Dirty, Dangerous, Difficult ... and Dehydrating

South of Janakpur near the Indian border is the village of Phulgama. Out of its population of 4,500, nearly every household here has at least one son who is a migrant worker abroad. 

Some 40% of Nepali men between the ages of 20-35 are migrant workers abroad, mainly in India, the Gulf states or Malaysia. In the last nine months alone, 741,297 people travelled overseas: mostly to the UAE, Saudi Arabia, Qatar, Malaysia and Kuwait. This does not include those who left on student visas, and there are no records of how many went to India.

Most end up working in ‘3D jobs’ —  dirty, dangerous and difficult. There is also a fourth D: dehydrating work. 

Risky outdoor as manual workers, excessive heat of the desert in the Gulf or humidity of the tropical jungles of Malaysia, poor diet, dehydration and unhealthy lifestyles all contribute to a higher risk of kidney failure among Nepali migrant workers. Dhanusha district has one of the highest proportions of workers migrating for work to India and abroad.

Nephrologists call kidney disease ‘the silent killer’ because patients do not show symptoms until it is too late, and migrant workers are especially susceptible to Chronic Kidney Disease (CKD) or End-Stage Renal Disease (ESRD). 

Increasing demand for cheap labour and minimum pre-departure health awareness training makes migration more risky than it should be. From a survey of hospitals and dialysis centres in Dhanusha and Kathmandu, the risk of kidney failure appears higher among male migrant workers than in Nepali men of the same age group. 

“This disease is idiopathic, meaning it is not caused by one specific factor,” explains Rishi Kafle of the National Kidney Center Nepal. “But after screening migrant workers going to the Gulf and developing End-Stage Renal Disease in 3-4 years, we can say that migration increases the likelihood of kidney failure.”

Kafle adds: “Because of the need to maximise earnings, working in extreme heat for long hours dehydrates them. And many opt for Coca-Cola and meat instead of healthier water and vegetables.”

While the risk of kidney failure is higher in returnee migrant workers in Nepal, the disease is on the rise globally due to lifestyle changes, diabetes or undiagnosed hypertension.

Currently, there are 28,266 kidney patients enrolled in the Department of Health Services for free treatment under the government’s Bipanna Nagarik Kosh, of which 17,044 are male and 11,222 female. Just in the past year, 9,176 more patients were added to the fund. Most hospitalised kidney patients are from age 15-65.

In a healthy person, toxins and waste in the blood are filtered by the kidneys. But patients with kidney failure need to circulate their blood regularly through a haemodialysis machine. The whole process takes about 3-4 hours and causes blood vessels in the arms to swell over time.

Nearly 2 million Nepalis suffer from chronic kidney disease (CKD), which is about 8% of the population. The rise in diabetes and hypertension is contributing to an increase in the disease. Everyone from migrant workers to many of Nepal’s top politicians suffer from kidney failure. Prime Minister Oli himself has had two kidney transplants.

Even with dialysis twice a week, some patients develop nausea, swelling and other problems when they eat or drink. The extra dialysis sessions cost money, and the livelihood allowance given to patients is never enough or timely.

Not every migrant working in hot climates returns with kidney disease, but a recent yet-to-be-published study led by nephrologist Sailendra Sharma states that one-fourth of all kidney patients in Nepal are migrant returnees. It points to recurrent heat stress as a primary risk factor.

The Madhesh Institution of Health Sciences in Janakpur has 103 regular patients who come for dialysis. Of them, 30 are returnee migrants not just from Dhanusha, but also Sarlahi, Siraha, Mahottari and Sindhuli.

“Not by the nature of the disease, but the way kidney disease is growing, I would call it an epidemic,” adds Kafle.  

Jagdish Sah left for Malaysia ten years ago. He had taken a loan for his sister’s marriage and he had to pay it back. As the eldest son, he was also expected to get married next, but he faced multiple rejections.

“Women have expectations too. They want to get married to well-to-do families. They didn’t want to get married to a family that lived in a mud house like ours,” says Sah, now 35.

Foreign employment was a one-stop solution to his problems. Or so he thought.

Sah was 24 when he left for a tailoring job at a garment factory in Malaysia. He often worked overtime, sometimes up to 12 hours a day in the hopes of earning extra ringgits. Even so, his highest monthly income would only be Rs35,000.

Workers got a 30-minute break for lunch, and there were limited toilet breaks. So, Sah just worked straight out.

