Nepal is one of the most vertical countries in the world, and people are falling from heights all the time. And as the road network grows, there are also those with injuries sustained in traffic accidents.

In the year since Sir Edmund Hillary opened the Spinal Injury Rehabilitation Centre in Jorpati, the Centre has seen the extent of one of the most debilitating categories of injury Nepalis face. And what they have learned helps us understand just how bad things are with rehabilitation care.

The broken bones and severed spinal columns, the psychological trauma and pressure sores of the spinally injured of Nepal indicate the poor state of health infrastructure, public services and the social safety net. Certainly, just about any other developmental indicator would expose our deprivation: under-five child mortality rate, the doctor-to-patient ratio outside Kathmandu Valley, the unavailability of drugs, or the prolapsed uterus.

But there are reasons to be particularly sensitive to the spinally injured. These are once-healthy women and men who were leading productive lives and providing for their families as working parents, wives or husbands. Due to falls from cliffs, trees, rooftops or trails, or crashes involving buses, jeeps or motorbikes, they are now paralysed-either completely as quadriplegics, or have lost control of their lower limbs and become paraplegic.

The terrible fact is that since their mental faculties are intact, the patients know that there is little hope of return to normal life. This is because the spine, once it has been severed, cannot be revived.

Able-bodied men and women thus become incapacitated while remaining mentally alert, having to rely on the sensitivity and magnanimity of family members. The burden on the family becomes heavy as the victims become complete dependents, with the result that that they slowly lose out in care and comfort.

Neglect of the paralysed within the home leads to mental depression and gradual physical decline. They lose control of bodily functions and develop bedsores. In a country where even major hospitals cannot prevent bedsores, which penetrate deep into the bodies and attack bones and vital organs, the dire situation at home can be imagined.

At the Spinal Injury Rehabilitation Centre, the focus is to try and help patients and their families to cope within the minimal support that our society is able to provide to the paralysed. Unfortunately, there is very little to be done for patients who have broken their backs in upper sections of the spine and are completely paralysed. In such cases, there is near-total reliance on the family members. However, other patients can be given physio- and occupational therapy, and the experience of the Centre is that life-energy can be revived in these patients.

And fortunately, there are also the occasional patients who can make dramatic recoveries for not having suffered a complete separation of the spinal column, and for having been discovered early, transported professionally, and treated with care and sensitivity.

The majority of the accidents leading to spinal injury are from falls. These falls tend to be from cliffs and trees, which women and men climb to collect fodder for livestock. It would be a different Nepal where villagers did not have to risk life and limb to climb inaccessible places to collect fodder grass. Women, in particular, are at risk because their phariyas come in the way as they reach out precariously on high branches to lop branches and leaves.

There is no data as to how many sustain injuries from falls every month across this country, and those that do find their way to Jorpati by way of hospital operating theatres are but a small number of the total. Many of those who sustain severe spinal injuries from falls die on the spot, or in villages before they are transported for treatment. Many will have their injuries compounded because of the lack of proper transport. Those who make it to hospitals to be operated by the country's handful of dedicated neuro- and orthopaedic surgeons receive minimal counseling and therapeutic guidance afterwards.

While victims of falls continue to be the largest group of spinally injured, we seem to be in the midst of a dramatic rise in mortality and morbidity from bus and other vehicular accidents. And with the rise in the sale of motorbikes, it can be expected that there will be even more spinal accidents in a society very poorly equipped to deal with any kind of emergency and trauma.

On top of it all, many civilians and security personnel are now incapacitated from bullet injuries. Hopefully, this is one kind of spinal trauma that will not continue to rise as all other kinds are expected to. There must be Maoist fighters and supporters who also suffer from spinal injuries, just as there are civilians and security personnel that do, and the Centre has sapproached the now above-ground leadership of the Maoists to consider bringing these injured to Jorpati.

Spinal injury is only one of the great and largely unadressed tragedies of our medical and public health systems, and provides an insight into the pitiable state of these in an age of modern medicine and rehabilitation. In spinal injury, as in a score of other areas, unfortunate citizens wait for those more capable to wake up and take a look at the state of public services in the country. And do something about it.

Will soon be home
Kanchi Maya Thapa, age 34, homemaker.
Accident: 23 June 2002. Fell from tree while gathering leaves for her livestock near her home in Bhaisepati, Makwanpur district. Kanchi Maya came to SIRC via Shanta Bhawan Hospital, Bir Hospital and the Nepal Orthopaedic Hospital. She arrived with no sensation beneath her umbilical region, with pressure sores and no bowel control. The sores are now healed, she has attained bowel control, and she can now move on her legs with the help of a walker. She was able to achieve this recovery because her spinal column was damaged rather than severed, and she hopes to be discharged from SIRC in a few weeks.

Hopes to keep teaching
Sudarshan Shah, age 26, teacher.
Accident: 23 November 2002. While returning home in Dipayal from his work in Doti, Sudarshan's jeep fell hundreds of feet. Everyone on the jeep died except him. He lost consciousness, and remembers coming to in Nepalganj hospital and finding his lower limbs without sensation. He was ultimatedly operated at Bir Hospital by Dr Upendra Devkota, and is presently being rehabilitated at SIRC. His pressure sores have been treated with reconstructive surgery and he is slowly learning to control his bowel movements. Expects to upgrade to wheelchair after recovery from various complications, and hopes to keep teaching.

(Kanak Mani Dixit, who recovered fully from a spinal injury suffered during a trek fall nearly three years ago, is one of the founders of the Spinal Injury Reha-bilitation Centre in Jorpati which runs on voluntary support from the public. spinalinju@wlink.com, 4470874)