Nepal Visit October 2014
The adventure began with a young Nepalese Plastic Surgeon, Indira Yonjan
(Lama) and her determination to improve medical treatment for all and
particularly women in her native Nepal. Indira completed her medical
undergraduate training at Kathmandu University before coming to the UK to
work and gain experience in general and plastic surgery. Indira maintains
strong local ties with Nepal.
Whilst working in Bristol, Indira met Mr Robert Warr and Miss Jana TorresGrau. Robert is a Consultant Plastic Surgeon who, along with friend and
former cancer sufferer Anna Dailly had established a breast cancer charity –
Breast Cancer International. The aim of this charity is to support breast
cancer services in developing counties and it had sprung from requests for
Robert to train and teach in Bangladesh. Recent instability had prevented
travel to this area and thus the charity was still looking for it’s first point of
focus. A link with Nepal through Indira seemed opportune.
Jana is a plastic surgical registrar with experience in the setting and
organisation of international healthcare projects. Furthermore, together with
Robert, she had organised and run a national course aimed at teaching
essential skills to surgical trainees. The course, recognised by the Royal
College of Surgeons, is currently run on an annual basis within the Anatomy
School at Bristol University. The team felt that if they were to facilitate
reconstruction of any kind including breast services then it is helpful to start
with the new generation of doctors and thus, this course fitted well with the
overall sentiment of the visit. It had previously been decided to run this course
internationally. Nepal would be a start.
Prior to departure Anna, with her background in political research undertook a
comprehensive review of Nepal medical services. Nevertheless, even with
local knowledge provided by Indira, the research, local contacts and
experience in international healthcare projects, the team found that
information on Breast Cancer in Nepal was extremely difficult to come by. The
reason, as it become clear is that there are no statistics available.
The aims of visit to Nepal were thus;
1. To experience the current status of existing breast cancer services
within Nepal and to collate information where possible.
2. Where possible to determine the awareness of diagnosis and treatment
options of breast cancer in the Nepalese population.
3. To determine the impact that breast cancer has on the family life in
rural communities. (It is known, for example, that women with Breast
Cancer can be ostracised in other developing countries.)
4. To establish how best to direct limited resources that would come
through charitable work.
5. To establish where and with whom to devote time and resources for
training in breast cancer surgical techniques.
6. To determine the extent of need for breast cancer surgical training.
7. To establish and run a basic surgical teaching course, mirroring that
run in the UK.
And so…. on 7th October 2014 Indira, Robert and Jana flew to Kathmandu.
Upon leaving Tribhuvan Airport, the team started to get a feel of the country to
understand why Indira had advised car rental rather that self-hire - chaos
being a flattering way to describe the local traffic! Indeed, such local
knowledge was to prove invaluable in making the brief visit as productive as it
turned out to be.
The following morning, the team visited the Nepal Cleft & Burn Centre, the
hospital where most activities took place. There they met Dr Rai director of
the centre. This incredible man, the son of a Ghurka officer, has made it his
life’s work to help Nepalis with no access to health care. In recognition of his
work, he has been honoured with Nathan R. Davis Award in International
Medicine and Public Health, the Cardinal Health Children’s Care Award in
2005, and in 2009 was presented with An Unsung Heroes of compassion
Award by The Dalai Lama.
The Hospital is funded by the Government of Nepal and was in a state of
redevelopment and expansion when we visited. It is intended that it will soon
become the teaching hospital for medical students of the local Tribhuvan
University. At present no breast services were offered at this hospital and Dr
Rai’s placed the team in contact with a Dr. Prakash Neupane in the Bhaktapur
Cancer Hospital. Upon visiting this hospital, it became apparent that many of
the simpler procedures that we undertake routinely in the UK were not offered
in Nepal. Furthermore, those that could afford it would often travel to India for
procedures.
On the weekend, the team ran the Inaugural International Basic Plastic
Surgical Skills course - using buffalo instead of pig hides. Feedback was
encouraging. Since returning from Nepal and running this course again in
Bristol, the format has been reviewed and the team feel that the revised
course should of even more value in Nepal.
On another day Mr Warr gave a series of lectures on his reconstructive areas
of interest, to an audience of General and Plastic surgeons. In the audience
was Dr Suzita, a passionate Nepalese Surgeon who had identified a need, for
breast cancer awareness, diagnosis and treatment in rural Nepal. With the
help of fellow doctors, she had set up a charity called The Nepal Breast
Cancer Foundation. To date, she has travelled to various rural parts of Nepal
with other doctors and nurses for health camps in order to increase the
awareness about not only early breast cancer screening but also, various
diagnosis and treatment options.
One further highlight of the visit was a meeting with Dr Damodar, the
chairman of Nepal Medical Council. This meeting allowed us to outline both
our aims and the challenges facing us and to facilitate any training that we
would wish to undertake in future visits.
On balance the trip was a huge success and paves the way for any work that
we would wish to undertake in the future. The visit has allowed us to identify
specific goals. These are:
1. To help support breast cancer awareness and management programs
in remote and rural areas. Timely detection of breast cancer will always
make further management easier and improve morbidity and survival.
We will achieve this goal by supporting Nepal Breast Cancer
Foundation. This will be the focus of much of the fund raising.
2. Training the local cancer and reconstructive surgeons in routine
techniques that will significantly alter the quality of the outcome for
women and their families. This part of the project relies little on
fundraising and is a matter only of time and organisation; time on the
part of UK surgeons who for the time being will fund their own trips and
organisation on the part of local teams to provide an environment
suitable for training with appropriate patients.
3. Continue to organise and refine the Basic Surgical Skills Course on
annual basis.
Future steps…
To the team’s knowledge, there is no other project in Nepal focusing on the
breast cancer treatment pathway. The trip discovered that there is a real need
for surgical training and that there are organisations of enthusiastic local
doctors keen on improving the healthcare system of the country. We
recognise that resources will be limited in Nepal and other developing
counties particularly when compared to the UK but our vision is that surgeons
within Nepal and other developing countries should have the knowledge and
the relatively simple skill sets to deliver treatment that will fundamentally
improve the quality of the lives of the women that are the bedrock of much of
the rural community and who sadly for many reasons are often last in the
queue for medical help.
We will fulfil our aims by
1. Fundraising through Breast Care International.
2. Annual visit to Nepal by the UK team.
3. Liaising with Nepalese doctors such as Dr. Rai, Dr. Prakash Neupane
and Dr. Suzita both for primary and secondary/tertiary care of breast
cancer patients.
4. Organising teaching courses for junior doctors.
5. Analysing our work based on feedback from our local partners so that
can upgrade our work on a constant basis.
Thanks:
We would like to thank Dr Rai for his support without which much of what we
achieved in this short time would not have been possible.
We would also like to thank the local doctors who contributed to make this a
successful exploratory trip, which formed the basis for the continuity of our
work in the future.