Introduction to Nepal
The mention of Nepal conjures up romantic images of a tiny beautiful
kingdom set in a land having the highest mountains in the world. This is
indeed the romantic view of this wonderful country, the people and culture,
but in truth it is a land of enormous physical contrasts and great poverty.
Nepal with a population of about 18 million people lies between China in
the North and India in the south. It can be physically divided into 3 horizontal
strips stretching from east to west. In the south is the once malaria infested
and densely forested flat fertile lowlands called the Teria. The central
region is hill ranges from 1,200 to 2,400 meters and within it lies Kathmandu,
the capital city. The northernmost strip bordering Tibet, is the Himalayan
mountain range which has the world's highest peak, Mt. Everest (8,848 meters).
More than 90% of the population lives in rural areas and depend upon
subsistence farming. The annual income of Nepalese is around 180 U.S. dollars.
Poor communication coupled with the fact that much of the country is unsuitable
for cultivation makes Nepal one of the least developed countries in the
world. Only 15% of the people have access to safe drinking water. Health
care is just not accessible to the majority of the patients.
Deafness and Ear Diseases - The Magnitude of the Problem
The hearing disabled are the largest group of handicapped people in
Nepal. According to the Survey on Disabilities conducted in 1981 on the
occasion of the International Year of Disabled Persons, 3% of the Nepalese
population were found to be suffering from severe disability. This survey
showed that hearing impairment is the No. 1 disability in Nepal. Of all
disabled persons 33% are hearing impaired. A survey on Prevalence of Deafness
and Ear Diseases conducted by Tribbuvan University Teaching Hospital and
the Britain Nepal Otology Services in 1991 disclosed that approximately
16% (2.7 million people) of the Nepalese population above the age of 5
years suffered from either otitis media or its sequalae. More than 55%
of the otitis media were seen in school going children. This survey shows
that every fifth case of hearing impairment in adults is due to otitis
media while in children (between 5 to 15 years) every second case of hearing
impairment is due to otitis media. About 1.7% (360,000 people) of the population
have severe to profound hearing loss. The survey also showed that more
than 35% of the hearing impairment could have been prevented.
E.N.T. Manpower and Surgical Facilities - Present Situation
There is one doctor for every 20,000 people. There are 30 ENT. doctors
and 3 audiologists in the entire country. In other words there is one ENT.
surgeon for every 600,000 persons and one audiologist for every 6,000,000
persons. Ear surgery is being done in only two cities in the country -
Kathmandu, the capital and Pokhara, a city about 200 kilometers west of
Kathmandu. The table below shows the estimated number of different types
of chronic otitis media in the e country, the total number of operations
being done in Kathmandu and Pokhara annually and the estimated number of
years it would take to operate on all these cases with the existing ENT.
manpower and facilities. This table highlights the magnitude of the surgical
task that lies ahead.
| Types of
Otitis Media |
Total cases
in Nepal |
Number of operations
done every year |
Time required to finish
these operations |
|
Perforated tympanic
membrane
|
1,296,000 |
300 |
4,320 years |
|
Otitis Media with
Effusion
|
287,000 |
300 |
990 years |
|
Cholesteatoma
|
162,000 |
100 |
1,620 years |
Mobile Ear Surgery Camps
In order to provide ear surgery to people who have no access to
E.N.T.
services in towns outside Kathmandu, it was decided by some ear surgeons
in Kathmandu to start mobile ear surgery camps until such time as there
are sufficient Nepalese surgeons and ENT. services available.
In 1988, the Britain Nepal Otology Services (BRINOS), a non-governmental,
non-sectarian charitable organization was established out of this need.
The BRINOS ear camps are held two times a year. The camp usually is of
14 days duration. The entire team consists of about 10 persons. A British
team consisting of three ear surgeons, one anaesthetist and two nurses
join a Nepalese team consisting of two ear surgeons, one or two nurses
and an audiometry technician and a helper. The Nepalese team does not have
the anaesthetist because there is a severe shortage of anaesthetists in
the country and it is not possible to get Nepalese anaesthetists for these
camps. There is always a British anaesthetist for the camp so operations
are done both under general and local anaesthesia in these camps. BRINOS
has so far done 11 mobile ear surgery camps, the duration of each camp
is about 2 weeks. In these eleven camps more than 10,000 patients have
been examined and more than 600 major and 200 minor ear operations have
been performed.
