Concept and Proposal
Surgery and global health: a Lancet Commission, 2014
Lancet, Volume 383, No. 9911, p12–13, 4 January 2014
‘Delivery of surgical care…plays a fundamental part in prevention, diagnosis, treatment, and palliation of a broad range of medical disorders, and is a crucial component of a properly functioning health-care system and a prerequisite for universal health coverage. Today, an estimated two billion people worldwide are without adequate access to surgical care, and a substantial global gap exists between surgical need and the equitable provision of safe surgical care’.
John G Meara, Lars Hagander, Andrew J M Leather
Deafness is an invisible disability. Without good hearing we cannot develop normal speech and language. In the developing world sufferers are frequently unable to benefit from education and therefore have very poor employment and social prospects. The hearing disabled are the largest group of handicapped people in Nepal. In 1991 Briton Nepal Otology Service (BRINOS) conducted a nationwide survey of deafness and ear disease in Nepal. The main findings extrapolated from 16,000 people surveyed were:
- 16.8% were significantly deaf. Based on the current population of 26 million (2011 Census figures) this equates to 4,368,000 people
- 8% had abnormal ear drums indicative of preventable ear disease
- 32% of hearing impairment is associated with middle ear infection or its sequelae
- 70% of those suffering from middle ear infection or its sequelae are of school age
- Of the 39% who had received treatment, 66% were unsatisfied
- 50% of all ear disease is preventable.
Moderate or severe deafness is the commonest disability in Nepal. Congenital deafness and chronic ear infection are the principal problems. Children commonly have many years of ear discharge and progressive hearing loss. Some die of complications such as mastoiditis, meningitis or brain abscess.
Until recently in Nepal there was one Ear Nose and Throat (ENT) surgeon for every 600,000 persons and one audiologist for every 6,000,000 persons. Ear surgery was only undertaken in the capital Kathmandu and in Pokhara, a city about 200 kilometres west of Kathmandu.
INF ran twice yearly camps for 20 years providing outpatient and surgical care as well as hearing aid services.
In addition there were a few overseas organisations and Non-Governmental Organisations (NGOs) running mobile ear camps in Nepal on an ad hoc basis. Many of these camps were for patient screening and medicine distribution alone, and not equipped to conduct surgery. Referral to Kathmandu or other cities is not an option for many, as people are too poor to be able to meet the costs of travel and surgery.
Services have been improving rapidly in recent years, but remain concentrated in the larger towns and cities. The standards and equipment are often quite basic and the potential patient numbers are huge.
There was a recognised need for an Ear Hospital/Centre in Pokhara to provide specialist services to the wider community of the western part of Nepal. Whist INF through its mobile Camps was providing treatment and surgery to a few, the needs in western Nepal far exceeded what they could offer with the available resources. The vision was for a centre providing quality care for acute and chronic ear conditions including infection and deafness. This could also serve as a base and referral centre for rural ear camps and community ear care in western Nepal.
It could provide training in and use of appropriate techniques, research low cost and appropriate interventions for the treatment of patients with hearing disability and provide training for health personnel not just from Nepal but also from South Asian Association for Regional Co-operation (SAARC) countries. The Ear Hospital/Centre would also have the flexibility to develop access to new developments such as cochlear implantation, bone anchored hearing aids and their long term care, seeking appropriate cost sensitive appliances. The Ear Hospital/Centre could be the first of its kind in the Western region of Nepal.
Key Targets
- To provide first class care for acute and chronic ear conditions including infection and deafness.
- To provide training for health personnel.
- To provide a base and referral centre for rural ear camps in Western Nepal.
- To provide local community ear care and health education.
- To train in and use appropriate techniques, drugs and equipment for developing country situation
- To research low cost and appropriate interventions to help developing world patients
- To maintain close links with national medical centres and health services and integration with local, national and international ear care services.
Building
There were various considerations in choosing a site for the Centre.
Important issues were:
- A sufficient population of people with ear problems
- A needy population unable to readily access affordable/free care elsewhere
- A more wealthy population either locally or by good transport links who could afford paid care, to support the financing of the centre
- Sufficient local medical support infrastructure such as other medical specialists, CT and MR scanning
- Relative ease of access by public transport for both patients and medical staff, including international trainers
- A place that would be reasonably attractive as a destination for visiting trainers, with good facilities such as accommodation available.
- Ease of access for trainees and professional staff, with local support such as schooling and good accommodation. A place that trainees and interns could be posted to from their training centres in Kathmandu or elsewhere
- Access to both poor rural and urban populations for community ear work
- No direct competition for paid work with national surgeons.
- Complementing local services by providing specialist expertise, rather than duplication of existing services.
Various options such as Surkhet or Nepalganj in Mid-West were considered.
Surkhet had insufficient local facilities and was felt to be too remote.
Nepalganj had visiting ear camp teams from Kathmandu and UK already in place and they were keen for us to establish our work in the western areas and hills of mid and Far West.
Eastern Nepal was largely provided for by other agencies such as Impact Nepal and the Kathmandu infrastructure.
Pokhara seemed the natural base for an INF project, with its history in the area and local infrastructure meeting most if not all the criteria above. Whilst locating the centre within local health services such as the Western Regional Hospital was considered, it seemed unlikely that they would be able to offer tertiary level ear care or community ear care work as priorities in the near future. A new build seemed the most sensible option.
In 2011 INF generously allocated an attractive plot of land next to its Green Pastures Rehabilitation Hospital in Pokhara. A Swiss partner charity (SON) remarkably raised the total funds needed for the building itself and a well-recognised local architectural company with UK links acted as the project management team with experienced engineers from Europe and Australia. Formal design work started in 2012, the land dedication and foundation stone laying ceremony was in November 2013 and full scale site work commenced in February 2014. The building was completed in 2015. The formal opening took place in November of that year.
The centre has ecologically sound energy sources including solar hot water and electricity and the single story building has in-built seismic resistance and we have alternative water sources available for any shortage of supply.
