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A fascinating account of Dr Dilys Nobel’s experience while offering general clinical training to health staff in Nepal…

Even at 6am, Ratna bus park is a vast and busy place with buses randomly placed (or so it would seem to a non Nepali-reading traveller such as myself!). So the prospect of meeting up with Urmila (PHASE Senior Nurse Supervisor) beside the correct bus for Jalbire was somewhat daunting. Yet there was no need to worry. As ever in these situations, we met in sunshine, smiling and in plenty of time to buy tickets with seats; a luxury! The 4-hour journey through what should have been spectacular sweeping river, cliff and mountain scenery was veiled by rain and low cloud. We were also delayed by an unscheduled stop, in an extremely muddy lorry park near Bhaktapur, to eliminate a worrying clanking from the wheel. With the clanking fixed (through judicious application of an enormous, heavy hammer!), the bus lumbered on with its ever-increasing load of passengers and cargo, past the worlds highest statue of Shiva, to Jalbire. At the end of the bumpy single-track road, Jalbire, an ancient Newar town, is in complete contrast, with its beautifully paved walkways and intricately carved window frames and doorways. Kabita (PHASE Community Development Facilitator) met us at the local “cafe” where we revived ourselves on a huge plate of Dal Baat. And very welcome it was too!

Clinical Training in Nepal

JALBIRI,  OLD NEWAR TOWN

From Jalbire, Hagam, or more precisely Yanglakot village, is just upstairs. More accurately, it is 4½ hours of walking up steps at a steady pace with a few well earned rests! Fortunately I needed very little for my stay as I had my ‘PHASE Teaching Guidelines’ on a new “tablet” sort of device, a sleeping bag, a change of clothes and a toothbrush, which I was well able to carry myself. Urmila and Kabita also travelled light. They also arrived in Hagam impeccably dressed, if wet from the torrential rain, while I was mud splashed and bedraggled! I am sure the difference is that a life spent having to travel anywhere in such conditions creates an expertise in keeping neat and clean. I also discovered that umbrellas are probably more use than even the most efficient raincoat in such persistent rain. But, my hands were full as I needed my walking poles. Well… for the way down at least!

We walked with many families returning from Jalbire who were carrying manufactured goods imported from Kathmandu, sacks of rice, cement and several plastic baby walkers (that must surely have been the latest “must haves”). It was a bit like The Hare and The Tortoise as people stopped to shelter from the worst downpours and buy refreshments at the small hamlets perched on narrow terraces on the way up, or to visit the beautiful Hindu temple sitting on the hillside. A troupe of monkeys were scurrying around peering at us from above, occasionally throwing objects in our direction but they soon tired of this and disappear back into the trees. Near the village the terrain flattened out a little and we stopped at a Hindu shrine of four little stone structures surrounded by a wall. On the wall in the soaking rain was a disposable baby’s nappy. This is not scant regard of hygiene but a reflection that there just is no infrastructure for the disposal of rubbish.

Yanglakot is at about 2000 meters altitude, with stunning views of the snow covered Langtang peaks. It was the first village PHASE worked with, starting some 7 years ago. There are roughly 100 houses (about 2000 people) all supported by small farms on very steep terraces growing maize, wheat, millet, vegetables and worked by bullock ploughs and hard manual graft. PHASE nurses Renu, Laxmi and student nurse Sujita, live in the upstairs part of a building rented from a family who have been working away in Kathmandu. It has 2 bedrooms, a kitchen area, where the evening Dal Baat is cooked on a 2 ringed stove run on bottled gas (clean but expensive fuel and an attempt to minimise deforestation), and a long verandah, where our dripping clothes were hung out to dry in the evening sunshine. From here, it is only a short trip to the tap in the village square.

Yet, all was not well. The nurses had learned that this ideal accommodation had to be vacated in 10 days, and new premises found, as the owner and family were returning to live in the village again. This problem took up much of their evenings. Fruitless negotiations were conducted with other house owners, and builders of new properties, all demanding much steeper rents for less living space, no toilet or a long distance to go for water. Urmila and Kabita were joining us for the training, that was to be delivered the next day, for Female Community Health Volunteers at the out-lying village and government health post an hour’s walk away. So that evening was spent frantically putting the last touches to posters with the benefit of the electric light, that most of those who can afford it hook up to in the evenings.

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WALKING TO YANGLAKOT

Before the training day could get underway Sujita was asked to see some patients who had come to the health centre. This was a good opportunity to revise the examination of the chest with an emphasis on persuading the patient to remove enough layers of clothing to enable stethoscope access. Even though it was early April it was still pretty chilly at this altitude—it was higher than the top of Ben Nevis.

The local health workers assembled in ones and twos and we had tea until there were enough people to start the proceedings. To open the day everyone introduced themselves and was asked to write on a piece of paper how they were feeling about the training. When these personal views were read later most were very positive about PHASE and the impact of training on village life and health. However, the few less positive responses cited their worries about spending the day training rather than on the farm as it was harvest time. I think this reflects the dependence the population has on a good harvest for its survival and the importance of PHASE’s livelihood work to enable some degree of help and fall back when seasons are not so good, or ill heath claims a farmer.

