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 3rd 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?
