A Nepal in need for primary care

Hugh Thomas is a locum GP and Out of Hours doctor in East Sussex and a public health teacher at St George’s, University of London.

2014 02 Nepal 2013 122Nepal is one of the poorest countries in the world, with a population of 29 million living mainly in remote rural areas, with very limited health care provision and the very high maternal mortality rate a major challenge. Government and Non-Governmental Organisations (NGOs) are working together to improve things, with at present only around 1 in 5 births having a skilled birth attendant at the delivery and very limited antenatal care.

Practical Help Achieving Self Empowerment (PHASE) started work in Nepal in 2005 and seeks to help Nepalis by setting up local schemes to improve literacy and education, agriculture, sanitation and health care. But what can a GP offer on a short (usually around 2 weeks) visit?

I have made two visits to a primary health care centre in the hill country about 100 kilometres from the capital, Kathmandu. Early September is a good time to go as the monsoon season is almost over and return air fares from London are reasonable. The exciting bus ride from Kathmandu, 3 hours on metalled roads and 1 hour on poor roads, with a final 2 hour hike up the hillside, helps you appreciate that the villages are remote. The bus ride and porter cost around £10. Other GP volunteers went much further afield and had to walk for up to 4 days to reach remote villages.

2014 02 Nepal 2013 018There is always the sound of running water in the hills – from rushing rivers in the valleys to fast- moving streams and waterfalls. Clouds are common in the valleys and rolling thunder is heard on most days; but the warm sun and general lack of wind mean that good trainers, light clothing and an umbrella are adequate apparel.

Prior to my first visit I bought books on tropical medicine and attended a week’s course for missionary doctors. Little of the extra training was relevant. Although PHASE had asked me to be a mentor to an Auxiliary Nurse Midwife (ANM), my role was less to use the basic knowledge from the DRCOG obtained 15 years ago, but rather to encourage the ANM in running basic primary health care clinics. I encouraged her to take good histories and carry out thorough clinical examinations. The patients had conditions that were little different to the UK – chest, eye, ear, skin and urinary tract infections, gastritis and gastroenteritis, joint and muscle problems. PHASE provided clear illustrated texts to aid diagnosis and appropriate prescribing. Guidelines for chronic conditions, such as hypertension and diabetes, were applied well. The ANMs speak limited English, but we generally communicated well and in the vast majority of cases our diagnoses were the same. In contrast to British general practice, there was little opportunity to explore issues such as stress and depression. Advice on alcohol and smoking was offered but it was hard to gauge its acceptance.

2014 02 Nepal 2013 128Each clinic has basic medications which are issued free to children and for a very modest cost (around 10p) to the generally poor hill farming families. For children the Integrated Management of Childhood Illness (IMCI) chart on the wall helps the ANM to decide whether antibiotics are appropriate or whether hospital referral is required.The use of growth charts also helps to identify the small number of cases of malnutrition. Patients were given a handwritten record of their consultations and were very good at bringing this back if any follow-up was required. The ANMs had to explain the dosage of the medicines clearly as many of the older patients were illiterate.

Antenatal care is important with around 70% of the mothers being anaemic. When seen they are routinely prescribed iron, folic acid and an anti worming tablet. Health education is provided by the ANM and a good rapport has been developed for postnatal care and immunisations.

Walking to the clinics for up to two hours, with the rice growing on the hillside paddy fields, was a test of my older age fitness for which I felt better. The accommodation was basic, with no electricity after the late afternoon. The outside toilet was basic, too: the locals do not use toilet paper, but have a cold water bucket . Washing was at the stream which was about 400m from the house. There was no opportunity for a bath or shower. As gastro-enteritis is a risk for all visitors I became a vegetarian for 2 weeks and avoided any fruit that might have been washed in un-boiled water. With two meals a day, based on rice or potatoes, the food could be considered rather bland but there were some interesting flavours to be enjoyed. Sweet things are not part of the usual diet, but I cheated slightly by having a small Snicker bar before going to bed. On both visits I lost around 5kgs in weight.

The ANMs receive fundamental nurse training and 18 months’ extra training where they obtain midwifery experience, including setting up drips after a postpartum haemorrhage, and suturing. They receive basic training in extracting teeth and doing simple fillings. They are instructed on dealing with basic medical and surgical conditions and recognising the cases that need hospital referral. It is in this latter area that visiting GPs can give support and advice. By taking along illustrated booklets and a laptop they can use the early evening daylight hours to give tutorials on subjects such as asthma, skin conditions, paediatrics and cancer. Cervical cancer is the commonest female cancer and PHASE is working to improve cervical screening and to provide colposcopy clinics.

2014 02 Nepal 2013 129Overall, the two-week visits to a very poor country emphasised to me the value of our National Health Service, the importance of good clinical examination and history-taking, and the effectiveness of basic medications such as paracetamol and penicillin. Seeing real poverty is a humbling experience which puts our rather trivial consumerism in perspective. My income for an out of hours session, even after tax, would fund an ANM for one month. It impressed me that children were cheerful and enthusiastic, despite having very little. The headmaster of the local school told me that none of his 150 pupils would go on to higher education – due to cost and the lack of expectation.

PHASE is attempting to deal with health, education and livelihood needs in a practical way and I look forward to supporting the work in future, both in the UK and on further visits to Nepal.

Hugh Thomas

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