I chose to undertake my medical elective at Tansen mission hospital as I was born here over 24 years ago in the year 2000! My parents were missionaries in Nepal in Butwal (1.5hr drive South of Tansen) for around 7 years. We left Nepal when I was 4 years old and returned to visit in 2008 and 2012. I have some fond memories from these times, but felt a deep longing to discover more about my past and early years spent in Nepal – now as an adult. I hadn't been to Nepal in over 12 years when I initially arrived for the elective placement with my parents; having last visited Tansen aged 12 years old; which felt somewhat significant! God made my path to organising the elective unimaginably smooth, such that I was sure from the very first email that this was where God was calling me to - the place of my birth.

On arriving at Tansen hospital we were kindly given a site tour. Tansen hospital was founded in 1954 by United Mission to Nepal (UMN) to provide healthcare to people of Western Nepal; a rural village area of Nepal with little access to medical services previously. Today it has around 200 beds and provides surgery, maternity care and community health programs. The hospital's vision is to offer compassionate high-quality healthcare while training local healthcare professionals. UMN also works in areas such as infrastructure development (water supply and engineering) and community development (supporting rural livelihoods and women's empowerment.) Today UMN continues to focus on poverty reduction, healthcare and social transformation in Nepal.

Many of the Doctors and students live within the hospital compound with various accommodation buildings and the guesthouse (GH) where I resided for the placement. We were received with an exceptionally warm welcome at the guesthouse and shown our rooms, which were simply furnished. There were signs advising not to drink tap water and use water for showering etc. very sparingly as water storage is a big issue in Tansen. It had not rained in over 5 months when I arrived, and the ground was dusty and dry. Almost everyone I met told me they were praying for rain to come as soon as possible. Within 2 weeks of my arrival one morning we were met with an incredible rain and thunder storm – much to the delight of all those living here; and an answer to many prayers. Without rain here there are real risks of fires, water shortages, and increased reliance on unsafe water sources for some of the most vulnerable people living in the area.

During the elective I initially shadowed the paediatric team. During my second week I also spent a day attending a community health visit with a nurse from the hospital. We were driven in the hospital jeep 1.5hrs (on some treacherous roads!) to a local village where the nurse undertook an informative antenatal education class covering nutrition and breastfeeding and then an antenatal screening clinic. During the latter portion of the observership I shadowed the obstetrics and gynaecological team.

During the elective I spent the majority of my time observing life in the hospital including the lives of staff, patients and local people. Placement days began at 7:45am with morning report which started with a Bible reading and prayer for the day ahead and named specific staff working that day in various clinical areas. This was a huge contrast to the start of the working day back at home in Wales which is usually at 8:30-9am with hurried introductions and brisk ward round. The ward rounds were also different here; doctors seemed to have more time for patients and often seemed more compassionate than many of the burnt-out staff I have worked with back home. Ward round takes as long as it takes to see all patients currently admitted and give each patient and their families the reassurance of an ongoing plan – this is similar to in the UK. Here patients families must totally care for the patient including all washing, feeding and other caring duties. This is a stark contrast to UK medicine where some patients may never have a friend or family member visit let alone care for them during their stay in hospital.

After the ward round there were usually patients already waiting to be seen in outpatients clinic. These patients had paid 100 rupees for an outpatient ticket (56p) and often travelled from far and wide to be seen. Some patients come to Tansen from India taking a 10+ hour car journey while still others walk many, many miles. This was sobering compared to back home where generally healthcare is reasonably accessible. 56p may not sound like a huge cost to us however, to some of those attending Tansen this was a significant sum; again sobering for me to acknowledge the uncomfortable truth – that I was viewed as (and was in fact) incredibly wealthy in comparison to some of those I was surrounded by. I found it uncomfortable when patients and locals often greeted me with “Namaskar” a greeting reserved for ‘greeting elders, teachers, or respected individuals.’

After all outpatients had been seen the staff undertook post-round checking-up on patients and management plans and making adjustments as necessary. One thing I noticed in the staff here was exceptional integrity; everyone worked as a team and wasn’t afraid to ask for help when they needed it. This meant second opinions were easy to come by giving patients maximal support from everyone in the team. The basic hygiene measures utilised in the hospital (basic hand washing with soap, open windows for ventilation, and mask wearing) were diligently observed by most staff. Again, in the UK I have noticed that these simple hygiene practices often fall under the radar with over-reliance on plastic gloves etc. to protect against infection in an increasingly time pressured environment.

One interesting case I watched unfold on the paediatric ward involved a mother who had tested positive for syphilis. Her newborn baby was also positive so the mother was advised to stay for her baby to receive treatment. Initially the mother and her husband were keen to leave the hospital as they felt their baby appeared fine and they had matters to attend to at home. The underlying feeling was also that they may be concerned about the prospect of having to pay for another week of night stays at the hospital. Eventually mum agreed to stay however problems continued. The first line treatment for neonatal syphilis is crystalline Penicillin G which the hospital did not have. Second line options were not available so the decision was reached to give Ampicillin (based on a very small evidence base of only a couple of papers indicating this as an efficacious approach.) This case highlighted issues of patients being able to afford care, patients living far from hospital and often being challenging to follow-up/treat in the community, and issues of some medications not being available here.

I was shocked to observe many young paediatric patients with antibiotic resistance to multiple classes of broad spectrum antibiotics such as penicillins and tetracyclines. This occurs commonly here as antibiotics are available to buy very cheaply over the counter (OTC) which is deeply concerning to observe. The practice of buying antibiotics to give very young babies instead of seeking medical counsel from a doctor before antibiotics are given leads to many babies taking multiple courses of antibiotics for virus’ before coming to hospital (now severely unwell and resistant to many antibiotics that would commonly be used to treat them.) This in turn leads to increased chance of last line antibiotics no longer working and potentially prolonged, worsening illness and even an increased risk of death.

Being able to see how healthcare is delivered firsthand in Nepal has had a huge impact on me. I leave Nepal feeling exceptionally grateful for the NHS and the service it provides; whilst also being able to acknowledge its flaws and that some of the practices here that are better than back home. I have been impacted professionally and will take my learning in Tansen and incorporate it into my future practice as a resident doctor. I will strive to maintain the excellent basic hygiene practices diligently followed here, as well as focusing on maintaining a compassionate approach to patients – giving them the full time they need to be adequately listened to and therefore managed the most effectively.

On reflection this elective has taught me that although some things in medicine are different depending on where you are in the world, most of the basic principles remain the same wherever you go. God is present in every healthcare system worldwide and we can choose to listen to his expert opinion or not day to day in the mundanities of everyday hospital life.