Healthcare Reflections

I’m done in Nepal. 30 days flown by and I'm now back in Canada, running around the country for interviews.  Nepal was an amazing experience and I’m glad I went despite significant reservations about finding "Neil safe" food half way around the world. Thankfully written allergy cards simplified everything, and food was successful :)

Looking back, my goals on an international elective were to see a different healthcare system, to see how as a Canadian doctor I could best support healthcare in a developing country, and to stretch my cultural boundaries and comfort zone.

What did I expect to find? For life outside the hospital, I spoke to other Canadians, and was well informed. I expected Kathmandu to be noisy, dusty, and impoverished but the people to be friendly. I was not disappointed! Within the hospital was a different matter altogether. Regrettably I was not well informed prior to departure and my expectations were fuzzy at best. On the one hand I pictured a destitute system where even the simplest of equipment was impossible to get. On the other I pictured the doctors working in full suit, tie, and white coat, much as in historic Britain. I never did fully reconcile these views to a universal expectation prior to arrival.

What did I find?

The Nepali people are warm, outgoing people, happy to engage in conversation with foreigners. The overall standard of living was low, and the people were definitely poor, but everywhere I looked I saw friendly people, doing required tasks with the equipment available. This usually meant manual tools such as pick axes, and elaborate body frames for carrying loads. Despite their hard lives, Nepalis were happy to stop and chat or sit down for a chia (tea).

Kathmandu itself did not disappoint: the streets were teeming with people, dusty, and garbage everywhere. Rules of the road were virtually non-existent. It is nominally drive on the left, but in practice it's "drive where the vehicle fits"!

The healthcare system, at least in Kathmandu Valley, is way beyond what I expected. Tribhuvan University Teaching Hospital (TUTH) is THE tertiary care centre for Nepal. The medical services it offered were easily on par with a large Canadian community hospital. CT, MRI, ultrasound, laparoscopic surgery, endovascular aortic repair (EVAR), cardiac surgery, angiography, interventional radiology etc. were all available in some form. The CT scanner might not be as advanced (64 slice), images were on film (not digital), and interventional radiology procedures were not as advanced, but it was all present. Cardiac surgery was actually using more recent equipment than anywhere I’ve seen in Canada (though they reused aortic cannulas). Occasionally access to an appropriate supplier did restrict the availability of some equipment, but this was rare.

So is the quality comparable to Canada? Sadly not. The buildings are relatively new (1960s the oldest), but overused and feel worn. Cleaning is patchy and hand washing virtually non-existent except in ICUs. Sterile technique for dressing changes is poor. With pure handwritten paper charts, tracking information is more difficult. Tasks that may take 15 minutes in Canada can take over an hour. Essentially technology that radically improves care is acquired, whereas incremental changes to processes that already function are generally deemed expensive luxuries.

Despite comparable equipment, care at TUTH is not equivalent to Canada. Why? In Canada I can arrive with my healthcard at any hospital and receive the care I require, regardless of financial means. In Nepal consultations are free, but all equipment used, including the hospital bed, must be paid for by the patients and their families. Necessary investigations or interventions may be unaffordable. Costs may be several times the average month's salary, leading patients to avoid seeking care until absolutely necessary. Sadly self dosing with antibiotics (and the implicit resistance this confers) and late presentations of illnesses with predictable complications are all too common.

Quality of personnel is also a variable factor. I found clinicians who had completed fellowships in Western countries were fantastic and provided exemplary care. Locally trained physicians were a more mixed picture. I'm not sure if this reflects actual improvements from Western fellowships, or a selection bias where the best clinicians are the ones who seek international opportunities. Certainly broader adoption of some basic tenets of Canadian healthcare by Nepali physicians would be beneficial, especially concepts such as hand washing, delirium management, and respect for patient dignity, privacy, and autonomy.

Overall TUTH is a busy hospital with clinicians that labour to provide the best care possible to the largest number of people possible. There are certainly challenges as detailed above. But there are definitely ways that we as Canadians can help. As this is already quite long though, I'll leave specific measures for my next post :)