Back in Nepal for a break in 2017, Sah had blurred vision and fainted. He thought it was high blood pressure, but a few months later at age 28, he was diagnosed with double kidney failure.

“Whatever he saved in Malaysia went for his treatment in Kathmandu. We even sold a plot of our land,” recalled Sah’s mother, Mantoriya Devi.

Sah drives his motorcycle twice a week from his village to the Madhesh Institute of Health Sciences in Janakpur for free dialysis. His family says it is as if the Jagdish who went to Malaysia and the one who came back are two different people.  

“This disease has already doomed my life. Why ruin someone else’s?” says Sah of his lack of marriage prospects. “It is because of dialysis that I have survived so far.”

His parents are too old and occupied with their chores to accompany him. Since Jagdish cannot work, his father, Ram Dev sells popcorn by the sidewalk from a wheeled cart.

Mithu Kumar went to Saudi Arabia to work as an electrical supervisor two years ago. He was 25. Recently when he started vomiting, he was taken to a local hospital. He was diagnosed with chronic kidney disease and was sent back to Nepal.

As Kumar lays down for his dialysis treatment at Save Lives Hospital in Janakpur, he says, “My only wish is that I am healthy enough to work again.” 

Umesh Kumar Yadav also worked in Saudi Arabia as a guard. He returned with chronic kidney disease, but he says he is the only one to contract the ailment among all the returnees from his village.

“Only the ill-fated people have this disease,” says Yadav. “Otherwise, it would have been the same for every other person from the village who is abroad working.”

Ambar Bahadur Sarki, 46, travels from Sindhuli for three hours every Monday and Thursday to Janakpur for his free dialysis at the Madesh Institute of Health Sciences.

Sarki worked in a palm oil plantation in Malaysia, where heat stress often exceeded the wet-bulb threshold for heat and humidity. “It was extremely hot at all times,” he remembers. He first got hypertension, which made both his kidneys fail.

Ram Udgar Mandal from Dhanusha started working in Saudi Arabia in his late twenties. He spent the next 17 years in the desert working as a driver. Now in his late forties, he was diagnosed with End-Stage Renal Disease (ESRD) four years ago. 

But this is an intergenerational cycle. Mandal’s son has now also gone to Malaysia to supplement the family income. He fears his son will meet the same fate as him. “We do not have a choice, do we?” he says.

Lalit Balampaki, 28, from Dhanusa was diagnosed with ESRD a year earlier in Dubai. He stays in Kathmandu along with his older brother’s family on a rented floor.

Balampaki worked in extreme heat conditions in a smelting factory in Dubai. He had to work night shifts twice or thrice a week. Sleep deprivation and extended periods without food were part of his daily routine. The pay was good, but his savings have all gone now towards hospital fees.

“More than the money, I earned the disease,” says Balampaki.  

Suraj Thapa Magar, 30, was the sole breadwinner of his family. He installed aluminum windows and doors in Kuwait

“It was the hottest in summer and coldest in winter,” says Magar, who worked for 10 hours a day even in 50°C. He also often neglected hydration, and one night he vomited blood. At 26, he was diagnosed with ESRD and has been in Nepal ever since.

Thapa has no other choice than to rely on the Rs5,000 allowance, but even that is not timely and not enough. He has to take loans to travel for his dialysis. The government hospitals are supposed to provide some medicines for free, but they are often out of stock. Thapa has looked for jobs, but kidney disease is a stigma and no one wants to hire him.

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In 2016, Nepal started providing free hemodialysis treatment for the poorest patients. Two years later, a monthly livelihood allowance of Rs5,000 was to be distributed to patients suffering from chronic diseases like dual-kidney failure and cancer.

Free dialysis is provided in 107 hospitals across the country, but that is only in theory. Many facilities do not have nephrologists because the government does not provide salaries. The machines also often are not working because they need constant maintenance.

Among the 11 hospitals that provide free dialysis in Madhes Province, three are in Janakpur. Nepali Times visited the enlisted hospitals but there were no nephrologists to supervise the treatment, and they were run by general physicians or senior nurses. 

“The government does not provide adequate salaries for the nephrologists,” says Kafle. “That is why nephrologists are mainly affiliated with the private hospitals.”

Bagmati Province has 44 hospitals with free dialysis, which is why many dual-kidney failure patients have opted to live in Kathmandu. The hospitals service over 8,000 kidney patients. 

Since most of them are migrant workers, the end result is that Nepal’s poorly-resourced health system ends up bearing the cost of treating kidneys that failed while working as labourers in hot, rich countries.