The young girl doesn't know she might be facing a death sentence.She smiles a little, watched by a mum whose face shows anxiety and fear. Other patients are already stood behind them. There’s little patient confidentiality in Nepal.Dr Suman Kamarcharya watches them walk out. He explains the girl has started complaining of tiredness and bone pain while writing.
“It could be leukaemia,” he says.
A terrifying diagnosis in the West,but in Ramechhap in eastern Nepal, it would be a hopeless one.The nearest dedicated cancer hospital – one of only two in the whole country - is an eight hour bus journey away.If her family is poor they would quality for up to 50,000 (£375) rupees of treatment. Just one cycle of chemotherapy could use up almost the entire sum and the family would need to commute to the hospital for months, and spend their savings and sell their land.
One option is Bhaktapur Cancer Hospital, near Kathmandu, which run by the non-profit Nepal Cancer Relief society.
Every day its reception is thronged with patients and relatives from every corner of the country. People wait anxiously but patiently. Nepalese people seem to have incredibly levels of patience and stoicism, perhaps partly forged on those gruelling bus journeys.Treatment and assessment times are usually within hours or days - faster than in the NHS - though the equipment is older. The hospital uses Cobalt 60 radiotherapy, which have been largely replaced by linear accelerators in the West.
On the wards, colon cancer patient Asha Khadhi, 45, has been through 12 cycles of partly charity funded chemotherapy, each costing 30 to 35,000 rupees.
He said: “I didn’t know anything about cancer. All we thought was when you get cancer you grow thin day by day and then you die.”
Gaura Baniya, 50, from Lamjung, had pain and discomfort for around eight months before she sought treatment and was diagnosed with pancreatic cancer. Her family has loaned money to pay for the care. The disease has extremely low survival rates, though she is upbeat.
“I didn’t know anything about cancer. I just ate a lot of medicine for the pain. Before, I thought cancer was a death sentence, but I feel it’s not too bad.”
On the palliative ward, a family sit around a man aged 33, with a rare and malignant brain cancer called astrocytoma. He has survived 40 days here so far. He is thin and barely moves.The hospital is better staffed and equipped than 10 years ago. But surgery is often palliative at best.Thanks to poor screening, a lack of awareness, and high treatment costs, many people only come from treatment when their cancer is very advanced.
Dr Kapendra Shekhar Amatya, a GI and breast surgeon at the hospital, said: “We have two different Nepals right now. One is the urban Nepal and one is the rural Nepal.Yes treatment has come up in a big way here in the urban areas, but in rural villages it’s still the same, there’s still a lack of education. In these places cancer is mostly neglected. It’s only the people who can afford the care who get the treatment. It also depends on where you go and who you see first. The system there is not geared towards identifying cancer. In rural areas people don’t worry about having a cough for months until they see blood.”
Rolpa is another one of those rural areas, in the impoverished mid-west of the country. It is beautiful area. But the steep hills and ravines make life a struggle. One hamlet is just across the valley from the district hospital, perhaps a mile away, seemingly almost within reach. But it’s about five hours walk away. The district’s northern villages are two days away by foot. Getting around is so difficult that people get osteoarthritis of the knees in their 30s.Many spend thousands of rupees on animal sacrifices with traditional healers before they make the journey to the hospital.
The country’s public health system, like that of many developing countries, is geared around the great infectious diseases of the poor, like diarrhoea and TB. Every group of villages has a health post with a health assistant whose training is focused on common ailments. There is a network of female health volunteers to improve child care. Their work has helped the country’s life expectancy to hit 69. Dr Binod Kumar Giri, head of the Rolpa district hospital, said:
“There’s been a lot of improvements in the last 10 years. We are doing very well in public health.”
But non-communicable diseases – like cancer, diabetes, kidney failure or diabetes – now make up 80 per cent of the country's patient contacts and 44 per cent all deaths.
