Feb 16 2018 update from CCNEPal regarding summer plans for 2018

This will be brief. I haven’t added to this blog in some time, not since reporting on one of the most recent thrashing incidents. This blog provides commentary on issues affecting nursing and especially critical care nursing, in the country of Nepal.

I hope to return to Nepal this summer, as I have done since 2007. Since 2011 I specifically focus on teaching critical care skills to nurses and doctors there. Every time I return I think about how whichever trip I just completed might be the last time. And yet, I get another ticket.

This time is similar. I have ideas as to how I can contribute but never is ever firm until I commit by buying the ticket.

Want to host CCNEPal?

I want to hear from people interested in hosting the training. I will spend part of the time in Terai and a bit of time in Kathmandu Valley. In 2017 I needed to cut the time short and not fulfill promises I made to teach at certain places. I want to follow through despite the problems. I am not destined to only teach at certain places but not others….. the overall goal is to advance the practice of critical care in Nepal. How can we work together to accomplish this?


One of my daughters tells me she may visit Nepal this time and if she does I will take time to be a tourist and show her around.  My other daughter has been lobbying heavily for me to join her in Maine as she works on the old farmhouse she bought. I love spending time with these two young women.


Feel free to browse the 262 previous entries on this blog. I love getting feedback!

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Resunga Hospital Incident Dec 20 2017

gulmi dec incident 2017

at some point, riot police were called. The typical weapon of police is the lathi, a four-foot stick.

This was first reported in OnlineKhabar, Nepali language. Rebublika published it after a day.

GULMI, Dec 21:  A patient admitted to Resunga Hospital of Gulmi has apparently died due to the negligence of doctors.

Shiva Lal Aryal, 53, a local of Malika Rural Municipality-6, Arje had gone to the hospital complaining of dental problem. As informed by the family members, Aryal who was taken to the hospital for normal toothache was insisted to conduct a surgery by the doctors.

Carelessness of the doctors ultimately led to his death, according to the family sources.
“Doctors had told us that a surgery needs to be conducted to take out the pus in his gums but unfortunately he didn’t wake up after the surgery,” said Hari KC, a relative of the deceased.

According to family members, the doctors were supposed to give antibiotics 24 hours before the surgery. However, they didn’t. Twenty-one-year-old son of Aryal is lying unconscious in hospital after the death of his father. Family members and relatives are refusing to claim the body accusing the doctors of the death. “We will claim the dead body only if the hospital administration along with the doctors holds a meeting with us,” said Shovakhar Giri, chairperson of Malika-6.

Tensions ran high in the hospital on Wednesday after Aryal’s death. Security personnel has been deployed at the hospital to avoid any kind of untoward incident. http://www.myrepublica.com/news/32917/



resunga hospital tensed dec 20 2017

Rasunga Hospital is located in Gulmi, Palpa District.



As regular readers of this blog will know, I try to keep track of these incidents. For a list, go to: https://wp.me/p1pDBL-1yu

Many previous blog entries have been focused on the issue of safety of health personnel.



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Thrashing Incident in Sunsari Nov 16th 2017


from Swasthya Khabar. Inaruwa Hospital in Sunsari. There was an incident. The hospital is tense.

Another incident of disrespect and physical violence against a doctor and seven health workers, this time in Sunsari (eastern Terai).

It was reported in Shwasthya Khabar in Nepali language. My ability to read Nepali is limited, so I used Google Translate.  I present the side-by-side of the translation. The source is: http://swasthyakhabar.com/news-details/10139/2017-11-17#.Wg5TJALM3Js.facebook

मुख्य समाचार प्रहरीद्वारा डाक्टरमाथि हातपात, इनरुवा अस्पतालमा तनाव

Police arrest a doctor on the doctor, stress in Anirawa Hospital

मदिरामा मातिएर बुट प्रहार गरे : डाक्टर झा

Beaten the watts on the wines: Doctor Jha

काठमाडौं- दुर्घटनामा घाइते भएका आफन्तको मृत्यु भएको विषयलाई लिएर प्रहरीले डाक्टरमाथि हातपात गरेका छन् ।

KATHMANDU – Police have arrested the doctor on the subject of the death of the injured in the accident.

जिल्ला प्रशासन कार्यालय सुनसरीमा कार्यरत नायब सुब्बा रामचन्द्र भट्टरार्इ सवारी दुर्घटनामा परेका थिए । दुर्घटना लगत्तै उपचारका लािग इनरुवा अस्पताल ल्याएको थियो । अस्पतालमा कार्यरत डाक्टरले भट्टराईको अस्पताल ल्याउनुअघि नै मृत्यु भैसकेको जानकारी दिएपछि प्रहरीले डाक्टरमाथि आक्रमण गरेको बताइएको छ ।

Nab Subba Ramchandra Bhattarai, who was working in the District Administration Office, Sunsari, had been on a road accident. After the accident, brought to the hospital for treatment. According to the police, the doctor working on the hospital has died before the doctor had already died before taking Bhattarai hospital.

