Healthcare Issues

I have been at Kanti Children’s Hospital for about four weeks. I’ve been holding off on posting about it because I had tons of other stuff to write about first, but now it’s time… 

Getting a chance to hear patients’ stories and concerns, and talk to senior consultants, residents, medical interns, and other volunteers over the past few weeks was an incredible learning experience. By asking a lot of questions, I learned a lot about medicine, diseases, diagnosis, and treatment but all of that can be found in a textbook and is far less interesting to read :)

Instead I’ll describe my observations in a global health standpoint.

*Just to clarify, this is strictly about public government hospitals – the private hospitals are a lot more up to standard but incredibly expensive (so I hear, haven’t started at a private hospital yet).

Approach to healthcare is different

Physicians here only really treat symptoms without doing too many tests to find the root cause. This is mostly due to the high patient volumes and the unreliability of test reports as well as cost and availability. Most of the time, they have to either send the samples out of the country to analyze because there aren’t sophisticated enough lab tests here, or instead treat by epidemiology, what is most probable (common in age, sex, background, history). If they can afford it, a lot of patients choose to fly to Delhi, India for treatment.

Treatment protocols themselves are different.

The basic science may be the same but I’m unlikely to use any of the protocols I ever see here. The World Health Organization (WHO) outlined an Integrated Management of Childhood Illness (IMCI) protocol for 3^rd world countries. Even the doctors here think it is a very preliminary system of diagnosis and treatment. The thought is, it is better to over-treat than to miss the five common (often deadly if left untreated) symptoms/diseases:

     acute respiratory infection – pneumonia

     diarrhea (w or w/o dehydration)

     fever

     ear infection

     malnutrition

For instance, doctors and nurses are trained to treat for pneumonia solely on basis of high respiratory rate. Nowhere in the protocol does it mandate a chest x-ray but most doctors will order one here because it is readily available in the city. In rural areas, respiratory rate and listening to the lungs may be all the proof readily available.

Standard of living

Children everywhere get a viral cough and cold about 12 times a year; the figure is the same in developed and developing countries. BUT pneumonia is vastly higher in underdeveloped countries.

Why? Nutrition, hygiene and standard of living differences essentially lead to weakened defense processes and easier transmission and retention of infection.

Want proof? In the 1700s, TB was rampant all over the world. Now it is still plaguing developing countries, but decreased drastically in Europe and America, not due to medicine, but due to industrialization, enhanced living standards.

Until third world countries start to develop, people will be faced with disease and illness on top of their other struggles (perhaps because of their other struggles).

Lack of education

The hardest but most important job of a physician is patient education. In a developing country with traditional values, lack of general education, and sometimes just downright stubborn people, this can be a huge obstacle in treatment. Adherence is so important yet hardly ever accomplished. Most medications are available over the counter so it’s fairly easy to bypass doctors altogether. Lack of education is a huge barrier, not because of doctors using terminology; the doctors use layman’s terms and explain it clearly. Anyone with a little education would understand, but there are people with “purano bichar” (old thinking) for whom it will never fully click. There’s just a clear lack of understanding, perhaps because they are just not used to thinking on that level, “bani chaina” (it is just out of habit), or perhaps it’s a mixture of confusion and denial. If a doctor tells you that what you and your family have done for generations is “wrong,” it’s confusing news to take. This is especially hard in malnutrition, diabetes, and high blood pressure cases where environment, lifestyle and “chalun” (what’s customary) are influential factors.

From what I’ve seen, it’s usually one of two extremes.

Either the patients (& family) think the doctor is omniscient and medication will cure everything. One mom at the clinic came back for a follow up w/o getting any tests ordered done and just expected the doctor to know everything. Diabetes and high blood pressure patients often rely purely on meds without making any lifestyle changes no matter how many times it is explained to them that their lifestyle is the root of the problem and just taking meds isn’t a proper solution.

OR the patients don’t have any faith in what the doctor says and chooses not to listen. One salient example was a malnutrition case. The patients’ parents were extremely frustrated because their child kept getting sick every month or so and they had to keep shuttling him to different doctors. They were from a rural area of Nepal and had to travel far to seek care. I could see their eyes glaze over when the doctor I was on clinic duty with tried over and over to explain to them that their son’s weight was nowhere near where it should be and he will keep getting sick if they don’t bring it up. At 1yrs old, he was only 5kg (11lbs). They kept reiterating that they came here because their son’s throat hurt and he had a cold & cough. The doctors kept trying to explain it in different ways and gave them information for a malnutrition clinic. The parents were extremely hard to counsel. They just didn’t understand that malnutrition is the root of all his problems and that curing a one-time cold will not ultimately solve the problem; they’ll have to keep coming back.

Another related issue is public healthcare knowledge. Since a lot of Nepal’s citizens live in rural areas, they don’t necessarily receive the same health education. For example, some parents simply have no idea when to bring their babies in for vaccines so they bring them in late.

OTC availability

I have talked about this briefly before but I just want to reiterate that this is a big problem. People often complain in the states about having to get a prescription from the doctor before being allowed access to medications. Some may believe that drug crimes may decrease that way, but unnecessary damage occurs when people blindly take medications without regard for consequence. I have seen absurd cases of parents feeding their children the wrong medication. The doctors will flat out yell at the parents and ask why they didn’t seek medical advice because their child now has liver damage from taking adult doses of adult medications. In the U.S., it might take a few extra steps to get better, but those extra steps ensure that we won’t do some serious damage.

Organization

The number of patients usually determines quality of care. The number of patients a doctor sees a day at the clinic here is remarkable. People stand in line early in the morning to get two minutes with a doctor, not even by themselves. There are often 8+ patients and families in a tiny clinic cubicle at the same time. It is crowded, chaotic, and just so easy to get lost in the mix. If you don’t push and shove to get seen by the doctor, frankly, you just won’t. There is no luxury of privacy or confidentiality.

You would think that there is a shortage of doctors, but that’s not the case. The doctors here tell me that it is a management/organization problem. There is a significant lack of subspecialties. Already considered a specialty, Kanti (pediatric hospital) just recently separated departments.

The government says healthcare is a priority but according to the budget, only 7.1% is allocated to healthcare. There is no systematic health insurance except for government workers and some small private insurance companies. People with disabilities only get help on the NGO level. There are no systems in place to help them and disability is often looked down upon.

What is being done?

Nepal has pledged to work towards the UN Millennium Development Goals. You can read more about it at http://www.undp.org.np/mdg/