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McKean Rehabilitation Centre and Manorom Christian Hospital, 2004 - Rachel Bowen, nursing elective

It is hard to try and condense the last three months into a few pages and to express through words all that I have seen, heard, smelt and learnt during this short-term encounter with Asia. As I experienced my nursing elective I came to realise how truly profound and significant the above Chinese Proverb was for Thailand. That one can only remember by seeing and fully understand by doing. It is my hope that the following report might, even in a small way, convey some of the experiences, and life, together with some of the insights that I have gained during my time in Thailand.

Through research, correspondence and prayer, it became clear that I had the opportunity to spend eight weeks between McKean Rehabilitation Centre, supported in part by the Leprosy Mission, located outside Chaing Mai, Northern Thailand, and Manorom Christian Hospital, an Overseas Missions Fellowship (OMF) run hospital in central Thailand. I would be nursing predominantly leprosy patients at McKean and AIDS patients with OMF. I had had no previous experience with either disease and had limited knowledge, as well as a very naive view of the current situation and work with each disease within Thailand. Yet I was excited and eager to begin this unique experience. I remember buzzing with anticipation and expectation as I sat in the plane on my way to Thailand. The only worries I had were towards my significant lack of Thai language and the uncertainty of the extent to which I would be able to nurse under the licence restrictions that Thailand have gradually been introducing to a more rigid degree.

However, after an invaluable orientation week in the provincial capital town of Lopburi, that included some language training, I began my elective at McKean. It was really exciting to see how McKean had become more than the original 20th century leprosarium institution, aimed at protecting the general public from contagion and meeting only the basic needs of people affected by leprosy. I began to realise from that day that McKean stood as a testament to work committed to addressing and overcoming the prejudice that has led to the ostracism and isolation of thousands of people affected by the disease. A lack of understanding and education has allowed fear to manifest with subsequent impacts upon those affected.

There are so many aspects to working at the nursing home that I want to share and so many stories of patients' pasts that I have heard and which stand as a poignant reminder of both the disease of leprosy and the Thai culture. Through them I found I developed a compassion and love for the people and experienced the reality of being able to transfer nursing from one culture to another irrespective of language barriers.

One particular incident that I feel is a poignant example that will remain with me for a long time involves a 77 year-old lady who I will call Pii Bon. She was a lady who was bed bound, had been diagnosed with leprosy and now suffered from dementia. She had been in the home for 20 years (one of many who'd lived there since arriving at the centre stigmatised and ostracised by their families and community) and was considered too old and disabled to rehabilitate (dehabilitated). McKean had thus become her home and family, as was the case for the majority of people in the home and village cottages. She was completely dependent upon others for all her care needs and thus I would often sit feeding her at meal times. She had a sacral pressure sore and so I began to encourage that she be turned regularly and increase her protein intake as her diet consisted predominantly of sticky rice and mango with very little protein content. However, after a shower one day as we were putting her back onto her bed to dress, the ulcer opened up and all the tissue that had been gradually breaking down, began to pour out. The size of the now very deep ulcer was just too much and I broke down. I felt the whole situation spoke of more than a physiological problem, but one of mismanagement, poor nutritional intake, limited and inadequate resources and the ability to only achieve basic nursing care, together with a resignation and acceptance of situations. Things could and should have been different. Pii Bon passed away a fortnight later but due to cardiac failure. Had she lived the ulcer would probably not have healed, as an operation would not have been an option given her age and diagnosis. It taught me a great deal and I faced the death of someone I had nursed intensely for the very first time. On reflection I am grateful despite being a very hard and real lesson. I was to face this again whilst working with OMF in the AIDS hospice in Lopburi.

My time in central Thailand was completely different to at McKean, I nursed alongside a Dutch missionary between Manorom Christian Hospital and the AIDS hospice that is a part of the Dramaraksa Project located at Wat Phrabatnampo (a Buddhist temple) north of Lopburi. A Buddhist monk who saw a need and responded by bringing people to the wat and caring for them founded the project. It is now nationally renowned and attracts hundreds of visitors each year. This was something that I struggled with, was shocked and amazed by. Daily coach loads of people would come to the temple, school children, doctors and business people. They would walk through the nursing ward simply looking at the patients yet never to approach them to talk. It felt as if they were on show and the intrusive nature of their presence made me want to retreat and be alone, yet patients who were too sick to even stand-up, could not escape it all. I found it very hard to work out the mentality and motives behind it all.

The site now has two building funded by donations and government grants. The first building consists of three floors housing 53 patients currently receiving the Government funded program of free anti-retroviral medication. These patients are gaining weight and are expected to return home with the prospect of employment. Six patients have already been discharged since the hospice entered the program at the beginning of January this year and two are already in employment. The second building consists of a 34 bedded nursing ward where many patients diagnosed with TB and those dying with AIDS are nursed, and where I was mainly based. It is a very unique place as Thailand has no other hospice facilities and so people from all over the country come to seek sanctuary away from the stigma that AIDS creates. It made me realise how AIDS is now the modern day reflection of the plight faced by leprosy patients at the beginning of the 20th century. With minimal knowledge of AIDS I found the experience a big learning curve and challenge. One particular issue that baffled me was the location of the hospice within the grounds of a Buddhist temple. It felt almost an irony for such circumstances to exist. That within a Buddhist believing society where Thai mentality shuns those who are a burden upon oneself, one's family and one's society, and believes that those who suffer with a disease is a direct consequence of past misdemeanors, a monk should seek to care for AIDS patients. However, it was an amazing experience and gave me much insight into issues underlying AIDS within a Buddhist society as well as learning about AIDS and TB management, and learning how to perform venepuncturesn on patients.

My time the hospice gave me further insight into eastern mentality and the consequences of that upon both care given and patient's attitudes towards their disease. I have come to realise that Thai people considers reality as something that needs to be related to as harmoniously as possible. They therefore see themselves as insignificant and part of a whole society that in itself is trapping and restricting. Consequently they are very passive and accepting of situations and therefore their disease with many giving up and resign themselves to the suffering the disease will inflict rather than seeing the potential of life.

At Manorom Christian Hospital I became a part of the missionary community working with OMF to serve Asia. It was a completely new world of ideas and possibilities and demonstrated how people are using their skills and gifts to their full and much needed potential. It is a very special place and one felt by more than myself. Thai people come from all over Thailand to be seen by a western doctor.

Unlike McKean, Manorom have decided not to opt for the '30 Bahht card' system of paying and receiving treatment and so patients have to pay for every consultation and investigation. During my time there I was able to attend surgery sessions and to work on the wards attached to one of the three sisters. There is so much I could include here, such as how I was successful in cannulating four patients, how I administered an intradermal injection for the first time in order to check that a patient wasn't allergic to an antibiotic prescribed by the doctor. How I administered intravenous injections and calculated infusion rates, or my encounters with hemorrhagic dengue fever or worse still, my personal suffering with scabies. I felt that I had learnt a great deal by the end of the three weeks, perhaps more so than during my time at McKean. However, I realised that that was not the purpose of my time in McKean as I knew it was an opportunity to encourage change and serve.

However, words could go on and on. So much is subtle and unable to be conveyed through words, you really have to 'do to understand'.

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