मृतक भट्टराईका आफन्तपर्ने जिल्ला प्रहरी कार्यालय सुनसरीमा कार्यरत प्रहरी निरीक्षक सन्तोष पोखरेलले डा तुसार झा, स्वास्थ्यकर्मी ओम गोहीबार यादवलगायत सात जना स्वास्थ्यकर्मी माथि गुण्डा सैलीमा आक्रमण गरेको प्रत्यक्षदर्शीले बताएका छन् ।

Police Inspector Satosh Pokharel, who was working at the District Police Office, Sunsari, of Bhattarai, said that the deceased was attacked by gangster Sally on the other hand, including Dr. Tusar Jha, Health Worker Om Goharbar Yadav and seven health workers.

प्रहरी निरीक्षक पोखरेलले बर्दी र बन्दुकको आडमा रक्सीमा मातेर आफूहरु माथि आक्रमण गरेको पीडित तुसार झाले बताए। अस्पतालको इमर्जेन्सी कक्षमा रहेका डा झा सहितका स्वास्थ्यकर्मी र एक जना कार्यालय सहयोगी समेतलाई बुट र लठीले कुटपीट गरेको झाले बताए।

Police Inspector Pokhrel said that according to the victim, according to the victim, attacked the victim on the side of the fire and gun. Jha said that the health worker including Dha Jha in the emergency room of the hospital and a colleague who was beaten up by robbers and robbers.

विराटनगरबाट इनरुवातर्फ आउँदै गरेको को १ च ७०३३ नं को एम्बुलेन्सको ठक्करबाट जिल्ला प्रशासन कार्यालय सुनसरीमा कार्यरत नायब सुब्बा भट्टराइको मृत्यु भएको हो ।

हिजो साँझ इनरुवाबाट आफ्नो घर दुहबीतर्फ जाँदै गरेको भट्टराई सवार बा२४प ४२४४ नंको मोटरसाइकललाई एम्बुलेन्सले ठक्कर दिँदा भट्टराइको घटनास्थलमै मृत्यु भएको प्रत्यक्षदर्शीले बताएका छन्।

Neb Subba Bhattarai, who was working in Sunsari, has been killed by Ambulance of 1 f 7033 no one coming from Biratnagar to Anwar. According to the eyelasheshi, the motorbike was beaten by Bhabhari Rider B 24 Pa 4244 in Bhattarai incident on Sunday evening.

मृतक भट्टराई आफ्नो आफन्त रहेको र सिरानी नदिएको तथा उपचारसमेत नगरिदिएको आरोप लगाउँदै डाक्टर माथि आक्रमण गरेको त्यहाँस्थित एक जना कुरुवाले प्रतिक्रिया दिए।

घटनालाई लिएर जिल्ला अस्पताल पूर्णरुपमा बन्दगरी स्वास्थ्यकर्मीहरु अस्पताल अगाडि र सडकमा धर्ना दिएर प्रहरी प्रशासनविरुद्ध नाराबाजी गर्दै प्रर्दशन गरिरहेका छन्।

A corroborate responded that the deceased Bhattarai was attacked by a doctor who was not a relative of his relatives and was not given permission and was not even treated. According to the incident, the closure of the district hospital is being done by the health workers before leaving the hospital and protesting against the police administration.

चिकित्सकमाथिको आक्रमण सह्य नहुने भन्दै इनरुवा नगरपालिकाका प्रमुख राजन मेहता, अस्पताल विकास समितिका अध्यक्ष रमेश कटुवाल, नेपाली काँग्रेका सचिव केदार भण्डारी लगायतले ऐक्बद्धता जनाउँदै चिकित्सको आन्दोलनमा सहभागी भएका छन्।

Rajan Mehta, Chairman of the Hospital Development Committee, Ramesh Katuwal, Nepali Congress Secretary Kedar Bhandari, and involvement in the movement of the doctors, said that the attack should not be done.

चिकित्सकमाथिको आक्रमणको विरोधमा सुनसरीका सबै स्वास्थ्य संस्था साँझदेखि नै बन्द भएका छन् भने दोषीलाई कारबाहीको माग गर्दै इलाम, उदयपुर, धनकुटा, पोखरा, सप्तरीलगायतका क्षेत्रमा डाक्टरले सेवा अवरुद्ध गरेको स्वास्थ्यकर्मी राजीव मेहताले जानकारी दिए।

Regarding the attack on the doctor, the health workers of Sunsari, who have closed all the health institutions of Sunsari, have been stopped from evening till demanding action against the accused, said the health service blocked by the doctors in the area of Ulam, Udaipur, Dhankuta and Saptari.

