Philippa Hardy / ED Locum Doctor / UK
Philippa Hardy is the author of website Escape Medic and is currently working as a locum in ED in preparation for a summer of expeditions. In 2016, she travelled to Nepal, spending time alongside Professors Upendra Devkota and Henry Marsh at the National Institute of Neurological and Allied Sciences (NINAS) in Kathmandu. At a general surgical camp in Ghorka District, she encountered a desperate situation with no easy answer, but all too common in developing world work.
Professor Upendra Devkota
Inspired by his mentor Dr Gongal, Professor Upendra Devkota left his district of Gorkha, Nepal to pursue a career in neurosurgery at the Glasgow Institute of Neuroscience under the expert guidance of Sir Graham Teasdale. He later continued his career at the prestigious Sir Atkinson Morley Hospital, the birthplace of the CT scanner, before deciding to take his expertise back to Nepal. In 2002, he founded the country’s first Neurosurgical Unit at the Bir Hospital, Kathmandu followed by Nepal’s first Neuroscience Institute in 2006.
At the time of Professor Devkota’s return to Nepal, the country was in political turmoil. The Royal Family had been massacred one year before and the government was grappling with six years of Maoist insurgency. There were a mere 400 physicians for a population of 15 million, most of whom lived and worked in Kathmandu. In the provinces, there was a breakdown in education and infrastructure and internal displacement from the insurgency. Malnutrition and gastroenteritis were common, with viral infections, parasites and tuberculosis contributing to most deaths.
By 2016, when I travelled to Nepal, there had been dramatic changes in Healthcare: life expectancy was 68 years and mortality amongst those under five had fallen to 40 per 1000 live births (from 209, 36 years before). Per capita expenditure on health had risen from $15 in 1995 to well over $70 in 2012 and death from lower respiratory tract infections and diarrhoeal illnesses had reduced significantly.
I was lucky to spend a short period of time alongside Professor Henry Marsh, as a guest of Professor Devkota at the National Institute of Neurological and Allied Sciences (NINAS) in Kathmandu. Whilst I can by no means comment on the overall healthcare situation of Nepal with any expertise, nor will I try too, I can give a small insight into my experience.
National Institute of Neurological and Allied Sciences
I spent the majority of my time at NINAS, where they have three operating theatres, all equipped with the latest neurosurgical technology. The have an excellent radiology department including a CT and MRI scanner, a 16-bed intensive care unit, four wards and daily consultant outpatient clinics. I was also privileged to join an exceptional team of 39 others from NINAS at a health camp in Gorkha District, the epicenter of the 2015 earthquake. The contrast from NINAS was stark: the region had just eight doctors spread across two underfunded district hospitals and three primary healthcare centres serving a population of 260,000.
In just three days in Gorkha, over 3,000 patients were seen and more than 40 general surgical operations performed, using donated equipment brought from Kathmandu, in a dilapidated post-earthquake building. The team included doctors, physiotherapists, pharmacists, dentists, nurses and the local women who provided food for the team each day. Some people travelled for up to three days to be seen by the specialists as they would otherwise have no access to healthcare at all, it being too great a distance to travel and too expensive.
The range of pathology was impressive. There were patients with large fungating tumours, which we sadly could not do anything for, breast lumps, cysts, syndactyly and polydactyly, hydroceles, varicoceles, spina bifida, diabetic ulcers, dental abscesses, back ache; the list goes on. Pregnant mothers were able to hear their baby’s heart beat for the first time with the ultrasound machine, and people were able to take medicine home free of charge.
I spent the majority of my time in the operating theatres, primarily due to the language barriers in clinics. Diathermy was sparse, so inguinal hernia repairs, saphenofemoral ligations and lipoma resections were all performed without it. I assisted with all of these operations, performed a spinal anaesthetic, intubation, hydrocele repairs, incision and drainage of abscesses as well as surgery for polydactyly under supervision. By the end of the camp I was leading some of the operations with minimal assistance. The term ‘see one, do one, teach one’ had never felt more apt.
On day three at the health camp I encountered Sumeesha, a young mother of a two-year-old boy plagued by rectal bleeding since birth, desperate for someone to save the life of her son. She had been walking from her small village for 50 hours; exhausted, she begged the professor to perform life-saving surgery on her son. It was a high-risk surgery when performed by specialist paediatric surgeons and almost unthinkable given the paucity of suitable equipment and absence of trained professionals to deal with potential complications.
She explained how her husband had been working in the United Arab Emirates for the last 18 months in order to send money home to them. She had no support, with little extended family. Not only was she unable to reach Kathmandu to seek medical help, the journey itself being far too expensive, but she would not be able to afford to see a doctor at all let alone pay for any necessary surgery.
The story was difficult to hear. I knew that without performing the procedure, the boy may have a catastrophic haemorrhage from his polyp some time in the future. Yet to perform it here, with limited equipment, no specialist care and no follow up in the event of complications… How could it even be considered? Especially given that the professor had turned away patients with hernias earlier that day: fairly routine procedures with little scope for disaster.
Stunned by the decision to go ahead, I could barely bring myself to watch surgical appliances more suited to an adult being used to attempt to remove a polyp. I felt there was an element of playing God and my conscience was slightly unsettled. I had to take a step back to reflect and to ask, ‘who am I to judge?’. In scenarios such as this, which are all too common in the developing world, this mother had no other choice. She cannot afford the journey to the general hospitals in Kathmandu or the appropriate treatment were she to arrive there. She had no option but to place her son’s life in the hands of a neurosurgeon with no recent experience in the operation he was about to perform.
It is easy to discuss these sorts of ethical dilemmas from the comfort of our seminar rooms, in a country where healthcare is free for all at the point of access. For people living in remote areas of Nepal, access to healthcare is almost non-existent. Surely a highly specialised neurosurgeon, with previous training in general surgery is capable enough of performing this procedure especially when the alternative is no procedure at all? Can we withhold treatment due to a potential risk of intra- or post-operative complications when the risk of those being fatal is lower than the risk of doing nothing?
Lost to follow up, I would never find out the eventual fate of the young boy but the image will remain forever in my memory.