Annals of the Royal College of Surgeons of England (I975) vol 57

The Britain-Nepal Medical Trust Rendering aid to a developing country is a complex activity at any level. Just how a small charity such as the Britain-Nepal Medical Trust should best function is a constant challenge. The Trust recently completed an agreement with the Nepalese Government to provide medical aid for a further 5 years. In financial terms the Trust's contribution is small, with an annual budget of little over £2o 000, whereas other international aid and loans amount to the equivalent of £2om, a third of the Nepalese Government's budget expenditure. In terms of manpower, however, the Trust is able to maintain a team of 14 members, of whom 7 are doctors, at very low cost. For the past 3 years the activities of the Trust have been concerned with tuberculosis and to a lesser extent leprosy control. The prevalences of these diseases are not precisely known, but the impression from hospital and clinical records is that they are probably high. The diseases are found in all villages from the southern plains to the high Sherpa settlements, as well as in large numbers in the main towns. Nepalese health authorities have recently decided to establish a vertical programme to deal with these major health hazards. The WHO and other agencies have advised on and supported schedules for the training of health auxiliaries both for preventive and curative roles. With its field experience the Trust has been able to share in these development projects and accept a supervisory position for the activities in eastern Nepal. Following stimulation and encouragement by members of the Trust, a pilot project was carried out by the Nepalese health author-

ities in a county-size district in the southeastern plains to judge the efficiency of the delivery of the BCG vaccine at the same time as smallpox vaccine by temporarily recruited vaccinators. The results indicated that a BCG cover of over 8o0% of the under- I population was achieved and higher than usual smallpox vaccination and revaccination rates. Field checks confirmed satisfactory vaccination procedures. The project was completed in half the allotted time and at half the estimated cost. The Nepalese Government now aims to extend this method of delivery to other areas in the country. The Trust team of locally recruited vaccinators has continued its mass and maintenance BCG vaccination campaigns, covering two further districts, Ilam and Taplejung, in north-east Nepal and achieving very satisfactory coverage of the under-I5 population. One of these districts, stretching into the foothills of the Himalayas, was tackled during the monsoon period as there is considerable migration from the area during the dry but cold winter months. In spite of the difficulties concerned with communications and supplies and the unpleasantness of the inclement conditions, a high rate of vaccinating was maintained. During this winter season the Trust has been supervising its own combined BCG and smallpox vaccination programme using Government-emploved Nepalese vaccinators. In the hope that its BCG campaign will eventually contribute to a diminution of the prevalence of the active disease the Trust has sought to broaden its treatment services. By March 1974 nearly 3000 cases of tuberculosis had been diagnosed in the Trust's

The Britain-Nepal Medical Trust treatment centres; 8o% of these cases were of pulmonary tuberculosis, many of the remainder being of lymphadenopathy. Treatment with streptomycin, isoniazid, and thiacetazone is given on an outpatient basis. A few inpatients are supported in hostel accommodation. Without sputum culture facilities we cannot be very sure of our cure rates, but by clinical and sputum smear criteria we judge only half of our diagnosed cases to be cured. By western standards this may seem disastrous, but in the Nepalese setting there are various explanations. About 6%/, of our patients die, usuially having presented with very advanced disea-se. Some patients remain actively infected after normally adequate courses of treatment; some of these are likely to have organisms resistant to our drugs, which include only PAS as a fourth alternative. The major factor for the failure of our treatment regimens is temporary or per-


manent default from therapy. At least 2O/o of our patients jeopardize their chances of cure in this way. These problems require better education of the patients, decentralization of treatment services, and the adoption of supervised and shortened regimens. Misunderstanding of western medicine, shortage of health personnel and drugs, the scattered population, and difficult terrain make these solutions difficult to attain. The Nepalese Government has now offered the Trust the authority to supervise the delivery of antituberculosis treatment throughout all its health units in eastern Nepal. This will allow members to concentrate on advisory and supportive roles and a much wider deployment of their efforts. At the same time knowledge will be invested in Nepalese health workers for the future. Leprosy control will be approached in the same way. I A BAKER

Correction We regret that in the article 'SI units: definitions, normal ranges, and conversion factors' in the April 1975 issue (p 222) two errors occurred in Table II. Under 'Expression in terms of SI base units or derived units' the expression in parentheses at the end of the second line should read 'I kg-m s-2, while the expression in parentheses at the end of the last line should read 'i kg m-1 S-2'.

The Britain--Nepal Medical Trust.

Annals of the Royal College of Surgeons of England (I975) vol 57 The Britain-Nepal Medical Trust Rendering aid to a developing country is a complex a...
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