Introduction, Aims and Objectives
My name is Dominic Jarvis and I am a final year medical student at Cardiff University. With the close support of Christians Abroad, and the generous support of Medical Missionary News and the St Francis Leprosy Guild, I completed a 4-week medical elective placement at Green Pastures Hospital, Pokhara, Nepal. Green Pastures is a 100-bed rehabilitation hospital that is part of the International Nepal Fellowship (INF). Established in 1957, the hospital is widely known for its long history in pioneering leprosy care in Nepal. Since then, the hospital has further developed specialised services including disability rehabilitation, palliative care and plastic surgery.
My intentions for this elective placement were to broaden my understanding of global healthcare through reflecting on the Public Health challenges that Nepal faces, particularly given resource limitations. I also set out to learn from members of the multidisciplinary team (MDT), such as Speech Therapy, Occupational Therapy and Physiotherapy, to gain a greater appreciation for the network of support behind effective rehabilitative care. By observing how the healthcare team at Green Pastures advocate for their patients with leprosy and physical disabilities, I hoped to become a stronger advocate for people with disabilities or stigmatised conditions in the UK.
A Perspective on Global Healthcare
As part of this elective, I set out to learn about Nepal’s Public Health challenges and to compare this to my experiences during my medical training in the UK. In the National Health Service, we are often confronted by the challenges of resource limitation leading to long waiting lists and having to be selective over how we use our services. However, throughout my time at Green Pastures, it was evident that this is a far greater challenge in Nepal. Resources are more limited, with many specialists and medications only being present in the capital, Kathmandu. This would either require patients to endure long commutes for treatment or to forgo certain treatment options altogether. However, the hospital’s resourcefulness was particularly evident given the limitations it faced. There was a focus on good hand hygiene practices and a lesser reliance on non-sterile gloves. Additionally, in surgical settings, reusable gowns and drapes were used to reduce waste. This has caused me to reflect on how I can be less wasteful and has encouraged me to consider how the NHS can implement similar practices to strive towards more sustainable healthcare.
Not only are resources more limited, but access to healthcare is also challenged by Nepal’s mountainous terrain and developing road network. This was highlighted by the case of a nine-year-old boy I saw alongside the plastic surgery team. This boy sustained a scald injury to his left hand and forearm as an infant. Due to living in a rural area remote from adequate healthcare, he developed a severe hand contracture. Eight years later, with the support of charity funding, his family travelled many hours to Green Pastures so he could receive advanced plastic surgery they otherwise could not afford.
I found this case challenging to reflect on, particularly coming from a healthcare system that is free at the point of use. I considered the potential challenges this boy may have grown up with because of this disability and whether they could have been avoided. In the UK, we have Public Health initiatives that inform patients what to do in the case of burns injuries and when to seek medical advice. Effective burns first aid can have a significant impact on the outcomes of burns and if done correctly, may have made a difference for this boy. Therefore, this case highlights the impact of geographical and financial health inequalities as well as the challenges of disseminating patient education, particularly in rural areas. This reminds me to be conscious of health inequalities and of disparities in health literacy in my future practice.
Alongside the surgical management of complex cases - such as that of the nine-year-old - I also observed some simple cases being treated surgically, which would likely have been managed more conservatively in the UK. A notable example was patients with pressure sores. Although there were often advanced grade pressure sores requiring debridement and surgical flaps, there were also well-granulating pressure sores managed with a similar approach. In the UK, these would typically be managed in a wound clinic with regular dressings and review. This again highlighted the challenges of healthcare access, with many patients requiring more drastic management because they are unable to commit to regular outpatient follow-up. Additionally, more drastic approaches were often necessary to maximise functional outcomes, enabling patients to return to work and avoid falling into poverty.
These cases have highlighted the importance of financial security as a significant social consideration for patients. The World Health Organisation recognises that everybody has a right to health and in Nepal the government provides free basic and emergency services. However, this unfortunately this does not include cancer care for those older than fourteen years of age. This presents a complex ethical challenge, whereby patients do not receive a universal standard of cancer care. An example of this was a lady I saw in her 70s presenting to surgical outpatient clinic with a large breast lump. This patient had multiple red flag symptoms for breast cancer, including a large, asymmetrical breast lump, nipple retraction, and overlying skin changes. However, due to her financial situation she was only able to afford the surgical excision of the breast lump without full investigation.
