INTERNATIONAL GP

Volunteering in the Kathmandu Valley

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Reprinted from Good Practice Issue 12, JanuaryFebruary 2014

STEPHEN A MARGOLIS

For Australian GP Steve Margolis, taking his muchneeded medical skills to Nepal proved a fullling and educational experience.

Approaching the later stages of our respective careers in education and medicine, my partner Valmae and I were looking for opportunities to give something back to those less fortunate. With many years of experience working with Aboriginal and Torres Strait Islander people, and having lived and worked in the United Arab Emirates, we looked for locations where our skills and experience might provide the greatest benet to those most in need. With English our only language, and personal safety a signicant consideration, Nepal became our destination of choice, a country of dramatic and stunning scenery which is bearing witness to a burgeoning populace and rapid urbanisation, but with limited resources and much of its population living in poverty. We started by approaching DocTours, a Sydney-based company that organises volunteer placements for professionals in countries with areas of need. Our destination was on the fringes of the rapidly expanding urban centre of Kathmandu Valley, where the population has risen from 1.6 to 2.5 million in the last 10 years. Mindful that personal connections are crucial for volunteering across cultures and languages, we decided to undertake a two-week preliminary/exploratory trip, which allowed Valmae to meet with teachers and me to meet with doctors. Through DocTours, we met our Nepalese hosts, Bijuli, Sunita and Phillip Timila, from Banepa, a town of about 20 000 located an hour (through some rather hectic trafc) southeast of Kathmandu. Bijuli has been supporting volunteers in his district for 10 years and has strong connections across health and education. The health service around Banepa mostly consists of village-based primary care delivered by health workers, the communitybased Scheer Memorial Hospital (similar to an old-style Australian country hospital) and Dhulikhel Hospital, the district teaching hospital of Kathmandu University. Although undergraduate medical education is now well established in Nepal, graduate education programs have only recently been established. Most of the doctors are trained in countries other than Nepal and bring a broad and varied range of experience to clinical practice. Through Bijulis personal connections, I had the privilege of working closely with the Scheer Hospital team across a range of inpatient and outpatient services, as well as a shorter experience at the Dhulikhel Hospital.

On rounds Each morning at Scheer would begin with a joint meeting of all medical staff, where the overnight admissions would be discussed, often followed by an education session. Ward rounds would follow and I usually chose to participate, only missing out when I was in the operating theatre. Around 25 inpatients made for lengthy rounds and provided a powerful insight into the health challenges faced by the community. Grinding poverty, limited education and few medical options combine to see most patients present to hospital very late in the course of their disease. Although hypertension, ischaemic heart disease, chronic obstructive pulmonary disease (COPD) and, to a lesser extent, diabetes are all very common, few people have access to, or are compliant with, outpatient medication. As a result, many presentations to hospital are the outcomes of these diseases, including myocardial infarction, stroke and pneumonia.

Few [local] people have access to, or are compliant with, outpatient medication
Infectious disease is also a major challenge, with tuberculosis and typhoid common causes for admission, with septicaemia (mostly from pneumonia), requiring inotrope support, occasionally presenting. Surprisingly, attempted suicide by organophosphate poisoning is also quite common. Dr Angela, the sole physician at the Scheer Hospital, welcomed my participation in her ward rounds, taking time to translate key points in the dialogue for me, allowing me to examine the patients (with their consent) and discussing each persons condition. Clinical acumen is uppermost because the range of investigations and treatment options is limited by availability and cost. However, late presentation and advanced disease means physical signs are often quite pronounced compared to the Australian clinical setting. Counting the costs Patients in Nepal must pay for all treatment, often upfront, and there is no insurance. While these costs are admittedly very low by Australian standards, they represent a major expenditure for people who earn an average of US$540 per year.1 >>

Image Valmae Ypinazar

Reprinted from Good Practice Issue 12, JanuaryFebruary 2014

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INTERNATIONAL GP

Contacts
If you are interested in visiting Banepa and offering your services, useful contacts include: Karin Eurell, DocTours, Sydney (02) 9967 8888 or enquiries@doctours.com.au Bijuli Timila, Banepa, Nepal +977 9841543982 or sunitatimilia@yahoo.com Scheer Memorial Hospital, Banepa, Nepal www.scheermemorialhospital.org Dhulikhel Hospital, Dhulikhel, Nepal www.dhulikhelhospital.org/ Baylor International Academy, Banepa, Nepal www.baylor.edu.np Esa Memorial School, Banepa, Nepal www.scheermemhosp.org/School.asp
Above left: Severe poverty and poor education often combine to see Nepalese patients often present at hospital very late in the course of their disease. Above right: Despite its limited resources and rapid urbansiation, Australian GP Steve Margolis found Nepal a country of great beauty and culture.

>> Simple tests, including full blood count, electrolytes, renal function, blood cultures and liver function are available at Scheer, as are plain X-rays and ultrasound, with echocardiography (excluding Doppler) available once a week. CT scans are available at a location 30 minutes away, but cost US$200. Medication choices vary depending on availability from suppliers, but most that are relatively cheap and commonly used can be provided. I was interested to note that patients request and receive almost no analgesia, meeting the cultural norm of the population serviced by the hospital. In addition to the traditional male and female wards, there is also a three-bed high-dependency unit with contemporary bedside monitoring, but no access to blood gas analysis.

