A Himalayan Health Initiative

Nepal is one of the poorest countries in Asia, with a high percentage of rural inhabitants (1) who are woefully underserved by the country’s health system. In 2010, in an effort to improve Nepal’s rural health, the Patan Academy of Health Sciences (PAHS) was established. This not-for-profit academic center provides medical training for doctors, nurses and other health professionals to provide a workforce for the country’s rural medical centers.

Fred Bosman, Emeritus Professor of Pathology at the University of Lausanne, Switzerland, volunteers as a lecturer at PAHS, regularly traveling over to Nepal to teach. We chatted to Bosman about the difference that one visionary institution is making to the health of a nation.

How did you first become involved with PAHS?
 

It came about when I met a Nepalese doctor who was taking a postgraduate pathology course at Oslo University Hospital’s Department of Pathology in Norway. He was accompanied by his mentor, Arjun Karki, then Chief of Medicine at Patan Hospital in Nepal. We got chatting and discovered a mutual interest in medical education.

I was Associate Dean of Education in Lausanne at that time, and at the tail end of a lengthy project to revamp the university’s medical curriculum. Karki was in the process of setting up a new medical college, PAHS, in Nepal and trying to establish a community-oriented curriculum. I had plenty of experience in experimenting with new educational modalities and, notably, focusing on problem-based learning.

I was still involved with a similar project in Cameroon, but that was coming to an end. Meeting someone with such enthusiasm for setting up something groundbreaking in terms of medical education in Nepal was very inspiring, and quite timely.

Karki asked me to join the PAHS curriculum committee and I started working with the other members on developing the medical curriculum. But, over time, my involvement shifted, with a stronger emphasis on supporting the Department of Pathology at PAHS.

What was the state of healthcare in Nepal when you started on that venture? And how has it evolved?
 

The main problem, and the driver for establishing PAHS, was that, in the rural areas of Nepal, there was almost no healthcare coverage at all.

Even now, in Nepal’s cities – the largest being Kathmandu, with a population of around 3 million – the full potential of modern health care is only really available to those who can afford to pay for it. That means that most people have difficulties in accessing appropriate medical care.

The proportion of the national budget that goes to medical care is not bad, but Nepal’s GDP is such that the level of care is well below what we would find in Europe or North America. There remains a lot to be done to improve this situation.

Another problem is the provision of education for medical professionals. Until the 1970s, there was no medical school in Nepal, and for a long time there was only one. When you ask medical professionals in Nepal where they trained, many will say Ukraine or Russia, because, historically, there were agreements between the Nepalese and Russian governments in terms of medical education. That is quite something, when you consider that students would have to go and spend a year learning Russian before even starting their medical training.

Now, the situation is different; there are twenty-four medical colleges in Nepal. Sadly, many of them are commercial, and, in some, the quality of the education is below par. Additionally, there is a huge brain drain as educated Nepalese move abroad, which affects medical staffing levels.

What were the goals of PAHS when you joined?
 

The first goal was to completely overhaul the principles of medical education in Nepal, to improve standards. PAHS wanted to implement a new curriculum, based on innovative educational methods and rooted in problem-based learning.

The second was to develop community-oriented education. The selection of students was based in part on finding candidates that were willing to spend at least part of their active careers serving rural communities. Between a third and a half of the student intake receive a bursary for their education on the understanding that they will not receive their license to practice until they have completed three years’ work in a rural area. This system helped address the needs of the overlooked rural communities in Nepal.

How have your teaching duties evolved over the years at PAHS?
 

In the early days, most of my interactions were with the students, due to the limited numbers of teaching staff. When I first went over, the pathology department at PAHS had one pathologist. There were limited resources for microbiology, chemical pathology, and hematology; resources for histopathology were almost non-existent.

That has dramatically changed over the years and it’s now a thriving department, with nine pathologists and six residents. In terms of infrastructure, it's equivalent to where Europe might have been at the beginning of the twenty-first century. This shows significant progress because, when I arrived, much of the pathology being practiced in Nepal was equivalent to what I was doing in the early 1970s.

