Bolde Outreach Camp

A small stoopa in Bolde Phediche

Bolde Phediche i s a beautiful secluded village nestled almost precariously in the sloping hills somewhere in South-East Nepal. Seven years ago two doctors had to travel six hours by foot without water to get from Dhulikhel Hospital (DH) to it. A few months later, one of the same doctors and a Community Programmes Coordinator from the hospital endangered their lives during one of Nepal's civil wars by walking through a jungle to reach more patients at the same place. They were mistaken for Maoists, and nearly shot by the Nepalese Army.

Today, patients from Bolde and its surrounding areas can find medical help every day, 24 hours a day at a Health Centre built and funded by DH and its Department for Community Programmes (DCP). A 'camp' of 14 doctors can now walk uphill for half an hour (safely) to reach the Health Centre to provide 25,000 people with specialised care, as they did on Friday the 2^nd of October this year.

Through word of mouth and the artful distribution of flyers to the right people, these 25,000 people know exactly when such doctors will be visiting the Outreach. This way, patients living in the catchment area of the beautiful but remote Bolde Phediche can not only receive quality healthcare, but arguably the best healthcare available to them, for close to no money. As it turned out on Friday the 2^nd of October, patients were surprised by a group of specialists all the way from Austria who accompanied a team of doctors, nurses and staff from DH to specialise particularly in the gynaecology, orthopaedic and physiotherapy departments.

The Austrian team led by Professor Doctor Rudolph Schabus included Physiotherapist Matthias Pakosta; Massage Therapist Angela Krottendorfer; and Medical Engineer Kahr Jurgen. As Angela put it, "This is not something which the average tourist can experience." The four professionals are just part of the example of how healthcare in Nepal can develop and change people's lives; literally transcending thousands of miles to get to patients who have never seen a non-Nepalese person before, and who had no idea that their ailments have led to intricate studies in other parts of the world.

Surgeon Dr Rohit of DH's Orthopaedics Department says that on that day alone, the medical team saw a total of 64 patients in a little over six hours. Also assisting him was Medical Officer Dr Pujan and Physiotherapist Nishal, and Health Assistant Sudip. "35 patients came just for the Orthopaedic Camp, at what I like to call 'my' Outreach," he says smiling at the thought of the progress DH has made to reach out to villagers.

Dr Rohit is particularly attached to Bolde Outreach for a few reasons. He has managed it since he first started as a Medical Officer at DH. He still visits frequently despite the bumpy ride and long journey from the hospital. Most of all, Dr Rohit is still attached to Bolde Outreach because he is one of the two dedicated doctors who used to walk for six hours through jungle and uphill to see his patients. He says that the cases he has seen the most are occupational injuries. "We saw many cases of traumatic injuries from work-related situations, and due to years of neglect the healing process has been made much harder, and the pain worse."

In most cases, physical therapy was the only cure or way of easing discomfort. "This visit was different for us because every patient had two or three doctors or specialists attending to them," said Mattias. "It's a good job we all agreed on the diagnosis every time!" Mattias was on hand to manipulate three spinal cases, and along with help from Professor Dr Schabus taught orthopaedic patients some physical exercises which can be performed when they are at home.

Angela had more difficulty discharging her patients compared to her colleagues. "I treat with Acupuncture Pressure Massage, so a few patients were gesturing to friends to come and try or asking for their other foot to be massaged!" she laughed. Meanwhile, Kahr had the tough job of gathering what materials he could to make several splints for patients. "The splints are only made to hold out until surgery," he said, whilst holding a piece of flimsy looking wood - and quite a few patients do require surgery.

Surgery can be an unaffordable option for most rural villagers under normal circumstances. At DH through the Outreach Centres however, surgery can be charitable. "We know some of our patients really can't afford surgery, and we will still operate," Dr Rohit explains. In fact, most of the time the price tag on a general check-up is just to "Ensure patients understand the importance of health. If something is free, sometimes it can take away the meaning. A check up and follow up treatment only costs 10 Rupees."

