Tag Archives: nepal

Dil Bahadur Kidney Transplantee – an update

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One of my hobbies is trying to get people to laugh on photos. Its pretty easy in Nepal I think. While having your photo taken is becoming more common, as there are many snapping mobile phones about, having photos printed is relatively expensive and, if not a luxury, something reserved for serious applications to officialdom.

If you can imagine pictures of your great, great grandparents when the world was still sepia coloured, or your youthful great grandparents when the world had turned black white, and then if you can picture the serious scowls they wore on their faces, add colour some colour and you have an idea of how portrait photography is most of the time Nepal.

Anyway, during the few seconds of overbearing stress while waiting for the photographer to click the button, its is really easy to make people explode into laughter.

There you go. Laughter therapy is free. The straight face behind the mask is Dil Bahadur and this tells something of our relationship. For him, because of the donations that have been collected, I am his (small g) god – a term I hate. But given the context of a culture with millions of Gods, I can see where he’s coming from: out of the dust and smog comes someone who agrees to help you (by asking his friends and family to part with some cash). But this luck has just been the cherry on the cake. Dil has done more than his best to get to this point: a great deal of fund-raising in his home town, representation in the press (Journo seeks support) and support from his colleagues, his family came to Kathmandu to help him through dialysis (and his wife donated a kidney), and recently becoming one of the very lucky few in Nepal to reach the operating table in Bir Hospital (which incidentally celebrated one year of successful transplantation on the 12th December 2009).

Back to the photo. Among the family there is a palpable sense of relief, but with Dil, constantly wearing a mask to minimise the risk of infection with his permanently weakened immune system, he knows this is a long term thing. He faces up to the cost of his treatment every time he goes to the pharmacy and parts with cold hard cash. So far, generous donations brought in around 1,300 Euro. This has paid for one of the (two recommended) doses of chronically expensive Zena-pax which increases organ acceptance by up to 40%, plus the initially high doses of immunosuppressants. So far so very good. Still another 600 Euro would required to get to a maintenance state, where the daily dose of drugs becomes much cheaper and (more or less) manageable.

After that the challenge changes: to earn enough money to feed the family and pay the pharmacist. Its possible. A group of patients are looking at a programme where they set up their own specialist pharmacy to cut out the middleman and save around 15% of the cost. A group of people connected with UNDP are planning a training course on how to “Start and Improve Your Business” so that families can improve their income to cover their increase expenditure. Its early days, but there must be some way found to make this self-sustainable otherwise transplantation remains only for the rich.

So, nearly there, nearly out of the woods. Thanks very much indeed for your support to get to this point.

Donations already received can be seen here: 
http://spreadsheets.google.com/pub?key=tdOFgjwTUeKCSow9L40a0qQ&single=true&gid=2&output=html

If you wish to contribute, please do so using this button below. It will take you to a secure Paypal site where you can use a credit card to make a donation. The account used is my own, it is currently empty and I will publish (anonymously, dates and amounts only) at a later date. Alternatively, Account name: R. P. Bull Bank name / Address: ABN AMRO / Leidseplein 25, Amsterdam; Account No: 519969626; IBAN: NL44ABNA0519969626; BIC / SWIFT Code: ABNANL2A. Thanks for your support!

If in any doubt the screen you should see on clicking the button above looks like this: Paypal screen

And now the doctors are going on strike…

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“My life is under threat now,” says Dr Nil Mani Upadhyaya, registrar of the Nepal Medical Council (NMC).
On December 15th, two men were waiting for him at his gate on returning from work and attacked him with a khukuri knife. Dr Upadhyaya is lucky to have suffered only minor cuts. The men then fled on motorbikes and could not be followed.

Why was he attacked? “That is the main question for me,” he explains, “I have no single enemy after 25 years of practicing medicine. There has been no demand for money. There has not even been a bad conversation on the telephone.”

“Part of our role at NMC is licensing doctors. There are some people who have trained outside Nepal, in Russia, or India who have failed the licensing exam to practice in Nepal. Some have failed so many times, up to 14, 15 times. Our guess is that it might have come from that group – but we really don’t know, we’re just speculating.”