The young people of Nepal are the first generation who will be more likely to die from these ‘western’ diseases, and the health system in Nepal – and other developing countries – is grossly under equipped for these expensive, complicated illnesses.
A 2012 paper in the Australasian Journal of Cancer said:
“Cancer management in Nepal receives the lowest financial contribution from the Government, as it is their lowest health priority.”
There were only 20 radiation oncologists, the paper said, in a country of 27 million people.Rolpa district hospital has only two full time doctors. One, Dr Bipin Karki, explained they can’t fully test for diseases like hepatitis or diabetes, let alone provide chemotherapy.Patients face a 6-8 hour bus journey to the regional hospital in Nepalgunj or an 18-hour bus journey to the more modern hospitals of Kathmandu. He adds:
“Health is far behind in priorities for most people. The goats need to be fed, the chickens need to be fed, work needs to be done on the land.
“They keep the problems to themselves for too long and then it’s too late.”
The communist dominated Nepali Government has made more than 40 lifesaving drugs available for free to poor people. But when it comes to caring for the growing problem of chronic diseases, it all comes down to how wealthy you are.A replacement heart valve at the Gangalal National Heart Centre reportedly costs 200,000 rupees, (1,500), around three times the average yearly income. A new national centre offers free kidney dialysis – but it is the only one of its kind, leaving thousands of people facing exhausting journeys and long waiting times, or expensive bills.
The urbanisation of the country is also fuelling the problem.Like many Nepali cities, Bhaktapur, home to the cancer hospital, is increasingly polluted.The sacred Hanumante River is now full of sewage, chemicals and discarded rubbish. Dozens of surrounding factories pour out black smoke. Car pollution is a choking menace.The shops here - and in the rural areas - are full of alcohol and cheap processed foods. School children eat dry instant noodles for lunch, straight from the packet.Overweight patients are still a novelty at Siddhi Memorial Hospital, an NGO-run children’s, on the banks of the river. But there are a few.
Paediatrician Dr Abhay Mandal said: “We very commonly see bronchial asthma due to the traffic. We find children increasingly eating junk food.
“Most of our patients are poor so there’s little obesity at the moment.”
Basundhara Sharma, a researcher and public health lecturer who is based at the hospital said: “Cases of heart disease, diabetes, cancer, and non-communicable diseases are growing.
“They are influenced by environmental problems like pesticides, chemicals, fertilisers and heavy traffic use due to leaded petrol.
“We also have to challenge sedentary life styles, overeating and drinking alcohol.”
The Nepal health Research Council has a started a study of non-communicable diseases, said Basundhara. She thinks the country’s new health policy should be held back until the study is completed.
In Ramechhap, at Manthali Co-Operative Hospital, Dr Suman comes back with the blood test results on the young girl. There are no signs of leukaemia. She walks out into the streets of Manthali, a provincial town that is now developing rapidly, like the rest of the country.Up on a nearby hillside people have to walk an hour each day to get water.But in the town there are Internet cafes, a small landing strip, and a mini-construction boom.Will cancer care, and that for other non-communicable diseases even begin to meet demand as the girl grows up?
According to the 2012 paper, 85 per cent of the world’s population lives in developing countries but they have less than a third of treatment facilities.The World Health Organisation said that in 2008, around 72 per cent of cancer deaths occurred in low and middle income countries.
Lancet Editor Richard Horton last year said that while infectious diseases where now ‘more under control’, western donors were responsible for an ‘appalling neglect’ of the ‘cancer epidemic’ in the developing world.
‘Closing the Cancer Divide’ is the report of the Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries. It argues the damage cancer does to a country’s productivity is greater than the cost of cancer care and control.
“Catastrophic diseases such as cancer, reduce productivity and drive families into poverty as well as detracting from economic growth and human development,” it said.
If Nepal and other developing countries are to maintain their progress and become more self-sufficient, ensuring that little girl has the chance of good care may not just be a moral imperative, but a financial one.