GANGA and Jamuna, the conjoined twins from Nepal who were separated here exactly four years ago, will return to Singapore for reconstructive surgery on their heads.

A date has not been set, but the Singapore General Hospital says it will honour a promise it made then to the twins' parents to bring them back for further treatment.

The girls, who will be five on May 9, need to have a hard covering for the tops of heads. It is now covered only by skin and hair, leaving the brain unprotected.

Dr Chumpon Chan, who led the team of doctors which carried out the separation, said that five years is the right age for such reconstruction, as their skulls would have stopped growing by then.

The separation made medical history because of its complexity. The twins were joined at the top of their heads, with their brains and blood vessels intertwined.

In a marathon operation which lasted 97 hours from April 6 to 10, doctors had to break their skulls and carefully separate the two brains. The operation was made more dangerous because blood entered the joint brain through Jamuna and left through Ganga.

The twins recovered enough to go home in November that year, after 13 months here.

Now the family lives in the Nepalese capital, Kathmandu, waiting for the fulfilment of assurances given by Dr Vivian Balakrishnan, who was CEO of SGH then, that the hospital would continue looking after the girls.

The plight of the twins, whose parents are poor villagers, touched the hearts of many people, who donated more than $660,000 towards their operation.

Though the surgeons waived their fees, the hospital bill came to almost $600,000.

Since then, the twins have not developed equally well.

Though Jamuna is unable to walk, she is faring better than Ganga. She moves herself around with her left hand, and is talkative.

Her twin is bedridden, unable to sit up, lift her head or talk.

Her brain bulges upwards, and wobbles when touched. She cries in pain if pressure is applied to it.

SGH says it has not forgotten them. A team flew to Nepal to check on the girls in 2002. But the plan to bring them back the next year was scuttled by the outbreak of Sars here in early 2003.

Now, the decision is to wait till the children are five years old, so it would mean just one major surgery, instead of several.

The vulnerability of the girls' heads has forced them to stay in Kathmandu, where medical care is available. But the expense of living in the capital is a huge burden.

Mr Arjun Shrestha, their grandfather, said: 'If their heads are OK, we can go back to the village. We have no economic problems there. Now, we have no money. We don't know what to do. We want Ganga and Jamuna to be happy, but the future looks dark.'

Living Separate Lives

'EAT, eat,' Jamuna urged us in Nepali.

The whole family was gathered in the small living room of their second-storey apartment to greet us when we arrived.

They knew we were coming and were excited. The twins were bathed the day before we got there, instead of waiting for their routine weekly bath.

It is cold in the airy reaches of the Himalayas, even in Kathmandu.

With springtime gaining, daytime temperatures rise to the mid-20s. In the cooler indoors, both Ganga and Jamuna keep warm under several layers of clothes.

Although it was just 4pm, the twins' grandmother, Mrs Ambika Shrestha, had already prepared a feast for us.

Following Nepalese custom, the guests ate first.

But Jamuna, who will be five next month, joined us, merrily eating slices of carrot and cucumber as we tucked into our green dhal curry, potatoes with onions, chapati and rice. There were two types of chicken, a special treat in our honour.

Jamuna became instant friends with us, greeting us with 'Namaste' - a respectful greeting - and blowing kisses. She wondered why we didn't understand her non-stop chatter.

In the next three days, she would pick up English from us, parroting our phrases with perfect intonation.

Of course, she has no memory of Singapore.

The last time Singaporeans had seen Jamuna and her twin, they were in the arms of their parents, waving goodbye at Changi Airport.

That was in November 2001. The twins were 1 1/2 years old. The future seemed full of promise, with the hardest part behind them.

Born joined at the head with intertwining brain tissue and blood vessels, they had pulled through a complicated 97-hour operation to separate them some seven months earlier.

Their parents left believing they would be back before two years were up, to have their daughters' heads reconstructed.

Today, they are still waiting, in a cramped apartment in Kathmandu, far from their home in the little village of Salyan Bazaar in the Himalayan foothills.

Bhushan, the twins' father, is not with them. He went back to the village two years ago to visit his ailing mother and never returned after she died last year. Although he calls every few months, he sends no money.

The twins are looked after by their mother, Sandya, 27, and their maternal grandparents, Ambika and Arjun Shrestha, who are in their 50s.

The family depends on Sandya's 5,000 rupee (S$118) monthly salary as a primary school teacher and the 7,000 rupee pension her father Arjun gets. The rent alone takes up half the money, and they are now six months in arrears.

Beset by problems

IT IS difficult for the family to do anything else but care for the twins.

Neither of them can walk. Jamuna pulls herself along the ground with her stronger left arm and leg. Her right leg is slightly shorter and very weak. So is her right arm.

