Medical research in developing countries like Nepal is still in its infancy. Research activities conducted by medical schools and external funding agencies are focused mainly on infectious diseases due to their high prevalence, which means that research activities in the field of pulmonary vascular diseases (PVDs) are primarily focused in developed countries. As a result, there is currently not a single unit for conducting research on PVDs stationed in Nepal. Yet many Nepalese are continuously exposed to several underlying risk factors for the development of lung diseases, such as pneumonia, chronic obstructive pulmonary disease (COPD), asthma and interstitial lung diseases, all of which are very common in this country, and some of them are significantly associated with PVDs.1 Additionally, about 3% of Nepalese people living at high altitude are chronically exposed to hypoxia.2 To counteract this problem, the Excellence Cluster CardioPulmonary System (ECCPS), Giessen, Germany and Agriculture and Forestry University (AFU), Chitwan, Nepal, decided to conduct research on PVDs based on common interests (Figure 1). Experimental setups for pulmonary vascular research are to be established. This will be further connected with medical schools and combine basic as well as clinical research.
Nepal is a small Himalayan country and lies between the two giants India and China. Geographically it is situated at 260 12’ to 300 27’ N latitude, 800 4’ to 880 12’ E longitude and at various altitudes ranging from 70m above sea level to the top of the world. Many ecological niches rich in a variety of flora and fauna can be found across the country. The extensive geo-ecological diversity entices the biomedical scientists from all over the world to conduct research in this diverse arena. Although beautiful, Nepal, like any country, faces its shares of issues. Public health is amongst these concerns, as Nepalese people are still suffering from several infectious diseases. Although the burden of contagious diseases remains high, the noncommunicable diseases are increasing, creating new challenges for the Nepalese health system, as the country-wide disease pattern is changing from contagious to non-contagious diseases. PVDs do not have geographic and socio-economic boundaries and as a result, many Nepalese people suffer from pulmonary vascular diseases. A lack of infrastructure and diagnostic facilities for different heart diseases means many potential pulmonary hypertension cases are hidden in the rural community, and therefore the exact prevalence rate is not known. Although no official data exists regarding the local magnitude of PVDs, several risk factors for the development of pulmonary hypertension abound in Nepal. The incidence of pulmonary problems is greater in urban area than in rural areas, reflecting the acquisition of several risk factors such as a sedentary lifestyle, consumption of fatty foods, obesity, smoking, air pollution etc. Although studies on pulmo nary diseases were conducted in Nepal,3,4 none of them focused on basic research. Only acute studies were carried out on mountain sickness3 or sildenafil trials in high altitude.5 The Ministry of Health and Population and the Government of Nepal have not yet formulated policies regarding pulmonary research in the absence of evidence-based findings. Thus it is urgent to address the issue of pulmonary diseases through research.
Epidemiology of PVDs
Nepal does not have a well-organized health facility for PVDs compared to developed countries. Proper databases for disease surveillance are scarce and pulmonary vascular diseases prove no exception. However, a recent hospital-based cross-sectional study on noncontagious diseases in Nepal showed that one third of the cardiac problems were associated with right heart diseases, which gives a clue for an indirect approximation of pulmonary hypertension prevalence within the country.6
Seimetz et al showed that COPD is associated with the development of pulmonary hypertension.7 COPD is the most prevalent respiratory disease in Nepal and ranks in the first position among non-communicable diseases.6
The reason behind such a high prevalence of COPD is likely due to the use of biomass fuel in traditional cooking stoves, the combustion of solid biomass fuels such as animal dung, wood, and crop residues, and air pollution from brick industries and old vehicles in the big cities. Additionally, the health hazards to housewives and workers in brick industries are likely underestimated in Nepal. The census 2011 report shows that more than 75% of households depend upon solid bio-fuels for domestic uses, which means near-constant exposure to many individuals.2 Furthermore, smoking is on the increase amongst younger Nepalese and the consumption of non-filtered cigarettes by elders could also attribute to a higher prevalence of COPD throughout the republic.
Nepal is a mountainous country and more than 3% of Nepalese people, predominantly Sherpa, are permanently living at high altitude. Most of the residents are well adapted to the high altitude environment, but many of the migrant people in northern Nepal are susceptible. There is an immense scope for conducting genetic studies among those populations. Moreover, local mammalian species e.g. yaks, pikas, and pandas are permanent dwellers in the Himalayan region. It would be worthwhile to screen these animals for hypoxia resistant genes.
Prospective and Challenges
Systematic studies on PVDs are still lacking in Nepal and there is no centralized database system. Some medical college teaching hospitals and government hospitals use a database system, but the software and format differ from hospital to hospital. This underscores an urgent need for an uniform recording and reporting format. Currently, most health institutions do not have a separate unit for pulmonary diseases where patients can receive good quality treatment. If such a unit was set up in different hospitals, database management would be significantly less complicated, and would create the opportunity for research activities. To this end, erecting a new research center will be crucial. Nepal has 17 medical schools, 7 national and regional hospitals, 14 zonal hospitals and 75 district hospitals, a statistic which holds fantastic potential for the establishment of a database system in order to conduct systematic clinical studies amongst the centers.8 Moreover, basic research on PVDs can be performed in collaboration with veterinary schools. Vet schools can provide an excellent platform for translational research using a number of laboratory animal models. To this end, we are designing a collaborative research set-up between ECCPS, Justus-Liebig University, Giessen, Germany and AFU, Chitwan, Nepal vet school (Figure 1) for translational research on pulmonary vascular diseases. Simple experiments will be carried out in Nepal and more advanced and sophisticated techniques will be conducted in Giessen, Germany. This collaborative approach will be a milestone for initiation of pulmonary vascular research in Nepal. As Nepal is rich in biodiversity, plenty of flora and fauna are available and we can focus our research on alternative medicine in PVDs. Additionally, research on acute as well as chronic exposure to high altitude can be carried out in Nepal, as every year several thousand Hindu pilgrims from India and Nepal visit a number of holy places, and many of them are susceptible to high altitude and develop mountain sickness. In conclusion, Nepal is rich in opportunity with regards to the study of pulmonary vascular diseases, and with the start of this project, further studies will hopefully be initiated in the country, eventually leading to better resources, data and mortality outcomes.
1. Bhandari, G.P., et al. State of non-communicable diseases in Nepal. BMC Public Health. 2014. 14:23.
2. Government of Nepal, National Planning Commission, Central Bureau of Statistics, National Population and Housing Census 2011, Nov 2012. 1:2.
3. Basnyat, B. Acute high-altitude illnesses. N Engl J Med. 2013. 369:1666.
4. Basnyat, B. Reducing the incidence of high-altitude pulmonary edema. Ann Intern Med. 2007. 146:613.
5. Reichenberger, F., et al. Effect of sildenafil on hypoxia-induced changes in pulmonary circulation and right ventricular function. Respir Physiol Neurobiol. 2007. 159:196-201.
6. Prevalence of NCDs in Nepal, Hospital Based Study, National Health Research Council, Nepal. 2010. 27:28.
7. Seimetz, M., et al. Inducible NOS inhibition reverses tobacco-smoke-induced emphysema and pulmonary hypertension in mice. 2011. Cell. 147:293-305.
8. Government of Nepal, Central Bureau of Statistics, Census of Hospitals in Nepal 2013. Aug 2014. 10:11.