Author: Bishnu Giri
Position: Medical Student
Institution: Manipal College of Medical Sciences, Pokhara, Nepal
E-mail: giribishnurath@gmail.com
Additional Authors: Dr.P.Ravi Shankar, Assistant Professor, Department of Pharmacology
Submitted Date: December 28, 2005
Published Date: January 5, 2006
This comment was originally posted as a “Reader Response” on the publication date indicated above. All Reader Responses are now available as comments.

We read with interest the editorial 'Improving Health by Investing in Medical education'(PLOS Med 21(2):e424). The emphasis on problem-based, community-oriented, integrated teaching was of special interest. In Nepal, though community-based learning (CBL) has been carried out for many years, the majority of the teaching still occurs in acute hospital settings. The ongoing conflict in Nepal had had an impact on all sectors, including medical education. CBL has been quite severely affected.

The Institute of Medicine (IOM), Kathmandu, the first medical college in Nepal, organises community diagnosis programmes (comprehensive assessment of the health status of a community in relation to its social, physical and biological environment) [1].

The Manipal College of Medical Sciences (MCOMS), Pokhara, Nepal mainly admits students from Nepal, India and Sri Lanka for the undergraduate medical (MBBS) course. The revised curriculum of Kathmandu University [2] to which the college is affiliated emphasises CBL. Community diagnosis, school health studies, family studies, participation in rural health camps, health education are the various activities carried out. The Pharmacology Department conducts exercises on acquainting students with the working of the Community Drug Programme (a system of community financing of drugs) and the investigation of medicine use in peripheral health centres using drug use indicators.

Around six years ago, when the insurgency was just taking root, students used to visit remote areas in Kaski (where Pokhara is situated) and neighboring districts as a part of their community diagnosis studies. They stayed there for a few days interacting closely with local communities. Community field trips were gradually curtailed with the rise of the insurgency and were finally limited to the Pokhara valley. The college authorities were apprehensive about possible harm to students and faculty members. Other colleges have also curtailed their CBL with the spread of the insurgency. My (BRG) friend from IOM wrote to me saying, 'The prevailing situation is affecting the site selection for community studies. The studies used to be conducted at sites outside the Kathmandu valley but these days the sites are preferentially chosen inside the valley'.

In private medical colleges, students mainly come from economically well-off families and have little idea of poverty and deprivation. Some of my (BRG) friends were surprised on seeing a family living in a small hut on a hillside in a village just outside Pokhara. Young women often give birth without trained medical assistance in rural areas. Women carry heavy loads of firewood and fodder for their cattle along steep mountain trails well into late pregnancy. Empathy and sympathy for the less fortunate may be qualities lacking in doctors who are not exposed to rural life. Their impression of the community's health status may be lopsided. Students in their future practice may not consider the patient's economic status while prescribing treatment.

The deleterious effects of conflict on health status of a community are an established fact. Urban students having little experience of rural Nepal may find it difficult to adjust if posted to a rural health centre after graduation. The present curtailment of CBL in rural areas may lead to production of less competent manpower and ineffective policy making in the not too distant future. We sincerely hope that, with the hope of peace being reestablished, CBL in Nepal will be strengthened and expanded.

Acknowledgement: The help of Subash Gurung, 3rd year medical student at IOM, Kathmandu is gratefully acknowledged.

References:
1) Hale C (1996) Community-based learning: an experience. In Essentials of Medical education. Adhikari RK, Jayawickramarajah PT (eds.) Health Learning Materials Centre, Kathmandu.
2) Kathmandu University (2001) Curriculum for MBBS Part One. Basic Medical Sciences. Third version. Dhulikhel.