Medicosnext
Prof. Dr. Chanda Karki Bhandari, MBBS, DGO, MD, FRCOG, FRTCOG, FICS, Consultant Obstetrician and Gynaecologist, B and B Hospital, was former CEO and Principal of Kathmandu Medical College, Senate Member of Kathmandu University, Executive Member of Nepal Medical Council, President of Nepal Society of Obstetricians and Gynecologists, and CEO and Principal of Nobel College of Health and Education. Here, she talks about her almost four decades of experience in the medical field.
How has the scenario changed from your early professional years to now?
I have been in the medical field for the last 36 years. The medical world before and now has changed a lot during this period. In these years, healthcare has seen numerous changes, from the way providers dress, to how they professionally deal with patients, to how medical records are stored, to digital use in medical practice, etc. Unlike today, medicine in the past was dependent only on the doctor’s knowledge, skill, and experience. Medicine these days has changed a lot, because of advances in technology and increasing privatization in the medical sector. Doctors of today have many more diagnostic tools at their disposal. The number of practicing doctors and nurses has increased in quantity.
Probably, we have gone from care to cure. Doctors can now cure many things that they could not cure before. New cures and treatments continue to be discovered and used; specialists get more and more specialized and expertise. Many doctors care a lot about their patients, but they fear lawsuits. In the last couple of decades, medical schools have evolved at a rapid pace. A lot of hospitals have come up, even outside Kathmandu. Unlike a few years back, people do not have to reach the capital to get their basic care. But, access to healthcare is still lacking in rural areas and in western Nepal, and the human touch, empathy, clinical skill, discipline, and doctor-patient relationship are on a declining trend. Communication skill, though taught in medical schools, seems to be lacking among healthcare professionals. There are increased conflict scenarios among doctors, patients, and health institutions. Medical professionals have started talking about business and politics now, etc.
Would you share a little bit about what motivated you to be an educator?
I have devoted 21 years of my life to medical education. I am thankful to Kathmandu Medical College (KMC), Kathmandu University, Prof. Dr. Lok Bikram Thapa, Dr. B. B. S. Rana, late Prof. Dr. Govinda Sharma, Prof. Dr. N. B. Rana and many others for making it possible.
I was motivated to become an educator due to various factors. There was a demand for teachers in medical colleges then, and I was called by Prof. Dr. Lok Bikram Thapa and Dr. B. B. S. Rana, to become a faculty teacher at KMC in response to that need. That was the time when the government salary was not adequate to cover the expenses of my daughter in school. Therefore, I was also in need of getting a job where I could be paid better. Secondly, I always had a mindset that I should dedicate the last 20 years of my career to contribute to my profession, which I thought I could achieve by being involved in teaching-learning process, in research process, and by being involved somewhere at the policy making level to make future of medical education better.
The country has undoubtedly seen rapid growth in medical education in the last two decades. Are you satisfied with the standard of medical education?
Thank you for this question. Today, I am also asking the same question—medical education Quo Vadis? The medical education system should definitely be based on principles advocated by Flexner and Osler, which has produced generations of scientifically grounded and clinically skilled physicians whose collective experiences and contributions have served medicine and patients well. Medical education has changed, and will continue to change, in response to scientific advances and societal needs. However, enthusiasm for reform needs to be tempered by a more measured approach to avoid unintended consequences. Movement from novice to master in medicine cannot be rushed. In Nepal, the ‘chaotic mushrooming’ of medical institutions and deficit in quality inspection or monitoring by the requisite authorities have resulted in a decline in the quality of Nepalese medical education. Currently, more than 20 medical colleges under the affiliation of Tribhuvan University and Kathmandu University and recognized by the Nepal Medical Council are functional. Furthermore, about one-half dozen medical colleges are in the pipeline to be introduced in the near future.
In Nepal, medical colleges are in adequate numbers today, and thousands of students are trying to shape their future here in various streams of medical science. I am definitely concerned about our future. There are thousands of unheard voices in the country, but I am sure the government will be honest, serious, and unbiased in the driving seat. As a responsible citizen of this country, and as an accountable government, one has to be concerned about the honesty and sincerity regarding quality inspection and monitoring of these institutions by concerned authorities to avoid the declining graph of medical education standard in Nepal.
