FEATURES

THE STATE OF GLOBAL HEALTH

One globe, two worlds: Teaching and learning in Nepal

by Elisa K. Watters

Elisa K. Watters

Dressed in a flowing, saffron-colored robe, the principal of the school led me through a maze of flowered courtyards and rows of cement rooms. Reaching an upper room, he laughed as he said in halting Nepali that he never bothers with keys. He shouted—not unkindly—in Tibetan to a much younger monk, dressed in a similar robe. The student disappeared in a flash around a corner of the monastery, only to reappear in seconds with keys. Handing them to his superior, he nodded toward me and smiled. I had just seen this young man as a patient the week before at the monastery-operated clinic.

Inside the room, several long, woven carpets lay rolled up on the floor. A large, throne-like chair faced the class. The principal explained that the white board on the sidewall was made especially for me.

Already anxious, I became even more nervous when 30 young monks silently entered the room, bowed respectfully to the principal and then to me. Some had brought their own carpet, rolled up under their arms. When they were all seated on the floor, the principal introduced me in Tibetan as their teacher, telling the students to listen well and study hard.

I never thought I would enjoy teaching, let alone find myself embarking on an incredible journey between the world of Western medicine and the world of Tibetan Buddhism, but more than two years ago, I found myself in just such an extraordinary position. It is not what I taught that has been the most rewarding, but rather what I learned.

How did I get here?
For several years, I had volunteered my services as a family nurse practitioner at a local clinic close to my home in Nepal. After a Maoist-induced conflict in the remote hills forced us to evacuate, my husband, children and I had to relocate to the capital city of Kathmandu to an area near the Tibetan ethnolinguistic group for whom we were developing literacy materials.

Development work, especially education projects such as ours, has sometimes come under suspicion. Questions and accusations about our intent and organizational involvement flow freely. After we spent several years investing in relationships, the community started to trust us as individuals and professionals. This foundation of trust opened the door to my teaching a health assistant course at the monastery.

Most of the monks are still able to return to their villages in the hills, where many expatriates or even out-of-district Nepali nationals cannot go in light of the political situation. Health care in many of these remote districts does not exist or, at best, exists only as a mark on a map—a theoretical health post or hospital.

Without any allopathic or even full or partial training in oriental medicine, the monks are looked to as traditional healers in their communities. Based on my vision that these young monks could provide some basic health prevention and care to their communities, I was given permission to design and teach the health assistant course for a large monastery. The principal selected the students.

Pictures worth a thousand words
From the start, I was impressed by the discipline of these young monks to assimilate information that was foreign to them. They helped each other understand the printed handouts written in less-than-ideal English, and when my Nepali was not understood, translations into Tibetan or one of their own first languages, such as Sherpa, Dzongka or Mugom, would ensue.

With so many languages being spoken in class, pictures and videos became effective tools for presenting a new worldview to the students. We all have been challenged at some point in our lives trying to explain something that cannot be seen, whether nursing theory or the structure of an atom, and I suspected it would be difficult to explain the microscopic world to students not familiar with it.

I quickly decided to forego the lecture in which I verbally and colorfully explained a blood cell. I found, instead, that a picture of red and white blood cells caught the students’ attention and woke them up. Video footage of cells speeding through an artery utterly silenced them. Pricking their own fingers and looking at their own cells through the lens of a microscope made them talk unceasingly.

For days after that class, monks I saw at the clinic as patients or others who found spare time to come and talk with me were fascinated that their blood was actually made up of much smaller parts. They had many questions: “When I cut myself, I bleed. So how come I don’t run out of blood? Where does the blood come from? How come some blood is dark and some light? Why do I feel my heartbeat in the blood in my feet? Why does pus sometimes come out with blood from a sore?”

After that experience, I tried to incorporate as many pictures, video clips and hands-on teaching materials as I could. I could tell by the flow of questions and animated discussion amongst the students that they were really learning and were excited about what was presented in class. Their questions became more reflective of their personal experiences and more relevant to the world they already knew. Teaching and facilitating their learning experience became fun for me and challenged my own ideas and knowledge.

Worldviews
In the West, basic concepts such as germs and how they spread are taught to children. Saturday-morning cartoons on television teach health and safety practices, such as washing your hands before you eat or looking both ways when crossing a street.

Green blobs in cartoons chip away at teeth with hammers made of sugar, only to be defeated by the gleaming white of a toothbrush and fluoridated toothpaste. Even though the green blob is a hugely exaggerated depiction of a germ or bacterium, viewers understand it as something small that we cannot see with our own eyes, but which will harm us if we do not brush our teeth properly. These cartoons reinforce the true-life images that a microscope reveals through its lens.

Much of South Asia, however, remains a culture of oral tradition with legends and explanations of its own for disease and other life processes. One day in class, a student asked me what the difference was between white and black tuberculosis. I asked him what he knew the differences to be. He explained that a high lama—a higher-ranking monk—had told him that they now know that there are two different kinds of TB. I thought perhaps he knew of different strains of this disease, but he went on to explain that white TB can be cured with allopathic medicine, but black TB is a spiritual force and can only be cured with varying degrees of prayers, ritual offerings and appeasement, which only lamas can do.

Lifelong learning
When I started teaching the monks, I knew I would not only step into a very different world, but also bring parts of my world with me. The physical setting itself was different enough. The differing worldviews we held, while making teaching a challenge, also provided me with a wealth of fascinating anthropological sketches.

Most of the students met the challenge of learning the class material. What I came away excited about, however, was that they had also gained a greater sense of inquiry. The students realized there is much more to discover and learned how to seek answers for themselves through experimentation or by scanning available media resources.

I learned that, no matter how much I discover about teaching in other cultural settings, there are always better ways to prepare materials and transfer knowledge. The experience also taught me that, as a clinician and teacher, lifelong learning continues to be an exciting goal. RNL

Elisa K. Watters, ARNP, MSN, FNP, South Asia Group & Shechen Clinic, of Seattle, Wash., USA, currently resides in Kathmandu, Nepal.

Photos: Daniel and Benjamin Watters

For more photos, click on images below: