2017 trip to Nepal- Project Aasha

A long overdue post on our December 2017 trip to the areas of Sotang and Bung in Nepal.

"If you want to build a ship, don't drum up people together to collect wood and don't assign them tasks and work, but rather teach them to long for the endless immensity of the sea"

- Antoine de Saint-Exupery

This was a landmark trip as Prof Tham Kum Ying... the first person who believed in our ideas and work came along with us. She was also the one who proposed bringing along the LKC students (Lee Kong Chian School of Medicine) along for the trip. Furthermore, during this trip, Kumaran and I were able to put our ideas into practice by bringing 2 physiotherapy students along to introduce the concept of allied health care workers and the importance they play especially in a rural community like this. 

This 2 week trip consisted of 7 medical students, 2 physiotherapy students and 3 doctors- A/P Tham, an Emergency physician, Dr Kumaran, an Orthopaedic senior resident and me, Dr Gayathri, an Emergency Physician. In Nepal, we were also accompanied by Mr Kami and his son Mingma Sherpa (his story in the section, "Goodness boomerangs back") Mingma Sherpa is an Engineering University Student. His father, Mr Kami is a climbing sherpa who has accompanied many of the Singaporeans on their climbing expeditions. The 2 of them, together with Tenzeng, a local from Bung were an invaluable part of our team.... besides functioning as translators, they opened the doors for a deeper cultural exchange, which allowed us to understand the Nepalese people better. To work well and collaborate within a system, being at 'one with the people' is crucial. 

Throwback to the story behind why we wanted a physiotherapist along with us on the trip...

2 years ago, while we were in Gorkha, we realised that the majority of the problems were due to musculoskeletal problems. It was frustrating when the villagers consulted us for chronic problems (such as knee and back pain for many years), expecting the medications we brought along to provide a 'quick fix'. It felt wrong to be giving out analgesia tablets and creams to aid their painful joints for a short period of time. I kept asking myself and Kumaran... what happens when we leave? Are we doing the right thing by conducting a general clinic and acceding to the people's expectations of giving out medications to solve their problems. (It felt like being back in Singapore, when I first saw patients with upper respiratory tract infections, expecting a whole bag of medications to feel better; when what they needed was adequate rest and hydration) It brought me back to the patients' mindset where medications and surgery are alway seen as the only forms of treatment... and a good doctor is one who gives more medications. It is a common theme... which I didn't want to propagate at our health screening camp in Nepal. In fact, when we first started this project in 2013, Kumaran and I decided that our Nepal project was not about running general health camps in Nepal... it is about local collaboration, empowering the local healthcare workers and improving the system so that it runs in a sustainable, effective manner. And to provide specific targetted help by collaborating with other subspecialties. Hence while in Gorkha, after our 100th patient with back pain, we toyed with the idea of bringing physiotherapists along. That Eureka moment conceptualised in 2017.

Background about the Bung

Bung is a remote village within the region of Solukhumbu, in Nepal, at an altitude ranging from 1200-1400m. There are about 4500 villagers scattered over a wide area. The nearest road currently is at Sotang, which is about a 4 hour trek from Bung.

Bung is served by 2 health posts, run by healthcare workers who have received about 18 months of training. They are trained to manage most chronic conditions and ensure that vaccinations and antenatal checkups are up to date. However, there is still a gap in their skills to manage acute emergencies as this is traditionally seen to be the doctors' role. Hence this also applies to the management of obstetric emergencies. This gap together with the home deliveries are the main contributing factors to the maternal and neonatal mortality.

Aims of the 2017 trip

Improve systems of care to reduce maternal and neonatal deaths

In 2016, as part of Project Aasha, the team had visited the village of Bung to explore a major problem that was highlighted to us- the problem of maternal and perinatal deaths. There is a much higher number of maternal deaths in the village of Bung, even for national standards. The main causes highlighted were postpartum haemorrhage (bleeding after delivery), sepsis (infections) and prolonged labour.  These are easily preventable causes of death; in todays' society, mothers and babies should not be dying during delivery. However, it was found that due to the lack of awareness and inaccessibility to the hospitals, the mothers would deliver at home and suffer such complications. Though the government strictly advocates and incentivises hospital deliveries, it often doesn't happen due to the accessibility issues.

Following the needs assessment in 2016, the 2017 served as a recee trip to assess the feasibility of a training program targetted at Bung village itself. This is based on the a very fundamental principle that for time sensitive conditions such as this, early intervention is crucial. In such inaccessible areas, where definitive help (hospital) is a 4 hour trek away, it is important to empower the local community to be able to recognise and provide immediate, temporising measures to help in the interim. Thus the concept of community champions- individuals in the community who are able to recognise and intervene for time sensitive conditions such as postpartum haemorrhage. This is based on the concept of the chain of survival. Though it was created for cardiac arrest, it applies to any time sensitive conditions. The diagram below describes the important role the community plays.

Our plan spans over 5 years- which would involved training the Female Volunteer Workers and other community volunteers to be able to deal with simple maternal and neonatal emergencies that may occur at home, during home deliveries. Besides that, we also decided to pilot the introduction of 'Birthing packs' to mothers in the event they ended up delivering at home. We collaborated with our obstetric colleagues in Singapore to prepare the teaching materials for this pilot trip and are working closely with them to involve them in subsequent trips.

The birthing pack that we gave the healthcare workers to distribute to the households so that if there is a need to deliver at home, sterile and safe methods can be practiced. (currently, they use anything sharp, like a farming sickle to cut the umbilical cord) 

Instructions that went into the birthing pack 

Introduce physiotherapist to a population stricken by musculoskeletal pains

As mentioned above, we wanted to introduce the concept of physiotherapy to the community. We prepared videos of various physiotherapy exercises and leaflet. During the health screening camp, we referred appropriate villagers to the physiotherapist who taught them the exercises to target their problems. The healthcare workers functioned as translators and would inevitably learn the exercises along the way. However, we also held a separate training session for the healthcare workers and presented them with the videos for reference.

Health screening for H pylori, diabetes, hypertension and eye conditions

Though the main aim was education and training, we screened the general population for various conditions as we discovered that many of them have never seen a doctor before. Those found positive for conditions were than referred to the hospital. This is a way of identifying key problems in the community and build rapport with them.

Train a group of school students to be First Aid Champions

This was an idea conceived in 2015, while I was in Ladakh. As part of empowering the community, I felt that the best people to target are the young who are still impressionable. The inspiration came from the young monks in the monastery, who asked many questions and interacted well when we were teaching them about first aid for traumatic conditions. Hence the idea of teaching first aid to secondary school students, who may be able to help within the community.

The trip itself with key highlights

Physiotherapy sessions and education

As expected, majority of the patients came with musculoskeletal related conditions. After a quick screen, they were directed to the physiotherapist, who assessed their condition and taught them appropriate exercises. Leaflets were than given out to them. Finally training sessions were conducted for the doctors and healtcare assistants and the video we had prepared were given out to them.

It was interesting as one of the villagers asked me, "Why do we need to treat out pains with exercises when we walk and farm so much; which is probably the source of our joint pains. I told them that the 'exercises' physiotherapist teach play a  role in stabilising the joint and strengthening the muscles and improved function. This prevents injuries which can result in chronic pain.

Health screening

We screened for diabetes, hypertension, H-pylori (bacteria that causes gastritis as a study in upper Khumbu had previously shown higher incidence), antenatal screening as well as eye screening. Interestingly, hypertension, diabetes and H-pylori was not prevalent. Many villagers arrived with non specific conditions. One of the more interesting cases was a lady presenting with abdominal distension, only to discover that she was about 6 months pregnant!!!!

First aid training

This was a hit with the students. Rather than the usual approach of didactic lectures, we decided to give them scenarios after a very short lecture to test the application of their new knowledge. Hence, after the lectures, each group was given a scenario and they had to act out the solution (eg: how to provide first aid for someone who has been injured during a football game). During the lecture, the class was rather quiet.... which was disconcerting. However, when we gave them problems to solve, they took the task very seriously and took great efforts to ensure that the acting was as real as possible. They went out of the classroom to get props like an improvised walking stick, towels or bowls to mimic being scalded by hot water and so on.

Training on obstetric emergencies

This task turned out to be rather complex and probably the most challenging. Initially we intended to teach the Female Volunteer Workers skills to manage obstetric emergencies and recruit them as community champions for maternal healthcare. 

However, upon talking to them, we realised that the basic knowledge itself was an issue. They are health ambassadors such that their role is mainly to talk to villagers, encourage them to attend their antenatal visits diligently and have institutional births. They are not skills trained and hence even if there is an obstetric emergency in the house, they are unable to help.

