Telemedicine in Nepal during COVID-19 [PODCAST]

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“Currently working in a COVID ICU in a tertiary center in Kathmandu, I have experienced how difficult it is for the health system to manage the patient load. A month ago, ICU beds were fully occupied, ventilator alarms would set off time and again, indicating low flow as the hospitals faced shortages of oxygen supplies, emergency rooms were over-occupied, and patients waited in queues to receive oxygen or just to be checked up by a doctor. At such a desperate time, telemedicine is a noble initiative. I thank my patients who taught me more than just mere medical knowledge and my dedicated fellow volunteer doctors who teamed up in this project to help the nation in these dire times.”

Astha Prasai is a physician in Nepal.

She shares her story and discusses her KevinMD article, “Telemedicine in Nepal during COVID-19.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Astha Prasai. She is a physician in Nepal, and she wrote the KevinMD article “Telemedicine in Nepal during COVID-19.” Astha, welcome to the show.

Astha Prasai: Thank you very much, Dr. Pho. I am very thankful to you for providing me this opportunity and allowing me to share my story.

Kevin Pho: All right, and we’ll get into your article in a little bit, but first off, can you just share your story and journey to where you are today?

Astha Prasai: I’m Dr. Astha Prasai. I’m from Nepal, originally from Kathmandu. I graduated from Kathmandu Medical College, and I have served for two years in a rural region of Nepal. During the COVID pandemic, I have been working in a tertiary hospital in Kathmandu, and I have been a part of volunteer doctors since April, May. I’m providing telemedicine service to people all around Nepal.

Kevin Pho: Tell me about some of the challenges that you face working in Nepal. Tell me about some of the patients that you see and some of the settings that you practice in. So what’s it like to practice medicine in Nepal?

Astha Prasai: Practicing medicine in Nepal is unlike something that we read in textbooks, because we sometimes do not get to do every laboratory investigation that we need to do, and we have to sometimes rely on the history and physical examination. Moreover, Nepal is a geographically diverse country. There are populations living in difficult terrains, and often health care accessibility and affordability is a struggle for many. We as physicians have to take everything into account: the economic aspect, the emotional aspect, and the risks and benefits in every part of our medical practice to provide service.

However, it is always an opportunity to learn something new. I have worked and served in a rural region of Nepal, and I’ve also worked in a tertiary center, and I feel glad that I’m able to learn a lot during my journey. I also look forward to learning even more during my practice, and I also thank my patients for always allowing me to learn something new.

Kevin Pho: Now, over the past almost two years now during the pandemic, can you share some stories, case studies, and your experiences about how the pandemic has affected the patients that you’re seeing in Nepal?

Astha Prasai: As I already said, Nepal is a developing country, and there are many people living below the poverty line. When it comes to the pandemic, there is a kind of crisis, not only health-wise but also economically. There are families who depend upon their daily income for their living, and when the country all of a sudden goes into lockdown because of the pandemic, they are not able to provide a living for themselves and their families. Often there are health disparities, because not everyone is able to access health care.

Moreover, when we talk about isolation and quarantine measures, it’s very easy to put into words or say to someone, “Please stay in isolation.” But there are families who share a single bedroom. There are four or five people sharing a single room, and in such a condition, it’s difficult to maintain isolation. Besides that, there are several other aspects that we need to take into account, and it has really been very difficult to implement everything to mitigate or break the COVID-19 transmission during this pandemic.

However, we, a team of volunteer doctors, felt the need that we needed to do something. During May, we started this telemedicine service. There was an overwhelming burden on the health care system. I was working in the tertiary hospital, and I realized how difficult it was for the hospital to handle the flow of patients. There were patients and families waiting in queues just to be checked up, just to be seen by the doctors, and hospitals had to unwillingly deny admission and unwillingly deny care. The patients and families were desperate. They had no option but to take them to their home. During those difficult times, we teamed up together to provide telemedicine service.

What I felt during my journey is that telemedicine has been there for the past few decades, but we have not emphasized its importance enough. That is what I feel, because through telemedicine, I believe that we can improve the accessibility and affordability of care. We can reach and provide health service to people living in every nook and corner of the country. Some people live in communities where they have to walk for hours to receive health care. There is also misinformation and stigma all around, and telemedicine can be a very strong tool, a very effective tool, to not only provide health care service but also spread health information, provide emotional support to the patients, and raise vaccine awareness during this time. So I’m glad that I was a part of the team, and I believe that we will be able to expand and extend this telemedicine service even more.

Kevin Pho: And you talk more about your experience in your KevinMD article, “Telemedicine in Nepal during COVID-19.” Now, please go into a little bit more detail about the workflow of telemedicine in Nepal. Would it just be audio only? Would you have any video component to it where you could see the patient? Tell us a little bit more about the workflow and how telemedicine worked in Nepal.

Astha Prasai: Mostly we use the phone. There are hospitals who also utilize video, but in our context, not everyone is able to have internet access. However, there is at least a phone in a family, so we utilize the phone as a medium of communication.

