How can we help?

Broader Economy

Nepal is a poor country with significant challenges. Politically it is unstable, having recently concluded a ~15yr civil war and transitioned from monarchy to democracy. The country is primarily hills or mountains, adding significant burdens to transit times or agriculture. A 200km trip can take 7hrs. Roads are the primary means of trade, and these delays inevitably spill into higher costs for other goods.

How can we help? An improved highway from India to Kathmandu would greatly improve trade. But it would also lead to an even greater influx of people into the overcrowded Kathmandu Valley. For development, Nepal has no clear options for export. Agriculture is it's a large industry, but chiefly consumed domestically. There are few natural resources. Land is at a premium. Labour is plentiful, but that is true in it's neighbours who are at a competitive advantage thanks to their ports.

I’m a firm believe that trade improves the lot of impoverished people, but I don’t really see many good options for Nepal beyond tourism. Switzerland, Liechtenstein, Austria, and other mountainous countries may be good models. Somehow I don’t see Nepal developing a clandestine banking industry. I’ll leave broader international development to the experts :)

Healthcare

I've commented on Nepal's healthcare challenges in other posts. To recap: affordability, accessibility, misuse of anitbiotics, poor hygiene, and rampant infections are some of these. Social determinants of health such as healthy food, clean water, sanitation, and access to regular primary care are certainly a major factor in many of these challenges. The best prescription then would be a stable governement with broad based economic growth. Clearly that's idealistic :)

What is achievable then? 

From my time in Nepal, the single largest factor dictating quality of care in hospitalized patients was where the attending physician trained. Doctors who had completed fellowship training within western healthcare systems generally carried the high standards of expertise from their training sites back to Nepal. Not only was their clinical knowledge and expertise improved, but through their leadership they raised the standard of care for their entire teams. I saw this carried out in cardiothoracic surgery, ICU, neurosurgery, and to a lesser extent, general surgery. Incidentally, Toronto was the most common fellowship location.

Why don't all Nepali doctors do international fellows then? A Nepali doctor needs to pass the Canadian licensing exams, apply, be accepted to the program, secure a visa into Canada, pay live in an expensive foreign country, and pay tuition. Even in cases where their tuition is covered and a stipend paid, the other tasks represent a non-trivial burden. The Candian exams alone could run $2000, assuming both passed first time. Nepali doctors may save for several years to be able to afford to train abroad. Fully sponsored fellowships would help dramatically with reducing this burden and improving the quality of care delivered in Nepal.

*Selection bias may be occuring - the best doctors in Nepal secure the foreign fellowships. While possibly true, my experience and observations suggest the incremental benefit is still worthwhile.

What about dedicated training missions where Canadian clinicians visit Nepal for education? 

I think there is definitely a role for these. They allow instruction to a large number of local clinicians, but are hindered by the immersion in the local culture. Reinforcement of practices such as handwashing would be difficult in a culture that does not value it.

Anything other than trianing?

Beyond training financial support of organizations such as NCCDF will allow incremental improvements to care, while making it more affordable for the poor. There are other comparable organizations with their own specific niches including cardiac surgery, and ophthalmology. Ideally the government will stabilize and healthcare be improved centrally, but this is likely to take decades to see real change.

What about equipment donations? If the equipment is coordinated with clinicians in Nepal, there can be a significant benefit to equipment donations. I was able to advance NCCDF's cause by bringing ventilator related equipment with me. Regrettably the Nepali government restricts importation of technology intensive devices such as patient monitors. When I left though, the surgery team at TUTH was anticipating receipt of >$400000 of refurbished equipment including laparoscopic towers and instruments. I don't know the exact breakdown of cost to TUTH vs donations pertaining to it. Generally equipment needs to be high value as a shipping crate costs ~$20000 to deliver from North America to Nepal.  Matching equipment to the needs is important. This is well documented in other posts pertaining to disaster relief and international development.. In short, cash donatiosn to the appropriate organization is usually best.

How will I be helping?

Going forward I hope to maintain ties to NCCDF and help them through advocacy, technical support, and donations from Canada. I also hope to maintain ties to global health in my residency, and to advocate for the creation of sponsored fellowship opportunities. And hopefully someday I will go abroad to provide healthcare to the needy while teaching the local doctors. Time will tell.

Fin

Thanks for reading! This is my last blog post related to Nepal. I'm not sure I'll continue blogging. Time will tell :). Travel, healthcare, technology, and politics are likely topics if I do continue (in that order too!). Happy travels! And remember to follow your heart! :)

Visas and SIM Cards

Way back at the start of these adventures I said I’d write a post on the Visa steps for each country. It didn’t happen before or during the trip. Making up for lost time now.

Nepal

Nepal is straightforward. You can either courier to the embassy in Ottawa in advance, or purchase at arrival. I was able to skip a rather lengthy queue by doing the advance option. Visa comes in 15, 30, 90 day increments, renewable while there (apparently easily, I didn’t try). Bring passport photos for the Visa.

