuries which prompt Baci ceremonies or animal sacrifice, cultural traditions stand out to my Western eye, but there is a place for culture and culture is woven into every part of the clinical and non-clinical environment here in the questions that are asked and the decisions that are made. As I prepare myself for the mental and physical transition back to the United States, I will continue to treasure and reflect upon the role of culture here in Laos and elsewhere in the world and how, though everything changes in our dynamic global environment, some traditions, some practices, and some places stay the same. I am so honored to have been a part of the sustainable, growing, adapting, empowering mission of the hospital as it works with, educates, and learns from this remarkable country and its rich cultural traditions.