March 15, 2013
How much did these cost?
Faculty members of the School of Public Health at B.P. Koirala Institute of Health Sciences (BPKIHS) in Dahran, Nepal guessed a range of prices none very high, but the real price was the lowest: 5 Nepali rupees for 20 hand rolled cigarettes. That’s .25 rupees each. In dollars well, in cents it’s something like three or four for a penny. Even in the poorest countries, a lot of people can afford to smoke them. Matches are probably more expensive.
And that’s how it is that lung cancer is one of the leading types of cancer in Nepal.
The School of Public Health, started in 2005, is the first and only one in the country. It s on a campus of health sciences a self-contained small town of 10,000 people where the British raj recruited Ghurkas before the tract and buildings were turned over to the Ministry of Health. The schools of medicine, nursing and dentistry opened about 20 years ago. The original buildings are still there and used, and many new ones have been built or are under construction. The reason it has a town feel is that everyone who works at BPKIHS lives there. A whole range of apartments and houses are given as part of salary to all note I mean all employees. The children go to excellent schools on campus and people walk, bicycle and ride motorbikes all over. Aleefia Somji, a CDDEP colleague based in New Delhi, and I were lucky enough to stay in the BPHIHS guest house during our recent visit to discuss antibiotic resistance. We’re setting up shop for the Global Antibiotic Resistance Partnership (GARP) in Nepal and went to Dharan because BPKIHS is the premier Health Sciences University in the country.
Of course it’s impossible to understand such a big institution in just a few days, but we were impressed by the high level of scholarship and the dedication of the professional staff. Three things stand out: first, everyone is both a clinician and a researcher. Second and related to the first is that people practice only through the university at the hospital or clinics. There’s no moonlighting in a private office, a practice common across the rest of Nepal and in fact, all over Asia.
But the third difference is equally impressive: All medical students spend 6 months of their one-year internship in small hospitals (the rest is at BP Koirala itself), two months at a time in three places. They go in teams of eight or nine interns plus a supervisor (there are 12 such teams each year) that stay together throughout their rotations. It has worked so well that the Ministry of Health is now requiring this of all public medical schools and has asked private ones to do the same. As in so many countries (poor and rich), getting doctors to practice in rural areas where facilities are bare bones and pay is poor has meant a lot of thinly-staffed clinics and hospitals. BP Koirala interns have transformed medical care in the six hospitals where they are posted.
We were lucky enough to see this effect in person, at the District Hospital in the eastern hilly district of Dhankutta. There, we met the team before their workday began. Not only are they learning the purely clinical side of medicine, but they’re learning to understand the lives of patients why they come and what they’ve done before coming. In our case, the fact that many patients come already having tried a variety of antibiotics from pharmacies and shops is most relevant, both clinically and in terms of thinking about ways of changing that behavior. The interns themselves are well-positioned to think about that and energetic and imaginative enough to devise possible solutions.
Getting back to the cigarettes, I bought them myself a neat little packet of 20 in Dhankutta at the request of Professor Pokharel, the Director of School of Public Health and Community Medicine at BPKIHS. Shyam, the young doctor who accompanied us, had not seen them being made and sold on the street and was as surprised as we were to find them so easily. The elderly woman selling them was just doing her job and had no problem with me photographing her, either. She was glad to make the sale, and had no way of knowing that the evidence would be used to make a public health point.