It has always been a goal of mine to go back to my home country, Nepal, and to connect with the community in a meaningful way. I am so grateful that I was able to achieve just that during my international selective during my final year of medical school. This was my first time going back to Nepal, after immigrating to Canada with my family as refugees in 2001. I had many subconscious and conscious expectations of what healthcare looks like in Nepal, a developing country, some which were true and some which proved to be false. Only once I had the chance to work on the ward did I fully see how, from a fundamental level, Nepal was so strikingly different. Different doesn’t mean worse than our system in Canada, nor does it mean worse, but I realized how many factors play into the delivery of healthcare for Nepali people, with the primary factor being socio-economic and cultural factors.
I had the privilege of working on a pediatric unit of the main teaching hospital in Kathmandu, Nepal – Tribhuvan University Teaching Hospital (TUTH). On my very first day, what struck me is the minimal infrastructure and resources present in the hospital. I was placed in the outpatient clinic for the first day, and witnessed just how chaotic the environment there was. No distinct clinic rooms were present, just a large square room with resident doctors parked at various corners of the room, with parents rushing to get their children seen, similar to people trying to get the attention of a bartender at a busy bar. The next day on CTU, noticing how there are no IV pumps, or very rarely did I see continuous monitors, even for very sick patients. A particular case that really touched me, but at the same time broke my heart, was a case of a young 23-year-old mother who had just given birth, but her baby was admitted to the NICU with gonococcal ophthalmia neonatorum. She was of low socioeconomic status, and had received very little prenatal care. She was a patient that had also expressed she likely would not be able to pay for her baby’s hospital admission. I remember in rounds, a family member of a patient in the bed beside her baby’s was saying that she is not eating throughout the day, and sometimes they would help her out with some meals. In Nepal, meals are not provided in the hospital – the hospital doesn’t have the funds to be able to provide that for patients, and actually most patients are required to have a family member as a requirement for admission- as someone who can bring medications from the pharmacy, take samples to the lab, and pick up lab/ imaging results – these are not done by hospital staff, because again, lack of resources. At this time, the attending on CTU asked the medical students on the team to bring this patient breakfast and lunch before they come to the ward. These meals would come out of the attendings own funds. This moment struck me with mixed emotions – firstly the sorrow for the situation that this young mother was in, but secondly a sense of pride, for the heart of us Nepali people. The sense of togetherness, of unity, of treating everyone as family – this is the very essence of what it means to be Nepali. This was a moment that filled me with pride, and an insight that although there are many parts of the Nepali healthcare system that need improving, we have held on to the humanness of medicine, and for that I am very proud.
I recall a case during my experience in TUTH where I saw the direct of effects of privatization of healthcare, and the effects of income as a major determinant of health outcomes. Our team was asked to see a 12-yo patient from a remote village, who, as of one month ago, lost the ability to walk. Through questioning this family, we learned that this patient had uncontrolled seizures at home for several years, and the parents had been unable to access medications. This patient required thorough investigations including MRI scans, and ultimately a hospital admission to workup the cause of her loss of ability to walk. Initially the patient’s family was resistant, stating that it would be out of their means to be admitted (the cost for admission was the equivalent to ~10$ per day). The family was eventually admitted after applying for compassionate fee forgiveness. Through the thorough workup, the cause of her loss of ability to walk was found to be due to uncontrolled seizures causing ischemic changes in the brain – a direct result of the disproportionate access to healthcare for people of lower SES in Nepal. This case was incredibly insightful for me to characterize how lower SES directly leads to lower health care outcomes within a private healthcare system. I witnessed the residents and the attendings I worked with doing the very best they could do to provide equitable healthcare for these patients, but I saw that working within a struggling system often leads to results that are unavoidable results of the system they work within.
Overall, my experience in Nepal has reinforced to me that to create large change in healthcare, systemic change is required – but it has also taught me the power of small, simple kind interactions, which can make a world of a difference. Martin Luther King Jr said “If I cannot do great things, I can do small things in a great way”, and my experience in Nepal has truly reinforced to me that sometimes, while trying your best to contribute the excruciatingly slow process of systemic change, the best you can do is do small, great things.
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