I went with NCELL. For 250NPR plus 1000 NPR credit I had a small amount of voice, SMS, and 1GB of data. I was told I overpaid at these rates. (note, this is all of $12.50 Canadian for 1GB of data for a month, way better than our $30/month!)

Turkey

Visa is even more straightforward. Pay on arrival or head to evisa, fill the details in online, pay, and print it out. (~$60 for Canadians, much cheaper for Americans or possibly EU passports). If you have dual citizenship, may save some money by opting for a non-Canadian passport.

Turkish SIM cards are more complicated.  With high duties on electronics, a registration system has been set up to block importation of phones without paying duty. All phones in the country need their IMEI number to be registered with the government. Apparently this is done at purchase of SIM card and there may or may not be a fee. Since I only needed 5 days, I instead slipped under the 2 week window allowed for registration, and didn’t bother registering. My phone is probably blacklisted in Turkey now, but oh well. By the time I return to Turkey I will almost certainly have a new phone.

For Turkish providers there is TurkCell, X and Avea. I ended up with Avea mainly because I found them first at the airport. Getting the SIM Card is pricey (~55 TL, or $25), but after that data was cheap (10TL or $5 / 1GB). Avea is the newest provider, and has poorer coverage but may have cheaper rates. Apparently poor English service if you need assistance, but I was able to avoid that. I only lost coverage at Topkapi palace. I did have trouble getting the phone to recognize the towers initially, but a hard restart of the phone (hold power and home buttons for 5 s on the iphone) resolved this.

India

The Indian visa applicatuion is painful. First point: processing is contracted out to a private company - the consulate and embassy aren’t typically involved (the consulate does grant approval, but all communication is through the contractor).

http://www.blsindia-canada.com/touristvisa.php

To apply, fill in the form on the website. Fill something in every field, including the identifying feature one (I heard of rejections for leaving this blank). Choose a feature: scar, mole, etc. Just put something. Be ready to provide an address in India, as well as employment information and a reference in Canada (mine wasn’t contacted to my knowledge).

Done? Double / triple check everything. The Indian visa application is involved and expensive.

Submission: you can either go in person for drop off or pick up, or courier it. I initially tried the in person option, but the offices are small, limited, and super busy. It looked like it would be an all afternoon wait, so I opted for couriering it. Paid the extra, and magically had a passport with visa back in 1 week.

Which visa? You’re only allowed one visa for a 180 day period, so just apply for a tourist multiple entry one - single entry are no cheaper and could potentially cause problems.

SIM: I didn’t find a SIM card in India: rather I borrowed a phone with a Tata SIM card. Worked well for calls.

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 :)

NCCDF

My time in Nepal is over but I still haven’t explained what NCCDF is exactly!

NCCDF = Nepal Critical Care Development Foundation. The logo is on this blogs main page.
NCCDFnepal.org or on Facebook for details

NCCDF is a charity started by Dr. Subhash Acharya dedicated to improving ICU experiences in Nepal. It was founded in 2012 when Dr. Acharya returned from his ICU Fellowship in Toronto. He was frustrated by death and suffering caused by needless delays obtaining equipment in the ICU.

NCCDF main aims are:
- to provide an ICU community across Nepal
- to provide Care Boxes at ICUs across Nepal. Care Boxes include essential equipment such as end tracheal tubes to be used in emergencies. If patients are able to afford the cost, they replace the equipment. If not it is donated to the patient.
- to launch a Critical Care residency track for Nepal
- to improve the overall quality of ICU care through workshops, seminars, and literature aimed at all ICU clinicians

NCCDF is in it’s infancy but has already made significant strides. The first NCCDF Care Box is to be presented to the Tribhuvan University Teaching Hospital within the week. Posters promoting hand washing have been distributed across Kathmandu. Their inaugural annual magazine, The ICU Post, has been published and is being distributed to ICUs across Nepal. The Critical Care Medicine specialty is in the process of being established through partnership with the Royal College of Physicians and Surgeons Canada. Workshops for ICU clinicians are pending.

All of this is extremely impressive for a young charity with no steady revenue source. Day to day operations are primarily conducted by Nipesh Acharya and Sahadev Aryal, who volunteer their time. Expert support from Canada includes a Toronto ICU doctor, Ottawa ICU doctor, and nurses from Toronto. All these people volunteer their time and have supported NCCDF with supplies during their trips.

NCCDF fundraising has been limited to date: a T shirt sale, a movie night, and a trekking trip that is in the works. They also receive some support from rent charged to visiting clinicians who stay at Canada House. The donations I collected before leaving Canada are a significant revenue stream for them and I thank you all for your support!

ADDENDUM: at the request of NCCDF, I've added photos from the recent donation of the Care Box to TUTH.

NCCDF Team donating the the first Care Box to TUTH

Supplies for the Care box

Care Box for distribution. It's subsequently unpacked into a useful locker at the destination.

