KATHMANDU, NEPAL -- The dialysis machine at Bir Hospital, the country's oldest hospital, runs constantly.
Chunni Deuja, 34, is lying on a bed with three other patients. Sometimes she wiggles uncomfortably in the tight space. Sometimes she moans aloud. Two needles peek out of a blood vessel near the wrist of her left hand. The needles, one to capture the impure blood and the other to return the blood after purifying it, are attached to the whirring dialysis machine next to the bed.
Deuja has been suffering from kidney disease for the last three years. Both of her kidneys are damaged. She has been undergoing hemo-dialysis, a process which purifies blood with an artificial kidney for years.
Deuja visits Bir Hospital twice a week at a cost of 2500 rupees, or $35, per visit. “I’ll have to undergo this treatment until my death and now I feel it is better to die than continue this [dialysis],” she says from her hospital bed.
Deuja says she has always had minor health problems. As a young girl she often suffered from headaches, stomach aches and dizziness. But three years ago she began having severe abdominal pain, breathing problems and high fevers. Her husband, Madan Deuja of Bhaktapur, a central district near Kathmandu, brought her to Gangalal Heart Disease Center at Kathmandu. The doctors at the hospital informed her that both her kidneys were damaged and she would have to undergo kidney dialysis for the rest of her life. The cost of the dialysis has left Deuja and her husband in a desperate financial state with no end in sight.
Limited Facilities and Limited Solutions
In the last decade, kidney-related health problems have emerged as a major healthcare issue in Nepal. While hospitals here offer no integrated data about the number of kidney patients in Nepal, the National Kidney Center estimates that as much as 10 percent of the population, 2.6 million people, are affected by some kind of kidney disease. Recent data suggests that as many as 3,000 people die from kidney failure every year in Nepal.
Data collected by The Press Institute from several hospitals in Nepal suggest that the number of kidney patients is on the rise.
According to Bir Hospital, the number of new kidney patients rose from 97 in 2002 to 179 in 2007. This data, the most recent available, includes both acute kidney failure, which can be treated with medication, and chronic kidney failure, which requires transplant or dialysis.
Similarly, records from Tribhuvan University Teaching Hospital, TUTH, show that the number of kidney patients rose from 135 in 2005 to 263 in 2007.
Dr. Rishi Kumar Kafle, a senior nephrologist at TUTH and president of the Health Care Foundation says the National Kidney Center conducted 724 dialyses treatments between 1997 and 1998. And in August of 2009, the center saw more than 1,500 patients who required dialysis.
While the number of kidney and dialysis patients is on the rise, the number of treatment centers, however, remain few. Of the eight facilities in Nepal that do offer dialysis and other kidney treatments, the cost remains prohibitive for most Nepali people. “Every year about 25,00 people suffer from kidney damage in Nepal for which dialysis is a must. But we can only provide the treatment to about 100 people,” Kafle says.
While dialysis services are limited in number, they are even more limited in terms of geography. Nearly every major facility that provides kidney treatment is centered in Kathmandu. Among the eight dialysis centers at Nepal, only the B.P. Health Institute in Dharan, an eastern city, are in the capital.
Treatment Costs Remain Prohibitive
Like many kidney patients, Deuja and her husband have spent all of their money and sold all of their property in order to afford her three years of twice-weekly dialysis.
Deuja's husband has a good job in the marketing department at a private firm in Kathmandu. He earns 6,000 rupees, or $81, per month.
But his income is not nearly enough. The dialysis, medications and hospital fees that keep Deuja alive cost up to 40,000 rupees, or $540, per month. (Dialysis alone is about 20,000 rupees per month.) Deuja's husband says they have taken loans from friends, family and neighbors. In total they have spent more than 1.1 million rupees on Deuja's treatment. “I have nothing left now,” he says.
“Since I couldn’t live without dialysis, I had to do it. But how long will I live this way?” she asks.
“Dialysis and transplants are the most essential treatments for kidney patients. Unfortunately, not many in this country can afford them,” says Dr. Kafle.
Government Restrictions Hinder Transplant Progress
The reality of kidney treatment here is bleak. Not only are there few centers that provide dialysis at prohibitive costs, kidney transplants – which are often the best solution for kidney failure – were not available in Nepal until December of 2008 and remain difficult to obtain. Only 16 transplants were recorded in 2009. There is conflicting data as to the success rate of these transplant surgeries.
Kidney patients still commonly go abroad to receive a transplant, though doctors say that too is rare given that more than 80 percent of the people here live in extreme poverty and would not be able to afford a transplant in India or China.
Though not widely available in Nepal, doctors here agree that transplants are the best solution for patients with kidney failure. Dr. Sudha Khakurel, chief of nephrology unit at Bir Hospital says, “Dialysis, at best, can only serve as a temporary solution to the problem. Though, a patient can survive on dialysis, the ultimate answer is transplant.”
Nearly twelve years after the parliament here enacted the Human Organs Transplant Act, the surgery is still not widely available. “"The government's law is difficult and cumbersome,” says Dulal.
Under the current policy, organs can only be donated by a close relative and if a kidney donor dies within three months of the transplantation, the doctor who carried transplantation can be charged with murder.
“Patients are paying very high cost in India and if the service were available in Nepal, patients would get services at lower cost,” Dulal said. The rise of a black market organ trade has further stalled any progress for legitimate medical transplants.
Dr. Ram Prasad Shrestha, director of Bir Hospital says dialysis costs about 20,000 to 30,000 rupees per month, about $330. According to statistics from the World Bank, the average Nepali family of five earns just $1100 per year. “The cost involved in dialysis is very high,” admits Shrestha.
With dialysis an unrealistic and unaffordable long term solution, doctors here say despite the availability of trained surgeons, and necessary medical within the country, kidney transplants are still not widely available here.
Nephrologists throughout Kathmandu say they blame poor policies and laws regarding organ transplants. Dulal of the National Kidney Center says, “We have enough human resources and infrastructure for kidney transplant, but the government is discouraging transplantation of body parts.”
Still, poverty remains the primary barrier in providing care for kidney patients. Even if the transplantation services are made available, most Nepali people suffering from kidney disease will still not be able to afford access to the service. Khakurel of Bir Hospital says, “The government has not been able to do much for the kidney patients who are living on dialysis.”
Kidney patients also agree that the government should take initiatives for their treatment. “We have to go abroad for a kidney transplant. I cannot afford it, so how will I survive in this situation?” asks Deuja.
Despite the criticism toward the government for the perceived indifference to kidney patients, government officials say they are committed to providing the necessary services.
“We are aware of our responsibilities. We are committed to improving the facilities and budget at the government hospitals like Bir Hospital,” says Padam Prasad Pokhrel, Secretary at the Ministry of Health. However, Pokhrel declined to answer questions about the government's plan of action to initiate kidney transplant facility in Nepal.
Pokhrel says the ministry provides financial assistance of up to 30,000 rupees, or $405, to kidney patients.
Patients in the nephrology ward at Bir Hospital agreed that getting that the aid, while a temporary relief, did little to assist with their overall care. In addition, many patients, including Deuja, say it took weeks of haggling with ministry officials before she was paid the 30,000 rupees – which covered only a few weeks of her care.