Seeing this caught me by surprise. In the UK there is a focus on rapid referral for triple assessment and Public Health initiatives to encourage breast self-checking. This comprehensive assessment allows us to efficiently plan appropriate treatment with oncological therapies, surgical procedures and/or palliation to maximise patient outcomes. Here, this patient was forgoing investigations, due to financial limitations, to immediately proceed with a surgical excision biopsy. Not only does this case represent the more limited screening services for malignancies in Nepal, but it raises important ethical questions regarding how private healthcare systems adhere to the medical ethical principle of justice. Although this is a more extreme example of how financial hardship affects healthcare outcomes, it underscores the importance of recognising the interplay between the biopsychosocial determinants of health and disease.
Reflecting on these experiences and the Public Health challenges they present has ultimately increased my appreciation for our National Health Service. It was challenging to see the barriers to healthcare that many patients faced, which reminds me of the healthcare privilege that we have in the UK. However, it was also inspiring to see how Green Pastures is able to reach these patients by tailoring management plans to the biopsychosocial situation of each patient. This reminds me to be conscious of how barriers to healthcare affect patients in my future clinical practice and to reflect on the health inequalities that are present across the UK. I intend to embody the patient-centred approach evident at Green Pastures to improve the healthcare outcomes of my future patients.
Palliative Care - Appreciating my Privileges
Something I enjoyed about my placement at Green Pastures was the continuity of care we had with the patients. It was lovely to see patients who had been admitted at the start of the placement show significant improvement and be preparing for discharge come the end. However, in some instances, patient care continued beyond the hospital and into the community. I was fortunate to see this community care first-hand whilst on home-visits with the palliative care team.
These community visits were the most impactful part of the placement. Not only was it an opportunity to collaborate more closely with patients in their homes, but by the nature of these cases needing continued support, these patients often had complex biopsychosocial considerations. One of these cases was a 23 year old man who, following a spinal cord injury, was paraplegic. This patient lived in a simple abode that resided up a steep slope and was inaccessible via his wheelchair. He explained feeling trapped at home and that he dreamt of living on the flat so that he could interact with his neighbours and potentially find some work.
This case resonated with me primarily because we are the same age. I thought of all my life experiences that led up to me being in that moment and considered how this may have been different for him. I realised how fortunate I am to have the opportunity to study healthcare, let alone the financial security to do this abroad, whilst this young man cannot even leave his home. That morning, I had also complained of sore knees after a weekend trek—being with this patient, it struck me: feeling pain is a privilege and so is being able-bodied. Yet, despite adversity, this young man continued to demonstrate great resilience and enthusiasm. This reminds me that everybody has different life experiences and expectations of care that shape their perspectives as a patient.
The reflections made on this case were further consolidated by another patient I saw. Alongside the palliative care community team, we reviewed a 27 year old man who had a hypoxic brain injury following a drowning incident a year ago. This gentleman had gone to the USA with the intention to study and now, following the incident, has unresponsive wakefulness syndrome. It was difficult to see photos of him on the wall - full of hope as he began his studies, unaware of what lay ahead. This case urged me to take advantage of the agency I have over my educational opportunities and to be thankful for the privilege to learn.
My time at Green Pastures has reminded me that we learn a lot from our patients, and sometimes it can feel unusual to be in a position to advise someone who you feel inspired by. These patients inspired me to demonstrate resilience in the face of adversity and to not assume a patient’s perception of their condition based on my own perspectives and unconscious biases. Importantly, they reminded me to be appreciative of the privilege I have to learn from and care for patients and to make the most of the opportunities afforded to me.
Leprosy – Excellence in Multidisciplinary Collaboration
My time spent with the palliative care community team highlighted the excellent multidisciplinary collaboration present throughout the hospital. There was no greater example of this excellence than in the care of leprosy. During my time at Green Pastures, their history and experience in the care of leprosy was apparent across specialties. This enabled me to gain valuable insight into the roles and remits of different MDT members whilst learning about a condition I had not come across before.
