The existing art and science of Orthopaedic & Trauma Care in Nepal reflects the level of available resources for medical care in general. Being a third world developing country, Nepal has many levels of medical care. Recent data show the mortality and morbidity due to accidents (road traffic or others) to be in epidemic proportions, resulting in significant loss of active young manpower of countries like Nepal. The high percentage of death rate due to road traffic accidents (RTAs) alone depicts the level of trauma care in our health institutions. Many areas in the country are still lacking basic health services due to poor economy, and ignorance and traditional beliefs often demand alternative approach of health care. Changes from traditional methods are often slow and at times require a period of integration of the new with the old. Also in the absence of proper primary care and transportation, the patients often travel long distances, causing undue delay in obtaining proper medical treatment. Thus initial management and subsequent follow-up care becomes a prohibitive logistic problem in our country and although the infrastructure development in Nepal does not appear to be lacking, manpower training and availability of basic facilities are inadequate or inappropriate.

As the national priority of primary health care involves mainly medical measures, the concept and practice of primary surgical care has yet to be developed. To avoid unnecessary complications, effective primary care should be available at the peripheral level by an appropriately trained person. The lack of simple splinting, for example, may make simple injuries more complicated by the time the patient is brought to the hospital. A scientifically trained general practitioner can effectively treat nearly 90% of common conditions, but until the basic requirements of adequate law and order, shelter, transport, communications, schooling, remuneration, facilities and equipments to treat common conditions are made available at the peripheral centres, all attempts to depute the trained doctors to remote and rural places will remain ineffective. On the other hand if there were adequate facilities at the periphery it could drastically reduce the number of patients with simple ailments seeking treatment in the main referral centres thus sparing the consultants there for more specialized work.

In Nepal more than 80% of the people live in the rural areas while more than 80% of the qualified doctors work in the urban sectors. Until there is improvement in the doctor patient ratio in the rural area, primary medical care will largely depend upon the locally available, economically affordable and socially acceptable traditional healers and unqualified rural practitioners. The Orthopaedic Care in Nepal ranges from commonly available traditional healers and bone-setters in the villages to the scarcely equipped hospitals in the towns. The trained Orthopaedic persons are less than one to one million populations and these are confined to the cities. Moreover, the average cost of proper Orthopaedic treatment remains too high to be affordable by the average person mainly because of little support from the existing health agencies. Sadly our popular rural health practitioners and bone-setters, who are mostly involved in the primary Orthopaedic care in the villages, usually do not have any formal education or training in this field.

A recent research on health care providers in India reveals that 60 to 80 percent of illness is treated by an ‘uncategorised’, ‘non-recognized’ and ‘outcasted’ lot of rural practitioners. The result of this study has forced the health planners to stand the modern concept of health welfare on its head and argue that these ‘non-licentiates’ be given access to confirmed status as major participants in providing front line health care to the masses. It is estimated that ten lakh rural non-licentiates are practising in rural India against three lakhs qualified MBBS doctors, 70% of whom are located in the urban areas. Therefore, it has been suggested by the Indian planners that a realistic policy of recognizing this reality and managing it in the public interest by providing the rural private practitioners training and skill could allow them to be used for first aid, first contact care, preventive and promotive works; and for illness surveillance and compliance of prolonged drug treatment etc.

Thus, it seems quite impossible, mainly due to poor economy, to provide effective Orthopaedic primary care to a large population in the absence of adequate trained manpower and supporting facilities. The situation is further worsened by the attitudes of the concerned people to deplore the services offered by the rural traditional healers and bone-setters. There had been hardly any attempt to provide them some work training. We should make them our ally rather than our enemy. In some developing countries Orthopaedic assistants are carrying out good fracture treatment at the health centre level and possibly this service could be carried out even further into the rural community in co-operation with traditional healers, provided that basic facilities e.g. P.O.P. bandages, splints, padding etc. are readily available.

The shortage of suitably trained manpower amid lack of appropriate facilities creates a great obstacle for proper Orthopaedic care in our hospitals. On the one hand we have an extremely large number of patients needing Orthopaedic treatments while on the other hand, we are short of skilled manpower, basic operation facilities and other ancillaries. The developing countries would be ill advised to copy the system and methods of the affluent countries for they depend on high-tech systems and can cause a mental state in which our doctors and nurses think that they simply can not do anything without proper facilities, equipment and specialist team. In the poorer developing countries there is lack of all these things; and also of drugs, space, time, books, journals and informations of every kind. Nevertheless, the two principal reasons for the misery are the pre-occupation with advanced technology and the associated inability to adapt principles to the prevailing circumstances. It appears therefore that the higher education/training in advanced world is simply not appropriate, and hence it would be far more suitable and better applicable if local doctors are trained in their own circumstances by the trainers coming from the advanced world. In this way we can learn the art and science of adaptation and improvisation to tackle our problems more appropriately.