The training was delivered with much skill, interest and interaction from the floor, and competition from participants’ children. Later, a heavy rainstorm necessitated a quick decamp indoors.  Each nurse had a particular message to deliver and there was a heavy emphasis on hand washing and childhood immunisation. Unlike villages in Gorkha and Humla, the cold chain for vaccines is not so difficult here because Jalbire has an electricity supply for refrigeration that is reasonably reliable. It also only half a day’s bus ride from Kathmandu, with Yanlakot only another half days walk or climb. Immunisation clinics are well established here and run regularly.

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OUTREACH TEACHING

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BABY CLINIC

For the next day’s clinic we were in Yanlakot itself. The building is in the main village square and we picked our way across the waiting patients to open up and start. All started fairly routinely with a patient with an exacerbation of chronic obstructive lung disease—a very common problem here caused by heavy smoking and cooking on wood fires in rooms with no chimneys. In Humla, PHASE had been promoting the installation of chimneys attached to the clay fireplaces, but old habits die hard and it takes time and money to effect changes. Our next patient neatly slotted in to our plan for the day, to work on mental health problems. Sujita was rightly confused when she saw the wide-eyed, heavy-breathing lady holding her hands stiffly towards her chest. “What is this?” she asked with a slightly anxious tone. This patient described episodes coming every so often over 10 or more years. Panic attack or anxiety, we decided. A perfect teaching opportunity for the nurses, and a realisation for me that stress and anxiety are not just a Western affliction!

As this patient left there was a beating on the clinic door, a screaming child and shouts of emergency. It was a 12 year old girl with a history of 5 days of constipation. She had been seen by Laxmi the day before and correctly treated with laxatives. Now the child had impacted faeces, a painful feeling that the stool is stuck. This condition was so painful that it was thought that the girl had an acute abdomen—a surgical emergency. In a country where the major menace is diarrhoea, constipation is barely given a thought and we had no ready-made enemas to combat the problem. Once again, this was a good learning experience for all of us as we attempted to improvise. Finally, the child was carried home in much more comfortable and a note was made to put a few enemas on the next drug order!

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HAGAM

The clinic progressed with 5 or 6 cases with dental problems, highlighting the benefit and wisdom of PHASE sending the nurses on the short dental course in Kathmandu and prompting Renu to ask to be sent on one. Cataracts were also a problem but required a trip to the hospital in KATHMANDU for treatment. Frequently, the old ladies with cataracts were prepared to put up with the inconvenience of being unable to thread needles, rather than venture into to the uncharted and expensive territory of hospitals and Kathmandu. Renu explained that they had recently also had a case of acute glaucoma. They successfully persuaded to the lady to go to Kathmandu for treatment and she is now being successfully treated with drops. No doubt this will have saved her sight. On another day we saw a 9-year-old boy who had fallen out of a tree and had a probable fractured wrist and elbow. Boys are the same the world over, but this boy was incredibly stoical as we improvised splints and advised a trip to Kathmandu—which still had not happened a week later. On the same day we saw a 4 month old baby with a meningocele, a form of spina bifida, who had survived and apart from a chest infection was remarkably well and developing normally. Both of these problems fed in well to our planned teaching sessions when we were back in Kathmandu a few weeks later. We also had a really messy session teaching the application of plaster casts, as well as a day on childhood disability.

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OUTREACH HEALTH EDUCATION

In my previous experience in Gorkha and Humla, most clinics had a high proportion of children suffering from diarrhoea and upper respiratory tract infections. However, Hagam seemed to have far fewer, with many more adult patients and more complex problems such as infertility, congenital heart disease, chronic gastritis and mental health problems. Perhaps this is reflection of Hagam’s proximity to the metropolis of Kathmandu.

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TEACHING IN AARUGHAT

We spent another day on outreach work, visiting homes for follow ups, postnatal visits and health education. Sadly many people were not at home as it was harvest time and they were in the fields or tending to animals—even a 3-day postnatal mother, and our young “Emergency” with constipation, were working.

I had a wonderful experience in Hagam, and want to thank the nurses who looked after me so carefully, fed me so deliciously and taught me so much about living in a Nepali village—and were themselves so keen to learn about medical subjects but to improve their English.

After my trip to Hagam I returned to Kathmandu and then travelled by bus with Gerda and Neil (a GP from Carlisle) to Aarughat in Gorkha for a week, to teach the nurses working in Government health posts in that area. We had undertaken this work last year and it was a pleasure to see many of the same faces again, and to witness how much they had progressed in the intervening year and how much better they scored on the pre-course test than last year. Although we did repeat some of the topics such as IMCI child health protocol, we also introduced sessions on mental illness and disability. The teaching evaluated well and the nurses really seemed to enjoy the interactive and role-play sessions. Perhaps for me a highlight was randomly meeting, outside the community centre in Aarughat and on their return from a trek to Tsum valley, the parents of a teenager I had overseen for several years in the youth club I run back home in Sheffield. We live in a truly global village!

Returning via Gorkha by micro-bus to Kathmandu, I spent a further week in the rather more grand surroundings of a conference centre, with carpets, flush toilets and air conditioning, teaching our PHASE nurses. As I mentioned some of the situations we met in Hagam slotted nicely into some of the new topics we introduced namely mental health, disability and splinting with plaster of Paris. Again much of the teaching seemed very well received especially the small group work with case studies and role-play.

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