Ward rounds at Scheer are followed by breakfast in the cafeteria and the rest of the day is lled with outpatient clinics. The clinical content of medical outpatients is similar to Australian general practice, with a number of chronic disease management issues, including monitoring of disease conditions and compliance with medications both prominent. I also visited the hospitals very busy obstetric unit, which sees 510 deliveries per day. Most patients delivering at Scheer receive antenatal care, helping to keep the C-section rate to around 15%. The government co-funds these obstetric services, which demonstrate high standards of care with good clinical outcomes. However, a high national perinatal mortality rate (27 in 20111) is due to the large number of women not receiving antenatal care and delivering at home unsupervised, which

occurs despite national government programs to support and promote antenatal care and hospital birthing units. Operations at Scheer are conducted at a high standard. Modern anaesthetic machines donated in 2012 allow safe and effective anaesthesia for patients who often have high levels of comorbidity and associated complications. The skilled surgeons provide a range of acute and elective operations, including laparoscopic cholecystectomy, vaginal hysterectomy and internal xation of fractures. Visiting international teams also provide specialised procedures; a cleft palate team from Japan was visiting during our stay. Inpatient care Although my principal attachment was to Scheer, I also visited the Dhulikhel Hospital, 10 minutes further west from Banepa.
Images Valmae Ypinazar

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Reprinted from Good Practice Issue 12, JanuaryFebruary 2014

This large and more modern hospital offers a greater range of services, including an intensive care unit (ICU), neonatal intensive care unit (NICU), and a formal emergency department. I spent one day working with the sole emergency department consultant and two days with the paediatric team. With Nepal in the early stages of developing a pre-hospital care system, and emergency medicine not currently recognised as a special discipline, the inpatient specialty teams are closely involved in the management of patients in the emergency department. Trauma, infections and the complications of pregnancy and chronic disease are the most common presentations. A larger range of investigations is available, but no CT. Clinical problems faced by the inpatient paediatric unit include multiple infectious diseases similar to those seen in adults, including tuberculosis, typhoid, hepatitis A and pneumonia. Some children I saw appeared small and undernourished, consistent with marasmus or kwashiorkor. The very modern and well-equipped NICU provides continuous positive airway pressure (CPAP) and ventilation for small, premature and septic babies. Learning opportunities Universal education has a very short history in Nepal. In 1951, there were only about 10 000 students attending school, primarily children of the ruling classes. But through successive governments and policy changes, the number had grown to 7 800 000 by 2010. This large increase has taken place in a country beset by poverty, isolated villages and very poor infrastructure, and the current literacy rate of the Nepalese population is

estimated to be 60%, with around 90% of all children attending primary school. One of the consequences of such rapid expansion of education is the critical shortage of qualied teachers; approximately half of the countrys educators have no formal teaching qualications. I volunteered in two private schools while I was in Nepal, both of which have an emphasis on teaching in English. The Esa Memorial School is part of the Scheer Hospital and has 60 students, ranging from early childhood (23 years) through to Year 5. Unlike Australian schools, the children stay in their assigned rooms while the teachers rotate through each grade. The subjects covered are similar to those in Australia, including English, maths, science and social studies. Nepalese is also taught. I gave support to the teachers in the classroom, engaged in conversational English with the older students, helped take English lessons, played singing games with the younger students and did some one-on-one work where I could see a need. The Baylor International Academy has an Early Childhood Care and Education facility that was established in 2010 and caters for children aged 25. This is more like a typical Australian early-childhood centre, with a single teacher responsible for their own group of students. I worked with an older group of students in the two days I spent there. I joined in with their songs, helped with reading and writing, conversed in English, did some one-onone work with a young boy, and generally supported the teacher where I could. The Nepalese children and teachers are very welcoming and appreciative of any skills brought to the classroom, and it is

not necessary to be a teacher in order to volunteer in this environment. Conversations conducted in English with the children and teachers go a long way towards improving their English-language skills, and any interests in music, art, dance and drama that could be shared would be most welcome. Both schools have very few resources so creating educational resources would be another volunteering opportunity. The only thing required is a joy of being with children. Offer your services Nepalese health and education providers welcome doctors and teachers from Australia who wish to assist with their programs. The options range from shorter orientation-style visits through to being a staff member over a period of weeks or months. Options for living arrangements include daily commuting from a range of hotels in Kathmandu (your choice), local district hotels and guesthouses, or home-stay with Bijuli and his family. Although taxis and buses are readily available and very cheap over short and long distances, road conditions are poor, which makes for long travel times. Valmae and I both thoroughly enjoyed our brief visit to Nepal and plan to return for a more extended stay, when we hope our contribution can be more substantial. Australian-trained GPs have much to offer Nepalese healthcare services and, depending on your training, experience and interests, this could include village-based primary care, hospital-based consulting or procedural practice.
Reference
1. Unicef. Available at www.unicef.org/infobycountry/ nepal_nepal_statistics.html [Accessed December 2013].

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Reprinted from Good Practice Issue 12, JanuaryFebruary 2014

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