Istanbul

After leaving India I stopped over in Istanbul for 5 days on my way back home. Flight over was luxurious as I was upgraded to Comfort Class. First time I was upgraded. The flight also was my first time with wifi on board, and first time where a doctor was asked for (I identified myself, but they had an actual licensed doctor already).

Istanbul / Constantinople / Byzantine is a city steeped in history. It has been populated since at least 4000 BC, and gained prominence around 0 when it grew under the Roman Empire. It was the seat of Empire for almost 1500 years, first the Byzantine Empire from 395 - 1451 and subsequently the Ottoman Empire until 1923. At it’s founding, the modern Turkish Republic’s capital was deliberately moved to Ankara away from the legacy of Empire in Istanbul. Modern day Istanbul is a large metropolis (pop. ~12 million) which straddles the Bosphorus, existing in both Europe and Asia. It has historic sites, modern sites, and is a fantastic city to visit. I stayed and spent most of my time in Sultanahmet, the historic part of the city.

First up on touring was the Hippodrome. Here the Roman / Byzantine chariot races took place historically. It is now a large paved public space, but monuments from ancient times remain, including a monument from the original hippodrome, an Egyptian obelisk moved here in Roman times, and a Greek pillar from ~300BC, also moved during Roman times.

Hippodrome. Obelisk in the front, Roman pillar behind. The Greek one is short and in the middle. The empty space became quite crowded with tourists during the day time.

First up in touring was the Hagia Sophia. Founded as a church by Emperor Justine in ~536, the present day structure is by and large unchanged. With the conquest by the Ottomans in 1451, it was converted to a mosque and the 4 minarets added. With the founding of the secular republic, it was converted tmo a museum in the 1930s. The dome is apparently high enough to contain the Statue of Liberty or Notre Dame. Not bad for a 1500 year old building!

Hagia Sophia. The 4 minarets were added when it became a mosque.

Main hall. the black left is scaffolding. I deliberately left this photo larger than the others: Note the off-centre structure in the apse. The original church was oriented with the apse towards Jerusalem. When it became a mosque, it was necessary to have a frame of reference to Mecca. Mecca being south of Jerusalem, it results in this slight angle.

Spectacular mosaic

And another spectacular mosaic. I forget the era on this. The original Hagia Sophia was full of elaborate interior decorations as the Byzantines prized interior architecture (and did not value exterior architecture, thus the somewhat drab appearance of the exterior). Many mosaics were destroyed in 700s Iconoclast era, only to be replaced in around 1100

Next up on the museum tour was the Topkapi Palace, the historic seat of Empire for the Ottomans. The palace is designed with three nestled courtyards and is a hodgepodge of architecture as it was modified over the years. It’s notable for the Harem (where the Sultan, princes, wives, queen mother, and favourites lived), Divan (seat of government and decision making), and special exhibits. Included in these are elaborate jewels from the Ottoman treasury, as well as relics evacuated from Mecca during World War I. Included in these relics are purportedly Moses’ staff, David’s sword, Joseph’s turban, among others. I was sceptical to say the least.

Courtyard in the Harem. Fairly typical blue tiles, used throughout the buildings. Also note the elaborate mosaic path, consisting of black and white stones and leading to the Sultan's chambers.

Fountain in the Tulip Garden. Tulips became very popular among the Ottoman elite around the 1730s. Note also the exterior architecture, typical of later buildings in the palace.

The other key site in the trio is the Blue Mosque. It is constructed with domes, modelled off the Hagia Sophia. With 1100 years of improvements in architecture and engineering, it is much more elegant than the Hagia Sophia, and much more airy inside.

Other highlights of the trip included the Archaeology Museum, New Year’s Eve fireworks, the Grand Bazaar, and Taksim Square

Grand Bazaar. It was originally a collection of merchants guilds with specialized areas. over time it became more intense, and eventually was roofed. At it's peak it was the centre of trade for the Ottoman Empire. Now it's mainly a touristy shopping experience. Delightfully warm on a cold day from all the lamps and bodies though! (no direct heat).

Bas-relief from the Alexander Sarcophagus in the Archeology Museum. The sarcophagus is from ~300BC, and still has colour on the figures. It was a spectacular piece. It also made me realize our images of sterile white Rome/Greece are false - they really were quite colourful environments.

Taksim Square. Behind me is a large green area with trees, grass etc. In front is the giant open area you can see. The centre of modern Istanbul, and site of New Year's Eve celebrations, and recent protests.

Food in Istanbul seemed to work well, and I ate a lot of lamb :)

Mezopotamia Lamb at Cheer's Soup Kitchen. I ate here New Year's Eve, and liked it so much I came back my last night in Istanbul. It helped that they were by far the best with the allergies.

And so ends my travels. This post was written on the flight back and will be uploaded from Canada. A final piece reflecting on my experiences with healthcare in Nepal is to come.

I’m not sure what the fate of this blog will be. I’ll be busy back in classes, studying, and prepping for residency in the next while. Of course I have 6 weeks off before I start residency. I think I hear South America beckoning…