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Roslyn Brooks is a medical doctor from Cooma, NSW, who has been working in Kalikot in Nepal with Médecins Sans Frontières (MSF) since September 2007. This is her second mission with MSF. Here, she describes her experiences in her first two months and the challenges of providing healthcare in such a remote region.
5 October 2007
I arrived in Kalikot after a helicopter flight from Kathmandu over stunning scenery – mountain crags, deep gorges, monsoonal flood plain and rice fields, mountain top villages and terraced fields, the peaks of the Himalayas. Remoteness, difficulty of access, and health indicators that are among the worst in Nepal, together with a history of conflict and violence over the past twelve years are the key reasons that Médecins Sans Frontières (MSF) has set up a mission in this north western region.
The hospital is on the side of a ridge 200m below the town, Manma bazaar, looking out over a steep drop into the Tila river gorge. The mountainsides are partly cultivated with terraced rice and corn fields, partly forest. We are at about 1500m here. Weather is fine and warm – the monsoon rains have just finished but the MSF team was quite isolated here over the past four months due to continual rain and fog.
12 October 2007
I am getting to know names and faces. All the Nepali staff are kind to me, and tolerant of my mistakes, and are ready to help when I ask stupid questions.
This morning we had to transfer a very sick patient (whose diagnosis later turned out to be gangrenous bowel) to a larger hospital by helicopter.
25 October 07
It has been quieter over the Dashain holiday season (Nepal’s longest festival that means ‘a day of Victory over Demons’), with some staff away and the outpatient department on minimal services. There are few patients coming. We have done some training with the staff - I worked with one of the Nepali health workers to discuss the assessment and management of trauma, while Renee, the other expat doctor from Holland, did some basic anatomy teaching and discussed causes and treatment of abdominal pain.
As far as patients and what we are treating here, there is a lot of pneumonia, typhoid fever, skin infections, diarrhoea (including some cholera), malnutrition and complications in pregnancy such as bleeding. There are many normal births, but most women have their babies at home.
In the remoter villages hygiene is poor, there is a lot of diarrhoea/ gastroenteritis and skin infections. Also the rate of death in both mothers and babies in delivery is high. There is very poor coverage with basic immunisation, even though the national health authorities are supposed to provide this. MSF is doing vaccination and antenatal/postnatal care as part of the outreach program.
10 Octobr 2007
Today is another festival, so people are resting and celebrating. Yesterday was cow day (cows were decorated and given special treats), today is bull day, and tomorrow is brother and sister
day when people spend time with their families, and brothers and sisters give each other traditional blessings. These are Hindu celebrations - there are many during the year, but just now is the peak festival season - perhaps it is because it is harvest time, and when people traditionally eat well and celebrate! A few months later will come the months of food shortage and hunger. Cows and bulls are sacred of course and although buffalo are used for pulling ploughs and other loads, people do not eat beef. However the traditional diet based on rice, lentils/pulses (dahl) fruit and vegetables, plus oil, milk, peanuts and cashews, eggs, occasional goat meat and fish, is very healthy when there is enough.
The hospital is very quiet on holidays, even though we have local staff working in the emergency room and one of us three doctors are always on call. Only about twelve people turned up for treatment yesterday, mostly about small things, although sometimes there are serious accidents or very sick people. The inpatient hospital (twelve beds and three obstetric beds) has only six patients at present! A lot of people have to walk anything from three hours to three days along rough mountain paths to get from their villages to the hospital. The sick person is usually carried on someone's back in a big basket or occasionally on a stretcher. I think they often stay home to get better (or die) especially during festivals, when everyone wants to stay home with their families.
Thursday night was busier - a man with a fractured forearm that we set and plastered, two small children with huge abscesses that had to be drained under light anaesthetic, then two deliveries. Normally we are not called for deliveries unless there are problems but Renee was worried about these two as one woman had high blood pressure, and the other was making slow progress in labour. She set up infusions of Oxytocin* to speed up the labour, then we kept a close eye on the progress. Renee and I both attended the first delivery although it was normal in the end, and the nurse did it as is usual - we both stood by the delivery bed madly encouraging the woman to push in a mixture of Nepali and English and body language - I think we were both pushing too! Both deliveries went well, two healthy boys and two very happy families.
*Oxytocin is a hormone that stimulates smooth muscle contraction at birth
16 October 2007
It is getting busier here. Last night I was called to see a man who had injured himself while cutting wood and had a pelvic fracture. He was injured at 4pm, carried here for hours along rough paths by a group of men from his village, to arrive at 2am. I am constantly astonished by the endurance and courage of the people. An old man might carry his sick wife for a day on his back, up and down climbs of 500m from their village to the hospital.
Yesterday I removed a blood clot from some really bad prolapsed haemorrhoids (a procedure I do in my general practice, but never for anything nearly as bad as these). The poor man was determined to be treated at once so he could leave hospital first thing in the morning to go to work! (he works in the bank in Manma Bazar, a half hour walk uphill from hospital). Back home, we would probably not consider getting out of bed for a week!
20 November 07
Two busy nights.
There was a tractor accident on the road on Sunday. The tractor pulling a truck loaded with passengers overturned, and one man was killed. At 10pm, twelve hours after the accident, three badly injured people arrived at the hospital. One man had fractured both bones in the lower leg, the bone ends protruding through torn skin; a woman had fractured both bones in her forearm as well as suffering bruises and abrasions over most of her body; and her 5 year-old child had a head injury and fractured shoulder. The following day we transferred the patients to the nearest big hospital - a difficult logistical exercise in view of limited travel options. The mother and child travelled by vehicle for two days, jolting over terrible roads, while the man with the fractured leg was carried by stretcher along the same road to a bus station two days walk away.
On Monday night another badly injured man arrived after being carried all day by his sons, after falling from a tree and smashing his jaw and lower leg. We can give pain relief, antibiotics to prevent infection in the exposed bone, and support the leg in a plaster slab, but definitive treatment means transfer. This time we were lucky – a commercial helicopter was coming the next morning and we could get our patient on this. While we stabilised this patient, a woman with a prolapsed uterus was in labour – the baby died before it was born and the fibrosed uterus had to be cut to allow delivery of the dead baby boy. Another tragedy – this mother will not be able to bear another child, and although she has carried seven children, only two daughters survive. Dr Sandeep stitches the uterus, and later he and Renee must explain to the woman that another pregnancy would cost her her life.
MSF’s work here can only help a tiny few of the people from the scattered villages in the region. Maybe our outreach team, through its health education and reproductive health camps, will slowly begin to lift health standards. Maybe our témoignage – witnessing – will bring more determined effort from the Nepali health authorities, along with the work of aid agencies, to prevent some of the daily tragedies among these most isolated of people.
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