Medicine in Rural Nepal
Mark Zimmerman, MD, Director, Patan Hospital
A few months back when I heard that this Conference was going to focus on rural medicine, I emailed Sanjay to ask if I could have 5-10 minutes to share some of Patan Hospital’s experience in attempting to reach out beyond Kathmandu. A few days later he informed me that I would be the keynote speaker for the Conference.
In Gorkha District there is a hospital called Amp Pipal. When I worked there in the 1980’s, we used to have movie nights. Friends would send out films, usually documentaries, on 16 mm reels borrowed from the British Council. Just above the hospital entrance was a plateau of flat land, and at its end a chautara. Using bamboo poles and the branches of the tree, sheets were suspended. All available extension cords were used to connect the film projector to the hospital generator.
This was in the days before TV or video came to the hills. Movies nights took place every month or so. Word went out and the plateau was filled to capacity, with people at the edges hanging onto friends to keep from falling off into the khets. On one of the first movie nights, just as the projector starting clacking into the quiet night, an older village man stood up from the front row of the crowd and wandered up towards the screen. He stood silhouetted before the huge figures, gazed, then walked around the side and investigated the back side. After a moment, he came out front again and stared into the glare of the movie. He blinked once, squinted to adjust his eyes, and then realized that he was staring into 300 faces. A few hooting calls rose from the crowd. Unaffected, the man again turned his attention to the screen. After a few moments more, he turned back to the crowd and grinned broadly. Finally one of his relatives came forward and ushered him back to their places.
Today I am that man. Caught unexpectedly in the glare of this conference’s bright lights. A bit out of place as a city doctor talking about rural medicine. But still able to stare in wonder and share my feelings with you. I too expect to be ushered away at the end.
In this talk I will mention the gap between the valley and the hills: a rift that has grown into a chasm under the influence of the Maoist People’s War. I will speak about what I know best: how the United Mission to Nepal and Patan Hospital have made attempts to reach across that divide. We are not alone and others deserve accolades in this regard. The conference is called ANMF Goes Country. From the pulpit that you have provided me, I will conclude by stating this: ANMF should continue to go country.
The other day, Nepalnews.com told of Om Nursing Home opening up full in vitro fertilization services. Other headlines in the last year have trumpeted the advent of stereoscopic neurosurgery, addition of several more CT scanners, knee replacement surgery, and other advances. While still a medical backwater, Kathmandu has grown remarkably since the 1980’s when we had a 2-week wait for a CT scan and several months for chest surgeons to operate on an empyema. Small wonder. The medical schools of Nepal are now on target to produce 300 Nepalese doctors each year. When they graduate, they come to us for jobs. A significant proportion of the medical residents who come to work at Patan Hospital have never been to rural Nepal. When asked about travel into the hills, they tell of the family trip to Pokhara or to Dulihkel.. Over half of the doctors in the country are now in the Kathmandu Valley, which contains less than 10% of the total population. At 1 doctor to 850 people, Kathmandu is more highly doctored than some parts of America.
It was early evening, about 6 o’clock, and the doctor was on call in Amp Pipal Hospital. Two lads stood in the emergency area, with a bundle at their feet. High cheekbones, almond-shaped eyes: they were from the hills. They had on thick wool caps. The doctor was startled when the burlap mound on the floor moved slightly. The boys unhooked the carrying pole from the blanket and pulled back an edge. In the light of a bare light bulb lay a thin man. His face looked like it had been through many winters and many monsoons, and he wore a stubble of beard. He lay limp in the boys’ arms as they hoisted him onto the exam table.
“What happened?”
“Fever.”
“Since how long?”
“4 months.
“4 months?! Why’d you wait so long?”
“We live 4 days away, over by the Buri Gandaki. Had to take care of the fields first. And then the cattle.”
“Your grandfather looks very sick.”
“Father.”
As the doctor took the man’s blood pressure, his disease rubbed against the doctor’s belly: a bulge protruding from under his right rib cage. The doctor pulled back the shirt and gazed at the football that he had tucked under there. He explained the procedure. The boys nodded. Their father looked apathetic, in fact, nearly dead.
After some local, he put a 14 gauge needle onto a glass syringe and pushed in. Immediate pay dirt. Bubblin crude rushed up into the syringe. Again and again. 34 times, long after his arms had grown tired. An amoebic liver abscess. 2010 cc. A flicker of light came onto the man’s face. The doctor ordered an IV and medications and sent the man to the ward.
The situation in the hills of Nepal is dire. People are afraid. Fighting goes on and pushes everyone to take sides. Progress has been set back decades. But let us not get mired in the negative. There are still people trying to stand in the gap. Dulihkel Hospital has outreach programs to 4 areas around the country, and all their doctors go out on regular visits to remote places. Dr. Shankar Rai, recently honored by an AMA award, continues to run programs called Scalpel and Smile, in order to provide general surgery training and plastic surgery in remote areas. The new National Academy of Medical Sciences (NAMS) has been set up to (1) give entrance priority to those who have worked outside the valley, and (2) require a year of remote posting between the specialty and the sub-specialty phases.