There has also been rapid growth in the number of health facilities, are you happy with the services provided?
Truly speaking, I am not. Rapid growth in the number of health facilities is more from the private sector, which usually has a business motive, rather than being service motivated, primarily. Again, the question of monitoring peeps in. I believe service can be from any side, but the responsibility of honesty, sincerity, and quality monitoring falls on the government’s shoulder. It has to “think” and decide first that it wants to bring positive changes in this regard. If we want to commit to achieving health for all, it is imperative to carefully consider the quality of care and health services. Quality healthcare can be defined in many ways, but there is growing acknowledgement that quality health services should be effective, safe, and people-centered.
There are a growing number of fertility centers nowadays. Do you think that the problem of infertility has grown? If so, why?
You are right. Infertility is one of the major health problems worldwide, including in Nepal. It is also being detected more as there is better awareness, more specialized infertility centers, and financial capabilities these days. The average prevalence of infertility in developing countries is estimated to be around 6.9-9.3%. An increasing trend of infertility has been noticed recently in Nepal; however, exact prevalence is still unknown. Among the various male and female infertility factors, abnormal reproductive tract, quality of sperm and embryo, abnormalities in the implantation process, and other conditions, including immunological factors, are common. Similarly, sedentary lifestyle, heavy use of alcohol, smoking, late marriage, miscarriages, and frequent abortion are other contributing factors for infertility. Increasing trend in sexually transmitted infections and heavy use of insecticides and pesticides in fruits and vegetables are also causative factors of infertility. The most common clinical causes of female infertility are found to be ovarian cyst, heavy menstrual bleeding, pelvic inflammatory disease, uterine fibroids, ectopic pregnancy, and thyroid disease. Whereas, in males, the infertility problems are mostly found to be due to oligospermia, azoospermia, hydrocele, mumps associated with orchitis, testicular torsion, epididymitis, etc.
What is your view of the current situation regarding health in Nepal?
This is a vast area to talk in a limited time like this. However, I can now say that healthcare services in Nepal are provided by both public and private sectors. It still has to work a lot towards meeting international standards. Prevalence of disease is significantly higher here than in other South Asian countries. Rural areas are in a worse condition. On top of this, it is very difficult to manage regular general healthcare service in the country due to natural hazards like floods, forest fires, landslides, earthquakes, and other interesting factors like frequent border blockades. A large section of the population, particularly those living in rual poverty, is at risk of infection and mortality by communicable diseases and malnutrition. Nevertheless, some improvements in healthcare can be witnessed; most notably, there has been significant improvement in the field of maternal health. These improvements include maternal mortality rate decreasing from 850 per 100,000 live births to 190 per 100,000 live births now. Life expectancy of the people has increased.
Over the past few decades, lifestyles have changed dramatically, and new issues have arisen. What are the most common reproductive health complications faced by women in both rural and urban areas of Nepal?
To answer this question, first of all, the health needs of women need to be known, which may be their specific health needs, reproductive system dysfunction, or disease concern and general health needs common to all, besides social diseases like female genital mutilation, sexual abuse, and domestic violence. If we talk about their specific health needs, we have to talk about the possible maternal complications, sexually transmitted infection challenges, tuberculosis, and mental health issues. If we are talking about their reproductive system disease, we need to know and talk about and deal with conditions like endometriosis, uterine fibroids, gynecologic cancer, HIV/AIDS, interstitial cystitis, polycystic ovary syndrome (PCOS), sexually transmitted diseases (STDS), family planning, and sexual violence.
What is the status of adolescent reproductive health in Nepal?
