An abandoned child with hydrocephalus, a buildup of fluid inside the skull that leads to brain swelling, lies in a crib at the Brahmasthani Awareness Society.
KATHMANDU, NEPAL – Mithila Bishunkhe, a frail 18-year-old, lies on a bed in Tribhuvan University Teaching Hospital in Kathmandu, Nepal’s capital. A flimsy blanket covers her body. Her lips are dry, and her eyes are yellowish.
“I long to see my friends and family, but my wish has not been fulfilled,” she says.
Bishunkhe is from Chisane, a village 15 kilometers (about 10 miles) north of Kathmandu. Her family abandoned her when they could no longer afford her medical care, she says.
Jaya Sharma, a senior nurse at the hospital, says Bishunkhe has chronic critical limb ischemia, a severe blockage in the leg arteries that results in extreme feet or toe pain, and forefoot gangrene, the death of body tissue from lack of blood flow.
“Once I fell ill, I was humiliated and abandoned by all,” Bishunkhe says, sighing. “I felt like I did not have any relative[s].”
Her legs started hurting when she was 11, she says. The pain gradually increased until she couldn’t walk the 15 minutes to school.
After an MRI cost 10,000 Nepalese rupees ($115) and four operations cost 800,000 rupees (more than $9,000), her medical bills forced her father to mortgage their house. This financial stress caused a rift in her family, she says.
“I spent most of the nights alone at the hospital during those months,” Bishunkhe says. “Neither my father, brother nor any relative visited me at the hospital. I thought it was all right, as they were spending so much money on me.”
The hospital discharged her after 18 months, she says. But when her leg pain worsened again, she needed to get another operation costing 80,000 rupees ($920).
“I was looked upon as a burden to the entire family, and my parents decided to kill me instead,” she says.
Bishunkhe says her father and stepmother attacked her after they learned about the additional surgery she needed.
“One night when I was asleep, I was gagged by someone thrusting a cloth forcibly into my mouth,” she says. “But then my 4-year-old half sister saw it and wailed aloud.”
A neighbor heard her sister’s scream and rushed into the house to save her, she says. She decided not to report the attack because her father mortgaged their house for her treatment.
She left her father’s home, but her maternal relatives offered no support. So she went to a Christian church, she says. They offered her housing and funds for semiweekly hospital trips, but that stopped after three weeks. In desperation, she went to Tribhuvan University Teaching Hospital.
She says a security guard and a doctor at the hospital informed her of the Brahmasthani Awareness Society, a nongovernmental organization in Kathmandu. It houses 25 abandoned patients and provides limited treatment and financial aid from its budget of 2.2 million rupees (around $28,800) funded by local and foreign donors.
The organization paid for her operation, she says.
“I underwent a surgical operation with the help of the organization, and I have been in the hospital since 19 days,” Bishunkhe says. “My parents or relatives have not yet contacted me.”
She and Brahmasthani Awareness Society attempted to contact her family, but they did not respond, she says.
Bishunkhe’s father, Ram Kumar Bishunkhe, says he abandoned his daughter because he could no longer pay for her expenses.
“My house was even mortgaged for money for her treatment,” he says. “But her illness was not cured. My small earning hardly meets my family’s basic needs.”
The government’s free care does not cover her condition.
“How can I manage more money for her further treatment?” he asks. “With no other way, I was compelled to abandon her. Since over nine months, I have not been in touch with her.”
Families abandon patients at hospitals, many times because they cannot afford to pay their medical bills. The government expanded in March 2013 its program that offers free medical care to poor patients, though it still does not cover all conditions. Abandonment causes overcrowding at government hospitals, which means others cannot obtain the care they need. Health care professionals ask the government to expand funding for the Ministry of Health and Population, with some calling for entirely free care for all poor people.
Nepal’s estimated population is 26.5 million people, according to the National Population and Housing Census 2011. About 25 percent of the population lives in poverty, according to the World Bank.
Nepal’s government allocates about 7 percent of its budget to the Ministry of Health and Population, says Dr. Baburam Marasini, a senior public health administrator with the ministry.
Rita Kharel, the founder of Brahmasthani Awareness Society, says poverty is the main reason why family members abandon patients at hospitals.
Dr. Rajiv Jha, a neurosurgeon at Bir Hospital, a government hospital in Kathmandu, says that 51 deserted, unaccompanied or abandoned patients arrived at the hospital’s emergency ward from April 2008 to January 2012. But he says there is no comprehensive research in Nepal attributing abandonment primarily to poverty.
At Tribhuvan University Teaching Hospital, family members abandon about five patients each year, says Chandra Kumar Rai, the hospital’s head of the Department of Administration. Some patients’ families desert them after admission when treatment becomes unaffordable.
Some patients, already abandoned by family members, come to the hospital alone, Rai says. Police find other patients unconscious and abandoned on the roadside and bring them to the hospital.
