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: March 22, 2023

Recent Blog Posts By Carmina Shrestha

Suicide – An Emergency Priority of Public Health Care

Suicide An Emergency

A significant number of emergency department visits annually arise as a result of intentional self-harm. Although no accurate description explains what leads to suicide or what comes after, it is a multifaceted phenomenon of public health urgency during a global health crisis. In the United States alone, suicide is the 10th leading cause of death and worldwide claims up to 800,000 lives each year. The international community must unite to come up with solutions to prevent the loss of life, as every single life lost is one too many.

With the COVID-19 pandemic, such an emergency naturally affects both individuals’ health and well-being and the communities in which they live. Unprecedented times unleash various emotional reactions from isolation, grief and trauma to other unhealthy behaviours, noncompliance with public health guidelines and the exacerbation of mental health conditions. While those who’ve been emotionally, sexually or physically abused in the past are more vulnerable to the psychosocial effects of a crisis, supportive interventions such as the Zero Suicide program and Cognitive Behavioural Therapy designed to promote wellness and enhance coping should be implemented [1]. 

In honour of World Suicide Prevention Week, and World Suicide Prevention Day held on the 10th of September every year, it is important to raise attention to the global importance of suicide prevention. Suicide impacts all people and particularly the world’s most marginalized and discriminated groups. It is a huge problem in developed countries and just as serious in low-and middle income countries where resources and access to healthcare professionals are scarce. In many regions of the world, the taboo and stigma surrounding suicide persist, causing people in need of help to be left alone. 

Suicide prevention with awareness campaigns ought to be prioritized on the global health and public policy agendas as a major public health issue. Routine screening for suicidal ideation by health care professionals providing care should identify and assess suicide risk among populations. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), risk factors of suicide include mental illness, substance use diagnoses, trauma or conflict, loss, family history of suicide, and previous suicide attempts [2].

Effectively implementing suicide prevention strategies at the populational, sub-populational and individual level requires ensuring patients’ lethal means are restricted, reduced, and that all accesss to weapons of self-harm are removed from the nearby environments. Healthcare providers should keep up to date with new developments, research, and technologies screening for suicidal ideation, allowing them to effectively serve patients beyond their clinics’ walls. Key to prevention are strong physician patient relationships that help ensure care transitions allow for physicians to act as supportive contacts reaching out with calls, texts, letters and visits to their patients particularly when services are interrupted. With access to technology the role of psychiatrists, and psychologists may continue uninterrupted as telemedicine serves as an effective platform providing patients with access to care, even during lockdowns. Besides these objectives, greater awareness and education into the community means encouraging the responsible portrayal of suicide in mainstream media. A sensitive issue of this magnitude ought to be communicated responsibly placing special attention to not trigger susceptible individuals. With school based interventions, professionals may act sooner before worsened prognosis’ effectively ensuring that access to peer support services is available. 

Suicide prevention is a responsibility of healthcare systems, medical professionals and communities. All countries must stand in solidarity and unify in collaboration to battle this common threat as preventing the tragic loss of life to suicide is of utmost importance. 

References & Further Reading

  1. In Health and Behavioral Healthcare. (n.d.). Retrieved September 14, 2020, from http://zerosuicide.edc.org/toolkit/treat/interventions-suicide-risk 
  2. Psychiatry Online: DSM Library. (n.d.). Retrieved September 15, 2020, from https://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425596 
Cite this article as: Leah Sarah Peer, Canada, "Suicide – An Emergency Priority of Public Health Care," in International Emergency Medicine Education Project, October 19, 2020, https://iem-student.org/2020/10/19/suicide-an-emergency-priority-of-public-health-care/, date accessed: March 22, 2023