जिल्लाको पाँच वटा प्राथमिक स्वास्थ्य केन्द्रमा कार्यरत चिकित्सकले घटना सुनेपछि राति ८ः३० बजे इनरुवा आइपुगेको र आन्दोलनमा सरिक भएको डा वसन्त यादवले जानकारी दिए। उता प्रहरी र प्रशासनले आफ्नो कमजोरी भएको भन्दै मिलाउने र वार्ता गर्ने तयारी गरिरहेको बुझिएको छ।

Dr. Vasant Yadav, informed that the doctor who was working in five primary health centers in the district came to the house at 8:30 am after the incident. It is understood that the police and administration are preparing to negotiate and negotiate with their weaknesses.

Okay. I asked my trusty FaceBook friends for a condensed version of the story, and the first one wrote:

its like …there was 1 death of police man occur due to embulance while returning from market by bike…..then dead body was brought to hospital…. one of the police officer was shouting and usuing slang word to every para medics and dr …medical officer and their co worker were beaten by police … that is the scene happened….death occur in road accident….but insulting to the dr …..misbeheved …. that is life of doctor

So, this one gets added to the list. Piecing it together, a policeman was killed in a road traffic accident, (by a passing ambulance?) then the police brought his body to the hospital where he was pronounced dead. The police did not want to hear that news so they thrashed the staff and arrested the doctor on duty. I am confused as to whether the doctor on duty had anything to do with the accident (he was not driving the ambulance and was not near the scene) but – voila! – he gets arrested. I re-read the translation above and it sounds like he is accused of a crime at the scene????????

??????? help!

UPDATE: somebody explained it to me – Police inspector is the culprit and the doctor is the victim. The drunk inspector thrashed the doctor, along with others because the doctor declared the inspector’s brother in law dead on arrival, who previously met with a RTA, road traffic accident.

Now the question is: how do the police get away with this? If there is supposed to be #JailWithoutBail, who lands in the jail? the police? do they arrest themselves?

If this is true, the police should know better.

UPDATE: Nepali Health ran a Nepali-language piece on this incident. http://www.nepalihealth.com/2017/11/17/24316/

Sunsari 1 house. Sunsari district hospital has been strained after the drug-based police inspector handled over the doctor. Thursday evening at 6 pm at the hospital. On the spot of Tausar Jha, the assaulted by Inspector Satosh Kumar Pokhrel, the deceased was attacked by alcohol.

Against the protest, doctors and health workers have now stopped all the services other than accidental. To discuss this issue, the district administration is preparing to register at 10 am.

Ramchandra Bhattarai, the district administration office of the road accident, was handed over to the hospital today. But when the hospital is completed, the doctors have died. He is said to be Vinju of Inspector Pokharel.

Dr. According to Jhaka, alcohol was allegedly harassed by other doctors of the Pokharel who were earlier identified. Finally, he said that he was attacked too. I’m the only doctor here. I came to know that the inspector had to bathe. Dr. Jha said, ‘I do not go after I go.’

After the attack, the hospitals of the hospitals had abused the service including casualty last night. However, Mukunda Gautam, head of District Health Sunsari, said that the emergency service was underway. He also informed that there will be registration at District Administration at 10 am in the morning to solve the problem.

SP Vidyananda Majhi team of Sunsari had taken immediate control under the instant inspection of the hospital. The SP said that after the medical examination, the fish did not consume alcohol.

With this incident, health workers are protesting against the police administration after they are in front of the hospital and by converting on the road.

Rajan Mehta, Chief of the Municipal Municipal Hospital, Hospital Ramesh Katuwal, and affiliate said that the attack should not be done

Regarding the attack on the doctor, the health workers of Sunsari, who have closed all the health institutions in the evening, demanded treatment for the perpetrator, said the health service blocked by the doctors in the area of ​​Ulam, Udaipur, Pokhara and Saptari and health workers Rajiv Mehta.

Dr. Vasant Yadav, informed that the doctor who was working in five primary health centers in the district came to the house at 8:30 am after the incident. It is understood that the police and administration are preparing to negotiate and negotiate with their weaknesses.

The protesters have warned that closure of the market will be closed for the indefinite period, till closing the market till Friday, as well as health institutions.

What is special?

Bhattarai died due to the collapse of Ambulance by 6 o’clock in the evening near Gonda Khela, between Sunsari Inrava- 6 and 5. He died due to the collapse of Ambulance from 1 to 7033 AH, coming from the Biratnagar to Ankara.

Bhattarai Rider, 24, 4244, who was going to Dubai from his house to Dubai, told that the incident occurred when Ambulance collapsed. He was hospitalized for treatment

Nov 18th about terai drunk cop

(from NMA FaceBook page)
Dr, a doctor working on INSURA Hospital on December 10, The Nepal Medical Association Central Office has been keenly concerned with the incident, according to police inspector Satosh Kumar Pokharel, who was beaten up by police, Ghali Gaulaj and other hospitals including Tussar Jha. Due to the worst condemned incident from Badriwala police inspector, all the doctors have been shocked
If such activities have been repeatedly repeatedly by the method of law and legislation, doctors and health workers can provide health services. The Nepal Medical Center, the central office, urges the police inspector to take action against such a serious situation as quickly as possible. As the police in Badri, there is no legal arrangement that can not be handled illegally.”