I learned how voluntary muscle testing is used by Physiotherapy to detect the early signs of neurological impairment, and how it can be used as an adjunct in the early diagnosis of leprosy. As for any condition, early diagnosis and treatment of leprosy is paramount to prevent the onward transmission of the infection and the advancement of the disease. For example, if left untreated, the condition can lead to bacterial build-up that damages the nerves responsible for swallowing and breathing. It can also impair breathing by affecting the nasal passages, often resulting in collapse of the nasal bridge. This is where Speech Therapy perform their vital roles in safe swallow assessments and helping patients maximise their verbal communication. Speech Therapy have also seen promising results with the use of respiratory muscle trainers in improving the respiratory function and, by extension, the confidence of their patients.
Unfortunately, despite the impressive work of INF, there are still obstacles to the early detection and treatment of leprosy. In 2010, leprosy was declared eliminated by the Nepal government. Despite this indicating that leprosy affected less than 1 in 10,000 people at the time, leprosy has continued to be a significant health issue, particularly for the most vulnerable. Many people affected by leprosy often face barriers to healthcare access and struggle with poor sanitation, both of which can hinder disease prevention and timely treatment. Additionally, leprosy is heavily stigmatised, which can discourage patients from seeking care or completing long treatment courses out of fear of judgement. Unfortunately, due to these factors, it is suspected that leprosy cases in Nepal have started to rise again.
One patient I interacted with had forgone treatment for 10 years since his initial diagnosis due to stigma. As a result of his advanced neurological impairment, he now presented with severe foot ulceration and damage to his digits requiring amputation. This demonstrates the significant impact that stigma can have on the physical and psychological wellbeing of patients. Although this patient did not require more than finger amputations at this stage, there are patients that require amputations of the limbs. This is where I got to familiarise myself with the role of the Prosthetic and Orthotic department, learning about the process of making custom prosthetics and their therapeutic benefits.
Notably, I observed the department’s involvement with a research project exploring the benefit of silicone prosthetic liners for leprosy patients with below-the-knee amputations. It is thought that this will reduce the incidence of patellar tendon pressure injuries associated with the use of the prosthetic. I was then able to observe the excellent collaborative work between the Physiotherapy and Occupational Therapy department, gaining an insight into how they help patients integrate their prosthetics into their daily activities. Of note, I saw that Occupational Therapy use their wheelchair accessible kitchen and their ‘Safe Farming Field’ to progress patients towards a return to everyday life and work.
Further to the hospital’s involvement with research into silicone prosthetic liners, Green Pastures continues to pave the way towards combatting leprosy in Nepal. This includes a current project evaluating how infrared thermography can be used as an early diagnostic tool and a way to grade neurological symptom severity. They also seek to explore how tracking referral sources for leprosy patients can improve targeted community awareness.
So in summary, my time spent with leprosy furthered my recognition of the importance of multidisciplinary input in patient care and consolidated my understanding of the remit of different team members. This experience encourages me to be a team-working clinician upon graduation and reminds me of the importance of taking a holistic approach in my future practice. Importantly, I am also reminded of the barriers that patients with rare or stigmatised conditions face in accessing healthcare. My elective experiences inspire me to mirror the empathetic ethos of Green Pastures in my future care of these patients.
Final Reflections
Having reflected on my time at Green Pastures Hospital, I feel immensely grateful for this experience. It has broadened my perspectives of global healthcare and, at a pivotal point in my medical training, has made me reflect deeply on the clinician I want to become.
Throughout my time at medical school, I have often been led to question why there is so much suffering. Through attending morning devotions, discussing the daily ‘Doctor’s Life Support’ entry, and involving myself with the welcoming INF community, I have felt able to put my challenging healthcare experiences in the context of my Christian faith. Seeing how the team at Green Pastures use their faith to empower the work they do has helped me to realise that in times of adversity and suffering our faith brings us strength. I hope to continue feeling inspired by my experience at Green Pastures and that it may always remind me of the privilege I have to care for patients.
I now look to incorporate the lessons learned as I complete my final medical training at Cardiff, confident that these experiences will help shape me into a compassionate, culturally competent, and patient-centred Foundation Year 1 Doctor.
