Southeastern Nepal’s Big Tourist Draw? Eye Care

JHAPA, NEPAL — Indira Subedi had always wanted to visit her ancestral home in Nepal. Ten years ago, as she was cutting grass at home in the Indian state of Assam, where she was born and raised, a stray blade pricked her eye. Her vision clouded over; blood clots speckled her eye, making it difficult to open. Someone recommended she seek treatment in Nepal, so she traveled to Birtamod, in the country’s eastern district of Jhapa.

Typically, the flow of medical tourism between Nepal and India is in a single direction, from the former to the latter — except when it comes to eye care. According to one estimate from 2016, over 200,000 Indian patients visit Nepal for eye surgery annually and another 1.5 million do so for eye treatment. “The cost of eye operations in Nepal is three times lower than in India,” says Jaya Prakash “Jack” Pokharel, a manager at Mechi Netralaya and Ophthalmic Research Center, a private eye hospital in Kakarbhitta near the Indian border, “which is why Nepal has become the main destination for eye treatment.”

After her procedure, Subedi convalesced at her husband’s ancestral home, in the Nepali district of Dhankuta. It was the first time she had visited Nepal. Relatives embraced her, thrilled at the unexpected arrival. They cried together, overcome because they could finally hold each other in their arms. Since then, Subedi has returned to Nepal again and again, serving as an interpreter and guide for Assamese neighbors seeking ophthalmologic care. In Jhapa’s eye hospitals, according to an estimate by a local doctor, roughly 70% of patients hail from across the border.

In the last five decades, following the 1978 creation of Nepal Netra Jyoti Sangh — a nonprofit devoted to fighting blindness — and a 1981 nationwide blindness survey, Nepal has made significant progress in the field of eye care. Despite an increase in population, the estimated number of people with blindness has declined. The number of ophthalmologists has increased dramatically, from seven in the 1980s to 400 in 2020, whereas eye care infrastructure — including community eye centers, eye departments and eye hospitals — increased from five in 1981 to more than 100 by 2010. In 2018, Nepal became the first country in the region to eliminate trachoma, the world’s leading infectious cause of blindness, as a public health problem.

The country’s success in the field of eye care is partly due to the efforts of one man: senior ophthalmologist Sanduk Ruit, who manufactured a less expensive intraocular lens in Nepal, making it widely available at a price that most people could afford. In the early 1990s, Ruit founded the Tilganga Institute of Ophthalmology, a network of hospitals, outreach clinics, training programs and an eye bank; headquartered in Kathmandu, the institute also manufactures artificial lenses and prosthetic eyes for export around the world.

In Jhapa district, Nepal’s ophthalmological renown reverberates beyond the district’s many eye hospitals. Mechi Eye Hospital, where Subedi sought treatment, was first established as a small center 27 years ago; a decade later, it relocated to a state-of-the-art facility. At the same time across the street, Bishnumaya Subedi Basnet, a local resident, was building her own house. She noticed that out-of-town patients had no place to eat or stay, so she began preparing meals for them. Later on, she decided to transform her house into a hotel. Twenty rooms were not enough, she says. People would sleep in the kitchen and the hallway, and as many as seven sacks of rice were consumed per day.

“Indians are bringing business to all the hotels here,” she says. More than a dozen-and-a-half hotels have now opened in the area, which Basnet remembers as desolate when the hospital was being built. Tulsi Paudel, who has been running one of the new ventures in front of Mechi Eye Hospital for the past four months, says his hotel is never empty. Often, when entire families visit, they also inquire about nearby tourist attractions — nature reserves, water parks, religious sites — that they can visit while the patient recovers.

“Many Nepalis like me must be happy to see Indians coming to Nepal for high-quality eye treatment and to experience financial benefits from them,” says Kedar Sharma, a resident of Ilaam district, which neighbors both Jhapa district and India. The two countries have a unique bond characterized by open borders, he says, but colonial-era infrastructural asymmetries and India’s much larger economy usually compel Nepalis to travel to India for work and other needs, rather than the other way around. The proximity can be convenient, but the skewed dynamic has also led to a collective inferiority complex among Nepalis, he says.

Jamuna Singham, from the city of Islampur in the Indian state of West Bengal, sought treatment at Mechi Netralaya in Kakarbhitta. She says she chose to do so because, while eye care is available in India, the quality of treatment in Nepal is better. It also is quick, affordable and doesn’t require her to return frequently for follow-up visits. (Keeping in mind its cross-border clientele, Mechi Netralaya schedules follow-ups with surgery patients via WhatsApp.)

Moreover, most people in the border regions of Nepal tend to speak Bengali or Hindi, which also attracts cross-border patients. “Every day, 200 to 300 Indian eye patients arrive,” says Pokharel. “Now that the hospital has started an insurance program, Nepali patients have increased as well. They come because they trust us.” In 2016, the Nepali government initiated a social health security program in certain hospitals to improve access to quality health services.

There are efforts to further leverage this trend. Mechi Eye Hospital will soon branch out into treating deafness and other ear problems, says Dr. Yubaraj Bohora. There is talk of turning Birtamod municipality into a medical tourism hub.

Rajeev Krishna Bista, municipal public health officer, says that while the city itself is not spearheading any such initiative, it is keen to assist with implementation if hospitals formulate a plan. “Looking at the patients who come to the eye hospital, there is a lot of potential for a health care hub,” he says. “But since this is a new topic, we are still discussing how to do it.”

Still, even within the field of eye care, continued progress is not guaranteed; and within the country, inequalities persist. A 2018 report by Community Eye Health Journal noted that 37% of the population in the eastern provinces of Koshi (where Jhapa district is located) and Bagmati had access to 60% of eye specialists, while not a single ophthalmologist practiced in the country’s mountainous regions. Ajit Kumar Thakur, a doctor and information officer at Drishti Eye Hospital in Birtamod, says the 1981 blindness survey indicated greater need for eye care in the Terai — that is, the lowlands of Nepal — which might explain the current geographical imbalance in access.

Moreover, experts point out that much of the progress in this field so far has been spearheaded by nonprofits, such as the Nepal Netra Jyoti Sangh, and further advancement may require more robust state support — especially as medical professionals seek greener pastures. A 2010 survey indicated that more than one-third of optometrists and one-tenth of ophthalmologists had moved out of Nepal for better opportunities.

“It appears the government is attempting to implement a policy of conducting eye treatment,” says Bohora, “but it hasn’t been able to fully produce the required human resources or build the required infrastructure.” He pointed to a government decision to conduct eye examinations on all children before they start school — many do not realize they have weak eyesight that can easily be corrected by wearing spectacles — and establishing eye technician positions across local hospitals. “The decision, however, has yet to be implemented.”

Sadananda Bhattarai, information officer for the health ministry in Koshi province, says that while a federal policy has been formulated, plans for provincial-level implementation are not yet in place.

Finally, doctors stress, the country cannot rest on its laurels. Continued innovation is key. “Right now, there are a lot of cataract cases,” says Thakur, describing the type of procedures that are most common at his hospital and in which Nepal has developed expertise. “But in the future, there may be fewer such cases and other eye diseases may emerge — and their treatment may not be as affordable as cataracts. We should consider this right now.”