‘Trauma Center’ is an advanced health institution required for the comprehensive care of the injured persons. It also offers advanced treatment to the injured persons and suitable training to the health personnel. Nepal is the one of the four countries in the world with the highest mortality rate of more than 20% due to road traffic accidents (RTA). The principal causes of RTAs remain bad road, undisciplined traffics, worst vehicles and above all improper and inadequate ‘Medical Facilities’ available at existing health institutions in Nepal. Therefore, a growing need has been felt since last 15 years to establish "Trauma Center" on a national basis and strengthen the existing hospitals to deal with the growing demand of modern care of the injured persons mainly due to growing numbers of RTAs. The high mortality and morbidity due to RTAs has been known to cause loss of active life or limb in such poor countries where human resources are always scarce. The prevalence of physical disability in Nepal has been estimated as 10% on an average and the principal cause being the various types of injuries affecting the locomotor system. It has also been felt that more than half of these physical disabilities could be prevented by proper primary trauma care of most common injuries.

However great the growth in RTAs, we must not forget that the vast majority of injuries, particularly those which are non-fatal, occur in the domestic setting of home, at place of work or in the street. In our country such type if injuries commonly occur due to fall from trees or hills.

HMG/ MoH and other National/Foreign agencies like British ODA, WOC and Japanese JICA have been involved in this effort since last many years under the leadership of eminent surgeon Dr D N Gangol to establish Trauma Centre in Kathmandu and at other suitable places in the country with the main objectives that RTAs could be effectively managed at nearby centre to save life or limb within crucial time. However, there was some difference between the planning and execution mainly because of the lack of commitment to address this issue. Ex-Health Minister Dr R B Yadav established a cell in MoH as’Trauma & Disability Prevention Center’ (TDPC) and nominated Dr R K Shah, an Orthopaedic surgeon, as its "Focal Point" to study the feasibility of Trauma Center in Nepal. The TDPC has been working since last four years with main objective of providing primary Orthopaedic care to the patients and suitable training to the local health personnel in the peripheral hospitals. In this way the zonal hospitals at Janakpur in the East and Nepalganj in the West were adopted as pilot-centers and through these centers regular programs like Orthopaedic/Trauma Training Workshops, Orthopaedic Camps, Orthopaedic Seminar/Symposium have been organized with support from WOC-UK and IMPACT-NEPAL. As a result the Orthopaedic patients of these regions are getting proper Orthopaedic & Trauma care and the paramedical staffs of adjoining districts of these pilot-centers were trained for appropriate primary care in this field. It was also at this time that a detailed proposal of establishing a ‘National Trauma Center’ at Bardibas/Janakpur was approved by MoH/HMG and Planning Commission and it was submitted to JICA for the grant of donation. This proposal also could not be followed up because of political uncertainty in the country.

Recently the Govt. of India has agreed to develop ‘Trauma Center’ at Bir Hospital in Kathmandu and MoH/HMG is gearing up to establish this centre in the capital. Nevertheless, the trauma centre in the capital may cause further drain of the already scarce manpower and resources from all over the country and thus regional balance and development may be seriously affected causing increased misery to the injured patients of the peripheral regions of Nepal. Thus the need of the day seems to be the development of peripheral Orthopaedic & Trauma Centers through which basic and primary Orthopaedic & Trauma Services and Training could be provided on a cost-effective manner.

One of the most pressing medical issues today is how to curb the growing epidemic of RTAs as these are the third highest cause of deaths in the developing country like Nepal and its major impact is on the poor. This is attributed to the major number of the pedestrians and cyclists who are involved in the RTAs in the country where large numbers are living below poverty line. It is also linked to the gross overcrowding of public transport and to the poor maintenance of roads and vehicles. Although density of traffic must also play a major part, it is interesting to remember that in the developed world where car ownership is much higher the incidence of fatalities on the road is decreasing. This is possibly due to better discipline amongst vehicle drivers, particularly in urban areas where traffic density is even higher than in the developing world. There is also another difference between East and West and that is the speed of the traffic, which may be terrifying at times. But there may be yet another cause for the decreasing rate of road traffic fatalities in the developed countries and that is the increasing expertise available in major trauma centres for coping with potentially fatal trauma, combined with well-integrated ambulance services staffed by paramedics. Although both the facilities to reduce fatality figures are difficult to reproduce in the developing countries like Nepal, much could be done to improve the lot of the injured who survive the journey to hospital. In our district or zonal hospitals where it is unlikely that there will be a trained Orthopaedic surgeon, the management of musculo-skeletal trauma may well be delegated to the inexperienced junior doctor or even paramedics who may have had minimal training in the treatment of fractures and soft tissues injuries. The experiences in some developing countries in Africa has shown that trauma care can be improved dramatically by the use of specially trained clinical officers, chosen from paramedical staffs like Health Assistants and Nurses, who are not only capable of treating most simple musculo-skeletal trauma by a conservative regime, but also have the knowledge to be able to separate out the more complicated case which require referral to a specialized trauma centre. However, the methods and devices that can be used in the developed world do not necessarily work in our circumstances. Therefore, the use of simpler methods is often the more prudent course to follow, allowing conservation of the limited resources of human skill, time and materials, and to avoid worsening the situation; for what resources are available must be used in the most cost productive way.

Therefore, it is essential to develop a strategy based on the available resources within the existing limitations, on improvisation, and on adaptation of modern art and science of Orthopaedic surgery to the prevailing circumstances.

Until Nepal has the will, the finance and the know-how to develop a ‘Trauma Centre’ at different places for the specialized Orthopaedic and traumatic services, such clinical officer or trained paramedic/ practitioner seems to be the only answer to improving the treatment of the growing numbers of RTAs.