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