Sexual and reproductive health of adolescents and youth should be a common and genuine concern of our policy makers, service providers, and academicians. We should be talking on current sexual and reproductive health status of young people in Nepal. Our service mechanisms are not yet sufficiently institutionalized to address the needs of young people, but it is urgent to scale up youth friendly services. Nepal Society of Obstetricians and Gynecologists had established and run an adolescent-friendly clinic at Bir Hospital for about three years. As per the understanding, it was handed over to the government, but somehow, the operation of this clinic was closed after handing it over to Bir Hospital, without understanding the need and importance of such a center.
Nepal is predominantly a young population country with a large proportion of the population below age thirty. This population has special needs because of having special characteristics. Despite having improvements, Nepal still has early marriage practices. On an average, Nepali men marry about four years later than women. Sexual practices after marriage is common for females. Young people are at greater risk of health hazards, because of inadequate use or non-use of family planning methods and involvement in early unsafe sexual practices. Despite the expansion of government and non-government services in family planning, the unmet need is still on the rise here, probably due to accessibility, choices, client-providers interaction, spousal or community support, and follow-up and financial constraints. Family planning for this group may not only have health benefits, it will allow them to enjoy autonomy and opportunity of education, employment, participation, and movement.
Early childbearing is still prevalent in Nepal. Women who begin fertility at younger age, particularly before 20 years, suffer from several health risks, with increasing risk to newborns. Young mothers in Nepal need comprehensive reproductive health services to prevent health hazards associated with early reproductive practices. Despite the massive investment in spreading the message, Nepali youth lack comprehensive and correct knowledge of HIV/AIDS. Comprehensive knowledge is important for making HIV/AIDS prevention program successful and promoting healthy sexual behavior. It is also necessary to reduce HIV/AIDS-related stigma and discrimination. Our national survey shows that only 26 percent females and 34 percent males (15-24) have comprehensive knowledge. One in 10 women aged 15-19 have experienced physical violence while the proportion reaches nearly 2 in 10 for 20-24 years. Women who suffer from physical violence exhibit far reaching health consequences of women and children. Despite improvements in the lives of young people, their vulnerability is also increasing. Age at marriage and first birth have increased; knowledge of family planning is universal; exposure to means of communication has improved; the recent surveys show increasing sexual and reproductive health vulnerability of young people. Therefore, a service delivery mechanism addressing the dynamics of young people is required to safeguard sexual and reproductive health and rights of young people.
Having served a long tenure in this field, what do you think are some of the most common women’s health issues, and what can we do to overcome them?
Some health issues affect women differently and more commonly than men. Furthermore, many women’s health conditions go undiagnosed and untreated. The following health problems are found to be very common and needs to be addressed to save women. First and foremost are pregnancy-related issues. Pre-existing conditions like anemia, asthma, high blood pressure, diabetes, depression, etc. can worsen during pregnancy, threatening the health of a mother and her child if not managed properly. Life-threatening conditions like ectopic pregnancy, unsafe abortion, obstructed labor, hypertensive disorders of pregnancy, including eclampsia, obstetric haemorrhage, etc. need proper attention.
Depression and anxiety in women due to natural hormonal fluctuations seems to be very common. Premenstrual syndrome (PMS) occurs commonly among women, while premenstrual dysmorphic disorder (PMDD) presents similar, but greatly intensified, symptoms. Shortly after birth, many mothers acquire a form of depression called the “baby blues,” but perinatal depression causes similar, but much stronger, concerns, emotional shifts, sadness, and tiredness. Menopause can also cause depression. Many women in our day-to-day practice seem to be suffering from gynecological problems like menstrual abnormalities, sexually transmitted infections, infertility, malignancy, uterovaginal prolapsed, etc. Among the malignant conditions, ovarian, cervical, breast cancer, and choriocarcinoma are frequently detected.
The common causes of death in women, as in men, now are ischemic heart disease, stroke, chronic respiratory diseases, chronic kidney disease, and diabetes, which suggests the need to expand the focus and develop a life course approach to dealing with women’s health issues. The government should focus on how we look at women’s health in totality, and not just focus on sexual and reproductive health; how we understand and address the gender gap in access to care and treatment, and how we use and generate data through research to facilitate a more nuanced understanding of gender-related health issues.