At least 15 of the total patients that day were gynaecological consultations, seen by Dr Shakya, Medical Officer Dr Prativa, or Nurse Krishna. Dr Shakya was also at Bolde for other reasons. "A lot of girls don't feel they can even talk to their mothers about their 'women' problems, they're so shy," Dr Shakya said after her talk on women's health to a group of 30-odd female students from the ages of 14 to 18. At one point the girls even stopped answering questions Dr Shakya was asking when they saw a group of men walk by outside their classroom.

Sessions such as these are not common at schools and happen only on a voluntary basis, which means a lot of girls still shy away from discussing issues such as puberty with anyone other than their friends – who only know as much as they do. Having someone to talk about such issues with is still rare in Nepalese society. "Some girls don't understand why they menstruate, and others don't know why they have menstrual pains, for example," begins Dr Shakya. "It's really good to come and speak to them here, in their own environment because they are willing to learn, they're just shy." Without the Health Centre, the girls may never have had a chance to discuss these issues openly.

Samita Giri, the Women's Health Programme Coordinator from the DCP was also on hand to give a talk on uterine prolapse to a mother's group. 16 mothers turned up at Bolde Outreach to talk about the risks and signs to detect prolapse. "They talked very openly about it because there were no men present," said Samita who highlights the all-important absence of men in order for women to be able to speak frankly about feminine issues.

Part of the discussion was to encourage women to let go of the traditional view that operations on older mothers are pointless as they do not have "long to live". "When uterine prolapse occurs in older mothers, they don't want to have surgery because they think, 'Well I'm old now anyway'. I had to explain that they shouldn't think like that, and that prolapse is dangerous." A contributing factor to this way of thinking in rural societies is because operations, taking medication, and getting treatment in general are perceived as ways to weaken the body further, thus hindering a person's ability to work in the future.

Samita taught the women how to identify the three stages of uterine prolapse, and more importantly, how to look for signs of stage one prolapse so that in the event of such problems, they can seek medical assistance immediately. "The women mentioned one case of a woman they knew who used hot water to 'cure' herself. They also said at the beginning of the session that they felt it was unnecessary to teach them, and that their daughters and granddaughters were the important ones. Afterwards however, they understood why we were addressing them."

Samita recognises the progress that can be made through talking to women in the community honestly and in a coherent manner. Most of them, just as Dr Shakya said, want to learn. Through community programmes little by little changes can be made in the way people think and act. "At the end of the session mothers were saying 'We should bring our husbands next time!'"

As a community-focused hospital, camps such as the one conducted at Bolde Phediche earlier this month are what keeps DH's message of working for the community, and with the community burning bright. From stopping off to pay a patient a visit on the walk to the Health Centre, to changing the way women think permanently about their bodies; every subtle difference each member of staff has made to each individual person in the community work as push and pull factors. Such changes keep the hospital going and they are also why the hospital exists in the first place.

As so many of the doctors point out, "Why wouldn't we want to visit an Outreach? It's the best part of the job!"

Gynae OPD at Dhulikhel Hospital – Uncovering the Norm of Social Stigma

A few days ago, I interviewed a female patient in the Gynaecology Outpatient Department (Gynae OPD to those familiar with the term). She was 29 years old and nine weeks pregnant with her fourth child. She already had three girls, the eldest being 13 years of age and the youngest still a toddler. All this was perfectly normal; average even for a patient in Gynae OPD in Nepal; however, this patient caught my attention because she was not here for a simple check up.

Maiya Rana had been instructed by her husband to find out the sex of their unborn child, and to abort it if it was a girl. I looked at her while Dr Shakya, the gynaecology doctor, translated to me, word for word, Maiya's husband's demands. The only emotion I detected in Maiya's countenance was stress as she tried to subdue her irritable toddler, while glancing from me to Dr Shakya. 
Maiya's problem is a problem many married women in rural Nepal face; the burden of bearing a son.  Such a burden rests heavily on the mother's shoulders, who must also carry the weight of social stigma if she does not produce a male successor for her family.

Maiya told us that this was an unwanted pregnancy. In fact, she says, her last daughter, who was born with a cleft palette, was also an unwanted pregnancy. "I only wanted two children," she sighs as she shifts the weight of her sleeping daughter in her lap. Maiya's husband had expected their last daughter to be a boy, but as Dhulikhel Hospital has a policy of not disclosing the sex of the baby during ultrasound check ups for fear of situations such as Maiya's, neither Maiya or her husband knew that they would be having a daughter until she was born.