Hence during the session, rather than teach, most of the time was spent understanding their system and how they functioned when a lady went into labour. We discovered that when a lady goes into labour at home, those around the mother would allow the delivery to take place naturally and would mainly cut the umbilical cord (using anything sharp that is found in the house, such as a farm sickle.. I discovered that this is commonly done in other rural settings) and then wrap the baby in warm blankets. Only if something seems amiss, would they call their neighbours and the healthcare worker, who may take some time to arrive. There was no awareness of worrying signs to look out for or simple manoeuvres such as uterine massage to contract the uterus nor the use of clean equipment to cut the umbilical cord. If a complication was to occur, no one really knew how to manage it at home and there is no 24 hour medical service within village. Neighbours may call the health care worker from his house who may take 1-2hours to arrive, depending on the distance. By which time, the mother may exsanguinate from post partum haemorrhage (bleeding during and after delivery of the baby)

Eventually we decided to teach the Female Volunteer Workers how to perform uterine massage, using the MamaNatalie mannequin. This mannequin is truly amazing.. it comes in a backpack (and is easy to carry around) and consists of a pregnant womb with tank to carry coloured water to mimic blood, a baby with the umbilical cord and many other components to simulate the delivery of a baby and the complications that may occur during delivery.

MamaNatalie was a hit amongst the villagers. Though we only intended to teach a small group of community champions, nearly all the women villagers (almost about 50 of them) turned up to try out delivering a baby through this. They all had a chance to perform uterine massage and feel the difference between a soft and a hard, contracted uterus.

Ultrasound training

We had brought a Sonosite and a portable ultrssound probe along. We planned to use it for the clinic as well as to explore the possibility of training the healthcare workers. The healthcare workers have not used the US machine much but were excited by the prospect of learning this new skill. The doctor at Sotang clinic however, had attended a course on the use of ultrasound in the rural setting and was familiar with its use. It is mainly used in the hospital for obstetric antenatal scans and free fluid in the abdomen. Prof Tham wet his appetite further by showing him how it can be used to aid musculoskeletal and abdominal pathologies.

Accessibility

This is a major problem, not just for the villagers, but also for us. The village of Bung is currently only accessible by foot  or helicopter from Sotang. (though a road is currently being built from Sotang to Bung)

The jeep ride from Kathmandu to Tipling takes about 15 hours, part of which involves an extremely bumpy sandy road. Following which, we walked about 4hours from Saleri to Sotang and on the 3rd day, walked 4 hours from Sotang to Bung.

KTM----> Tipling---> Sotang ---> Bung

This was my most adventurous, craziest, bumpiest road journey I have ever taken. This bumpy car ride may induce labour in a term pregnant lady!!!

The walking trek itself is not challenging as the upslope is gradual and doesn't involve any technical climbing. But good trekking shoes is a must as we had a few shoe incidents along the way!

Communication

The network coverage is poor in the village of Bung, which meant that we were not even able to contact the locals on their mobile phone nor use the internet. This is a major shortcoming, which affects our ability to constantly communicate with the healthcare workers while we are in Singapore. This affects our ability to share E-learning platforms with the team in Bung.

Friendships forged

Once again, the hospitality and the warmth of the Nepalese people was infectious. They give all they have, despite scarcity of their own resources. Friendships were forged.... and facebook accounts were exchanged.
Amongst us, the group dynamics was extraordinary. Being a multidisciplinary and multispecialty group, we had much to learn from each other.
And lastly, with the physically challenging journey (long bumpy jeep rides, long treks, no showers, stricken with URTI and gastroenteritis), we all grew closer and stronger.... 

Future plans

Our future plans involve:

1. 3 year plan to train the health care workers to be skilled and confident in handling medical emergencies and the use of ultrasound. 
2. 3 year plan to train the health care workers in being able to assess and teach physiotherapy exercises to villagers with chronic musculoskeletal issues.
3. 5 year plan to reduce the maternal and neonatal mortality rate through education, awareness, early recognition and early intervention. The approach has to be 2-prong; where we work with the community as well as with the local authorities. Together with the local village leaders, we plan to use their local data to convince the authorities that more needs to be done to prevent home deliveries (eg: providing accommodation near hospitals capable of Caesarean section so that the villagers can stay there nearer their due dates; sending out trained midwives to the healthposts)
4. 3 year plan to develop First Aid champions in the community and identify super trainers amongst them
5. Development of the Eye project in Gorkha (Click here to read more)

Please feel free to contact us if you are interested to support in any way.....
https://projaasha.wixsite.com/blog or email gayathri.nadarajan@gmail.com

Click here for a photo journal of the trip.