IMPACT Nepal, another non-governmental organization was set up in 1994
with the aim of preventing all types of disabilities. One of the main achievements
has been to hold eye, ear and orthopaedic camps to restore sight, sound
and movement. IMPACT Nepal started to hold mobile ear surgery camps in
1995. These camps last for 8 days and are of shorter duration as compared
to BRINOS camps. This camp is done totally by a Nepalese team consisting
of about 7 persons. There are three ear surgeons, two nurses, one audiometry
technician and one helper in each team. So far IMPACT Nepal has conducted
3 mobile ear surgery camps. In the three camps 3506 patents have been examined
and a total of 145 ear surgeries have been done of which 125 were major
and 20 minor surgeries. As mentioned because of the shortage of anaesthetists
in the country, no anaesthetists are available in these camps and usually
all operations are done under local anaesthesia. However a few operations
were done under general anaesthesia in the camp in Palpa because there
was an anesthetist in the Palpa hospital who provided general anaesthesia
to our patients.
In both the IMPACT Nepal and BRINOS camps the team usually travels by
4 wheel drive vehicles. Sometimes the British team travels by air when
possible. All instruments and equipment are carried in the public transport
bus with the helper accompanying these instruments and equipment. There
is, however, an amount of risk of damage to the instruments and equipment
during loading and unloading on to the bus top as well as during transport.
We are trying to look for funds to buy our own minibus so that all the
personnel; as well as the medical equipment can be carried together safely.
The first three days of the camp are spent in screening the patient. The
ear surgery starts from the 4th day onwards. The follow up of the patients
is done by the local ENT. surgeons if available or by the local general
practitioners who are instructed what to do by the visiting ear surgery
team.
Hearing Aid Camps
Nepal Ear Foundation (NEF), a non-governmental charitable organization,
was founded in 1994 with the aims of prevention, early detection, treatment
of ear disease and deafness and rehabilitation of those suffering from
hearing impairment and deafness. It is currently running a 4 year Prevention
of Deafness Programme in Kavre District, which lies just east of the Kathmandu
Valley, in conjunction with the Primary Health Care System of the Ministry
of Health. With the support of LBH, Denmark, it has since last year started
to distribute hearing aids and ear moulds to the needy children studying
in various schools for the deaf and to all hard of hearing people in two
districts (Jhapa and Dliankuta) in Eastern Nepal. Traveling as a mobile
unit, NEF has so far given out 70 free hearing aids to hearing impaired
children of two Schools for Deaf. Another 311 hearing aids were distributed
to the hard of hearing people in Jhapa District in May 1996. Hearing aids,
batteries, ear mould materials and the entire instruments and equipment
were carried in a bus and fitting of hearing aid and manufacture of ear
moulds were done on the spot.
Proposal
It is proposed that a Danish team of one ear surgeon and one anaesthetist
join the Nepalese team and hold mobile ear surgery camps in towns where
ear surgery is not being carried out. Neither NEF nor IMPACT Nepal has
any anaesthetic equipment. Therefore small, portable type anaesthetic equipment
will be needed. Some ear surgical instruments and equipment will need to
be supplemented as we have only a limited amount of these instruments and
equipment. The Danish team should join the IMPACT Nepal camps rather than
the BRINOS camps as there are already sufficient numbers of surgeons and
other personnel for participating in the BRINOS camps.
Both the Mobile Ear Surgery Camps and the Hearing Aid Camps have their
limitations. Our experience is that whenever we hold ear surgery camps
we examine many patients who are suffering from hearing loss due to nerve
disease which cannot be corrected by surgery and many such patients have
to be turned back because we have not been able to provide them with hearing
aids and they cannot come to Kathmandu to buy a hearing aid because they
cannot afford it. Similarly when we conducted the hearing aid camp in Jhapa
District recently we saw many patients who had a hearing loss due to chronic
otitis media and many of these can be corrected by surgery. But in this
camp in Jhapa we had no facilities to do surgery.
Therefore a proposal from our side is that the NEF/LBH programme of
distribution of hearing aids should run simultaneously or parallel with
IMPACT Nepal's or BRINOS ear surgery camps so that those persons who will
benefit with hearing aids will be given hearing aids and those who will
benefit with surgery will be operated on. As proposed above the Danish
team could help NEF and IMPACT Nepal's Ear Surgery Camps with personnel
and some instruments and equipment.
