Nurse lecturer Ann-Marie Dodson reflects on her ‘busman’s holiday’ in Nepal and the inspiring people that she had met on her journeys through the Himalayas.
May is a special month for many nurses as 12 May is International Nurses Day. I usually make a special effort to do some fundraising for Cavell through a challenge or volunteering.
However, May is also very significant in the mountaineering community, as Sir Edmund Hillary and Sherpa Tenzing Norgay were the first to summit Everest (Chomolungma or Sagarmāthā) on 29 May 1953, the news breaking in time for the late Queen’s coronation).
There maybe a few who can say that they can meld their passion for nursing , love of mountains and concerns for climate change. I can through my in person connections and Twitter connections.
“My life changed when I first went to Nepal. I want to give back as much as I have received”
This opinion piece will focus on Nepal and demonstrate how social media can bring like-minded people together, with contributions from two special people from my twitter community: Pramesh Pradhan in Nepal, and Mark Morrisey in Australia.
It will discuss how skills and interests are transferrable and can lead to good world citizenship and how an understanding of other countries’ religion, politics and socio-economic status helps our understanding of other cultures adding to our cultural competence as a nurse in the UK in our daily working lives.
It will conclude by discussing soldiers from the Gurkha regiment, Diwash and Jay Rai from the same tribe, who are re-training to be nurses at Birmingham City University, where our military second their staff to undertake their pre-registration nurse training.
I first knew I wanted to nurse at the age of four. However, my parents, school and GP felt I was too frail with severe asthma to go to my chosen convent school with a considerable commute.
So, I was educated at the local girl’s grammar school, where nursing was viewed as an occupation rather than a profession. Being a nurse was seen as a “waste of a good education”.
I am sure many will be familiar with this back story, alongside the lack of understanding of what nurses actually do.
The pandemic shone a light onto how crucial nursing care is. Nursing is such a rich and varied career requiring so many of the skills of a mountaineer.
These include psychological and physical strength, resilience, problem-solving, critical decision-making, risk assessment, courage, good planning and organisational skills, ability to lead, awareness of self and managing health to name a few.
So, I had to chose an alternative path, which was a geography degree, become a school teacher and aspire to become a mountain leader.
However, a summer job in a hospital for older people, gave me the courage to stand up against my parents and go with my heart. I never looked back and changed careers. It was my vocation.
It has allowed me to meld my nursing skills with those that I need to be able to be to function and be safe in remote environments, and contribute to educational, health and environmental issues outside the UK.
It was 2008 when I was able to go to Nepal for the first time. My love affair began with what is now my spiritual home. I have visited the Himalayas almost every year since, until the pandemic.
Nepal is land-locked. It lies in the Himalaya, which is the highest and most extensive mountain range with eight of the 10 highest mountains in the world.
It is bordered by several countries whose borders are politically and militarily sensitive, with roads are being developed across Nepal from China to India.
The area is still geologically active, growing by approximately two inches (5cm) a year and subject to natural disasters such as earthquakes and landslides, as well as the impact of the annual monsoon and global warming, with glaciers retracting at an ever increasing rate.
The country is still recovering from the massive earthquakes in 2015. The mountainous areas are sparsely populated but are the magnet for climbers and mountaineers across the world but mainly confined to the Solukhumbu and the Sagarmāthā national park.
Tourism is a major contributor to the economy which brings challenges as well as benefits to the economy.
The “middle hills” contain the Pokhara and Kathmandu valleys, with flatter land being at a premium and where over half the population live.
At higher altitudes, the alpine-like landscape gives way to tundra and glacial moraines. It becomes uninhabitable during the long winter season, so there are seasonal movements of indigenous peoples and visitors up and down the mountains.
Nepal is extremely reliant on tourist income and “remittances” from those Nepali’s working abroad. The low lying tropical savanna, the “Terai”, is the main agricultural land.
Many of the plants that we have in the UK, such as rhododendron and viburnum, were brought from here by Victorian explorers.
Knowledge of the geography and the challenging terrain helps understanding of how the difficult environment impacts on the ability to govern such a country and the socio-economic constraints on the health of the Nepali people.
Politically, the monarchy reigned until 2008 when the Communist or Maoist party founded the Federal Democratic Republic of Nepal.
In the years that I travelled there, I have seen improvements in the infrastucture, education and health. Although literacy rates are improving, only half complete their education.
That said, Pramesh is typical of the people I have met, being highly educated and motivated. He holds three degrees, starting with business administration but later an MA in sociology and anthropology.
He works predominantly as a guide for tour operators and diplomatic missions, which he needs to be certified (and has studied event management ) and speaks five languages.
This necessity to diversify and have several jobs is not unusual. The millions working outside of Nepal in Malaysia, Qatar, UAE and the UK, for example, will send “remittances” to support their families.