If there is anybody who can provide me more details, please send them. I will publish them here, anonymously if necessary. send email to joeniemczura@gmail.com

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Medical Education Ordinance certified, but continuing vigilance is needed. calling Doctor Narsingha….

narsingha changu narayan

Narsinga dispatching the unkillable demon, ” Hiranyakashyapu” as depicted in a stone carving at Changu Narayan Mandir. Using a median sternotomy incision, of course. What does it take to kill something that won’t die?

According to legend (with help from Wikipedia https://en.wikipedia.org/wiki/Hiranyakashipu ), Hiranyakashyapu asked for the following boon from Brahma:

O my lord, O best of the givers of benediction, if you will kindly grant me the benediction I desire, please let me not meet death from any of the living entities created by you.

Grant me that I not die within any residence or outside any residence, during the daytime or at night, nor on the ground or in the sky. Grant me that my death not be brought by any being other than those created by you, nor by any weapon, nor by any human being or animal.

Grant me that I not meet death from any entity, living or nonliving. Grant me, further, that I not be killed by any demigod or demon or by any great snake from the lower planets. Since no one can kill you in the battlefield, you have no competitor. Therefore, grant me the benediction that I too may have no rival. Give me sole lordship over all the living entities and presiding deities, and give me all the glories obtained by that position. Furthermore, give me all the mystic powers attained by long austerities and the practice of yoga, for these cannot be lost at any time.[5]

Doing the right thing

This past week in Nepal politics was suspenseful in it’s own dreary way.  The back-and-forth decisions regarding a proposed additional medical college in Kathmandu were dizzying as described in The Kathmandu Post. http://kathmandupost.ekantipur.com/printedition/news/2017-11-07/ministry-presses-nmc-to-allocate-seats-to-national.html

It seemed like Dr. Govinda KC needed to deliver a public tongue-lashing in order to move the process or else begin his fourteenth fast-unto-death; then finally the President of Nepal certified the ordinance governing medical education, placing a moratorium on new medical colleges in Kathmandu for the next ten years.


Um, no. Not exactly. The law promulgated is an ordinance, not a law. It is subject to confirmation when the new parliament is seated after the upcoming election.

The President of Nepal has now certified the Medical Education Ordinance.

from Republica:

….. The ordinance is a milestone in medical education reform, said Dr Singh. “This is one of the greatest achievements for which Dr Govinda KC was fighting since 2012, staging 13 hunger strikes till now,” he added.

The ordinance has provisioned setting up at least one government-run medical college in all seven provinces of the country within five years and places a moratorium on opening new medical colleges in the Kathmandu Valley for the next ten years.
Similarly, it has provisioned a common entrance exam system nationwide for MBBS.

Likewise, specialist doctors should serve for at least two years in remote areas or three years in the accessible areas after their completion of their studies, according to the ordinance.

Also, the government-run medical colleges should allocate 75 percent of the MBBS seats for scholarships. “Another major achievement of the ordinance is that it has provisioned formation of Medical Education Commission, which will monitor all medical colleges, and define criteria and infrastructures to operate medical colleges,” said Dr Singh. “If anyone snatches away the hard-won provisions of the ordinance from people, we will again launch appropriate movement against such move,” he added.

The Underlying Principle

The underlying principle is that medical education in Nepal needs to be supervised by doctors, not politicians, in order to maintain quality and ethical standards. Over the past five years it has seemed as though somebody is building a new medical college in Kathmandu Valley (or trying to) every few months.

If there were no limits, Kathmandu would have about twenty medical colleges, more than Delhi; London; New York; or many entire African countries.

Every young man or woman in the Valley who wanted an MBBS would be able to walk to school like they were in kindergarten.

And of course, such an MBBS degree would be of little value. The prestigious medical journal, Lancet, published an article about the problem in December 2016. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)32423-0/fulltext?rss%3Dyes

The increase in medical colleges—mostly private and urban-centric—has very little to do with the most remote and inaccessible communities. In a country where 80% of the population lives in villages,1 medical training needs to focus on the rural population. Of the 19 medical colleges in Nepal in 2012, 14 (74%) were private and eight (43%) were in Kathmandu Valley alone, serving only 1·7 million—6% of the total population.1, 6 Of the 11 medical colleges outside the Valley, almost all were based in the cities, largely depriving health care from those living in rural regions of Nepal.6

Doctors Society Of Nepal

The Doctors Society of Nepal organization published this letter:

congrats to gkc

The steps now being taken are logical and sensible but would never have happened without a champion and a movement of supporters.

