Nepal is known around the world for its mountains, but its ‘vertical’ landscape is responsible for a disproportionate number of head and spinal injuries. Despite being an appealing tourist destination, Nepal remains an underdeveloped country, with a high number of illiterates and a low income per capita. Subsistence farming is still the main activity in rural areas, and subsistence farmers are the main people at risk of spinal cord injury. The Nepali context makes it clear that rehabilitation needs to consider far more than physical abilities. It has to faciliate the social and and economical integration of the person, and work on his/her emotional state.
As in most developing countries, there is little published data on spinal cord injuries (SCI) in Nepal. The little research that has been done shows that there is a raise of SCI in the last ten years. The picture of SCI in a developing country is quite different than what is found in the western world. The most common cause of spinal cord injury is fall from height, followed by road traffic accidents. Injuries are also on the rise from construction and industrial activities. In comparison, only a negligible number of spinal injury is caused by trekking, climbing or adventure sports.
“the poorer you are, the harder the fall” (Kanak Dixit, founder of the Spinal Injury Rehabilitation Centre)
SCI in Nepal remains a condition that affects the poor population disproportionately.
These people, mainly porters and subsistent farmers, have no understanding of a spinal injury: what it means and what they should do about it. “He was taken by the Eastern wind (spirit)” – that is the cultural explanation for their inability to move parts of their body. The knowledge about Spinal cord injuries is low, if not non-existant. This makes the victim even more in need of special guidance and counseling.
In Nepal, a spinal cord injury is a life threatening. The first challenge is that of ‘discovery’. Rescue carried out carelessly and without transport facilities, becomes messy and traumatic. The victim is often carried on the bare back of a porter or on a wicker basket. The further transport of victims to hospitals is over rough roads which often exacerbates existing injuries. This easily explains the high number of total spinal cord lesions. Ambulances are inequipped. Even if the patient is rescued immediately, it takes up to two and a half days to reach a hospital able to treat a spinal injury.
A person with spinal cord injury faces many obstacles to reach a decent level of independence. This is due to the mobility barriers, unfriendly transport system, stigmatization of disability, social rejection by the community, lack of vocational opportunities and self help groups or advocacy.
The challenge of SCI in Nepal
“Not everything that is faced can be changed. But nothing can be changed until it is faced.” (James Arthur Baldwin 1924-1987)
Raising awareness: The lack of knowledge about spinal injury and its treatment within the population at risk, their economical situation as well as the restricted number of specialized medical care may explain why many patients with SCI are not receiving proper treatment, or tend to break up their treatment earlier than advisable. Rehabilitation often comes at a point where the family has used up all financial resources. Lack of proper rehabilitation with little follow up makes even preventable and treatable complications life threatening. Immobility and poor care leads to renal failure, septicemia or chest infections, usually the main cause of morbidity and mortality of the spinally injured in Nepal. Twenty five to thirty percent of discharged persons die within three years due to various complications after discharge (Scovil, C. 2007).
Developing Rehabilitation Standards: The Spinal Injury Rehabilitation Centre is the only centre specialized in spinal injury rehabilitation. Since its creation, the centre has inspired other institution to care for and rehabilitate SCI victims. In Pokhara, the Green Pasture Hospital and Rehabilitation Centre specialized in Leprosy offers 12 rehabilitation beds for the spinally injured with a comprehensive rehabilitation plan, including follow up through community based rehabilitation. In Surketh, 10 beds are provided for the spinally injured but its rehabilitation is limited to mobility training and medical care. There are three more private neuro-orthopedic rehabilitation centers in Kathmandu, dealing with spinally injured. Unfortunatley most of the facilites limit their services to physiotherapy and medical care. In fact, all rehabilitation facilities are working on NGO or private basis as the government has not been able to provide for the spinally injured. This is why services are few and far between.