Maiya says that her husband longs for a boy so badly that they will keep trying until she can conceive one, and every female they conceive from now until then will be aborted - because he says so. I wait for a reaction of shock from the doctor, but she merely continues to listen to Maiya intently. When Maiya pauses, Dr Shakya turns to me and quietly says, "Have you ever heard anything like this before? This is perfectly common here in Nepal. A lot of men here are used to abusing women's rights."

And it's true. Women here who have total control over their bodies are the more privileged ones, for want of a better term. What is considered a basic human right in any developed country is a constant uphill battle for many women here in Nepal, particularly rural areas where literacy levels are low, and fertility rates high. Once a woman such as Maiya is married into a family, she is then and there considered the property of said family. She will cook, she will clean, she will work if the husband wants her to, and she will raise their children – the luckier ones will not have to care for the elder generation on top of her daily duties. Maiya is considered one of the luckier ones.

I ask her why she cannot stand up to her husband. "He tells me I have an easy life, and he is the one earning money. All I have to do is look after the household and bring up our children. I have no money, so how can I say no?" She tells us that she has actually been on the contraceptive pill on and off for nine years, but is reluctant to disclose whether or not her husband knows about this. I ask if she wants to have the baby or the abortion if it was her decision. She replies without thinking, "Choosing either way is criminal. It's a life."

Clearly, her husband's concern is only that Maiya will conceive a boy, with no second thoughts or guilt about using abortion as a form of contraception. No questions have been asked in the first half hour of the consultation about how it will affect Maiya's health. Only after she has spoken to us about her husband's desire for a boy, only after she voices her concern for the health of the baby, and only after she enquires whether or not we can find out the sex of her baby, does she ask, "How will an abortion affect my health?"

But Maiya does not show a shred of self pity, which is the admirable part. She is stronger and more mature than her 29 years betray, possibly because she had to grow up so much quicker than the average 29 year old I know. Married at 17, she knows very little about the world outside of her work and her family. Perhaps this is blessing in disguise, because Maiya's life is not likely to change anytime soon.

Then Maiya tells us something surprising. She says her 13 year old daughter has already said she never wants to get married. "She says I can't take control of anything in the home, so why would she get married?" Maiya says rather bemusedly. She also knows that she is not alone in bearing the pressures of needing to conceive a boy. She tells us a story about a friend who gave birth to four daughters, and then a fifth. According to her friend's husband, they would only be able to bring up the child if it was a boy – so he gave his wife an ultimatum; the daughter or their marriage. The friend chose her marriage, and abandoned their fifth child at the hospital.

As the consultation and interview draws to a close, I am caught off-guard by a question directed at me. Dr Shakya turns to me and asks, "What advice would you give her?"

The only advice going through my mind is too obvious, yet impossible for Maiya to take. I think for a few moments, and try to reply without sounding too ignorant of Maiya's circumstances. "I think you should take control of your body. It's never too late to stand up for yourself, and if you want this child, regardless of the gender, you should keep it. An abortion should be your decision, because it's your health."

Maiya seems satisfied with my answer and is smiling as she leaves, because, she says, having someone to listen to her for a change has been lovely. "Sometimes even when we can't change their lives, just listening to them is a form of a help," says Dr Shakya. "I can't help every woman the way I want to, but I can listen."

The Middle of Nowhere

Godamchaur Outreach Centre, just one of Dhulikhel Hospital's 10 Outreachs.

On Sunday I got the chance to visit one of Dhulikhel Hospital's Outreach Centres.  This tiny brick room attached to the side of a village primary school is literally all there is to it.  Godamchaur is in Kathmandu district, but so far removed from the liveliness and pollution (!) of the city that you could be anywhere else in Nepal.
Getting to Godamchaur Outreach is more than trying; don't even think about it unless you have a sturdy 4x4 or actually live there, which is essentially what it was built for.  We drove through Dhulikhel, Basghari (where I live), Baskapur, Kathmandu and then finally reached Lalitpur.  Godamchaur Outreach is a partnership outreach of Dhulikhel Hospital's which makes it more technical support than patient support.  Still, for a country where 80 percent of people aged 5-18 years live in rural areas, it makes such  a huge difference to access to healthcare.