Although she is adept at moving around, she often asks her grandfather: 'Why can't I walk, Ba?'

He tells her not to give up her exercises, which she does diligently, in the hope that she may walk one day, or even just lift her right arm.

But the weakness in her body is not as severe as her other problem.

There is no bone covering the top of her head - only skin and hair. To prevent accidental knocks which could damage her unprotected brain, she wears a special cap sent from Singapore.

Because of her condition, no school has been willing to risk taking her, though she is well past three, the age at which most Nepalese children start school.

Despite these problems, she is much better off than her identical twin, Ganga. The more advanced of the two before they were separated, Ganga now lags far behind, unable even to sit up, or talk.

'Ganga is like a six-month-old baby,' said her grandfather.

She spends her days lying on a padded cloth on the living-room floor, playing with a mobile toy hanging over her. When lifted, her elongated head rolls to one side.

Each time we visited and called her by her pet name 'Gangu', she turned and smiled at us, gurgling with pleasure when someone stroked her face.

Dr Chumpon Chan, one of the two lead neurosurgeons who carried out the separation, said she is not likely to develop much more.

Her brain was deprived of blood for some crucial minutes during the operation. Dr Chumpon said the problem was worsened by a bad bout of meningitis, or inflammation of the brain lining, immediately after the surgery.

Doctors had hoped her growing brain would compensate for what was damaged in surgery, but this does not appear to have happened.

The damage may have affected her eyesight, he fears. Her legs also cross each other, like a pair of scissors - a sign of cerebral palsy.

Her most pressing medical need is to have a shunt inserted in her head, to drain the fluids that have accumulated in her brain.

Once the excess liquid is drained, said Dr Chumpon, her head may weigh 300g less, and she may be able to lift it.

That was the question that arose frequently during the visit: Why had the twins not had medical attention?

Sometimes they go to a hospital near where they live, but that is for mundane complaints like the urinary problems Ganga occasionally has.

For the operation to insert the shunt, Singapore General Hospital (SGH) referred the twins to Dr U.P. Devkota, head of neurosurgery at Kathmandu's 500-bed Bir Hospital in September last year.

Bir has four neurosurgeons, all highly experienced, doing more than 700 operations between them each year.

The operation can be paid for with some of the donated money. But the family has refused to have it done in Nepal.

Dr Devkota told them it carried a 10 per cent risk, they said.

The Straits Times paid a call to Dr Devkota at Bir. The neurosurgical ward on the top floor is clean and does not have the stench of urine of the first floor.

But its small windows let in little light, and the dust that pervades Kathmandu is ever-present.

Dr Devkota said it was the family's decision whether to proceed with the operation. Because of the intense media publicity surrounding Ganga and Jamuna, he was reluctant to persuade them to have it done.

Dire situation

WHILE the twins' family waits and hopes for the promised call from Singapore, life for them does not extend far beyond the small, two-bedroom flat.

In fact, the only time Ganga leaves it is to see a doctor.

Still, the family is not entirely isolated. Two other families share their building, with each occupying one floor.

A neighbour, 12-year-old Gita, visits frequently to help look after the children, whom she adores.

During our visit, Sandya's younger brother, Divas, 22, had also come from Salyan Bazaar.

The holidays had just begun for the student, who made the 24-hour bus ride to the city to help look after the children.

But mostly, it is a simple life that allows for few luxuries. The financial burden of living in the capital city and caring for the twins sees to that.

A couple of bars of chocolate we gave Jamuna disappeared under the couch while she wasn't watching, to be rationed out later.

Sandya holds tightly to the promise made by the then CEO of SGH, Dr Vivian Balakrishnan, to bring the twins back for further treatment in a year or so.

She believes a return to Singapore will result in an improvement in Ganga's condition. The hope has kept her going.

As her children grow, she wonders how much longer she and her parents will be able to keep carrying them. Looking at Ganga, she said: 'Many times I think I want to die with Ganga.'

The child's situation is dire.

She is able to sleep only a few hours at a stretch before she must be fed, or turned. Sandya and Ambika take turns to rock her back to sleep.

She chokes on solid food, and can accept only liquid or mash. Her favourite meal is biscuits mashed up in Horlicks or milk. Her other staple is rice pudding.

As for Jamuna, she is getting to the age when she chafes at being confined so much.

An inquisitive child, curious about everything around her, her usual outings are to a nearby temple, and occasionally to the hole-in-the-wall shop three minutes away for groceries.

The temple is a little further away, but Jamuna goes there with her mother and grandparents every day to pray.

Their prayers for the children are fervent, as is their wish that they be answered one day.