At the Kanti Children’s Hospital, a government hospital in Kathmandu and Nepal’s only children’s hospital, extremely poor families abandon three sick children every year, says Ramesh Narsingh K.C., the administrative duty officer.
Family members also abandon aging parents at the Brahmasthani Awareness Society, Kharel says.
“Sons and daughters too abandon their aged parents at BAS,” Kharel says. “Kindness is disappearing from the society. Old persons are left here, as they can not contribute anything, even if they are cured."
Patients face double abandonment at private hospitals, Rai says. If parents abandon patients at private hospitals, the staff then takes them to government hospitals without notifying personnel there.
Bikranta Jha, a senior administrative officer at Ishan Children and Women’s Hospital, a private hospital located in Kathmandu, denies this. Patient abandonment happens rarely in private hospitals because poor families do not seek treatment at them, he says.
“Government hospitals are far cheaper,” says Bikranta Jha, who is not related to Rajiv Jha. “So poor people go to the government hospitals for treatment, where overcrowded situation facilitates abandonment of the patients. Cases of [private hospital staff] taking the patients to the government hospitals are very rare.”
The government has been expanding free medical care for patients living in poverty, but restrictions still leave treatment out of reach for some. Nongovernmental organizations supplement care to close the gap.
The Ministry of Health and Population established the country’s first free health care policy in 2006 and expanded it in 2007 and 2009, according to the Nepal Population Report 2011. Under this care, Nepal’s poor, destitute, disabled and elderly citizens can receive emergency and inpatient services and access 40 medicines for free at all district hospitals.
This health care policy also provided up to 50,000 rupees ($575) of free care and facilities to any of these patients suffering cancer, heart disease, liver disease, Alzheimer’s disease and Parkinson’s disease, says Mukunda Adhikari, the undersecretary of the Ministry of Health and Population.
Krishna Pariyar, 38, has tuberculosis and says coughing has plagued him since he was 17. The free government treatment covers his tuberculosis medicine but did not cover care for the chronic asthma and lung disease that he has also suffered.
The cost of his treatment caused his whole family to desert him, he says. First his uncle, who cared for him after his parents died, abandoned him because of his medical costs. Then years later, after marrying, his wife and daughter left him.
Pariyar says he went to Bir Hospital after his wife and child left him, but he could not afford the admission costs. Here he learned of the Brahmasthani Awareness Society, which provided financial support that allowed him to obtain oxygen for more than three years at the hospital.
"I came to this place as my family and society left me to be alone without any support," Pariyar says.
The government expanded its free care program in March 2013. It allocated 50 million rupees (about $575,000) to provide poor Nepalese patients free medical treatment for other serious diseases apart from the previously covered five, says Adhikari and Mina Ojha, senior assistant at the Ministry of Health and Population.
But the ceiling for this care is 100,000 rupees ($1,150) per patient. And it does not cover all conditions.
This free care also still requires recommendation letters from the patient’s local governmental office and the district and national medical boards, which can be difficult to obtain, Rajiv Jha says. The letter details patients’ financial difficulties based on their average incomes and property owned by their families. If patients come to a hospital without this recommendation, they either cannot access the free care or they must return to their village to obtain the letter.
"Patients are mostly alone,” Jha says. “It takes about three to four days to get the recommendation letter. During that time, the condition of the patient may turn critical or fatal. In such a situation, how can a patient utilize the free treatment service?"
Overcrowding at hospitals also limits access to treatment. Abandoned patients cause hospital overcrowding because they fill the limited beds designated for the poor, Rai says.
“They occupy the beds for a long time, due to which other serious patients are deprived of the free service,” Rai says. “Healthy children are adopted by others, but it is difficult to rehabilitate the old and disabled patients.”
The number of government hospital beds is inadequate, especially for the poor, Rai says.
Tribhuvan University Teaching Hospital reserves 10 percent of its 500 beds – 50 beds – for poor patients, although at least 100 poor people visit the hospital every day on average. Rai says the government should increase the budgetary allocation for treatment of poor people who do not currently qualify for free care.
The budget allocated to the Ministry of Health and Population during the past year was inadequate, Marasini says.
The Ministry of Health and Population requested more funds from the Ministry of Finance early in 2012, Adhikari says.
The finance minister will announce in early July the full government budget for the fiscal year from 2013 to 2014, including the amount allocated to the health sector, Marasini says.
Hospitals should provide care to all unaccompanied patients, Kharel says. Any hospital’s refusal to do so is denying poor and helpless patients their right to treatment.
“Family and the state should be responsible and humane by helping and loving each other,” Kharel says. “The government should focus on this problem and increase budgetary allocation on the health sector for the poor people.”
She says all care should be free for the poor.
“The government should also provide the services of an attendant to the poor patient free of charge,” she says.