Back to Vishnu

Vishnu has chosen here to appear in the form of Narasimha in order to be able to kill Hiranyakashipu without violating the boon given by Brahma. Hiranyakashipu cannot be killed by human, deva or animal, but Narasimha is none of these, as he is a form of Vishnu (a deva) incarnate as part human, part animal. He comes upon Hiranyakashipu at twilight (when it is neither day nor night) on the threshold of a courtyard (neither indoors nor out), and puts the demon on his thighs (neither earth nor space). Using his nails (neither animate nor inanimate) as weapons, he disembowels and kills the demon.[12]

It seems to me as though this tale of Narsingha is a parallel to the effort it has taken to set the path of medical education in Nepal on a proper course. Judging by the steps it took to get to this point, there will be future efforts to disregard the ordinance just like there have been efforts to ignore every previous agreement.

Addendum: Dr. GKC has warned the same thing – it’s a temporary victory… http://english.onlinekhabar.com/2017/11/12/409339.html#.WggWm6xWzZM.twitter

Finally, I don’t usually comment directly on political matters nor do I interpret Hindu beliefs. My main objective for this blog has been to promote widespread adoption of advanced resuscitation principles and training. I encourage those with other viewpoints to comment.

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Will Nepal become a “degree factory” for doctors?

The Big Problem with medical education in Nepal

Unless the trend of opening medical colleges in Nepal is stopped, the country risks gaining a reputation as a “diploma factory.” The MBBS degrees awarded to young students in Nepal will not be useful in getting a medical job outside Nepal. 

People don’t talk about it, but the fact is, many young medical students have the dream of  going to UK, India, EU or USA to work as a doctor. It’s the best way to pay off the heavy student loans of medical college in Nepal. It’s not easy, but – it’s possible, because the medical council and the medical association are working hard to maintain some semblance of quality and accreditation.

The Nepal Medical Council and Nepal Medical Association have stood firm on the issue of quality, but are continually being challenged by politicians who wish to make money from awarding licenses to operate more and more Medical Colleges, which is lucrative due to high tuition fees and limited oversight.

Case in Point

The following article appeared in Republica Nov 6th, 2017:

KATHMANDU, Nov 6:  Education Ministry has directed controversial Kathmandu National Medical College to allocate the seat numbers for new admissions from current academic calendar.

Breaching its own jurisdiction, the ministry has directed the controversial medical college to allocate the number of seats.

Though the Medical Council posses the right to allocate the seat for each academic calendar, Education Minister Gopal Man Shrestha wrote a letter to the college and directed to allot the seats.

The Senate and Executive Council of Tribhuvan University granted affiliation to the college on July 27. Later on, the university withdrew its decision to grant the affiliation citing that the college does not meet the basic requirements to operate a medical college. However, the Supreme Court, last week, issued a stay order against the decision of TU to scrap the affiliation granted to KNMC. Following the order, Minister Shrestha issued directive in writing lured with financial gain.



Nepal already has more than twenty medical colleges, with seven located in the Kathmandu Valley. ( TU, KU, Kist, NMC, NMC, PAHS).


This is from an infographic published in Republica a few years back. There is an ongoing debate about the need for new medical colleges which has been propelled by Dr. Govinda KC and which affects every aspect of medical system planning in Nepal. got o #IamwithDrGKC to find many links regarding the protests and negotiations.


This seems to be the fifth or sixth time somebody with political connections has tried to open a new medical college in the Kathmandu Valley.  I am losing count!


Dr. Govinda KC conducted a hunger strike – his thirteenth – not too long ago to bring attention to this issue and to pressure the government to adopt measures to prevent this. The ink on the agreement is barely dry…. and now – this.

It must be noted that a team of experts led by Kedar Bhakta Mathema, former vice chancellor of Tribhuvan University, had recommended a 10-year moratorium on establishing new medical colleges in the Valley. The original HPE Bill also had a provision for that. But under pressure from some lawmakers, particularly those from the CPN-UML and the CPN (Maoist Centre) who have stakes in some medical schools, a House committee had inserted a new clause as per which the facilities that had already obtained the letters of intent and built infrastructure would get affiliation for running the MBBS course. This would have favoured facilities like Manamohan Memorial Institute of Health Sciences and B&C Hospital among others which are backed by UML and Maoist leaders.


This issue is so obvious and important, that Lancet, the prestigious medical journal, has reported on it in Dec 2016. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)32423-0/fulltext?rss%3Dyes

Nepal is a low-income nation with a population of nearly 26·5 million. The doctor–patient ratio is 0·17 per 1000 population—substantially less than the WHO recommendation of 2·3 doctors per 1000 population.1 Nepal has seen a burgeoning of medical institutes in the past 10 years. However, this rapid surge in the number of medical colleges—with increases in fees and corruption involved in student admissions—has not aided undergraduate and postgraduate medical training, deteriorating the quality of medical education.2 The financial motives involved in these private medical colleges have further incurred political meddling, often resulting in disproportionate and unregulated licensing and affiliation to such colleges, which are not instructed to establish themselves in rural areas.2, 3