The attack was a trigger for the NMC’s sister organisation, the Nepal Medical Association (NMA), to threaten a one day bandh on 28th December unless their demands were met. The NMA represent the interests of medical professionals in Nepal. The bandh will result in a voluntary stopping of work in all departments except emergency.

Dr Kedar K.C., president of the NMA explained that the primary demand was for measures to increase safety of doctors in the workplace. Apparently there have been up to 40 attacks on doctors in the last 2 years across Nepal. Bundled in with this are a call for increased health budget, increase in the number of doctors, better equipment, abolishing 5% tax on salaries (which is anyway passed on to the consumer) all the way to setting up Bir Hospital as a centre of excellence and the foundation of a new medical university.

This is a worthy list but already the NMA’s strategy has fallen apart before it has started. Firstly it has diluted the issue of violence against doctors with many other complicated issues, including some self-serving ones (tax reductions, increase in private hours allowance). It could be perceived as using the frightening attack on a senior doctor to force through an increase in their benefits.

Secondly it is using the thuggish tactic of the bandh. While this could be justified in extreme cases, and after all other options have been explored, here the NMA is offering the public punishment as a kneejerk reaction to an event of 13 days earlier that additionally didn’t happen in a hospital. In calling a bandh, while not blocking roads, it puts itself in the same camp as all of the other flag-waving, violent, tyre-burning, unwilling-to-negotiate rock-heads.

What does the head of the NMC think about the bandh? “From a personal point of view, and that of registrar, I would not support it, but then I am a victim too. From a medical ethics point of view, I should not support it. It is a very crucial question for me.”

If Dr Upadhyaya has his reservations, it would seem unlikely that the long-suffering public are going to be offering their unswerving support. And there is the third point – never call a strike of a public service unless you have built up firm public support for your case beforehand.

How does Dr Upadhyaya he see the best way to improve the protection for medical staff in Nepal? “It is very difficult question. If the whole country is going in one direction, how can you protect [anything]. We are in the same direction as Afghanistan; there is no law and order here.”

“The home minister said about a year ago ‘I cannot safeguard my own life, how can I safeguard the lives of others?’.”

So then what good is this bandh going to do? Let’s wait and see. Perhaps the government will shrug their shoulders and call their bluff.

The NMA has missed a great opportunity for developing public relations. It could have detailed the terrible cases of violence against doctors, the dedication that medical staff show, the long hours, awful equipment, weak management and the fact that hospital budgets are lower than WHO minimum recommended levels. They could have played on the fact that ministers often use the public purse to get treatment overseas. Or wheeled out some happy, satisfied patients to rally support for doctors. It could have managed the expectations of the public, that doctors always do their best for patients, but that they cannot work miracles and sadly some patients will die.

It could have opened a conversation with the public about why doctors (and society at large) are suffering violence and what should be done. And then, importantly, show that they’re actually listening and thank them for engaging.

Instead, tomorrow, doctors will further loose favour with the public and strengthen the choking culture of the bandh as the only way to fix problems. In many ways, they will have just made the problem worse.

Smallest buddhist in the house. Seto Gomba, Kathmandu.

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Smallest buddhist in the house. Seto Gomba, Kathmandu., originally uploaded by rpb1001.

I am lucky. I complain about a lot of things, but life for me is interesting and life for me is good. This evening, Christmas eve (although this has little meaning for me), was spent as the fourth attendee of a Buddhist wedding. The other three were the bride, groom and their young daughter.

The wedding took place under the auspices of a particular Ringpoche (name escapes me) in the Seto Gomba, the White Monastery, near Boudha in Kathmandu.

In this picture, the wedding is over and formalities are being completed in the office. Every monk in the house, and all employees too, are receiving a 100 rupee gift from the groom from a rather thick wad of cash managed by Tenzin Chopel (hand outstretched, right).

Here, hesitantly comes the smallest monk of the Gomba into the office to receive his money.

Best viewed large on black, click here

Kathmandu's Bir Hospital celebrates first anniversary of successful kidney transplant.

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Dr. Pukar Chandra Shrestha, transplant surgeon, Bir Hospital, Kathmandu, Nepal, originally uploaded by rpb1001.

