Real Life Medicine in Nepal – The Headache Phenomenon

Nepal… Where on earth is that country? Mt Everest — the tallest mountain in the world. Mix them up and we have a country with a tag of one of the poorest in the world, an economy ravaged by a decade long war and a healthcare system that has done anything but to uplift the health standards.

Headache! I hear that complaint every time I sit down in my clinic to see a patient. Has headache become a national disease all of a sudden or is it manifesting in its fullest form now that the country is finally going through a transition? Blame it on the civil unrest and the constant barrage of violence, political instability you read everyday on the newspapers or the constant worry of the skyrocketing fuel prices and unaffordable amenities. We pay for water that doesn’t run in our pipes; we pay for electricity that comes just a few hours in a day and the schools that are closed at most days of the week due to political strikes. A nation where children die of diarrhea and malnutrition and people have to walk for several days to reach the nearest health facility, where everyday is a constant struggle and living for today the reality of life. A country where stress was on an all time high due to the civil war with people craving for a day’s peace rather than food and healthcare. Can the headache phenomenon blamed on these or am I simply projecting my own headache worries on every patient that comes my way? Am I overlooking someone who comes with a genuine medical cause for a headache?

And what if they have a real cause? I ask a few questions and do a short physical exam (I can’t afford to do a detailed history and examination with 30 more patients waiting outside to be seen in a space of 2 hours). And at the end of it, I am still left with a long list of diseases to choose from. Is it migraine, cluster headache, tension headache, sinusitis or just a manifestation of depression? Am I just plain incompetent that I can’t even handle a case of headache or is it that the patient comes up with complaints that fit a little in everything to leave me looking like a fool at the end of the encounter? And being a concerned physician I suggest a few tests to the patient. A few blood tests are always the way to start the proceedings, a simple X-ray maybe but absolutely no CT scans or an EEG. (We had a MRI donated by some Japanese guys, but it broke down in the first month and has been nonfunctional ever since because the repair costs were too high. But I am secretly glad because as long as it’s out of order, I won’t have to bring it up with the patient who would never be able to afford the MRI anyways.) Come on, do you think someone is going to waste his month’s salary on a single test when the problem is as simple and common as Headache. He might as well relieve himself with some cheap painkillers than make his family go hungry. Besides there’s always a chance the blood tests might show something, which they almost never do. And I have given up trying to convince patients because I don’t have a convincing argument to put forward or maybe I have started to overlook medical causes and started blaming everything on the headache phenomenon.

And by the way, they don’t need me to write a prescription. You can just walk up to a pharmacy and buy almost anything. But they will come back. I don’t know why. I can only hope that they have become better; they have finally found a way to afford the CT scan or at least a new symptom has come around which will lead my young medical brain into a sensible and correct diagnosis. But mostly the situation doesn’t change and we start again from ground zero. Without the help of my fancy tests which they can’t afford, I will be clueless like the first time around and with their headache worse, they will demand for a spot diagnosis or some wonder drugs to keep them going for the next few months. Maybe the sacred doctor patient chit chat will act as a placebo and help to keep the analgesics doses at a reasonable level. Maybe I will diagnose the episode as a manifestation of depression taking into consideration the facts I derived from my five minute history and prescribe them an antidepressant.

Doesn’t sound like an ideal practice of medicine but it works sometimes. Maybe we should just call it situation based medicine. The practice of medicine based on sheer practicality which takes into account the whole picture and yet misses the plot. Will the situation get better if the country stabilizes and tests become affordable? But is the problem just the diagnostic part? How many years will it take to change the belief that Headache is just a way of life and nothing sinister? How will we convince the patient to understand that headache is a symptom and not a disease? As a matter of fact, I don’t follow that myself all the time. Will I have to change myself first? But I would be willing to change myself and take up the challenge of changing thousands of my fellow countrymen if only peace and stability would prevail. Meanwhile, I would have to console myself saying that my country is suffering from a headache phenomenon and I too am a part of it. Hopefully hope will prevail, things will change and one day, I will be able to practice evidence based medicine like the rest of the world.