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Aberdeen geriatricians go global - First stop - the Himalayas?

Professor Phyo Myint and Professor Prasanna Gautam describe their experience of training Nepalese doctors in geriatric medicine - a country which, hitherto, has not had a single geriatrician.

Nepal is a beautiful country in the spectacular mountainous region of the middle Asia. After years of armed conflict and instability, it has now become a stable democratic republic. The civil unrest created severe social upheaval, including the in-migration and displacement of the country’s older citizens. The exponential rise of older people aged 60 years and over from 3.2 per cent in 2001 to 8.3 per cent in 2011, with rapid growth rate in the very elderly age group, has already become alarming for the fragile health services provided by the Ministry of Health and Population (MOHP) of the Government of Nepal. 


Following a three day high profile conference in Kathmandu in 2009 on Healthy Ageing, organised by Nepalese Doctors Association, (UK) and Connect for Change, supported in part by DFID, the Government had formulated a national health policy for its older population resulting in a 50 per cent reduction in the hospital costs and free supply of 24 commonly prescribed medicines. Other facilities on offer are separate and fast track consultation in the outpatients and designation of some beds as 'geriatric beds' in the government hospitals.  However, to date there has been a dearth of training in care of the elderly. There is not a single geriatrician in Nepal to provide specialist services. The country’s two dozen medical colleges do not include Geriatric Medicine in their curriculum and age related changes are only generally taught in their basic science courses. The concept of Occupational Therapy is practically unknown in Nepal. There is only one School of Physiotherapy in the country which will produce the first cohort of graduates next year. The ethos of the physicians working within a multidisciplinary team does not exist. 

A call for help
It was in this context that Dr Prasanna Gautam, former Medical Lead of the Department of Medicine for the Elderly and Senior Lecturer in Medicine, Aberdeen University was approached early in 2014 by Manmohan Memorial Teaching Hospital (MMTH) in Kathmandu, to lead care of the elderly services. This new hospital was being established in the memory of the visionary late Prime Minister Mr Manmohan Adhikari whose government had initiated a state old age pension for Nepalese elders in 1991- the first by any government in this region of South East Asia. MMTH was also planning to develop a medical college and had adopted ''the elderly friendly hospital'' as its mission statement. 

Prasanna Gautam provided a six week on site intensive training to Dr Shah, a general physician and rheumatologist, two staff nurses and one physiotherapist prior to establishing an Outpatient service and a Day Unit as the Department of Gerontology in MMTH which opened in March 2014. Dr Shah gained further experience at Woodend Hospital and Aberdeen Royal Infirmary, Aberdeen, for a month in September. 

A strong collaboration was being forged between the Department of Medicine for the Elderly and the Medical school in Aberdeen and MMTH. A further collaboration was proposed with the School of Health Sciences, Robert Gordon University (RGU) in Aberdeen which is the main producer of highly skilled professionals allied to Medicine. The Ministry of Health and Population and WHO in Nepal were then approached by us to secure support for holding an intensive national course in Geriatric medicine for Nepalese doctors representing as many regional hospitals in the country as possible. The funding was obtained from the WHO and MMTH. 

Two principle objectives of the course were (1) to provide an introduction to the principles and practice of Geriatric Medicine and Gerontology, and (2) to promote the concept of holistic medical care for the older people in the hospitals in Nepal. Emphasis was given to quality of life issues, multidisciplinary team working and principles of rehabilitation both in the hospital and in the community settings. The course was a successful and high profile event opened officially by the Minister of Health and Population, the Honourable Mr Khagaraj Adhikari, MP. He said: “The government is very happy to support this kind of training because although at the policy level we have made several provisions nationally for the proper healthcare of the elderly people in Nepal we have no trained manpower to deliver the service. I am thankful to organisers for bringing this collaboration”. 

