Kathmandu:

In 1988, my second year in Nepal, I hiked with two friends into the mountains of Gorkha district. I was working as a doctor in a hospital there, and for vacation we set off to trek around the Manaslu Himal, on whose majestic faces we gazed every day.

About a week into the journey, we crossed the Larke Pass in waist-deep snow and in the evening finally came down to a hut used by shepherds. We were hungry and cold, and the local Tibetan man who’d guided us over the pass chopped chunks of wood from the rafters of the shed in order to build a fire to warm us and cook soup.

Further on, we walked above the Buri Gandaki River and stopped for lunch in a small village called Prok. There we chatted with a man, and when he learned I was a doctor he insisted we come see his friend. He led us to a house and we met a thin fellow who moved with slow, deliberate steps, and he carried a small container.

“What’s wrong, Dai?” I asked.

“Coughing up blood.”

“How much?”

He slid the quart-size copper pot towards me, half full of frothy blood.

“How long have you been sick?”

“Three or four months.”

“Can’t you get medicine around here?”

“In these mountains? There’s neither medicine nor doctor within a week’s walk.”

I thought the man probably had TB and I told him he was seriously ill and needed treatment soon. None of the tablets we were carrying would help him. I tore out a page from my notebook, and wrote my name and “Amp Pipal Hospital.” He’d heard of the place.

Though we’d walked down and out of the snow, our path remained difficult. I’ll never forget walking precariously over 20-foot sections that were suspended from the cliff face. Where the path could not be carved into the rock, it jutted out on logs laid haphazardly on scaffolding socked into cracks in the sheer cliff walls. I forced myself to walk sideways over wobbly sections of wood, my hands pressed against the rock as I looked down through gaps at the river 300 feet below.

Upon returning to Amp Pipal, I completely forgot about the man from Prok - until about a month later when he was brought into our outpatient department. I was shocked. His family had carried him down for 10 days over those difficult paths. He looked worse. I examined him and ordered a chest X-ray, expecting to see TB. I was surprised that there was no sign of it but could see that he probably had amoebic parasites in his liver. An abscess had burrowed up into his chest, and that was the cause of his hemorrhaging. I drained two litres of bloody pus from his liver and gave him some inexpensive metronidazole tablets. Within five days, he was markedly better and able to head home.

Twenty years later, last April, I rode out again to Gorkha District as part of my work with the Nick Simons Institute (NSI), of which I am executive director. NSI supports rural health care in Nepal, the “backbone” of which is the “mid-level worker.” Nepal’s mid-level workers, called medical assistants, are similar to the physicians’ assistants or nurse practitioners of developed countries - classified below doctors, they often do the work of the absent doctor. One of NSI’s goals is to improve the care that these mid-level health care workers provide.

I was coming to Gorkha to check on our NSI Assessment Team. We had a team of eight health care professionals who were conducting a week-long programme to determine the skills of health care workers. Our team tested 10 workers each day, eventually covering every government mid-level worker in that district. We put the health workers through a series of stations where they had to demonstrate their competency on mock patients.

Unfortunately, most of the health care workers did poorly on our assessment, even on basic skills. Some had no idea how to examine a patient and had only rudimentary (or no) skills in delivering babies. Nepal’s maternal mortality ratio is one of the highest in the world. In one sense the assessment was a success: we identified specific skill gaps of these vital workers.

All this took place in the Gorkha District Health building. In the afternoon I spoke with one young worker.

“How does the test seem to you?”

“Good. We’re glad someone cares enough about us to try to help.”

“Where are you working?”

“Health post way up the Buri Gandaki River. It took me four days to walk down.”

“Are you anywhere near the village of Prok?”

“Yes, right below there.”

In 20 years there had been some progress. Government workers had moved into areas they had not been before. There was even a manned health post high in the mountains near Prok. There was expanded health care for rural people, but the progress was incomplete. The challenge of the future is to take it to a higher level of quality.

There is reason to be hopeful. The Health Ministry knows that it must continue to improve the skills of its 5000 mid-level workers. Following our assessment of 163 workers in four remote districts, the government has given approval to develop a new course to upgrade the skills of existing government health care workers. Stephen Knoble, a Physician’s Assistant, is working with the National Health Training Centre’s Rishi Ram Khadka in putting this new training programme together. We hope that by early 2008 this course will be added to other in-service trainings being conducted for rural health care workers.

We hope not to forget the man from Prok, nor the view from the hills of Gorkha.

The writer is MD at Nick Simons Institute