Nepal

Poor Bear the Burden of Rising Heart Disease in Nepal

Publication Date

Poor Bear the Burden of Rising Heart Disease in Nepal

Publication Date

KATHMANDU, NEPAL – Bhagawati Ghimire, 38, sits on bed No. 136 at the main cardiac hospital in Kathmandu, Nepal’s capital, awaiting her brother’s return. He has gone to get her medicine.

“I have a big operation tomorrow,” says Ghimire, pale and lean, as tears well in her eyes. “But I am uncertain about the result. If I don’t survive, who will look after my three kids?”

It has been 17 days since she was admitted to Shahid Gangalal National Heart Centre, the main cardiac hospital in Nepal. Doctors here told her that two of her four heart valves had failed and must be removed and replaced in a major operation.  

Ghimire, who is from Makwanpur, a district south of Kathmandu, says she’s suffered chronic arthritis, body inflammation and heart pain for the past 10 years. But she was unaware of the severity of her medical condition because she lacked the money and knowledge to seek treatment.

“Poverty, initial negligence of minor heart pain – hoping it will cure itself – and lack of knowledge about treatment consequently led me to this situation,” Ghimire says, wiping the tears from her eyes. “I don’t know how poor people like us will be able to afford treatment.”

The replacement of a heart valve costs 60,000 rupees, $840 USD each, according to the heart center, an exorbitant sum as the average Nepali earns less than $200 USD per year, according to World Vision International, a development and advocacy organization.

Six months ago, unable to tolerate the severe chest pains she was having frequently, Ghimire fainted. Her husband, Shiva Ram Ghimire, panicked and carried her to a nearby health post with the help of a few villagers. The doctor at the health post prescribed some painkillers and referred her to a nearby hospital.

Her husband borrowed money from the villagers to admit her to Bharatpur Medical College in Chitwan, the neighboring district to the west. The initial bill cost about 35,000 rupees, $500 USD, Ghimire says.

“Despite having spent all the borrowed money, the pain was not relieved, and the doctors informed us that the treatment was not possible in Bharatpur and referred me to Shahid Gangalal [National Heart Centre] in Kathmandu,” she says.

She then came to the heart center, where she was told she would need surgery because two of her heart valves had failed and needed to be replaced.

Heart disease is on the rise in Nepal, where many people can’t afford proper nutrition and health care. The disease disproportionately affects the poor, who are often forced to mortgage their homes and land and still fall short of the money needed for treatment. Together, the government and cardiac hospitals have implemented multiple initiatives, such as distributing free heart valves to the poor, but some say they don’t reach everyone and can’t keep up with the rising heart disease rate.

In 2010, Kathmandu heart center surgeons performed 1,400 different types of heart operations, according to the center’s statistics. About 150 people have had double-valve replacements and at least 500 people have had single-valve replacements every year since 1998, when the heart center’s outpatient department was established.

Dr. Arun Maskey, heart center executive director, says that the number of heart disease cases is increasing daily.

“Heart disease is caused due to poverty, changing lifestyle, weight gain, smoking and drinking habits, hypertension, etc.,” he says.

Heart disease is now the leading cause of death in adults ages 15 to 69 in South Asia, where people suffer their first heart attacks six years earlier than people in the rest of the world, according to a February World Bank report.

The report found that this new “health crisis” – marked by rising rates of heart disease, diabetes, obesity and other noncommunicable diseases – disproportionately affects poor families. Living conditions, nutrition, incomes and access to health care haven’t improved as fast as life expectancy has risen in South Asia, leaving many people vulnerable and forcing them to pay out of pocket for care.

Poverty and a lack of awareness prevent many people from seeking treatment at hospitals during the early phases of their illnesses, leading to life-threatening risks such as valve malfunctions and artery blockage.

“Treatment of heart disease in itself is an expensive technology,” Maskey says.

Dr. Sekhar Rajbhandari says the treatments are also expensive at Norvic International Hospital and Medical College, the other major hospital that provides heart care in Kathmandu, where he is a cardiologist.

