For my Work the World elective I travelled to Pokhara, Nepal and spent four weeks in a General Government Hospital. I did two weeks on a paediatric ward and two weeks on a surgical ward, including experience in theatres. One of my focuses was on cancer in Nepal.
The hospital I was working in was small and so had limited specialist equipment or resources - there was an endoscopy unit, which can be used for colorectal cancer screening but it did not have a Magnetic Resonance Imaging (MRI) machine, which can help in detecting cancer metastasis. There was no official oncology ward, so patients who were suspected as having cancer tended to turn up on the surgical ward.
One patient that I saw had a very large distended abdomen that was diagnosed as ascites. This is often a symptom of an advanced ovarian tumour, which is one of the most common cancers for women in Nepal. I also saw one patient of about 50 years of age who had bowel cancer. I was able to observe his pre-operative, peri-operative a post-operative care, although my placement ended before the end of his treatment.
In terms of nursing care I was able to see surgical wound dressing care and colostomy care performed on this patient. I was impressed by the care he received which was mainly implemented by the student nurses. They did their best to change the dressing and stoma bag in sterile conditions. However, I felt concerns for the long term care of this patient as I was unaware of what the health care system in Nepal provided in terms of on-going care for cancer and its associated problems.
When I asked either the doctors or nurses about cancer in general they did not seem confident when answering. They explained that there was a cancer hospital in Bhaktapur (near Kathmandu) and in Bharatpur (near Chitwan National Park).
I was impressed that Nepal had specialist care for patients with cancer. However, my knowledge of transport facilities and the involvement of family in health care meant that I was aware of potential problems. I calculated the journey times as I travelled on the public transport between these towns and cities. By bus it would take 5 or 8 hours – the cheapest option. Having met patients at the hospital, I knew that this may still have been too expensive for the poorest people.
In the UK access to cancer services can vary according to geographical location, but our transport services are significantly more developed and affordable. In developing countries, utilisation of services is often directly proportional to the distance from the services. Also, in Nepal the family provides much of the basic care for patients – it might be simple to move one person to a hospital far away from home, but it is difficult for other members of the family to move with them to provide support. Community nursing care is not well developed in many areas at this time.
If this patient was unable to access cancer services and developed cancer that required more than just surgery, he would require palliative care. Again, there is little in the way of palliative care available and in every instance patients would need to visit a hospital some distance away. There is nothing in Pokhara.
I enjoyed my placement in Nepal immensely and look forward to going back in the future. Although my reflections may seem slightly negative in terms of the quality of health care, I do believe that the health care professionals at the hospital were doing the best they could considering their limited knowledge and resources. I also feel hopeful that there is services available in Nepal to cope with cancer and palliative care – hopefully in the future these will grow and cover more of the country.