Though we are talking about women’s health, we need to go back to some of the socio-cultural factors that prevent women and girls benefiting from quality health services and attaining the best possible level of health, like unequal power relationships between men and women; social norms that decrease education; and paid employment opportunities and potential or actual experience of physical, sexual, and emotional violence. Poverty is an important barrier to positive health outcomes for both men and women, but it tends to yield a higher burden on women and girls’ health. Therefore, if we want to improve women’s health, our focus should be exclusively on women’s reproductive roles and their other general problems.
What are some of the major achievements in women’s health in the last three decades?
Right to abortion is guaranteed. There has been tremendous work in providing safe abortion service in the country free of cost. Maternal status has been improved in the last few years in the country, most probably due to the safe motherhood program of Nepal. This safe motherhood program was started to work together with the Ministry of Health (Safe Motherhood Program, 2002), Population and Family Health Division of Nepal, with an aim to reduce the maternal deaths in Nepal by improving the quality of maternity services and encouraging more women to use available services by mobilizing local groups or community people (NSMP, 1997). They started outreach clinics, established essential obstetric care (EOC) centers, provided training with essential tools, and sensitized the responsibility to those human resources who worked in remote areas (NSMP, 1997). CEOC sites have been improved both quantitatively and qualitatively. There have been efforts to reduce the incidence of post partum hemorrhage by enforcing active management of third stage of labor and by using misoprostol routinely after home delivery with the help of female community health volunteers. Use of magnesium sulfate for managing eclampsia has been made possible. Thus, maternal mortality rate has significantly gone down.
Technologies like liquid-based cytology, colposcopy, hysteroscopy, and mammogram have been made available in the country, facilitating early detection of malignancies.
Numbers of female doctors have increased and better health care facilities have come up outside Kathmandu Valley also. Male doctors are also choosing Obstetrics and Gynecology as their career subject. Voices can be heard against early marriage, early child bearing, and domestic violence. Girls’ education and women’s representation in parliament are definitely on the rise, which has very important positive impact on women’s health.
What are the challenges to women’s health and health promotion, and what measures do you suggest addressing these same challenges?
As we have discussed few minutes ago, besides having general health problems as those of men, women have unique health and healthcare challenges, too. They suffer and die from pregnancy-related conditions like postpartum hemorrhage, rupture uterus, ectopic pregnancy, unsafe abortion, etc. Other chronic diseases like anemia, heart disease, cancer, hypertension, and diabetes are the other important causes of their sufferings and death. Women are twice as likely as men to experience depression. There are conditions like osteoporosis that are not considered as women’s health problem, because it has hardly been noticed and studied as to how many women have problems related to osteoporosis. We are also not talking about conditions like Alzheimer’s disease, which affects many women. These health issues places a huge financial burden on families.
Women in our country do not have easy access to healthcare services; neither do they have the right to decide about their health. Other so-called important members of the family decide on her health needs based on their impression about her.
Until and unless women are educated, and until they are financially self-sustained, this condition is not going to change. Therefore, we need to work mainly on girls’ education from now. In addition, raising awareness about symptoms and risk factors of the possible health conditions and diseases may be an important component of prevention and early diagnosis and timely treatment of those conditions. Involving community members and working through them to help our women get insurance for healthcare may help a lot. Increasing their access to means like regular health check-up plans, cancer screening means like pap smear, mammograms, etc, and the human papillomavirus (HPV) vaccine may help them to a large extent.
Such prevention and wellness initiatives protect and improve health of women and ultimately of the family and the entire community. Policymakers may consider initiatives related to immunizations, nutrition, and oral health. Eating nutritious foods, exercising, maintaining a healthy weight, and reducing risky behaviors can help prevent many chronic diseases. Policymakers should consider the broad range of health policies in the states, provinces, and the country to explore opportunities to improve women’s health. Improving access to insurance coverage, preventing and reducing chronic health conditions, and promoting wellness significantly affect the lives of women of all ages. Because women represent the cornerstone of a family’s overall health, ensuring their access to quality care can lead to improved health for children and families.
