Rural medicine in Nepal

Rural medicine in Nepal

Introduction

Nepal is a fascinating country, famous for its mighty Himalayan peaks

and ancient untouched cultures. In spite of its great beauty and attraction,

Nepal remains one of the poorest countries in the world. As in many

developing countries, most of the population lives in rural areas while

most of the medical facilities and health professionals are found in the

capital city. Although there are many rural hospitals scattered throughout

the hills of Nepal, many function very poorly, suffering from shortage of

staff, medicines and low quality of care. Some however have gained a

reputation for offering good and appropriate service to the communities

they serve. I currently have the privilege of working in such a hospital,

the TEAM mission hospital in Dadeldura.

The hospital in Dadeldura Dadeldura is the district headquarters

of the Far Western region and as such is relatively large town. It is

on the top of a ridge of mountains and has a spectacular view over

rolling river valleys rising up to steep hills, backed by an East to West view

of the snow capped Himalayas. The hospital has 30 beds, with 2

wards. Men, women and children, medical and surgical cases are all

mixed together in these wards. Initially I was surprised to see that it

was possible to run a hospital with only 30 beds. However there were

never any patients who had to sleep on the floor since I have been here

and 30 beds seem enough. There is a much higher threshold for admitting

patients; for example, patients suffering from typhoid, which

is endemic, are usually not admitted, and TB patients usually stay for only

a few days. The hospital sees about 100 out patients a day and does

about 50 deliveries a month.

The hospital is run by two doctors, both family physicians from

USA. One has been at that hospital for 20 years and is an extremely well

known figure in the community. He told me that on his first visit

to the hospital, he had to walk for three days to reach the hospital

as the road had been blocked by landslides.

The real keys to the hospital are the 5 CMAs (Clinical Medical Assistants).

These workers are the Nepali equivalent of PHC nurses in South

Africa. They sit in out patients department and see most of the patients.

They also manage the wards, giving injections and doing dressings.

As there is no radiographer, they take all the X-Rays. They also

conduct all of the deliveries that happen at night. For caesarean sections

they scrub and assist in theatre. They are the main people to see

patients after hours and so take turns to be on call, working the whole of

the next day as well after a call. And for all this they have 15
months training.

Many of them are highly experienced and a real pleasure to work with.

Challenges

A thing I have found surprising is the relatively high proportion of surgical

and especially orthopaedic patients that we admit. People are

often falling out of trees - or off the steep terraces that they farm on.

They climb the trees to cut off branches to feed their buffalo. (As

a result, most of the trees here have no side branches and just grow vertically

up). About 3 patients with fractures come to the hospital every

day, and supra condylar fractures of the humerus are especially common.

In my first three days here, 4 women arrived in labour with dead

babies. Two were in transverse lie with cord prolapse and we had to

deliver the babies by caesarean section. One was a breech and delivered

vaginally, and in the case of the other we had to do a destructive

procedure on the skull to deliver the baby. None of these women had

been for antenatal care, which seems to be the rule rather than the

exception here. It is not hard to see why Nepal has one of the highest

maternal mortality rates in the world. Very few patients are admitted here

to await labour, and the concept of maternity villages does not seem to

have been proposed at all in South Asia. As some mothers come from

several days walk away, this situation is very difficult. At least they can do

caesarean sections at this hospital. There are many district hospitals

in Nepal where not even this is possible.

The lack of referral facilitates is difficult. The hospital is not far from

the India border, so if patients have money many choose to go there.

But there is no close relationship between TEAM hospital and larger

referral hospitals. In my first week here we had several difficult cases

with no one to ask - like an open skull fracture with meninges showing

- and a man with Fournier's gangrene. It made me appreciate

"Mailadoc" (email discussion list) and the good referral backup we had

while I was working at Manguzi Hospital, in KwaZuluNatal. We often refer

patients to larger centres, up to 8 hours away, without being sure they

will reach the correct place or receive the correct treatment. I have seen

several people who travelled far and spent much money on investigations

such as X-Rays and blood tests, only to not have enough money for

treatment, or to be told that it was an incurable illness. Referral often

does not seem rational and a lot of money seems to be unnecessarily

spent by anxious relatives wanting to do the very best for their loved

ones, even if that means spending money they have had to borrow.

At first I thought that being able to collect blood from a willing family

member donor was a huge advantage and would prevent the situation

we tried to avoid at Manguzi of our blood supply running out. I have

since found out that this is not true.

Generally speaking, people seem very unwilling to give blood except

to very close family members. Women seem particularly reluctant, fearing

that it will make them too weak to work in the fields. I have now

observed three occasions where very anaemic patients, one with an

ongoing gastrointestinal bleed, had to be sent home or to another centre

at great cost, simply because no

willing donor could be found. The problem of unusual blood types is

even more of a challenge. Last week, after persuading over 10 villagers to

have their blood tested, seeking a donor for an A negative patient, none

was found to match. Eventually the patient was sent to a bigger centre.

Some solutions

An innovation at this hospital that I have found very useful is the solar

lights. Each light fitting has two lights - one working off the main power and

one off a solar battery. The hospital does have a back up generator but

this has to be turned on manually at the workshop. When the lights go out

in that crucial stage of a delivery or operation, with a flick of a switch one

can be using solar power, while waiting for the generator to be turned on.

Unlike the situation in South Africa, where interpreters are widely

used in consultations, here there is a high expectation on expatriate

doctors to be able to speak the local language. I had to take a 4 month

course in Nepali before working here and all of my work with staff and

patients is done in this language. The increased depth of communication

that this makes possible has lots of rewards. One of these is being

better able to appreciate and in some ways manage the personal

and contextual aspects of the consultation.

I am amazed at the number of patients, even in this very poor

rural community, who present with physical symptoms, but have underlying

depression or anxiety, often from family related problems.

Conclusion

In all, though, it is in many ways like a rural hospital at home. The doctors'

houses look the same, the communal social life is the same, and the fact

that all the staff in the hospital are related to everyone in the village is

the same. It has not taken me long to feel at home here.

I have found that rural health care has many similarities all over the

world. It is my hope and prayer that its joys and challenges will keep me
in this type of work for a long time to come. For those who like adventure,

enjoy a challenge, find other cultures stimulating and want to

make a difference in the world around them, I can recommend it