The increase in private medical colleges in Nepal has been a great source of debate in newspapers and national media.4 The establishment of medical colleges is often highly politicised, but repeated hunger strikes by a philanthropic activist and orthopedic surgeon, Dr Govinda KC, against the unregulated and uncontrolled accreditation of private medical colleges3 have failed to consolidate agreements made in the past. KC’s eighth hunger strike—lasting 15 days—ended on July 25, 2016, with an agreement with the government to establish medical colleges in remote regions, implement the previously drafted Mathema Committee report, abolish medical fees in government medical colleges, and depoliticise academia.3, 4 The agreement, however, is still doubtful, because the government has failed to implement the past seven agreements (from seven hunger strikes), which were breached owing to political tampering from private medical colleges.3, 5

The National Human Rights Commission and the Nepal Medical Association—the umbrella organisation of Nepali medical doctors—showed strong solidarity, and on July 15, 2016, issued a press release showing concern over KC’s deteriorating health and urging the government to honour their past agreements with KC.4

The increase in medical colleges—mostly private and urban-centric—has very little to do with the most remote and inaccessible communities. In a country where 80% of the population lives in villages,1 medical training needs to focus on the rural population. Of the 19 medical colleges in Nepal in 2012, 14 (74%) were private and eight (43%) were in Kathmandu Valley alone, serving only 1·7 million—6% of the total population.1, 6 Of the 11 medical colleges outside the Valley, almost all were based in the cities, largely depriving health care from those living in rural regions of Nepal.6

The growth of urban-centric medical institutes does not come with a golden solution that could regulate norms and policies. The first step to revert this growing trend is to immediately consolidate the Medical Act of Nepal in line with the Mathema Committee report. The second step is to entirely depoliticise medical and academic institutions, enabling them to run under the principles of pure academia and humanitarian service. The third step is to immediately monitor the Nepalese Medical Council and university boards, and bring transparency to their decisions with stringent implementation of the rule of law.

If this is allowed, there is no end to the number of “medical colleges” that can be authorized by politicians. A Nepal MBBS degree will become worthless in the international  scheme of things. Nepal risks becoming known as a “diploma mill” and will be a pariah among the system of migration for doctors to other countries in addition to not meeting it’s won needs for trained doctors.

It should be noted that one privately-owned medical college, the one in Janakpur, is already for sale after years of instability.

Caribbean Diploma Mills

In USA, we are already aware of “offshore” medical colleges operating in small countries that have poor regulation, and rigorous steps have been taken to prevent these graduates from ever practicing in USA. https://forums.studentdoctor.net/threads/caribbean-diploma-mills.1261082/

Is this what potential medical students want in Nepal? Will this help Nepal address the myriad of issues in population health?

The answer is NO. Of course not.

Posted in medical volunteer in Nepal | Tagged , , | 2 Comments

Harrassment of female M.O.s in Nepal, a case study.

Update: got 280 hits in the first eight hours. Please share on FaceBook. Feel free to send anonymous stories about this topic.

At the end of my last blog, I requested readers to send stories about the incidents in which they were harassed or threatened because they were a doctor. Here is one of the replies. A doctor was harassed and it led to an arrest. It is lightly edited – I separated it into paragraphs and changed some punctuation. The write gave me permission to publish it here and I told her I would remove her name and specific reference to location.


“I am working as a MO in _____ Zonal Hospital, ______ since past 4 months on the 2 year bond through DOHS. On 2074/05/06 I along with another female MO, 2 of us were on duty in the ER, at around 11 pm a male in his mid 30’s along with his mother & wife visited the ER bringing their female relative with C/O sudden chest discomfort, was a K/C/O MR referred to Kathmandu from ______ (as far as I remember) who was going to Ktm the next day. While I was attending the patient in the dressing room (because no vacant bed was available in the ER main room) another male MO who was not on duty came to visit me for some personal work & he was patiently waiting at the dressing room door.

“Ever since they came he & his mother were complaining about the sanitation of the hospital & all. He even took pictures of the hospital boasting that he was a journalist of some kind. We kept ignoring them because if we start addressing every complain we would go crazy working here. But when he kept complaining for quite a while our male MO responded politely saying that we admit our hospital is not very clean but looking at the no of patients we receive everyday its not possible to keep it all neat & tidy at that time of night. He angrily replied that its just an excuse & if we aren’t capable of doing so we should just resign & someone worthy will replace us.

“I couldn’t resist so I intervened & said if you have any complain regarding patient care I will address it immediately but about sanitation please report to the administration next morning or being a reporter address it through your channel. Instead of listening he told me to shut up & do my job & brought out his id card boasting about being a radio station manager or something. Our male MO told me I have right to refuse seeing his patient but I didn’t feel right in making the patient suffer because of a foolish visitor like him so I left the dressing room & ordered an ECG.

