Tired before the long journey

Most articles related to rural health bombard us with problems, the solutions to which are often out of reach. We can classify most of the issues into large and sometimes intersecting domains; logistics, workforce, finance, and education. Also, most reports on medical education boast its universality. We can build the two arguments; 1) There is an apparent lack of a well-trained workforce in the rural and 2) We should solve this problem by incentivizing urban trained physicians to work in the rural. The second part of that argument doesn’t always hold; a discussion for other times.

A solution many governments, including that of Nepal, implement in solving the apparent lack of physicians is to produce more paramedics. I have before, and I continue to argue that paramedics have a significant role in rural health. Certain aspects of rural health deserve a bit more robust education and training. One such aspect is mental health.

A 67 years female visited a rural PHC. The endless excuse of a road through the forest, down the hill, and across the river brought her to a very dedicated health assistant. She complained of fatigue. “Do you have any abdominal pain?” asked the concerned provider. “No,” replied the old lady spontaneously. Almost as if she knew where this discussion is headed. “Are you bleeding from anywhere?” “No.” “Fever? Headache? Nausea? Vomiting? Diarrhea? Anything?” The old lady kept nodding no as the list of symptoms, as long as the road that brought her to the PHC continued. A multivitamin was prescribed before calling up the next patient. That week I talked about depression with my paramedics.

Mental health is an essential yet ignored aspect of health. As universal as that is, my two years in Beltar made me acutely aware of mental-health-related ignorance that prevails among the providers in the rural.
Paramedics we produce are not equipped enough to deal with a lot of mental health issues. After being a boss, a colleague, and a friend to many hardworking and dedicated paramedics in rural Nepal, I can confidently tell that they seek to understand more. The lack certainly is on the delivery side. We need to figure out ways to train our rural providers to better manage mental health issues.

While some rural health issues are extensive and require significant effort to solve, others are easy to address yet equally important. I sometimes wonder if we should incentivize physicians who serve in the rural for a limited time to train the paramedics who stay there longer. Being in the same room as the patient who could not articulate her symptoms of depression and the paramedics who, while being very attentive, wasn’t adequately trained to identify subtle signs of depression can be a good incentive. But I strongly argue that is not a good kind of incentive.

An update to the curriculum, refresher training and provision of adequate resources to learn about mental health can help the providers of rural help many of these patients who are “tired” before their long journey to the PHC.

Cite this article as: Carmina Shrestha, Nepal, “Tired before the long journey,” in International Emergency Medicine Education Project, May 5, 2021, https://iem-student.org/2021/05/05/tired-before-the-long-journey/, date accessed: December 2, 2023

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