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Nepal, a small country in the southern part of Asia (figures 1 and 2), is well known over the world for its magnificent natural beauty. Roughly about half the size of the United Kingdom (about 150 000 square kilometres), its rich geography ranges from the hot and humid tropics of the Southern Terai plains (figure 3) adjoining Northern India, to the high mountain range in the north adjoining Tibet, China. Perhaps Nepal’s best-known natural landmark is Mount Everest, the world’s tallest mountain at 8848 m (figure 4). Nepal is also the birthplace of Gautama Buddha, the founding father of the modern Buddhist philosophy (figure 5).
National flag of Nepal.
Map of Nepal (source: survey department of Nepal).
The plain Terai region of Nepal (courtesy Dr Arun Sedain).
Mount Everest (courtesy Dr Yogesh Subedi).
Lumbini, the birthplace of Gautama Buddha.
Despite its rich natural resources (figures 6–9) and several hundred years of cultural heritage, hidden among its majestic glories lies the poignant reality of challenges of providing good medical care in one of the least developed countries of the world. As in any other third-world country grappling with the processes of westernisation, stroke is common in Nepal and appears to increase every year. But Nepal has almost none of the skilled manpower and well-equipped facilities needed to deal with this common problem. For a total population of over 30 million, there are fewer than 20 trained neurologists and only a single stroke neurologist—almost all of them concentrated in the capital city of Kathmandu, with its population of 3 million!
The fewa lake with the Machapuchare (fishtail) mountain range (courtesy Dr Dinesh Karki).
Spectacular annapurna range seen from poon hill (courtesy Dr Dinesh Karki).
Mustang, the ancient forbidden kingdom of Nepal (courtesy Dr Dinesh Karki).
Rara Lake, the biggest and the deepest lake in Nepal (courtesy Dr Malati KC).
A lack of adequate data keeping means that we do not know the exact incidence and prevalent of cerebrovascular diseases in Nepal. One study estimated Nepal’s acute stroke incidence at around 50 000 per year.1 The government-owned Tribhuvan University Teaching Hospital (TUTH) in the capital city of Kathmandu, is the country’s largest tertiary care centre. My study of admissions to the medical wards of this hospital found that 50% related to stroke (74% ischaemic; 26% haemorrhagic) and that the ischaemic stroke mortality was 8%.2 Another study showed that 52% of the patients with ischaemic strokes were left with mild to moderate disabilities, and a further 24% remained severely disabled.3
The country’s poor economy and lack of medical infrastructure mean that people with strokes get minimal necessary care. Even though 16.5% of the patients with acute ischaemic stroke patients presented to the emergency department within 4.5 hours of the onset of symptoms, most could not afford the standard of care expected in a developed country.3 4 Even in Nepal’s government-owned hospitals, patients must make an upfront cash payment before receiving emergency medical care.4 One 50 mg vial of recombinant tissue plasminogen activator (alteplase) costs around 750 US dollars (GBP £615). Putting that into perspective, the average monthly income for people in Nepal is merely a couple hundred US dollars.
Although thrombolysis for ischaemic stroke has been a standard treatment in western countries for at least two decades, the first person with ischaemic stroke to receive thrombolysis in TUTH was in 2013. The patient had presented within an hour of onset of symptoms and was very lucky to receive treatment in time because she happened to be from a well-off family who could afford an upfront cash payment for immediate scanning, and then the expensive drug treatment. Equally important, she had enough family members and resources to bring alteplase immediately from a pharmacy half an hour’s drive away (it was not kept on stock even at the tertiary centre and could only be bought out-of-pocket from a private pharmacy). Eventually, she was discharged home with a Modified Rankin Scale score of 3, which she maintained at follow-up visit 3 months later. Even today, although most patients can get an urgent scan, most do not have the resources to receive alteplase.
In early 2018, the Department of Neurology at TUTH published a local mechanical thrombectomy protocol, written by a neurologist who had just completed clinical fellowship training in cerebrovascular diseases at the University of Alberta in Canada. The first successful mechanical thrombectomy with a stent retriever (a first for the whole country) was carried out in February 2019. Fortunately, this time alteplase was available at a nearby pharmacy and could be given within 45 min of the patient’s arrival at hospital. The patient also qualified for endovascular treatment but obtaining the stent retriever device was another huge challenge. The cost to buy the device kit from a private pharmacy was over 3 000 US dollars (GBP 2 500), and as usual, the buyer (the patient’s family) was expected to make the full payment upfront. Luckily, the pharmacy owner was kind enough to charge for the device in instalments, following requests by the treating physicians. However, our streak of bad luck was not over. The regular angiography suite within the main university hospital building was not functioning on that day and the patient had to be transferred to another suite in a separate building. All these arrangements wasted much time: the treating team performed the groin puncture only 3 hours after arrival, and could achieve good recanalisation only after a further 2 hours. Nevertheless, the patient improved and was discharged with a Modified Rankin Scale of 3.
Today, the treatment of acute ischaemic stroke in many countries in the world has advanced from time-based therapy to tissue-based therapy.5 However, such treatment is sadly still beyond the reach of most people living in low-income countries like Nepal. The cases described above exemplify the pain inherent in the specialised management of acute ischaemic stroke in developing countries like Nepal. The patients and their families feel that pain, both financially and logistically. Neurologists feel that pain too—with the sense of helplessness that the modalities are there but are out of reach. A seeming scarcity of neuroimaging facilities, finances and transportation issues—in some cases, a lack of driveable roads to where people live, and a lack of awareness of treatment modalities available, add to this distress.4
Despite these painful experiences, we are hopeful that things will improve over time. The Nepalese Academy of Neurology has been trying to convince our government to make more funds and subsidies available to treat patients with acute stroke. The Department of Neurology at TUTH has been active in providing intensive training to doctors and nurses both within, and outside of, the university hospital system. We hope that our hard work and determination will help to improve patient care and outcomes, and thereby avoid preventable deaths and disabilities in patients suffering from acute stroke.
Footnotes
Contributors The author is solely responsible for the design, draft, revision and final approval of the work. The author agrees to be accountable for all aspects of the work.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Map disclaimer The depiction of boundaries on the map(s) in this article does not imply the expression of any opinion whatsoever on the part of BMJ (or any member of its group) concerning the legal status of any country, territory, jurisdiction or area or of its authorities. The map(s) are provided without any warranty of any kind, either express or implied.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Commissioned. Externally peer reviewed by Colin Mumford, Edinburgh, UK and David Simpson, Edinburgh, UK.
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