Yesterday I went to Baunepati Health Centre, which is roughly two hours down the worst dirt road from Dhulikhel that I've ever seen.  I felt that this was really what I had been waiting to see since I've been here; how much of a difference Dhulikhel Hospital's Outreach Centres are making to people's lives.

Under Sudip's care ( a trained paramedic) dermatologists, orthodontists and other professional specialists visit Baunepati Health Centre once a week.  When doctors are not dispatched from the hospital, there are usually three paramedics on duty, 24 hours a day.  I accompanied Sudip, two orthodontists, two dermatologists and two other doctors to see first hand how one of Dhulikhel Hospital's Outreach Centres operates.
Oh boy did I see a lot.  I witnessed five tooth extractions, and the complications which went behind them; an armpit abscess; a snake bite which had become infected; and lastly before lunch a bad case of osteomyelitis of the foot.  It was not so much the severity of the cases which got me though.  Seeing the paramedics and doctors work away case after case really made me think that the medical profession is not one for people who only care for themselves.  The journey to the outreach was over two hours long.  The journey back had taken around about the same time, with the snake bite victim rocking back and forth with us along the decrepit road, eyes narrowed in pain the whole way.  No, what really amazes me again is simply how much people care about each other here.  I get the feeling here that nobody treats their occupations as "just a job".  Maybe it's because they all work for a non-for-profit hospital built specifically to aid the poor, but I have yet to hear one doctor, nurse, paramedic, or any other medical professional who works 14 hour days, six days a week, complain once.
Seeing the patients made me see how much those working at Dhulikhel Hospital love helping them.  After seeing the patient with the underarm abscess, I heard Sudip sigh and mumble something quickly in Nepali at her.  The patient turned her head away and said something softly, so that Sudip had to lean in closer too.  "What's the matter?"  I asked.  "I gave her seven days antibiotics to take, but she only took one.  She said it makes her weak, see?"  Sudip shrugged his shoulders and looked at me helplessly.
It was then it suddenly hit me.  The medical staff here did not train merely to help their patients recover, they go out of their way to try and teach them how to improve their lifestyles.  They have a relationship with their patients I've never seen before back home, where patients are a statistic and doctors do not remember your name.  I was moved by what I saw at Baunepati, not because I saw a paramedic trying to explain to a patient that she had to take her antibiotics even if it meant she was too weak to work for a couple of days, but because I've seen other medical staff attempt to do the same thing.
It is incredibly difficult to try and change a way of thinking which has been embedded into a tradition so rich and full of history.  In a country where 80 percent of under 18s still live in rural areas, how does one find the time and access to education?  It is not merely drumming into someone why they need to take their medication, there need to be so many changes from the bottom upwards.  Essentially, change is upturning a whole tradition of values.  Why someone needs to go to an Outreach Centre over a witch doctor, why someone should always use a toilet rather than the bushes, and why someone should let their child go to school rather than stay at home and work so that they have food for now is not going to be easy to explain to someone who has never known any different.
Which is where Dhulikhel Hospital's "micro-finance groups" come in.  DH fund several "micro-finance" groups to help women in the community earn a living.  Unfortunately Nepal is still a patriarchal country, where women have less say then men and are mostly just considered wives, mothers or labourers.  The micro-finance groups attempt to change this perception of women by giving them a means to support themselves and their families without relying on others.  In each micro-finance group, roughly 10 women are given a loan of 6,000 rupees (roughly 450 GBP) each.   With this money, each woman can find their own entrepreneurial path; from candle-making; soap-making; farming to breeding livestock. The micro-finance group is a typical example of helping developing countries through trade rather than aid, as the four percent interest creates another pot of money which goes to another woman.
I can only write about what I've seen over the past few days, but there is so much more to the healthcare system, Dhulikhel Hospital, the people, and the culture here I've yet to learn.
"Dhanyabad" for coming with me, and I'll be sure to update you as I learn.