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Research

Towards the future – “Rural Health Research Institute”

Report and advice from a Japanese researcher / Ryukichi Ishida,
Sustainable cooperation, learning the “Heart of Nepal”,

 

 

Why “Research”?
This health center in Thawang was planned as a future medical collage which can change the serious health inequity between Kathmandu and rural Nepal.
In Nepal, research on the rural health is not common, and it is one of the reasons of this inequity. It results in the poor health policy which cannot promote the rural health effectively.
Another purpose of research is to learn the local medical knowledge from the local traditional healer and village people. We must empower and revitalize the ethnic medicine (Jadibuti etc) as the important historical heritage and the precious resources for the future sustainable development. So far it was usually ignored or regarded as the enemy of modernization by the local health provider and the health policy maker.
So, we are planning to make these research project along with constructing the modern curative facility.

Experience in remote rural Nepal
My first experience was 45 years ago when I was still a medical student. I visited Dr. Noboru Iwamura in Tansen Mission Hospital by walking 5 days along Kali Gandaki from Pokhara, and learned his “Community based preventive approach” for Tuberculosis (Tb) control, attending his “Tb Caravan”, visiting from village to village on foot. (O’Conner 2005)  In 2006, I started medical volunteer work in Tansen Mission Hospital and Rukum Chaurjahari Hospital, and found too many late presentation cases and preventable trauma disability cases. Why couldn’t they come to the hospital earlier? To answer this question, in 2009, I launched “Primary Trauma Care Research Caravan” walking though the hilly area of Mid-western region from Jumla to Baglung via Jajarkot, Rukum and Rolpa, opening research camps in 12 villages on the way. This research was designed as a preliminary study to get a general, bird’s eye view of the area, mainly focused on the epidemiology of trauma, public health, and topographical and sociological characteristics. It was also designed applying Dr. Iwamura’s teachings to my field of specialty, Orthopedics.

Findings of Primary Trauma Care research caravan 2009
Of 69 overall post trauma disability cases, as much as 64% received only traditional + home treatment. Traditional care was surprisingly dominant. Out of 13 patients who were carried to the city, there was only one female. Gender disparity was obvious. In addition to trauma, bone and joint infection were serious orthopedic problem, but most of the patients have no chance to get modern treatment. So, some traditional healers used a carpenter’s nail driving into the infected bone. “Jackal wine” was commonly used for arthritis patients. Local healer used paste of young chick and bamboo tips even for serious open fractures and sometimes result was miserable amputation.

Thawang as a research base camp
After the experience of research caravan from Jumla to Baglung, on 2009, Thawang village was selected as a key place for the future research activity. The reason of this selection was as follows.
Topographical (Geographical) feature of this village represents the difficulty of rural hill region. It takes 2 days to carry patients to the operation possible hospital, including one day walk and 12 hours jeep.
The quality of local human resource for research is higher than other remote villages. Culturally, this area is preserving old indigenous culture of Kham speaking Magar. This feature represents most of the rural Nepal with marginalized and discriminated indigenous people. Politically, this village has long history of “critical” social movement and recently it was a “power center” of people’s resistance against the old monarchy.  This is interesting point of this village from the view point of research on the relation of social change and health change.
After the long caravan passing through this village, I felt that this village may have the possibility to develop as a base camp for my “critical” medical anthropology research, which finally aims to change the total situation of rural health in Nepal
In future, this institute will also provide the trial intervention for the integration of traditional and modern medicine, creating the local researchers for this practice, and inviting many local traditional healers to this institute.
Medical-anthropology beyond health problems
During 2012, I started a new second life in Nepal as a medical-anthropologist under the guidance of CNAS/TU, after graduating 40 years long original life as an orthopedic surgeon in Japan. And mainly from the “Traditional Bone Setter (TBS) research caravan 2012”, I am getting the overview information on the TBS, and making cooperative relationship with them, as a first step for the future integrative program.
Just after returning from this 2 months long research caravan in the Midwestern area, I suffered very strong dizziness attack and admitted to the emergency ward of Annapurna Neurology Institute. Fortunately it was not due to the brain stroke, and diagnosis was “vestibular neuronitis”. Symptom is now gradually improving, but not fully recovered. And due to this dizziness, I fell down in Thawang and suffered from the clavicle bone fracture. Due to my health condition, my effort was concentrated to construct the base camp /research center in Thawang/Rolpa for the future research.

Findings of Traditional Bone Setter research caravan 2012
There was a strong influence of TBS in this area.  Over 60% of Primary Trauma Care (PTC) relies on the TBS procedure. So it is necessary to educate TBS for reducing “Preventable trauma disability”.  The modern health providers are not well educated for PTC, and this is the reason why most villagers select TBS.
From the interview to the traditional healers and villagers, including 12 TBSs, 2 Jaisi and 6 Dhami/Jhakri, difference of their roll was recognized.  TBS is specialized for fracture/Dislocation treatment, and sharply different from Dhami/Jhakri who is Shaman/ faith healer, not prepared for fracture/dislocation. Jaisi is a kind of traditional healer common in Magar community. They treat patients mainly by “Jadibiti” (traditional remedy) with some faith cure.
Within 12 TBSs, considerable difference was observed.
In rural-Hill/northern area, influence from Buddhist culture was observed, but in suburban/southern area, influence from Hindu culture was prominent.
Except the TBSs in remote area, famous TBSs are already incorporated some kind of western medicine, for example some TBS use antibiotics for open fracture, and in suburban case they utilize X-ray for diagnosis.
From my appreciation of their ability, some of them have prominent ability but some of them are risky to create post trauma disability. Former positive side must be preserved and standardized, and the latter negative side must be educated and changed.

Precious “Cultural Heritage” / How to preserve and reactivate?
Some TBSs seem to have important knowledge as indigenous cultural heritage with 3000 years long historical roots in Ayurvedic medical system. Especially in the steep hill region with high risk of trauma, this knowledge seems to contain the crystal of people’s long struggle against this geographical difficulty. But regrettably, most of these TBSs have no reliable successor and their skill and knowledge is extinguishing. Now, we must make urgent efforts to preserve this precious indigenous heritage.
From the study of the literature on TBS/ Traditional medicine, integrative experience in China and India may be effective for the rural Nepal.

 

Challenge to overcome the Inequity
In future, this institute will provide the integration of traditional and modern medicine, and we must create the new type health provider, “Rural Specialist”, friendly and effective to the villager’s health, different from the “Modern Specialist educated in Kathmandu”. Our challenge will create the way to overcome the serious inequity between Kathmandu/Japan and rural Nepal.
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Sustainable cooperation, learning the “Heart of Nepal”,
From “Pre-modern” to “Post-modern” beyond the “Modernization”
 Health” for Peace. “Peace” for Health. Toward the “Equal World”
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