“He followed me to the ER & started complaining again. I told him not to disturb my other patients he arrogantly replied that the hospital is not my personal property to stop him from talking. I asked one of the HA to inform the hospital police on duty (who usually are around the ER but sometimes go on a stroll within the hospital premises).The so called journalist now told me try not to scare him with police threat & came & sat in the chair inside the ER booth. I handed over his patient to another female MO to take 2nd opinion on the ECG from our on call consultant. I went outside the ER where our male MO was & he again followed us. Our male MO told him to stop creating a scene there but instead he said he would slap him for pointing fingers at him & verbally harassed us. Even his mother & wife couldn’t stop him from blabbering.

“Quite surprisingly all along he didn’t even cared or asked us how his patient was being treated. The hospital on duty police informed the local police & they arrested him while his mother & wife were trying to make him escape. Our another female MO on duty performed the drunkenness examination found it to be negative (no breathalyzer or any blood/urine test available in the hospital). I took a picture of the guy during that time & the police took him to the custody. I was so disturbed after this incident I couldn’t attend a single patient afterwards.

“Next day early morning we were informed he was out on bail by some another journalist who came to the hospital alone as a mediator & was asking us to compromise. We narrated the whole incident to our medical superintendent & he advised us to inform NMA far-west branch. The NMA meeting ended with the conclusion that if he is ready to apologize lets not exaggerate the matter & focus on measures to be taken to prevent such future mishaps.

“Struggling without food & sleep at around 1 pm I finally came back to my relatives house few minutes away from the hospital (as I am originally from Kathmandu & I haven’t gotten a quarter in the hospital yet) I was called to the hospital again for some emergency meeting. I rushed to the administration office but I had no idea that the so called journalist was the one who called the meeting & as soon as I entered he started demanding that I take as much time as I want but I should apologize in written for putting him in custody the whole night, for taking his picture without his consent & for using the word harassment. He was repeatedly demanding to delete his photo right in front of him. I told him I am legally unaware if its wrong to take his picture I ll find out & if it is wrong I ll apologize & delete it later but for mobilizing the hospital police & saying you verbally harassed us I won’t apologize at all.

“He now started accusing me that I am taking advantage of being a female & I unnecessarily intervened while he was arguing with our male MO last night. I told him I have every right to take a stand for my fellow staff. He & his mediator furiously stormed out saying if I don’t compromise he might file a case against me in cyber crime & for defaming him. After he left we decided to have a meeting without him the next day as in 2074/05/08 to decide how to move forward with this. So in today’s meeting almost everyone supported my decision that I should give no any written or verbal apology but I should delete his picture in his presence.& if he is apologetic lets end this matter if not we ll also fight back. Till now no any other response from the another side.

“I am still persistent on the thing that I won’t apologize under any circumstances.

Should we just accept the apology if it comes from him (which I highly doubt) & let it go or take other steps?

Is taking a photo under such circumstance legally wrong?

Is there no such thing as verbal harassment?

Is he just trying to suppress me because I am not a native from here?

Is there anything I should actually apologize for?


I replied via email to say I thought she handled it correctly. She got backup, the administrators got involved early, the police were called and removed the guy.

I will refrain from further commentary because I would like to hear from readers as to their assessment of this situation. How common is it? What to do?

If you wish your reply to be anonymous, send to joeniemczura@gmail.com and I will remove name etc before posting.

Addendum: I do want to point out that in this incident, the male M.O.s seem to have supported their colleague. The incident happened months ago, but we just finished Bhai Tika.  All the males in this story deserve this:

bhai tikaThe male colleagues of this story seem to merit a special bhai tika. sometimes we take this meaning of these ceremonies for granted. Yes, women should stand on their own two feet; but aren’t we all here to help each other?


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#JailWithoutBail is not the only answer

22046705_10207227182116277_3867416075149521485_nThere have been highly publicized episodes of threats and attacks against doctors in Nepal. In September the Cabinet proposed a rule change to put the burden of payment to surviving family firmly on the back of whichever doctor was involved when a patient died. This led the Nepal Medical Association to protest, and hospitals in Nepal were closed for a week this past September.  The cabinet decided to delay implementing any new rule, and (among other things) a committee was formed to study the issue.

the surgery was successful now the doctors are not at riskthe


One idea that zoomed to the top was “JailWithoutBail.” It’s simple. Anybody who threatens or harms a doctor is arrested and brought to jail. Evidently this was passed in Queensland Australia several years ago. There are reports that it has not really changed anything in Queensland, and we will get to those. Even if it is an ineffective idea, time has come for serious consideration. We need to do something. We need a slogan and an easily understood plan.


In a previous blog I called for starting a database, a collection of accounts of all thrashing incidents so we could study them like epidemiology.  In yet a different blog I collected newspaper accounts of thrashings so they could be read all at once. It is clear that most incidents of threats or violence do not make the news and they are not reported. At one specific hospital in Terai I was told they deal with four incidents per day in which families are unhappy, and that it is “part of the culture there” for families to be demonstrative.

