A brave little four-year-old girl with a pink hairband twisted on the crown of her head, pink and purple polka-dotted shirt, and purple socks is sitting in the procedure room. She had fallen earlier that day while playing and hurt her right arm. She has a small abrasion over her cheek and her forehead has a piece of guaze over it. Bayalpata Hospital Medical Director Dr. Bikash Gauchan motions over to me to show her X-Ray. Distal ulnar fracture. He requests that our charge nurse Urmila sister help prepare the plaster materials, mentioning to me how our next stock of plaster from Dhangadi (city to twelve hours to the south where we get many of our supplies) should be higher quality. Urmila sister, with the same confident, style that I have come to respect of pretty much all the charge nurses in the United States I have ever worked with, prepares the materials. The child’s father lovingly, calmly, rests his hand on her other shoulder. As Dr. Bikash goes about setting the child’s fracture, I speak with the father briefly. He’s a wiry man about five feet ten inches with a gentle face and an angulated jawbone. He wears shaded glasses and sports the dress of a professional. I appreciate him consciously slowing down his Nepali so that I can understand. He’s from the area, has a bachelor’s degree in education, and works for an NGO on education issues. He grew up here, as did his parents. His daughter is the oldest of three children. I ask him what he thinks of Bayalpata Hospital, to which he replies that he’s very pleased with them. Pushing him a bit more, I ask him for any advice or improvements that could be made. At first, he is hesitant to say anything negative; after further probing he mentioned that his biggest concern is that our free services may not be sustainable and that he hopes we would be able to stay at Bayalpata in the long-run. Dr. Bikash finishes setting the fracture, instructs the father on the follow-up plan, and sets them on their way.
Allow me to digress briefly to mention a bit about our X-Ray, since identifying that fracture was not possible four months ago. As we have recently published in Globalization and Health, there is a large gap in X-Ray services globally:
Diagnostic radiology is a major growth industry in the healthcare sector worldwide, but most citizens in rural and impoverished areas currently lack access to any form of imaging. While 96% of emergency departments in the United States have CT scanners, large swaths of rural populations in resource-poor countries lack access to basic ultrasound and X-Ray. Unfortunately, very little solid data exist that provide an accurate picture of the current global neglect. Even where diagnostic imaging is available, the machines are often unreliable; in some surveys nearly 70% of the X-Rays in developing country settings do not work.
We in fact wrote that paper after being frustrated by the lack of viable, affordable options for us. The process of procuring the X-ray, as we have described previously, was made possible through collaboration and persistence. Currently, we have a WHIS-RAD installation operated by Dhan Bahadur Bogati, another long-time Nyaya employee. Without formal education in healthcare prior to his work with us, he has stepped up to the challenge and, through a few trainings, including an on-site one this week, has learned the trade quite well.
The next patient is a teenage gentleman who fell off a bus in Sanfebagar (town about 20 minutes down the hill) bound for Kathmandu. Like many young men in Achham, he is looking elsewhere for work. Another excellent X-Ray had been shot by Dhan Bahadur ji. Mid-clavicular fracture. Dr. Bikash discusses briefly with Udayji, one of our health assistants (equivalent to nurse practitioner or physician assistant. He has been with Nyaya Health since the founding of Nyaya’s clinical services in Achham, nearly three years now and takes a gentle, compassionate approach to his patients. We share vegetarianism and an interest in ultrasound diagnostics. Dr. Bikash applies posterior force to the patient’s shoulders and Udayji creates the figure-of-eight, the typical non-operative management of mid-clavicular fractures. A quick search later that night (the miracle of Internet in Achham is another story) did reveal that some orthopedic surgeons are now recommending early surgical correction; we should remember to give the referral orthopedist (nearest one in station currently is Dhangadi) a call to ask about that.
We had been anticipating the next patient. He is a police officer from a neighboring village only about an hour away. He was working on a gate at a temple for the upcoming festival of Maaghi Sankranti when he also fell. Our driver Dilli dai picked him up in the ambulance after his fall. Radial head fracture. This time we will have to refer him to an orthopedist in Dhangadi. Dr. Bikash feels that such a fracture, especially given the quality of our plaster, would not suffice for this gentleman. The patient is obviously disappointed and questioned why we couldn’t do it here. Dr. Bikash explains n that we are not yet equipped for such problems, and he reassures him that he would get adequate treatment, albeit after a day’s journey. Udayji provides a sling, and the policeman sets afoot on the long trip to Dhangadi.
We had seen these patients within the space about 20 minutes one chilly afternoon at Bayalpata Hospital. Dr. Bikash jokes that if he worked at Bayalpata Hospital for four years, he could become a senior orthopedic surgeon. Orthopedics in Achham is frought with the challenges characteristic of many of the clinical problems we face—inconsistent supply chains, lack of specialists, minimal follow-up. The care we provide remains very incomplete, but we’ve made some progress, as these three cases demonstrate.
Many of us in “development” work discuss about what kinds of interventions are “band-aids” and what kinds get at the root of the problem. Indeed, the root of poor health for our patients is poverty. But anyone who says that healthcare is only a band-aid on development problems should come, if they can stomach the 2-day trip, visit Bayalpata Hospital and talk to Dr. Bikash, Udayji, Dhan Bahadur, and Urmila sister. Every day they are devising fixes to a myriad of health problems facing Achhami citizens today, not in some distant future. Our work is humble; we’re not solving poverty and injustice, but, as these three cases illustrate, we are helping, in small, tangible ways, to make Achham a safer, healthier place to live.
Duncan Maru, MD, PhD is one of the co-founder’s of Nyaya Health. He is currently a resident in the Internal Medicine – Pediatrics program at Brigham and Women’s Hospital and Children’s Hospital of Boston.