“Replacement of a valve at Norvic Hospital, including medication and other general expenses, requires a total of 300,000 rupees [$4,200 USD] at the minimum, and the cost may increase as per the situation,” Rajbhandari says. “However, just the replacement of a single valve cost[s] 60,000 rupees [$840 USD].”

Ghimire’s husband is a farmer and they live with their son, 10, and two daughters, 14 and 18, on a small piece of land.

“The small piece of land yields crop that is not sufficient for the five of us for even six months,” she says. “But [it] too has been mortgaged at the village merchant.”

Her two daughters quit school to support the family and currently till their neighbor’s fields to earn money.

“All our money and property has been used up for my treatment,” Ghimire says.

Jagannath Devkota, 56, is another patient at the heart center. Severe chest pain, arthritis and a fever initially made him consult a local hospital. Unable to diagnose his illness, the doctors there referred him to the Kathmandu heart center.

“I got myself checked in different hospitals, but my illness was not diagnosed,” he says.

Like Ghimire, Devkota also learned from the doctors at the heart center that two of his heart valves were useless.

In most cases, it is the two valves on the left side of the heart that fail because they work harder than those on the right to control the flow of oxygen-rich blood from the lungs to the rest of the body, according to the Texas Heart Institute.

Devkota says he cried bitterly at the news – and the cost to replace them.

“I have been informed that replacing the valves and the operation will require 200,000 rupees [$2,800 USD], which supposedly is the discounted rate,” he says. “I am [a] middle-class man who struggles to make ends meet. How will I gather such a huge amount of money?”

Devkota, who is from Pokhara, a city in the region to the west of Kathmandu, has three daughters and two sons. He says his eldest son has gone to the village to request money from family and friends.

“If he manages to collect the money, I will undergo the operation,” he says. “If not, I will struggle with this sick heart [un]til my last breath.”

Meanwhile, the government here has created several initiatives to increase access to care for poor and disadvantaged patients, such as those from the Dalit caste, known here as the “untouchable caste,” by offering free and discounted treatment.

”[The] government of Nepal has managed free treatment to the helpless and poor patients below 15 years of age and elderly people above 75 years,” Maskey says. “Including these, the government has managed the free treatment using PTMC, a system used to expand the narrowed valves without surgery. There is a provision of distribution of 200 valves for free to the poor patients.”

But patients like Ghimire, who received a free valve, still must pay for surgery and other costs because she does not fall into either age group.

The government and the heart center have also joined to offer free treatment to those who travel from different parts of the country and have reference letters from their localities and districts. The provision offers free treatment up to 50,000 rupees, $700 USD, and free distribution of 200 heart valves, worth 60,000 rupees, $840 USD, each. The heart center allocates 10 hospital beds, including food and other accommodations, for the free treatment.

Norvic Hospital is also exploring new technologies. Norvic is the first private sector hospital in the country to introduce a cardiac catheterization lab, where catheters are inserted into the heart for investigative and interventional purposes.

“There is no provision of artificial heart transplant in Nepal,” Rajbhandari says. “However, replacement of both the valves, PTMC and different types of operation are available in Nepal.” 

But despite government and hospital initiatives, some say heart care in Nepal is still insufficient.

Maskey says the distribution of free valves is insufficient because of the increasing number of heart disease cases each year across the country. Devkota says he did not receive a free valve.

“Due to several reasons and limitations, the current services available are not expanded to support the remote villages,” Maskey says.

There also aren’t sufficient statistics on the number of heart patients in Nepal because of a lack of effective data collection on heart patients, money to seek treatment and awareness of heart disease. As a result, many people, especially in rural settings, don’t seek treatment on time or at all, which can be life-threatening. Moreover, it’s hard for the government and hospitals to assess the situation without reliable statistics.

Government representatives say they know the situation is bad.

“The situation of heart diseases and its care is terrible in Nepal,” says Padam Bahadur Chand, Ministry of Health and Population spokesman. “The government has not been able to manage equal and free treatment to people of all ages in all the locations of the country since ours is a developing nation and have limitation with regard to technology and resources to make such facilities available to all.”

Ghimire says the poor are the ones who suffer most.

“The government has not managed to treat poor people like us,” Ghimire says. “How will the poor like me, who fall in the age group between 15 to 75 years, receive treatment?"