Story by: Elin Doyle
On the side of a valley in North-Eastern Nepal, just south of Mount Everest, lies a small rural community hospital. The surrounds of the hospital are adorned by scattered settlements and terrace cultivation. In the 1960s, a former surgeon in the Scottish army started a health project here, perhaps it was the mountainous ranges that reminded him of home, he finally settled in the village of Okhaldhunga. Today, Okhaldhunga Community Hospital (OCH) serves more than 250,000 people in Okhaldhunga district, a district three times the size of urban Stockholm.
Although the hospital now has 50 beds available, the average number of hospitalized patients in 2016 was 63.5.
We met daily at 8.30am to begin our rounds. Our first destination was the intensive care unit to see a male patient who arrived late the night before after going unconscious following a week-long fever. His wife and 15-year old son had managed to bring him here and were now sitting on the floor next to his bed, eyes red and swollen from tears. “High protein, normal glucose, and few cells”, medical coordinator Dr. Erik Bøhler, originally from Norway, said thoughtfully. “Hmm… I guess the closest we can get now is encephalitis.” He brought a chair and asked the man’s wife to sit down. “We’re not sure about what this is. But the prognosis unfortunately does not look good”, he said, laying a hand on her shoulder. Tears started to fall down her cheeks.
We continued to the general ward, where the first patient was a middle-aged man with diabetes. The man was gaunt, atypical of diabetic patients. “He has been admitted here many times the last years”, Dr. Bøhler said. “It is a common problem here, that diabetics don’t want to take insulin injections. People don’t like injections.”
“What sort of diabetes does he have?” I asked, curious that he did not look diabetic. “We do not know. Diabetes is becoming more and more common here now, among children also. People are talking about a type 3 diabetes, since adults who lack the well-known risk factors for diabetes type 2 are now getting diabetes in Nepal.”
A nurse came running, ”You must come now! Hurry up! There is an emergency in the other room!” We quickly moved into the room next door, where an old lady laid on here bed her whole body convulsing uncontrollably. “I don’t know why. She is here due to urinary problems”, the nurse quickly explained. Dr. Erik turned to the lady’s relatives and spoke in Nepali, and quickly scribbled some a prescription on his notepad, “she is probably having alcohol withdrawal seizures”, he explained as we moved on. “It is another quite common problem here, that patients don’t tell us that they normally drink a lot of alcohol at home. After spending a few days here, they start to get withdrawal symptoms.”
We moved on to the isolation ward, there was only one female patient there this morning. She had progressively gone paralytic in both legs. She had been to many doctors and done many expensive tests, but they had all turned out normal. Now she had no more money left for any treatment. Her husband had brought her to OCH as a last destination, awaiting her death. However, here a sputum-TB test was done, which showed positive. She turned out to also have extrapulmonary spinal TB, which had been the cause of her paralysis all along. Through financial support from the social office at OCH she could begin her treatment and her leg motility was now already improving. Life takes dramatical turns sometimes.
On our way out, we bumped into another TB patient. He was apparently on his way somewhere. “Where are you going?”, one of the doctors asked. “I want to go home”, the man replied. “You are not finished with your treatment. You really need to stay some more days.”
“No I’m fine already, I can go home.”
“No please, I really need to go home.”
“I need to go see the traditional healer.”
It took a while but he was convinced to stay at the hospital, at least for now.
When arriving at the emergency, we were met by a seven-year-old child with his arm in a triangular cotton sling. He had previously fallen from a tree while cutting leafy branches for his family’s cattle and had fractured his arm. The boy’s father handed over his son’s medical record booklet “There is school holiday now”, Dr. Erik said, “and there is a major increase in fractures among children during school holidays. The kids are helping out more with the work at home then.” It was not just children climbing trees , an 83-year-old lady came in with a broken arm some time before, having done just that.
“Ring! Ring!”. A midwife from the maternity ward was calling. “There is a baby showing signs of acute distress. You need to come and perform a caesarian immediately!” We hurried to the operation theatre, where the mother was already lying on the operation table fully anesthetized. The midwife had noticed sustained slow heart rate in the baby, not relieved by letting the mother lie on her side and giving her extra oxygen, an indication for acute caesarean section . A few minutes later the little baby girl was out. She had had the umbilical cord strangled around her neck and was covered in meconium because of her distress.
After lunch, I went to the social office. Patients come here who cannot afford to pay for their hospital bill for themselves. Nepal is among the world’s least developed countries, with a total health spending per inhabitant USD 137 in 2014, corresponding Swedish figure of USD 5,219.
A continuous stream of people was finding their way to the social office. The next one in line was a woman who wished to apply for a free treatment grant for her son, who had just been treated for a fracture. The social worker on duty, Dr. Erik’s wife Kristin, performed a short interview with her. The woman was asked about her land and cattle and how much the land yields, her and her husband’s work and salary, her loan possibilities, expenses (including children), and other relevant details to determine her relevance for the charity program. The woman was found eligible of a grant, and happily received the yellow little ticket to bring to the cashier as payment for her son’s treatment.
The financial support for the charity program at OCH primarily comes from donations from private persons and from missions’ organizations worldwide. After the woman and her child had left, I asked her whether Kristin believes patients are sometimes lying in order to receive free treatment when they know the possibility exists. “I believe it is less of a problem here than it would be in Norway or Sweden at least, some while ago we went to three municipalities performing a check-up of all those who had been receiving charity, to see whether they had been really eligible for it. It turned out only one of all patients had wrongly received charity.” There are three different categories which patients who cannot afford to pay their bill at OCH can fall into; poor, very poor, and very, very poor. The categories are based upon how large loans the patients are able to take. In Nepal, many people are dependent upon loans, especially in the rural areas. Men who have been able to go abroad for work to earn more money can lend money to others – sometimes with unscrupulous interests. How large of a loan someone is able to take depends on the amount of land and cattle they own. The three charity categories at OCH are therefore based upon how many months a patient could survive with whatever loan they could get; 5-6 months for poor, 3-4 months for very poor, <2 months for very, very poor.
In Kristin’s small office there is a shelf full of papers on patients who have previously been granted charity. An average of around 380 patients per month were receiving charity last year, which equals to around 13% of all registered patients. This included both admitted patients and outpatients. “We want to be a hospital for the poorest, the ones who are often invisible in society”, Kristin finally emphasized.
The clock struck 5pm and this day’s shift had come to an end.
“One day as a doctor at Okhaldhunga Community Hospital can throw up just about anything”, I thought to myself, while making my way back to the guesthouse.
 Nepal: WHO country profile. http://www.who.int/countries/npl/en/
Sweden: WHO country profile: http://www.who.int/countries/swe/en/
Youtube Link: https://youtu.be/fBDiuPFNdWk