At first, I would like to share how we started out and how we went through all this. Initially, when we came up with the idea of providing telemedicine service, we thought that the phone would be the best method of communication. We received authorization from the Ministry of Health and Population, and they also helped us publicize. Initially we publicized through social media, but later we realized that we were not able to reach a large population, because not everyone uses social media here. There are elderly populations who do not have technological literacy, so we began to publicize later through radio and television, and we used to have early morning shows for the first few days. We then began receiving calls even from elderly people, and out of 77 districts, districts are the geographical units of Nepal, we were able to provide service to 57 districts of Nepal.

To date, as we look back and analyze the data, we found that our outgoing calls were more than the incoming calls. It shows that we were also constantly following up the patients. Using a phone was a very easy medium, though there are certain challenges, because we are not able to see the patient. We are not able to physically look at the patient and look at how the patient is. But we had no other option, and however, I feel that we were able to at least utilize our knowledge, and using the phone as a medium of communication, we were able to serve during those desperate times.

Kevin Pho: So tell me, what are some typical or common cases that you could address over the phone? Because as you said, you are pretty limited. In a lot of cases, you can’t even see the patient. You can’t perform a physical exam. Tell me what kind of typical cases you see that you could help patients with just over the phone.

Astha Prasai: Most of the calls that we would receive would be from people who were in isolation and were curious about what they could do in isolation. There has been a tendency in Nepal to randomly desire to use antibiotics, and I think via telemedicine, we were able to regulate the use of antibiotics, at least tell people that it’s not a bacterial disease but a viral disease, and antibiotics need to be used only when unnecessary.

Besides that, we would also sometimes receive calls from patients and families who would desperately request us to arrange hospital beds and arrange oxygen. However, it was not possible to do that, because we already had a shortage of hospital beds and oxygen supply. That’s why we had started the telemedicine service, to look after patients at their home distantly. However, we had made a list of phone numbers, and we would provide contact information to those families so that they could contact local persons, and whenever any bed was available in any hospital, they could transfer their sick family members to the hospital. We also made sure during our follow-up that the severely ill people were transferred safely to the hospital and were receiving appropriate care.

Besides that, we would also receive phone calls from people who were curious about vaccines, because initially there was misinformation regarding vaccination too. We could hear people saying that they were afraid of receiving vaccination because they had heard about many side effects, about blood clots and many side effects, and we were able to raise vaccine awareness through our telemedicine service. Besides that, small, minute pieces of information that could help them isolate and prevent transmission to others, we were able to provide that information too. We had made an official Facebook page where we would post information that was provided by the government, and we would ask them to also refer to those official websites.

Besides that, we would also receive requests from people to look at their investigations and lab reports. For that, we had provided an email address, and we had also asked them to provide their lab reports to our official Facebook page. We have a separate page known as HFN Technology Health, and they would provide that information, and then we would do the follow-up. So these were the calls that we would receive.

Besides that, I forgot to mention, we would also receive calls from people who just wanted to share their stories, wanted to share their fear and confusion. I even received calls from people who were in isolation for more than a month, because they felt very embarrassed. They were hesitant to break isolation. They did not have symptoms, and according to the guidelines, they clearly could break isolation, but they had that fear. They were emotionally very stressed, mentally very stressed, and they were not willing to break the isolation. So we also received calls from such people. That made us realize that it’s very important to also focus on the emotional health and mental health of people while also taking care of their physical symptoms. So yeah, these kinds of calls were basically the ones that we would receive.

Kevin Pho: We’re talking to Astha Prasai. She is a physician in Nepal, and she wrote the KevinMD article “Telemedicine in Nepal during COVID-19.” Astha, we’re speaking in the middle of August. Tell me, how difficult or easy is it for a typical citizen of Nepal to get a COVID vaccine?

Astha Prasai: It’s very difficult, so to say, because vaccine availability is a problem, number one. Number two, as I already said, there is misinformation circulating around. But with time, as people are aware that it’s important to be vaccinated, we do not have enough vaccines. There are people who have received just the first shot and are waiting for the second. There are many people who have not received the vaccine yet. Initially the frontliners were the ones to receive the vaccine, then the elderly population, and now even the younger population. But some are hesitant, and some want to get the vaccine but are not able to, so the vaccine coverage is not what we had expected.

I also think that there is a kind of disparity, because as we compare, there are developed countries who are doing trials on whether or not we need a booster dose, whereas there are some resource-limited poor countries, or developing countries like ours, who are still struggling with vaccination. While we talk about the public health measures like testing, tracing, or, say, isolation and vaccination, which are very important in order to break the chain of COVID transmission, in our part of the world, or in a country like ours, it’s very important that we try whatever is possible to uplift the health system in order to break the chain of transmission. In terms of vaccines, the condition is still, I would say, miserable.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Astha Prasai: The COVID-19 pandemic, in fact, has shattered the world in every possible way, and we are trying to rise from the ruins. However, it’s important that we uplift each other. While the government and the world as a whole are trying to overcome this miserable crisis situation, even from the individual level, I think we have to put in our effort. Even the public has to understand the importance of using masks, social distancing, and all those measures, and help each other in this time of crisis. Together we can overcome this, and we can fight this battle together.

Kevin Pho: Well, thank you so much for joining me, and thank you for sharing your time and insight.

Astha Prasai: Thank you very much.

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