What are you doing? And why? These sorts of questions tend to be reserved for those times in your life when you’re faced with big decisions like what to do as a medic in overseas mission.

As a newly trained GP, I was attracted to the vision statement of INF (International Nepal Fellowship), a small mission which has been engaged in health programmes focusing on poor people in western Nepal for fifty years. INF’s mission statement is simply ‘to serve the people of Nepal, especially the poor and disadvantaged’.

I could understand the attraction of Nepal. One of the world’s poorest countries open to foreign aid (see Fact Box), yet with the most spectacular mountain terrain in the world. But who are the poor and disadvantaged?

• Laxmi was relied upon to raise the children, keep the household together, and work in the terraced fields. Without basic education, she was unaware of the cause of her progressive ill health, and did not believe effective remedies were within her reach. The clinic was meant to be free but there were no drugs there. When she died, she joined the statistic that the greatest cause of maternal mortality is not childbirth but TB.
• Ram Bahadur had to leave his young family every spring to find paid work with the road gangs in India. He was sent home when he cut his hand painlessly and revealed white patches on his body. He could not return to his village or support his children because he had the ‘maharog’, king of plagues, leprosy. Even trained health workers stigmatised him: he had nowhere to go.
• Surrendra’s grandmother was always coughing around the house, for as long as he could remember, but the witchdoctor could not stop it. He was sad when his baby brother stopped feeding and fell asleep after screaming a while, never to wake up from his TB meningitis. Then his mother took ill, and the crops failed that year, and they all went hungry that winter.
• Vishnu was hand picked as a teenager by her uncle and taken to Mumbai to earn money for her alcoholic father. After 12 months she complained of weight loss and painful black lumps on her skin, and the brothel owner didn’t hesitate to send her back home. Like most AIDS sufferers in Asia, she developed a cough of TB and knew her days were numbered.

TB is the greatest curable killer of healthy adults in Nepal, and AIDS will mostly present with TB here. Leprosy is still endemic, marginalizing victims from society. If, like INF, you are looking for work amongst the poor and disadvantaged, people suffering from TB and leprosy are a good place to start.

The Vision
INF’s Tuberculosis Leprosy Project (TLP) has a vision ‘that the community of the Mid Western Region of Nepal be free of the burden of tuberculosis and leprosy’ To achieve this, the TLP aims to:

• Stop the spread of disease by curing infectious patients (controls tuberculosis).
• Stopping the damage of disease by finding and treating patients quickly (controls leprosy).

TLP, working in Nepal’s poorest and most remote development region, meets this challenge through two types of service: a field programme covering the entire region, and a clinic programme in four area centers, with several supporting units (see box).

INF Tuberculosis Leprosy Project Field Unit: working at district level with Basic Health Services of the government, and at regional level with support units Referral Clinics: (in Ghorahi, Surkhet, Jumla and Nepalgunj): providing back-up referral and follow-up rehabilitation services Information Education Communication Unit: Four health educators working in schools, campuses, community based organizations and mass media. Laboratory Unit: eleven staff on three sites providing quality control of fieldwork and specialist support. Training Unit: 5 facilitators providing nationally recognised courses in TB and leprosy to government health workers. Research and Evaluation Unit: strengthening recording and reporting activities. In addition, the Project has responsibility for the TB and Leprosy drug logistics for the region, and also holds the main database on TB and leprosy cases.

Of course, TLP does not work in isolation. Everything we do is coordinated with His Majesty’s Government of Nepal (HMG) health services. We want to strengthen local health services, not replace them. For example, support is channeled through the integrated Basic Health Services and therefore involves an emphasis on training of Government health staff including the Nepal National Tuberculosis Programme and Leprosy Control Division, thus creating a positive impact beyond the region.

The future
There is still much to do for these ‘poorest of the poor’ in Nepal. For instance, giving patients access to reliable DOTS (directly observed treatment, the most effective treatment approach there is for TB), and developing RPOD (rehabilitation and prevention of disability) programmes for leprosy patients. In addition there is a need to link with the private medical sector, to promote consistent policies and prevent multi-drug resistance.

These activities require resources. Expatriates and qualified national staff are needed. There are currently many vacant senior posts, including a TLP Director. Money is needed for preventative and curative activities, through individual gifts received through INF, and by grants from various donor agencies. Your prayers will enable TLP to continue to serve those we are called to. Join us.

For more information on INF, click here.

Kingdom of Nepal GEOGRAPHY Area 147,181 sq.km. A mountain ringed Himalayan state between China (Tibet) and India. It contains 8 of the 10 highest mountain peaks in the world. Population Ann.Gr. Density 2000 23,930,490 +2.38% 163 per sq. km. 2010 29,715,459 +2.12% 202 per sq. km. 2025 38,010,174 +1.37% 258 per sq. km. Capital Kathmandu1,500,000. The city has doubled in size during the 1990s. Urbanites 14%. PEOPLES Indo-Aryan 79%. 27 peoples. Mainly south and east. Largest: Nepali 12 mill.; Maithili 2.85m; Bhojpuri 1.79m; Tharu(6) 1.29m; Awadhi 483,000; Urdu 261,000; Hindi 220,000; Rajbansi 110,000. Tibeto-Burman 17%. 68 peoples, mainly in north and west. Largest groups: Tamang 1.17m; Newari 892,000; Rai(10) 567,000; Magar 558,000; Limbu 328,000; Gurung(4) 294,000; Sherpa 158,000. Munda-Santal 0.3%. 2 peoples. Other 3.7%. Bhutan refugees 150,000; Indians, Tibetans. Caste groups are important in this largely Hindu society. These are often more important sociologically than is ethnicity. ethnicity. Some groups: Chhetri 3.8m; Hill Brahman 3.1m; Magar 1.7m; Maki/Lohar 1.2m; Yadav/Ahir 1m; Musalman (Muslim) 850,000; Chamar 263,000. Literacy 40%. Official language Nepali. All languages 124. Languages with Scriptures 6Bi 11NT 9por 12w.i.p. ECONOMY An isolated subsistence economy. The terrain is difficult and in habitable regions there is a high population density with rapid deforestation and ecological damage. The development of roads, agriculture and social projects has been slow. Main foreign exchange earners are tourism, agriculture and Gurkha soldiers. Heavily dependent on foreign aid and good relations with India. HDI 0.463; 144th/174. Public debt 48% of GNP. Income/person $220 (0.7% of USA) with 42% living below the poverty line. POLITICS Nepal was never ruled by colonial powers. Political isolation from the outside world ended in 1951. In 1962, the King assumed executive power in a government system with no political parties. Massive civil unrest in 1990 brought about extensive liberalization and multi-party elections. The 1990s were characterized by a succession of short-lived coalition governments in a time of difficulty. The Congress Party formed a majority government in 2000. Poverty and official corruption have been factors in provoking Maoist extremist terrorism in some areas since 1996. The assassination of most of the royal family in 2001 seriously destabilized the country. RELIGION The world’s only Hindu Kingdom. Hinduism is recognized as the national religion, but the constitution guarantees some religious freedom for other faiths. People are free to choose their religion but it is illegal to convert others. Any infringing of this is liable to lead to imprisonment for nationals or expulsion of foreigners. Official religion figures of the 1991 census are suspect with minority religions under-represented. Persecution Index 42nd in the world. Facts & figures from Operation World 21st Century Edition, by Patrick Johnstone & Jason Mandryk, Paternoster Lifestyle Publishing, ISBN 1-85078-357-8