Now that the staffing levels have increased, my duties have shifted to teaching the teachers. I coach them in problem-based learning methods such as writing teaching cases and developing evaluation tools. Since the introduction of the pathology residency program, I have also been involved in teaching the residents.

How much time do you give to PAHS?
 

I usually visit Nepal for two weeks at a time, and must have traveled there around 25 to 30 times since I started. The two-week period is chosen according to the student calendar – which itself is determined by the myriad of religious festivals in Nepal. And, because these are determined largely by the moon’s cycles, the academic calendar shifts every year.

If I add it all up, I have spent over a year of my life in Nepal.

What disease trends have you observed in your visits to Nepal?
 

The major disease burden in Nepal was traditionally from communicable infectious diseases. There has been a shift over the last couple of decades to higher prevalence of non-communicable diseases such as cardiovascular pathologies and cancer. Cervical cancer prevalence, which is in decline in Europe, is increasing in Nepal because its screening programs don’t cover the entire population.

Of which of your achievements in Nepal are you most proud?
 

In my opinion, the basis of delivering medical care is the understanding of disease. And, in this, pathology is essential. So it was always important to me to have a decent amount of pathology on the curriculum at PAHS. The beauty of providing a problem-based curriculum is that you can always provide pathology training in the context of a patient’s case.

In that respect, I am most proud of helping to establish a curriculum in which pathology is well represented in a contextual way.

I am also proud to have been able to mentor the pathology faculty at PAHS towards the implications of modern pathology techniques – setting up immunohistochemistry, for example.

What have you found most frustrating about working in a low-resource setting?
 

I could see on my arrival that there was no way to advance pathology practice at PAHS in a department of one pathologist. I encouraged collaboration between pathology departments in other institutions in Kathmandu to create a more advanced unit where techniques like immunohistochemistry, and even molecular pathology, would be feasible. However, over time, I noticed there were huge cultural barriers to that. The Nepalese culture and conditions of employment do not favor a natural tendency to find collaborative solutions.

Another problem is salaries for those laboratory medical professionals in state-owned institutions. Workers paid by the government receive a salary they can barely live on, and many take on second jobs at private labs. It’s frustrating when you can see the solution to a problem but you have to step back and accept the way things are.

When you are working in a foreign setting, you realize that you need to work with the local people, and not try to impose your way of doing things on them. You are there for them, and not to realize your own dreams.

What has been most rewarding about your experience with PAHS?
 

It has been very satisfying watching PAHS grow into being one of the top medical schools in Nepal. And it has been rewarding to see the pathology department grow into the strong and well-staffed department it is today.

Additionally, with the help of a private foundation (MEDIC), I was able to provide the pathology department with a slide scanner. This has enabled digital pathology in PAHS, particularly in terms of sending images to other institutions for second opinions or advice on cases. It has also enabled me to offer virtual slide seminars every two weeks for the residents at PAHS, and help with their continuous development.

What advice would you give to other laboratory medical professionals looking to volunteer overseas?
 

The first thing I would say is: do it! The second thing is: be ambitious.

But, at the same time, to avoid frustration, it’s important to realize you have to work with what’s there, not with aspirations to mold it to what you know.

When I first went to Cameroon, I was warned that resources were so challenged that I would need to provide my own chalks for the blackboard, and that the blackboards themselves had seen better days. So I went there armed with chalks and blackboard paint. You have to make do with what’s there. If you expect to be able to work in the way you are used to at home, you will be extremely disappointed, because that’s not the way it is. You have to arrive with no preconceptions, work with the resources that are there, and accept things as they are. If you are not ready to accept practicing or teaching pathology at a more basic level, don’t do it.

I would also advise people to consider the impact. If you think about the legacy of research, the half-life of a good paper might be 5 years. But when you consider the effect of providing education or mentorship, it stays with people for a professional generation. That impact has been the driving force for my volunteering ventures.

My experience at PAHS has been one of the most satisfying adventures of my professional life. I have done lots of other rewarding things in my career, but this was a real adventure.