May 22, 2023
KATHMANDU, NEPAL — One morning in 2019, as the sun was gradually warming the lowlands of central Terai, two boys approached 14-year-old Muskan Khatun as she was walking to school and offered her what appeared to be a drink of water. When she refused, they flung the liquid at her and fled. “I felt as if I was sitting on fire and being burned alive,” she recalls. She would later learn that the liquid was acid; it had seared her hands, neck and chest as well as the right side of her face.
Passersby rushed Khatun to a nearby hospital. Birgunj, located in the Terai region, is one of the largest cities in Nepal, 135 kilometers (84 miles) south of Kathmandu, but doctors there did not know how to treat her: They simply bandaged the wounds and didn’t give her painkillers. “Thinking about how I survived that situation feels like a dream,” she says. (Her recollection is based on what she remembers and what her father told her.) Later, an ambulance transported her to Kathmandu, a journey of six hours. Her entire body had swollen by then.
Burns are the second-most common injury in rural Nepal, according to the World Health Organization, accounting for 5% of disabilities. The country has one of the world’s highest incidences of flame-related burn injuries due to the prevalence of open-fire cooking and communities that live in cold and high areas. Many Nepali women wear sarees, with pallus — the loose end — draped over the shoulder, which can also make them more prone to burn injuries. Organized burn care, however, is concentrated in the capital, forcing many to travel long distances.
Nepal has six hospitals with burn care units in Kathmandu and just three in the rest of the country. According to a recent study, 20.3% of the population has access to organized burn care within two hours of travel, 37.2% within six hours and 72.6% within 12. Kiran Nakarmi, head of burn, plastic and reconstructive surgery at Kirtipur Hospital in Kathmandu, says 9 out of 10 of his patients hail from outside the city. “They are all from low-income families,” he adds. “By the time they reach the hospital, 24 hours will have passed and they will not have received first aid.”
Kirtipur Hospital is the country’s largest facility for burn treatment; it is where Khatun was admitted. For half an hour, doctors poured water on her body: Cold water, which absorbs heat, prevents wounds from worsening. Two days later, she underwent her first surgery. Forty-five percent of her body was covered in burns; few patients in Nepal survive such extensive injuries. She was discharged after three months, after which she was required to return every week for follow-up treatment. Back in Birgunj, her father ran an aluminum business, but the commute didn’t make sense. So, the family sold their land and moved to Kathmandu, renting a room near the hospital. In the past four years, she has had six surgeries. Her doctors told Khatun to think of the hospital as her “half-home.”
More than 560,000 Nepalis have sustained a significant burn in their lifetime. According to government health statistics, more than 1,700 people were hospitalized for burn injuries over the span of one year between 2019 and 2020, while 83,660 received outpatient treatment; 89 people died. In Nepal, mortality rates relative to the extent of burn injury are similar to those in the United States in the pre-World War II era, before the discovery of antibiotics. “Since 90% of burn patients are from disadvantaged backgrounds, burns are a neglected topic in our country,” says researcher Kamal Phuyal. “Because the majority of Nepal’s policymakers are upper class, they make policies that benefit them.” In a survey of 100 health center workers, he says, not one was trained in tending to a burn.
Ocean Pun Magar, a medical officer at the hospital in Rukum district in northwestern Nepal, says they “only give antibiotics, put bandages on simple cases and refer complicated cases to Kathmandu.” Rukum is approximately 600 kilometers (373 miles) away from the capital.
Kirtipur Hospital in Kathmandu, which runs as a trust, imparts burn care training at district hospitals across the country. But the initiative, a partnership with Nepal’s National Health Training Center, isn’t bearing fruit. “Doctors don’t want to work in the field of burns,” says Nakarmi, adding that the work is complex and often unpleasant. “There is also a growing trend for trained nurses to go abroad.”
Sunita Neupane, GPJ Nepal
Magar also notes that, in some cases, people assume their wounds will heal on their own. “Patients also apply aloe vera, tomatoes and cow dung to their wounds,” Phuyal adds. “When the wound worsens, they travel to Kathmandu, and spend hundreds of thousands of [Nepali] rupees.” A 2021 study found that the average cost for specialized in-patient burn treatment was 260,270 rupees (1,989 U.S. dollars) — more than double the average per capita income in Nepal.
In September 2022, a landslide destroyed Darpana Budha’s house in Kalikot in western Nepal, killing her father-in-law and triggering a fire that injured her toddler. It took three days to reach a hospital: an army helicopter was summoned because the landslide halted all ground traffic. But this was only the beginning of the family’s ordeal. Budha’s 2-year-old daughter, who sustained burns on both her legs, was repeatedly directed to different facilities. She is currently undergoing treatment at the capital’s Sushma Koirala Memorial Hospital, her fourth facility, and has had 21 surgeries so far. “The bone is burned and pus keeps oozing,” Budha says. “We owe the hospital hundreds of thousands of rupees. We now have no houses or land left to sell.”
Given the prohibitively expensive and prolonged nature of burn care, doctors and other advocates suggest that treatment be subsidized by the government. “It is poor citizens who are most affected, so it is necessary for the government to arrange funds,” says Santosh Bikram Bhandari, a plastic, reconstructive and cosmetic surgeon at Sushma Koirala Memorial Hospital.
Shree Krishna Thapa, program manager at Burn Violence Survivors Nepal, says the charity is lobbying for the inclusion of burns in the Indigent Citizens’ Treatment Fund guidelines. The fund, first established in 2006, provides financial assistance to Nepalis suffering from illnesses such as cancer, stroke and kidney and cardiovascular disease, but burn injuries are not an eligible category.
“Burns fall under primary health care,” says Sanjay Kumar Thakur, a former spokesperson at Nepal’s health ministry (he has since moved on to a different ministry). “All health workers and doctors are trained to perform primary health care. There is no need to refer every burn case to Kathmandu.” Referring to the high cost of burn treatment, he noted that Nepal’s social service unit, which aims to reduce health care costs for those who can’t afford it, operates across all government hospitals. “The government also provides subsidies for that.”
Khatun is 18 now, and she has devoted her life to raising awareness about burn injuries. “My wound became more complicated because I did not receive first aid in time,” she says. She is determined to ensure that no one dies an untimely death because they weren’t treated swiftly or properly. “I used to fear the scars on my face at one point. But these scars now give me the courage to move forward.”
Sunita Neupane is a Global Press Journal reporter based in Nepal.
Sunil Pokhrel, GPJ, translated this article from Nepali.