We would need a bigger jail. Much bigger. That specific place deals with the problem by having better security – you can’t enter the building without going through security and you need a stick-on badge ( like they do in USA).


It is sad that there would be such a level of adversarialism, but – that is subject for another day. Denial is part of the problem – I was once told by a videshi trekking guide that there was no such problem of violence in Nepal since the Nepalese are gentle Buddhists. I would ask my readers whether they agree?

Types of confrontations and grievances

When I teach in Nepal I focus on critical care skills. Ten years ago when I first started coming here it was immediately obvious that nurses and doctors did not want to get involved and did not have the right skills when they did, so my teaching was designed to eliminate the barriers to participation. I started collecting stories about angry family members, and I have a long list of incidents which is not “scientific.”

  • a pregnant woman is admitted to deliver a baby and dies while in the hospital.
  • a political figure dies at home and the body is brought to the hospital two hours later, along with 400 members of cadre.
  • A family member is brought to the Emergency Room, in a critically ill condition, and the family argues with the doctor when they hear that nothing can be done or that the only alternative is expensive.
  • a person undergoes elective surgery and there are complications leading to death.
  • death of a child after admission to a pediatric unit.

Different response

  • sometimes a family member attacks immediately. right there in the room.
  • sometimes the hospital limits the visitors and sometimes not; not all Emergency Rooms are not “secure” in the same way that in-patient areas would be. Many entrances to the ER and not all are guarded.
  • sometimes they go and get a local political figure from one of the major parties, and then that political person gathers a crowd outside the hospital, demonstrating while the leader negotiates a cash payment to the family, while threatening to unleash the mob. (This becomes a form of extortion. There is no accounting for the proportion of the settlement that is kept by the  politicians. There are reports that two-thirds of the money gets kept by the party). In Terai there was a case where the administrator of a government hospital agreed to a payment, for which no funds were available. He then cut the salary of every employee. The employees went on strike for a week, and the hospital was closed. Other hospitals experienced a flood of displaced sick people who would normally use the government hospital.

I was once told about a small hospital in the western hills where an angry mob threatened the staff after a death in childbirth, and the doctors and nurses barricaded themselves inside for five days waiting for the police to come. Finally the Army arrived and dispersed the crowd after convincing them that the local court system would take care of it. This served as part of the basis for my second book, The Sacrament of the Goddess.

The Role of the Police

I am not familiar with all the ins and outs of justice in Nepal, so I will happily accept correction. But from what I have observed, the local police captain has a large input into settling cases informally. He serves as a mediator, often conducting negotiations on the spot. In many cases, the local police captain is appointed from Kathmandu, not from the area they supervise.

Many of the incidents in which an assault takes place are over before the police are called, or before they arrive. Many hospitals do employ ghar dai, or security guards, but they are gatekeepers, not armed and do not physically intervene as a rule.

In some hospitals I am told, the police were reluctant to come and get involved in such incidents. Clearly the local captains need to be alert to a set of procedures and standing practices so they know what to do when they are mobilized. Regardless of the wording of the #jailwithoutbail law when it is promulgated, the police and APF ought to be able to work out informal ways to make sure every police agency will be sensitive to the problem.

Many of these episodes occur at night when hospitals tend to left with junior doctors while the senior doctors are sleeping at home. I have been told of two incidents where the doctor was kidnapped by a mob and brought some where else. In one of the cases, the family brought the doctor to the police; in the other, the doctor was brought to a dry paddy where he was stripped naked and given a shoe necklace. Fortunately the police arrived in force to prevent him from being burned alive, which was reportedly the nexty step.

One size does not fit all

There are some questions. Is the present system of MBBS training giving the new doctors the skills they need to deal with emergencies? Do they have enough backup from senior doctors? Are they trained to identify situations that are getting out of control?

Do the hospitals have security systems in place? what are they? How often do any of these events actually happen? Should every hospital have an actual police person on duty?

If #JailWithoutBail is adopted, when are the police called? who tells them which person to arrest? who goes to jail and when? do we wait for actual violence to occur? or just the threat? Should it be every family member present who goes to jail, or just the senior male? Should we routinely prohibit local leaders of political parties from getting involved since they tend to be the ones who gather the mob? should they be allowed to get a percentage of the settlement?

Under what circumstances does a family payout get negotiated, and who decides whether the doctor is responsible or not? For example, in some of the cases of deaths during childbirth, the woman may not have done any pre-natal visits to a doctor. Whose responsibility is that?  Should there be a limit on such awards? When a death involves surgery of some kind, is it the doctor’s fault or should the actions of the entire surgical team be investigated? Not all hospitals employ the same standards of care regarding sterility of equipment, training of support staff, or availability of surgeons post-operatively.

Because of the variety of situations that may arise, any #JailWithoutBail law needs to be examined within a larger set of circumstances under which it may be applied.

Tomorrow – part two! the answers!

Write to me

I am collecting stories of thrashing incidents, please feel free to send me a story if you have one. email it to joeniemczura@gmail.com



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