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Planning your elective--Nepal Peter Chamberlain shares his experiences, and series coordinater, Mark Wilson, adds some useful information Nepal, the world's only Hindu kingdom, is a land rich in diversity and culture. Within 150km the altitude rises from 100m on the hot plain bordering India to Mount Everest, the world's highest mountain at 8848m. Famed for its resilient Sherpa mountaineers and ruthless Gurkha soldiers, it is also a land of much hardship and political struggle. A country of warm hearts, breathtaking scenery, and tremendous opportunities, Nepal is an ideal place to experience a developing world elective. The recent deaths of the country's royal family have temporarily plunged the nation into chaos. But the situation is gradually improving and life is returning to normal. For up to date information check with the Foreign Office at www.fco.gov.uk Geography and peoples For a country that boasts eight out of the world's highest mountains, Nepal is surprisingly small. Within this area is a phenomenal mix of tribespeople and customs reflecting the Indians (Hinduism) and Tibetans (Buddhism) on the southern and northern borders respectively. Each zone is dominated by ethnic groups whose lifestyles are adapted to the physical constraints of their often hostile yet beautiful environment. People are generally very friendly and welcoming, albeit ready to sell you some of their goods. Most modern influence arrives via India on which Nepal is highly dependent economically. The Tibetan effect is a more trendy, philosophical one brought down by the many refugees who fled through the Himalayas during the Chinese invasion. Along with the Hindu and Buddhist traditions is a strong caste system and a myriad of gods, idols, and highly decorated ancient temples. Supporting this mosaic of different cultures and groups is a complex range of flora and fauna. A leopard frequently roamed the hospital compound in which I was staying and periodically killed the odd dog. Climate differences rotate through extremes of cold, hot, and wet. The monsoon season is July to October. Torrents come down in unavoidable bouts leading to a resurgence of already abundant bacteria and frequent, sometimes dangerous, landslides.
 Nepalese family picking greens The healthcare system Nepal is one of the poorest countries in the world (average income $150 (£37) a year), but famine is not common with 80% of people relying on subsistence farming. The situation is improving, especially in areas of increased tourism. There is only one doctor per 16000 people, yet there are 100 dharmi-jhankri (faith healers) for every doctor. Partly because of poor sanitation and poor education infectious diseases--for example, tuberculosis, malaria, and leprosy--are common. HIV has been a problem for the drug community for a long time but is becoming much more widespread. Health care in Nepal is improving with involvement from the government recognition of the benefit of simple healthcare education. In the majority of regions health care is provided by health assistants who are trained for a year to a basic standard. Doctors and hospitals are considerably harder to find and the majority of people end up having to walk or travel many miles, typically presenting at an advanced stage of their disease to a small district hospital staffed by generalists. There is little support from the government in health funding, reflecting the minimal government revenue generated. Health care is typically a major strain on most families despite its provision at a minimal cost. Outcasts and those with no family support often resort to begging. Mission hospitals and other non-government organisations provide free health care in certain areas using outside funding. I was fortunate to be part of an experienced and enthusiastic team which showed unfailing compassion to patients with leprosy who still carry a social stigma. This is partly due to the terrible secondary complications caused by the infection but also from the health beliefs many Nepalese hold, entwined with superstitions, the use of "holy men" as witch doctors, and religious practice. Poor living conditions and waste disposal along with beliefs, such as the sanctity and close communion with the cow, ensure that infections continue to be the country's biggest killers. In a recent newsletter my supervisor described an account of having to manage a man who had drunk 10 pints of cow's urine as a cure for his dyspnoea. One of my most enjoyable experiences was the involvement in theatre. I felt that my presence as part of the team was important in getting through the day's work. Responsibility was given but not without adequate supervision. I was able to help in operations ranging from delicate tendon transplants to more general surgery, such as the odd (and rather large) hydrocele. Tips on planning The majority of electives available are either through private hospitals or Christian missionary hospitals. Nepal has one medical school in Kathmandu and another is being built in Pokhara. Government hospitals, while cheaper for the patients, are often disorganised and pose a greater language problem. Rural experience with itinerant doctors can be very rewarding but difficult to arrange. Visas are easily accessible but should be applied for as a tourist not a student (a 60 day visa costs £20). Early vaccinations against polio, typhoid, hepatitis A, B, and C, rabies, diphtheria, tetanus, meningitis C, and, where appropriate, Japanese encephalitis are strongly recommended. Malaria prophylaxis is required below 1500m. Language can be a problem initially. However, Nepali, which is similar to Hindi, is quite simple in structure and day to day vocabulary. Nepalese doctors tend to use a mixture of Nepali and English due to the inadequacy of the language to support much medical terminology. The cost of living is refreshingly cheap. A simple meal costs about £1. Hostel prices vary between 50p and £3.50 a night. Mission hospitals tend to provide their own accommodation and meals for a small charge. Safety and travel Travelling in Nepal is an experience. One hundred people on a 20 seater bus is not uncommon. Most drivers seemed very reckless taking into account the frequent ravines and potholes. Despite this, accidents were quite rare and for 5p a ride across town is good value. Internal flights are quite accessible and cost about £40 for a single journey. Flying can save a lot of time in the event of a landslide. While I was there major landslides caused hold ups ranging from three hours to two weeks. Royal Nepal Airlines currently holds the most frequent crashes award for air travel. Crime is not common in Nepal. This may reflect the dire conditions of Nepali jails--do not expect the British Embassy to get you out with your marijuana habit intact. Paying over the odds is a far easier way of losing your money than theft. Indeed, one of the first phrases you will learn is "mahango cha" or "too expensive" despite the Asian prices. Care should be taken to avoid areas of antigovernment Maoist activity, especially at night. These terrorist skirmishes reflect the social discontent, poverty, and corruption unfortunately not solved by the introduction of democracy in 1991. Don't miss You must visit the Himalayas. Trekking in Nepal is remarkably easy to organise and so is very popular. Unlike mountaineering, it does not require any specialist equipment except a pair of hiking boots and some cash. White water rafting during the monsoon, however, demands a more foolhardy attitude. Expect to be tipped in earlier than you thought, have your life flash in front of you, and come out with a bout of giardiasis. Peter Chamberlain fourth year medical student, University of Liverpool md0u7161@liv.ac.uk Mark Wilson author of The Medics Guide to Work and Electives Around the World. He also runs www.medicstravel.com, a website designed to help students and junior doctors find work overseas mark@medicsworldwide.com 
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