Those families that own lodges and tea-rooms in the Solokhumbu near Everest are comparatively rich, especially the climbing Sherpa and “ice doctors”, who lay down the ropes and ladders and establish the camps, particularly for the Everest climbing season on the Khumbu ice fall.
This is incredibly hard and dangerous work, with a high mortality rate and short working life. Nepal has a high rate of unskilled labour, with many still living in what the World Health Organization describes as subsistence farming.
There has been a huge move away from wood as a fuel to solar, hydro and wind power. In 2020, the World Bank listed Nepal as the 6th poorest country in Asia.
This is the same as patterns observed in Europe with the Industrial revolution, where there was is an on-going mass migration and overpopulation of the Kathmandu and Pokhara valleys.
The infrastructure is inadequate to support the demand of the populous, leading to consequent poverty and homelessness.
Young people move from the harsh mountain life, leaving their elders to cope alone, which threatens traditional Nepali lifestyles with their focus on the extended family.
When reviewing the health needs of different populations, I find it is useful to refer to the GDP (gross domestic product), the infant mortality rate (IMR) and the (MMR) as a minimum data set to be able to compare different health systems.
For consistency, I use World Bank data. However, it must be remembered that data may not be accurately recorded or contemporaneous. I am more interested in trends. In 2020, there was a decline of GDP of 4% per capita in Nepal.
The pandemic reached Nepal later than in the West, as those working overseas, or as migrant workers outside Nepal, returned home with the virus. It took time to reach more remote mountainous areas, as many had to travel by foot for weeks.
Pramesh says: “It is usual for an impoverished and dependent country like Nepal to be hard hit. It was an acid test for Nepal’s health system, economy, and people’s resilience. The effect will get not yet be over and would take a few years to fully recover.”
As a % of GDP spending on health (in US dollars), Nepal’s GDP was 5.17% compared to the UK’s 11.94% in 2022.
Although there is a limited health budget, overall life expectancy is improving in Nepal (WHO 2012). However, there are still major differences with health indices from Nepal and those of the more developed world.
For example, regarding maternal death rates in 2016, there were 250 maternal deaths for every 100,000 live births compared to eight in the UK. The IMR in 2021 was 23 infant deaths per 1,000 live births nationally with four in the UK.
Due to malnutrition, children under five have reduced or stunted growth. A high level of goitre – swelling of the thyroid gland – is seen in some areas. I have met children who walk for nearly two hours to school and exist on one meal a day.
Endemic disease is apparent, which includes diarrhoea (cholera and dysentery) parasites causing visceral leishmaniasis; leprosy and tuberculosis, not helped by poor sanitation and having limited access to a tap or piped water which can be of poor quality.
In recent years, with the increase of international contacts and tourism, sexual health problems have increased, as more casual sexual encounters occur and society becomes more secularised. Sexual trafficking and prostitution have increased, as has HIV.
Other health related problems include drug addiction and alcohol misuse. Some of this is thought to be due to societal changes and poverty adversely affecting mental health.
In the high mountains, where it is only possible to live some of the year, I have seen different disease patterns such as respiratory disease from the cold, altitude and dry air.
Cooking in poorly ventilated areas, inhaling smoke and kerosene fumes, and peoples from all over the world coming in from the cold and huddling around a stove burning yak dung have a deleterious effect on the lungs.
Germs spread easily is such environments. A case in point was when Nepali soldiers supporting the UN humanitarian efforts during the Haiti disaster in 2010 were accused of spreading cholera. Hypertension is also notable perhaps due to chronic hypoxia and diet.
There are 8.9 nurses per 1,000 of population in the UK, whereas there are 3.3 in Nepal (World Bank 2020), which is increasing.
It is supplemented by auxiliary nurse-midwives (ANM) which requires an 18-month training focusing on primary care, midwifery and reproductive health. An ANM is a lifeline in rural remote health posts.
When Ed Hillary returned from Nepal after his successful summit attempt, he vowed to return to Nepal to improve the conditions of the mountain people. He set up a Himalayan Trust in New Zealand .
There are now branches in the UK and Australia. Associate adjunct professor Mark Morrisey supports and fundraises for the Australian Himalayan Foundation (AHF) and volunteers with Action for Nepal, after visiting Everest base camp over a decade ago with his son.
He, like me, recognised the special qualities of the people, saying that “the Sherpas and other locals were our steadfast companions, providing unwavering support and guidance throughout our journey.
“I knew that in their hands, we were safe from harm and that they would do whatever it took to help us in a crisis.”
He too has undertaken extra qualifications and learning in “remote area nursing”. Mark shares his child protection and safeguarding expertise by training staff in AHF.
He has helped establish a health post and birthing centre in Waku. I support the UK branch of the Himalayan Trust and the Nepali NGO REED Nepal.
When Mark and I visit Nepal, we pay for ourselves and our services are “pro-bono”. It is important to comply with the law and, if working, obtain the correct visa and permissions.
The Nepalese government are reviewing the registration, work and outputs of NGOs. There are organisations and individuals who have abused their positions, taking money for themselves and exploiting children in orphanages.