Forty two participants, many of them senior doctors from the thirty-two Government hospitals scattered throughout the twenty districts in the country took part in this course. It comprised seven plenary sessions, three key note speeches and a state of the art lecture from the visiting faculty. There were two half-day workshops on Comprehensive Geriatric Assessment and on establishing a Care Home for the Elderly. The topics included the spectrum of geriatric medicine, establishing geriatric services, manpower development and research, stroke, osteoporosis, elder abuse, surgical aspects, palliative and end of life care. There were sessions on stroke rehabilitation, case studies in multidisciplinary team working and community geriatrics. Two elderly women, one blind since childhood and other a frail widow, who had been subject to horrible abuse themselves, participated in the elder abuse workshop co-ordinated by Mr Prakash Khanal. They provided harrowing tales of their personal experience of physical and psychological abuse and the insults which had forced them to seek refuge in the house of a kind lady. The relevant issues on social gerontology were also highlighted. The fifth afternoon session chaired jointly by us provided an overall review which brought out lively discussions and was highly useful in reinforcing the key messages of the course.

The pre- and post-course questionnaires showed that participants scored 4 or 5 out of maximum 5 points regarding the usefulness of the course and whether it would change their practice. They were given a certificate at the end of the course by Dr Guna Raj Lohani, the Chief of the Curative Division of the MOHP. 

An ancillary half day seminar, ''Improving the quality of life',' was also held at the Nurses School in the Campus at Banasthali, near MMTH.  Approximately 40 participants, including Nurses, Physiotherapists, Pharmacists and Lab technicians participated. The seminar was on rehabilitation and professional development options of therapists. The objective of the seminar was to disseminate the concept of holistic medicine, comprehensive geriatric assessment and multidisciplinary team working to help develop health care workforce that fits for the purpose in Nepal. 

The dinner reception for the faculty, hosted by the MMTH Chairman Mr Pandey, an MP and the Chief Whip of the ruling Coalition party in the Government, was entertaining and useful to get to know one another. This was also attended by the Health Minister and the Education Minister, former Finance Minister and four members of parliament, and several other local dignitaries.  The proceedings of the whole course are being compiled to be published in an abstract book form. It is likely that there will be further development and mutually beneficial collaboration between the Department of Medicine for the Elderly (DOME), NHS Grampian, the School of Medicine of Dentistry, University of Aberdeen and Robert Gordon University from Aberdeen, and MMTH in Nepal. The overall experience was overwhelmingly encouraging for the visiting faculty. 

The local sight-seeing opportunities provided visits to a few of the fascinating World Heritage Centres of ancient architecture and temples. The faculty members were able to see the Himalayan range of mountains early in the morning in a Mountain Flight in a small plane of Simrik airline! The views of Mt. Everest and other six highest mountains of this world from the cockpit gleaming different shades of pink and white in the early morning sun was the most spectacular panorama that we shall ever see. 

Prasanna Gautam
Former Lead Clinician
NHS Grampian and Honorary Professor of Gerontology, Manmohan Memorial Teaching Hospital, Kathmandu, Nepal 

Phyo K Myint
Professor of Medicine of Old Age, University of Aberdeen & Consultant Physician, Department of Medicine for the Elderly, NHS Grampian  

In addition to the authors of this article, the visiting faculty consisted of: Professor David Reid, the Head of the School of  Medicine & Dentistry, University of Aberdeen; Ms. Thérèse Jackson, Consultant Occupational Therapist for NHS Grampian Stroke Services, the Subject Lead in Physiotherapy, Mrs Ann Wallace and the Subject Lead in Occupational therapy, Mrs Dawn Mitchell from RGU and Mr Prakash Khanal, a science journalist who is researching on ''Skills Transfer by the Diaspora'' as a PhD fellow with the University of Reading.  The local Faculty consisted of Mrs Durga Mishra, Associate Professor of Public Health Nursing, Mr Chhatra Pradhan, the Secretary General of Nepali Senior Citizens Federation, Dr Deepa Shah, Lecturer in Medicine with special interest in Care of the Elderly, Dr Ashish Dutta, a Lecturer in Psychiatry with special interest in dementia syndromes, Professor B D Jha, Professor of Anaesthesia, Dr Raj Kumar Chhetri, Associate Professor of Surgery and Consultant Urosurgeon, Dr Ram Prasad Shrestha, a senior Consultant Surgeon and former Director of Teaching Hospital of National Academy of Medical Sciences, Kathmanduand Dr Gongal, Consultant Hepatobiliary Surgeon  with special interest in Palliative Care.                         


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