KATHMANDU, NEPAL — On a morning in 2019, as the sun gradually warmed the lowlands of central Tera, two boys approached 14-year-old Muskan Khatun as he walked to school and offered him a drink of water. When he refused, they threw the liquid on him and ran away. “I felt like I was sitting on fire and I was burning alive,” he recalls. He will find out later that the liquid is sour; it burned his arms, neck and chest, as well as the right side of his face.
Passers-by took Khatun to a nearby hospital. Birgunj, located in the Terai region, one of Nepal’s largest cities, 135 kilometers (84 miles) south of Kathmandu, but the doctors there did not know how to treat him; they just bandaged the wounds and did not give him painkillers. . “Thinking about how I got out of that situation feels like a dream come true,” he says. (His memory is based on what he remembers and what his father told him.) His whole body was swollen then.
According to the World Health Organization, burns are the second most common injury in rural Nepal, accounting for 5% of disabled people. The country has one of the highest incidences of fire-related burns in the world, due to the prevalence of cooking over open flames and the prevalence of communities living in cold and high altitudes. Many Nepali women wear sarees with the hem loose over the shoulder, which can also make them more prone to burn injuries. Organized burn care, however, is concentrated in the capital, forcing many to travel long distances.
Nepal has six hospitals with burn care units in Kathmandu and only three in the rest of the country. According to a recent study, 20.3% of the population has access to organized burn care within two hours of travel, 37.2% within six hours, and 72.6% within 12 hours. Kiran Nakarmi, Chief of Burns, Plastic and Reconstructive Surgery, Kirtipur Hospital, Kathmandu. , says 9 out of 10 of his patients are from out of town. “They all come from low-income families,” he adds. “It will be 24 hours before they get to the hospital and they won’t get first aid.”
Kirtipur Hospital is the country’s largest facility for the treatment of burns. Khatun was admitted there. Doctors poured water on his body for half an hour. Cold water, which absorbs heat, prevents wounds from worsening. Two days later, he underwent the first operation. Forty-five percent of his body was covered with burns. Few patients in Nepal survive such extensive injuries. He was discharged after three months, after which he was required to return weekly for further treatment. Back in Birgunj, his father ran an aluminum business, but the journey was futile. So the family sold their land and moved to Kathmandu, renting a room near the hospital. In the last four years, he has undergone six operations. His doctors told Khatun to consider the hospital his “halfway home”.
More than 560,000 Nepalese have suffered a significant burn in their lifetime. According to government health statistics, between 2019 and 2020, more than 1,700 people were hospitalized for burns, while 83,660 received outpatient treatment. 89 people died. The mortality rate in Nepal, relative to the extent of burn injury, is similar to that of the pre-World War II era in the United States, before the discovery of antibiotics. “Since 90% of burn patients are from disadvantaged groups, burns are a neglected topic in our country,” says researcher Kamal Fuyal. “Since the majority of policy makers in Nepal are upper class, they make policies that benefit themselves.” He says in a survey of 100 health center workers, none were trained in burn care.
Ocean Poon Magar, a doctor at Rukum District Hospital in northwestern Nepal, says they “only give antibiotics, bandage simple cases and refer complicated cases to Kathmandu.” Rukum is approximately 600 km (373 mi) from the capital.
Kirtipur Hospital in Kathmandu, which operates as a trust, provides burns care training in district hospitals across the country. But the initiative, a partnership with Nepal’s National Health Training Center, is not paying off. “Doctors don’t want to work in the burn field,” says Nakarmi, adding that the work is difficult and often unpleasant. “There is also a growing tendency for trained nurses to go abroad.”
Magar also notes that in some cases, people assume that their wounds will heal on their own. “Patients also apply aloe vera, tomatoes and cow dung to their wounds,” adds Fouille. “When the wound gets worse, they go to Kathmandu and spend hundreds of thousands [Nepali] rupees”. A 2021 study found that the average cost of specialized hospital burn treatment was 260,270 rupees ($1,989), more than twice the average per capita income in Nepal.
In September 2022, a landslide destroyed Darpana Buddha’s home in Kalikot, western Nepal, killing his father-in-law and starting a fire that injured his toddler. It took three days to reach the hospital. an army helicopter was called in as the landslide stopped ground traffic. But this was only the beginning of the family’s trials. Buda’s 2-year-old daughter, who received burns on both legs, was repeatedly referred to different institutions. She is currently undergoing treatment at Sushma Koirala Memorial Hospital in the capital, her fourth facility, and has undergone 21 surgeries so far. “The bone is burned and the pus continues to ooze,” Buddha says. “We owe hundreds of thousands of rupees to the hospital. We have no house or land to sell now.”
Given the extremely expensive and time-consuming nature of burn care, doctors and other advocates suggest that the treatment be subsidized by the government. “Poor citizens are affected the most, so the government needs to provide resources,” said Santosh Bikram Bhandari, a plastic, reconstructive and cosmetic surgeon at Sushma Koirala Memorial Hospital.
Sri Krishna Thapa, program manager at Burn Violence Survivors Nepal, says the charity is lobbying to include burns in the Indigent Citizens’ Treatment Fund guidelines. The fund, which was first established in 2006, provides financial assistance to Nepalis suffering from diseases such as cancer, stroke and kidney and cardiovascular diseases, but burn injuries are not an eligible category.
“Burns fall under primary health care,” says Sanjay Kumar Thakur, a former spokesman for Nepal’s health ministry (he has since moved to another ministry). “All paramedics and doctors are trained to provide primary care. There is no need to refer every burn case to Kathmandu.” Referring to the high cost of treating burns, he noted that Nepal’s Social Service Department, which aims to reduce health care costs for those who cannot afford it, operates in all government hospitals. “The government also subsidizes for this.”
Khatun is now 18 years old and has dedicated her life to raising burn awareness. “My wound got more complicated because I didn’t get first aid on time,” he says. He is determined to ensure that no one dies an untimely death because they were not treated quickly or properly. “I was afraid of the scars on my face for a moment. But these scars now give me the courage to go forward.”