For my elective I chose to go to Nepal and split my time between working in a large government run hospital and in the outpost of a local village. It was a fantastic way to get an overview of healthcare in Nepal and the struggle to deliver it. Nepal is a developing country with a developing healthcare policy. With a largely mountainous landscape and a population of around 29 million people - many of who live rurally - the challenge of providing healthcare with limited funding is immense.
Healthcare is not free in Nepal and unfortunately - as in many developing countries - there is corruption. In Nepal this type of corruption can result in an individual not being able to afford treatment or having to sell his house and land resulting in his family becoming destitute – something that is not recoverable in a country like Nepal.
Arriving in Kathmandu, the roads were hectic with motorbikes everywhere. People were burning their rubbish on the streets which gave the whole place a sickly sweet smell of burning plastic. The main river was heaped to the banks with household waste and there were locals in amongst it all doing their laundry. Having visited India a few years ago I thought I would be used to all of this. However time had made me forget exactly how much of a culture shock landing in the middle of a developing country can be. The biggest shock was the driving. If there was a space in the traffic even approaching the dimensions of a car or bike the driver went for it! Later in hospital I was to see the result of such bad driving time and again.
For the 5 weeks I spent in Pokhara I lived in the Work the World house occupied by up to 18 elective students from all over the world studying medicine, nursing, physiotherapy or dentistry. Primarily based in Pokhara city, my placements ranged from general medicine & emergency medicine in the newly built teaching hospital, to outreach clinics and health posts in isolated villages. In ED we saw the many similar conditions to those we see in the UK. However there was an awful lot more trauma (resulting from RTCs and falls from trees!) and an alarming number of cases of meningitis. In the outreach clinics we saw more GP-like cases. In the lulls we visited the wards and saw some interesting paediatric cases including: Typhoid, Organophosphate poisoning, Viral Meningitis, Tetralogy of Fallot, Pulmonary TB, G6P deficiency, CMV hepatitis.
Our two weeks in general medicine were similar in so many ways to the time we spend in hospital in the UK. They were also very different. The day started with presentations of the previous day’s admission in front of the whole team. Interns are responsible for these presentations and in general get ripped apart by consultants, quite often justifiably. After the meeting we went on ward round where we were told to examine patients and asked questions by the consultants in a similar way to the UK. The main difference between the UK and Nepal seems to be that each doctor has their own opinions and these very much shape the treatment given/information disclosed
Holi is a Hindu religious festival of colour. It is an important event in Nepal and involves all the locals covering each other in paint and throwing water bombs at each other. Everyone joins in; however tourists become targets (in a playful way) for the locals. I went for a walk on Holi to see what would happen. In short, I got targeted massively!! On another day we took a boat across Lake Phewa and climbed to the world peace pagoda that overlooks Pokhara. The views were fantastic.
To come to Nepal without going trekking would have been a crime.
From the house we were staying at we could see the Annapurna range of Himalayas one of the most popular trekking regions in the world, one of the most beautiful too. It was breathtaking to say the least.
For our final free weekend we headed to the south of Nepal by bus for 6 hours. This area of the country is lowland plains and jungle, home to many species including Tigers, elephants, Rhinos, crocodiles, monkeys, deer and many more. It was a relaxing trip, one of the highlights of which was a two hours downriver cruise in a narrow boat hollowed out from one tree trunk where we saw many beautiful birds. We were also lucky enough to go on an unforgettable elephant jungle safari.
The Village HEALTHCARE Experience
The highlight of my trip was undoubtedly the Village Experience. Our comfortable accommodation in Nalma village was provided by a local family. We worked in the health outpost which is normally staffed by a local with very little medical training. It was extremely basic. Those that were not treatable at the health post had to walk 3 hours to the nearest hospital. The cases we saw in the health post were mainly those we would see in a GP practice in the UK. There was also an abundance of pelvic inflammatory disease and alcohol abuse.
Summary & Reflections
With regard to models of health in Nepal, it is safe to say that the medical model of health most definitely holds sway, and probably will for many years. It would seem that in much the same way as it did in the UK years ago, the medical profession in Nepal must first concentrate on treating the illness before it starts to focus more on the individual and society itself. Given the fact that 60% of years of life lost are due to communicable diseases maybe this model fits better in Nepal than in the UK.
Doctor patient relationships in Nepal - with almost no exceptions - are paternalistic. Patients get told what is going to happen to them and what treatments they are going to have. They do not ask questions and doctors do not volunteer information. Even the informative model of the doctor patient relationship seems far in the future.
My time in Nepal was interesting, educational and moving. While this report has painted a rather bleak picture of the healthcare system in Nepal I would like to point out that the overall movement of this system is in the right direction. With organised TB eradication, HIV treatment and leprosy rehabilitation centres all being introduced it would appear that the government is acting in the interests of its population.
Coming back to working in a developed country with the NHS and a consideration of social issues in treatment makes me realise how lucky I am. The health professionals do a great job in Nepal; they just need the enlightenment that took the western world so long to achieve to make things even better. With doctors from the western world visiting and settling in Nepal and the increasing availability of knowledge, it cannot be that long before change happens – or can it?