I am personally aware of death threats when communities feel it is unfair, when some villages are supported financially and developmentally, and others are not.
Our main role is fundraising in our home country but as small charities, sadly the needs of a whole region cannot be met, although some of the innovation and project work will be implemented by the government across Nepal.
As I am a nurse and educationalist, I can give my time as a “consultant” pro-bono” to evaluate how the charity’s money has been spent and help assess the healthcare needs of a village.
The community leaders and teachers will meet with HT-UK and REED to give a wish list of improvements that are needed. This can range from a fence around the school, to water or electricity in a health post.
Pramesh is also actively involved in safeguarding and child protection. For example, training and educating the police. However, he has shared his expertise as far as the US.
He says: “What I have helplessly seen during my childhood drove me to commit to children later. As a child protection activist for more than two decades, I feel happy when I can, even if it is small, contribute to children.”
“Although undoubtedly we have a grave shortage, recruiting internationally has ethical implications”
Finally, I need to address the shortage of men in nursing. The current registered nurse vacancy is 15.7%, which is slightly lower than in 2022, with an increase of 3.37% of nurses on the register. But there is also an increase in nurses leaving the profession (King’s Fund, 2023).
Of our 705,000 nurses, only 11% are male (NMC, 2023), although the Nursing and Midwifery Council, Health Education England, universities and careers services do their best to promote men in nursing and midwifery.
Only 4% of registered nurses come from the EU and hospital trusts, especially, are actively recruiting from India and Nepal.
Although undoubtedly we have a grave shortage, recruiting internationally has ethical implications, as it takes nurses away from countries that have many fewer nurses and underdeveloped healthcare systems.
Although strides are being made in terms of diversity, inclusion and representation, this is not the case with nursing in particular.
In relation to men in nursing, it is said that “nursing is one of the most gender-segregated jobs in the UK (NMC, 2022).
As a nurse teacher, it would not be fair to have favourites but when I meet students from Nepal there is a real connection, because I have some understanding of their roots and culture.
I have also worked with military nurses clinically or as their personal tutor. One became my manager after leaving the Army.
I have also completed mountain leader’s rescue and emergency care in remote areas alongside them.
There are 126 different ethnic groups in Nepal. The “Rai” are one of them and when meeting nurses in Nepal many of them are “Rai”.
Student nurse Diwash Rai is a 30-year-old from the Solokhumbu, who enlisted in 2013 in the Brigade of Gurkhas in the British Army and was a logistics supplier for seven years.
“I decided to become a military male nurse in the Queen Alexandra’s Royal Army Corps (QARANC), because it suits my compassionate personality.
“I have always enjoyed helping others, and nursing allows me to make a significant difference in someone’s life. I considered this career, which would enable me to continue my education and learn and develop new skills.
“I was really passionate about pursuing a nursing career, which is an exciting profession with tremendous growth, advancement, and great graduate prospects.”
Diwash is now a second year student nurse and will visit his family once his training is complete.
Jay Kumar Rai joined the Brigade of Gurkhas in 2006. After nine months of infantry training, he worked as a radio operator for nearly eight years, after which he made a career change and joined the QARANC as a healthcare assistant.
Jay has always had a special interest in health. He said the “invaluable exposure to the hard working NHS always ready to help the sick and needy ones, inspired me to take up the challenge to become a nurse.
“Having completed the access to healthcare course online and getting through the military nursing selection board, I am doing my best to achieve the nursing degree.
“As with everything in life, nursing also has its own challenges but I am determined to accept the challenges and use them as an opportunity to learn and contribute towards greater good of the NHS. I believe in bringing a change and making difference to people’s lives but it has to start from oneself.
“For me, the attributes learnt while in the military, like being disciplined, good time management, work and strive for team goals, communicate clearly, be flexible when needed, and remain professional have ingrained in me deeply, which, I believe, will help me greatly while practicing nursing in the future.”
Jay clearly recognises the transferability of his previous training and learning to nursing.
Gurkha soldiers are regarded as some of the bravest among brave, highly trained, and lucky because of their status and a settled income.
However, Pramesh feels that a small nationalistic section of people do not feel comfortable that Nepal’s people have to serve others.
When I am travelling across Nepal, I meet retired Gurkha veterans and the occasional soldier on leave. I am reminded of their strength and tenacity but also the compassion, because many of the water stands, sanitation projects and bridges have been installed and constructed by the Gurkha Welfare Trust.
My life changed when I first went to Nepal. I want to give back as much as I have received. I have been lucky to meet people with the same interests as myself on Twitter (X) and I have been able to take staff and students on educational programs and trekked to Everest base camp several times.
I am blessed to be a nurse, as there are so many opportunities to share our knowledge and expertise. Namaste.
Ann-Marie Dodson, senior lecturer in adult, critical care, hepatology and transplant nursing, Birmingham City University