12 December 2009

Today, the 120 year old Bir hospital in Kathmandu celebrates the anniversary of its first successful kidney transplant.

Bir’s renal transplant department was the brainchild of surgeon Dr. Pukar Shrestha who spent six years training in UK. In his last role he was a senior registrar at the Freeman Hospital in Newcastle before choosing to return to Nepal over promotion to consultant.

“I was thinking, ‘Nepal needs me’,” he recalls. “In the UK there are many like me, but here in Nepal every patient needs doctors like me.”

In the past 12 months 16 patients have been given kidneys donated from family members. “16 is good success over 11 months, however we used to operate on up to 15 patients every week in Newcastle.”

The department’s target is one transplantation per week. But there are major obstacles to achieving this. For instance, the department has no operating theatre. “We have to borrow the theatre from cardiology or neurology and this is a big limitation,” says Shrestha. Additionally there is no facility for tissue cross matching in Nepal and samples need to be sent to India which is both costly and takes 4-6 days. “On the positive side,” adds Dr Shrestha, “we have a really capable and dedicated team here. We’re also lucky to have strong ties with organisations outside Nepal such as Freeman Hospital, Transplant links and Health Exchange Nepal who are helping us with training.”

Previously the only option for those with Chronic Renal Failure (CRF) was to go to India. While there is no official data, it is thought that up to 100 people cross the border every year paying upwards of 8,000 Euro, sometimes purchasing an organ there.

Now Nepali’s have the option of both Bir Hospital and Tribhuvan University Teaching Hospital (TUTH) which had its first transplant success in mid-2008. While the average cost of a transplant in the USA for example is at least US$ 50,000, both hospitals charge less than 3,500 Euro for a transplant using the best available drugs. “I was trained in the UK and want to work in the same way,” says Dr. Shrestha.

Dr Rajani Hada, Associate Professor of Nephrology at Bir is enthusiastic about transplantation. “Over 50% of patients are below 30. With a transplant they can go on to lead normal, productive lives.”

It is estimated that annually 2800 people suffer from CRF in Nepal. Dr Hada believes that while transplants save lives, the most effective way is early screening and thus prevention. “In my ideal world I would screen all children at school. It costs just 25 NRP (23 Euro cents) for a urine test, and we could catch problems early and treat them. We could eventually reduce that number significantly.”

Present at the short ceremony at the hospital is Dinesh Thapa, 22, who was transplanted seven months ago with a kidney donated by his mother. “We have a new life. For us, the transplant is a miracle,” says Dinesh.

The immunosuppressant drugs he takes daily to stop the body rejecting the kidney cost around 150 euro per month, an amount that is equivalent to a good government salary. “We sell our land,” says his mother when asked how they finance this cost. He is studying journalism and in two years hopes to be able to have job and be able to cover this cost himself.

While operations themselves have been very successful, the cost of medication is a major stumbling block. Some organisations such as UNDP are looking into income generation programs to help transplanted patients and their families afford the drugs. Dr Hada called for the government to remove taxes from immunosuppressants and even offer a subsidy to patients.

“We need to do something for these people,” says Shrestha later, “Dinesh is not working, how long can he sustain these costs?”

“We can’t make an emotional bond with patients or we’d end up in a mental hospital,” says Dr Hada. “Making good decisions for all our patients is the best we can do.”

Gadhimai Mela, Nepal

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Gadhimai Mela, Nepal, originally uploaded by rpb1001.

Last week I attended the Gadhimai Mela. Mela means festival in Nepal. For me it was like another world entirely. The Mela has gained some notoriety internationally because of the ritual slaughter that takes place there. Approximately 12,000 male buffaloes are ritually sacrificed there and many thousands more are slaughtered in the 5km zone around Gadhimai’s temple.

I am writing up this experience for the interested to read. Is hard to get a flavour of how it was from pictures alone, but then I don’t guarantee that the text will make it that much clearer.

Meanwhile, see the photos here. Some are bloody but please put your squeamishness to one side.
http://www.flickr.com/photos/rpb1001/sets/72157622780160303/

There is a great reflective piece on this here: http://sushma.blogspot.com/2009/11/are-we-civilised-yet.html