Final Report of 2004 Trip

Introduction

entrance to kanti HospitalOn July 7th 2004, I set off to Kathmandu to experience a completely different continent, culture and health system as part of my medical elective. For five weeks I was based at Kanti Children's Hospital - the specialist paediatric centre for the whole of Nepal - and rotated round most of the hospital departments. From this I learnt much about paediatric medicine in Nepal, the importance of good basic clinical skills, and the frustrations of trying to treat patients within a limited health system - which is further crippled by corruption.

In addition I experienced a wider view on Nepal as a country. We (the Western students who were based at Kanti) spent much time clinically and recreationally with Nepali students, which naturally led to thought-provoking conversation and a deep insight into the country's current challenges. Travels outside Kathmandu demonstrated the diversity of the country, as well as consolidating previously unseen issues about the development of a country's economy.

However, this trip would not have been possible without the generous support of several trusts. The following account is written to report some of the aims achieved, the lessons learned and the future work made feasible by this support.

Aims - Were they achieved?

1. Learn about the nature of paediatrics in a developing country

medical outpatients Kanti was an ideal place to learn about paediatrics, as it is the only specialist paediatric centre in Nepal. Consequently, there is a breadth of experience available from the doctors that would have been unavailable elsewhere. With the help of Nepali students to translate, I was able to ask patients directly about their journey to the hospital (which in some cases involved initial referrals to traditional medical practitioners and local health posts). I also took time to read journals from the Nepali Medical Association and the Nepal Paediatric Society, which are difficult to access from the UK.

One caveat to this objective was the fact that Kanti is a specialist hospital. Therefore, patients are often referred by local centres, and there could have been the problem of seeing ultra-specialist cases and few general presentations. However, Kanti does still have a secondary care role for the population of Kathmandu city, and in addition to the specialist wards and clinics there is a busy emergency department. Thus the opportunities to see the spectrum of common and uncommon diseases are not too biased.

2. Discover the difference in the prevalence of childhood illnesses between Nepal and the UK

Some important aspects of childhood illness were discovered. The culture and religion (predominantly a mix of Hindu and Buddhism) in Nepal dictates that many children are brought up by the family in the accepted expectation that some will die before reaching adulthood. It is also fact that boys tend to be valued more highly than girls. This combined with the high cost of health care, means that some problems such as heart and thyroid disease present at very late stages. This gives students an excellent opportunity to see advanced clinical signs.

However, it also means that conditions normally treated early in the UK (especially due to the use of comprehensive screening programmes) had to be treated on a palliative basis.

Nepal also presented a balanced mix of conditions that were common and uncommon in the UK. Meningitis, tuberculosis, cardiac abnormalities and surgical problems such as inguinal hernias and hydroceles were all in abundance. However more 'tropical' conditions such as typhoid, viral encephalitis and giardiasis were common complaints too.

3. Gain a broad insight into the range of specialties offered at KCH

This was made possible by rotating round departments. However, it was on a semi-organised basis, whereby we would be attached to a department for 4-5 days, but we still had the flexibility to visit other areas whenever we wanted. General medicine, surgery, burns, oncology, cardiology, emergency, observation and outpatients were experienced. An eye-opening emergency night shift was completed.

4. Develop key clinical skills in diagnosis and treatment of illnesses in children

measuring the pulseAlmost every day we were involved in ward rounds and outpatients where we would be supervised in taking a translated history and conducting a full examination. Sometimes this was prior to admission, at other times it was purely to give us practice (and relieve the boredom of the patients!). Great benefit was derived from the teaching of the senior doctors, especially as they were used to having to make significant diagnoses with only their 'hands, ears and head'. X-ray scans were costly, MRI scans had to be done in centres outside the hospital, and laboratory tests were limited and expensive too. The late-presentation of some cases meant that clinical signs were advanced; while this was obviously detrimental to the patient, it did expose us to valuable experiences that are not available in the UK.

In addition to teaching from the doctors, we also frequently conducted our own "International Students' Ward Round", mainly because routine ward rounds were sometimes conducted in Nepali. With the help of translation by Nepali medical students - who were keen to learn about our Western medical education - we consulted patients, discussed cases ourselves and compared our management suggestions with the actual plan. This comparison was often very useful and there were even interesting comparisons between international students that reflected differences between e.g. Scotland and Holland.

5. If possible, observe the organisation of community child health in Nepal

children at hopeful homeThe nature of the placement at Kanti meant that visiting rural health clinics was difficult to organise. In addition there were some fears about Maoist activity in remote areas where the satellite clinics are often conducted.

However, during my last week I became very involved in a local orphanage called Hopeful Home (www.hopefulhome.org). My daily visits exposed me to some of the social problems that lead to difficulties in promoting child health - and complemented my UK interest in Looked After Children. Time here was incredibly insightful as well as being a whole load of fun!

Additional Outcomes

In addition to meeting the above aims, the following outcomes resulted from my time in Nepal:

• Staying with a Nepali family allowed the opportunity of seeing first-hand a different culture, religion and attitude towards life.
• The development of links with particular doctors, departments and agencies outside the hospital will facilitate my return and future work in Nepal.
• My work in a local orphanage "Hopeful Home" has driven me to do some UK-based fundraising in the near future. In particular, I hope to build a network of UK-based volunteers who have already visited the orphanage, in the hope that some of the children can be sponsored to achieve their goals - which include becoming doctors and politicians.
• A new-found enthusiasm to do work in the developing world (very possibly Nepal) during my future career. If my current aim of specialising in community paediatrics is realised, I would be very interested in working at some point for UNICEF, Doctors Without Borders or similar agencies.
• The development of a website for other students, medical professionals and volunteers who intend to visit Nepal in the future. During my stay in Nepal I kept an online journal of my experience, and this was updated on a near-daily basis. There are now many photos available on the website and this resource will be developed further over the next month. The site is available at: http://web.onetel.com/~dhogg/nepal

Other Experience

scottish gatheringThere was a fantastic group of students while I was at Kanti, who came from the UK, China, America, Canada, Germany, Holland, Malta and beyond. In addition to our hospital work we travelled around the Kathmandu Valley on long weekends. This non-clinical experience was just as important as our time in the hospital as it allowed us to see more rural parts of the country. We were also able to see the family and local context in which medical problems develop before medical attention is sought.

Future Work

As mentioned in Additional Outcomes, my time in Nepal has broadened my horizons in terms of what I, once qualified, may be able to become involved in. In the next few months I hope to build on the links I made with some of the hospital staff and other individuals.

The website will be developed in September. Already I have had enquiries from other students who have found the site to be useful, and who require further information about doing a medical elective or volunteering in Nepal. Pages about medical equipment required, fundraising opportunities and key contacts will be added, as well as a comprehensive photo gallery.

It is also my aim to return to Nepal as soon as time allows. I am hopeful of returning in 2005, but in the meantime I remain in regular contact with various individuals in Nepal including Kanti Hospital and Hopeful Home.

A Final Word

ambitions decidedThese five weeks in Nepal have contributed to my medical training both in ways I hoped and ways I never imagined. The prospect of living and working in a completely different culture can be full of expectations, but often it is the most insignificant of factors that make the biggest differences. It is very difficult to describe just how much was learned and experienced in this short report. However I am utterly convinced that it has enhanced my medical knowledge, professional attitude and personal experience in an extremely positive way.

I am therefore very grateful to all trusts and individuals for their generous support to make the trip possible.