The organization that I have worked with came out of a bird-watching expedition. Robert Fleming, a respected ornithologist and missionary in India, came to Nepal in 1951 to watch and capture birds; he would discover one new specie during that trip. In his entourage happened to be two doctors – one his wife Bethel, the other Dr. Carl Fredericks. Though coming as tourists, after word of their presence spread, the doctors were deluged with patients. Several thousand were seen in two weeks. Subsequently, an invitation was issued from the district seat in Tansen for these missionaries to start a hospital.
In 1954 Tansen Hospital and the United Mission to Nepal were founded. In 1956, in a converted Rana palace, came Shanta Bhawan Hospital, later to become Patan Hospital. In 1963, Okhaldhunga Hospital, and in 1969 Dr. Tom Hale opened Amp Pipal Hospital.
Amp Pipal is just up the hill from Luitel, the UMN school that produced in its 1970 class, the SLC first and second in Nepal: Baburam Bhattarai and Upendra Devkota. One was destined to lead the Maoist insurgency, the other became a neurosurgeon and Health Minister. This area was a hotbed of Maoist activity. In 2001, after missionaries working in Amp Pipal decided that the Maoist fighting all around was too much to take, UMN pulled out of that hospital. Fortunately, the local community rallied to keep the hospital going, and an MDGP doctor from Patan Hospital continues to head it up.
We in Patan Hospital cannot justify our existence solely on treating people from the valley. We have tried to use our position to “leverage” assistance to the hills. All residents and MDGP registrars who sign a contract at Patan Hospital must agree to the clause that states they may be sent to Okhaldhunga Hospital. With a 4 or 5 applicants for each opening, we are in a good bargaining position. Recently, Kiran was posted out there. Although at first unsure, when Kiran was reassured that the hospital was running well and that two expatriates were out there. He had participated in surgery for a ruptured uterus. A woman saved by re-transfused blood, hand-held flashlight when the generator went off, and prayer. As soon as Kiran returned to Patan Hospital, he asked to give a Grand Rounds about his experience. He wanted people to hear about what he had seen.
In Kathmandu specialists in anesthesia will tell you that only doctors are capable to put people under. You will hear similar things from specialists in radiologists and obgyne about their own fields: they advocate for the laws that exclude non-doctors from their procedures. They live so far from the reality of the hills. Out there, hospitals have one or no doctor at all. With the cooperation of HMG and the funding of INGO’s like UNICEF, Patan Hospital has developed programs to train non-specialists to become doctor-extenders. In 6 months we can equip a nurse to give anesthesia, in 4 weeks will refresh a midwife to run a maternity unit, in 6 months will teach an MDGP doctor to do ultrasound. These programs run throughout the year. We have regular graduations ans I hear of their stories: from Taplejun, Bhojpur, Kailali, Bhojpur – these Maoist areas and other areas from the Terai – about 20 districts so far. These brave folks attest to the fact that someone is still out there trying.
We feel that family practice training, MDGP’s, should be given our highest priority. These are the folks who can go out and run a hospital. My colleague Dr. Bruce Hayes conducted a study of all graduates of the IOM MDGP program (combined TUTH and PH residents). He was able to contact 39 of the 46 grads. Of the 39, 28 (64%) were working in remote rural locations – not a bad percentage! Bruce traveled to interview each of these MDGP doctors. He found that the single most important factor in favor of working in the hills was that the doctor had spent a part of childhood in a rural location. Having a wife from the hills was also influential in that direction. This finding has been made in studies in other developing countries, as well as at Thomas Jefferson University in Philadelphia.
Patan Hospital is considering starting a medical school. To do so we must overcome a number of obstacles – physical, political, and some philosophical. One that faced us from the start was this: why an 11th medical school in Nepal? For me, the answer is this: the hills. If we can produce young doctors who share a passion for the underserved, who have a higher likelihood for working in the hills – then and only then we need to start that medical school. Can this be done? We pray that it can.
ANMF has established itself. Each year more people come to our ranks, and each year more folks hear about it. Significantly, those who join tend to stay. Yesterday Sanjay spoke of the people from Nepal who would email asking for assistance. He was sad to not be able to help someone who, say, might ask for cancer meds. I would say: this is good. Of course you can’t help them all. But their asking indicates this: you have been spreading hope. Those of us who work there and our patients know that we are not alone; we have good friends in this network.
Today, I want to propose to you that you take this conference’s slogan and apply it long-term. Assistance just to the valley misses the real target. Pass a resolution that ANMF will encourage and preferentially fund projects that target hill regions. Stand in the gap.
The next day on rounds, the man with the liver abscess had pulled out his IV. “He eats fine,” his son told the doctor. He did look great, for a man who was nearly dead the day before.
“He wants to go home, Dr. Sahib.”
“He was really sick. Why not stay a week or so?”
They said nothing.
“OK. You can go home in 4 days.”
The next day when the doctor came to the bed, they had all their gear rolled up and tied with a naamlo, laying on the bed. The old man was half sitting, half standing. One son had already taken the carrying pole up to the chautara. At tea break that morning, the doctor watched them go. They walked in single file down the stone steps by the tea shop. One son, the father, then the other son carrying the pole. Some way down, they turned left past the tree and disappeared into the hills. Let us not forget them.