This week, a 70-year-old woman with emphysema and heart failure was admitted to Bayalpata Hospital with shortness of breath and limited ability to walk, likely related to heart failure. She had murmurs indicative of aortic and tricuspid valve insufficiency. Based on an echocardiogram (ultrasound) performed by our Health Assistant Uday Kshatriya and interpreted with the assistance of Dr. Sizan Thapa and Dr. Bijay Acharya, she had dysfunction on the right ventricle of her heart, muscle thickening on the left
ventricle, enlarged filling chambers on both side, and a dilated aorta. He used the curvilinear probe used for abdominal exams since a rat had sadly eaten away at part of the cardiac probe. The image, shown below, had quality sufficient to our team’s current expertise. Fortunately, her kidney function, which we measured in our laboratory, was normal. She has improved symptomatically with administration of lasix. The team discussed starting digoxin but felt that without the ability to monitor levels and her poor baseline function it was not going to provide more benefits than harms. Even before she had this acute episode, she had limited mobility and walked with a cane. She lives several hours away; to reach our humble hospital, she undertakes quite a journey. Her son has to carry her for an hour to reach the road, then she has to take a tractor for 30 minutes to reach a cross-roads, then a bus for 30 minutes to the main transit area in Sanfe, then another bus for 30 minutes up the hill Bayalpata. She has to wait for her vehicle at each stop. She does this all to come to a hospital that lacks a cardiologist, a heart monitor, an EKG, or any methods of monitoring digoxin levels. To add indignity to injury, when she is in the inpatient unit she has a hard time keeping the flies away. Her life expectancy is quite limited, yet with appropriate management of heart failure with existing technologies, we should be able to improve both the quantity and quality of her life. She does not live in a village covered by our community health workers. We spoke with our Director of Community Health Agya Poudel about monitoring her blood pressure, heart rate, symptoms, and kidney function through some mechanism via the local clinics. Yet sadly it seems that her follow-up will be largely thrust upon herself and her family. She is one of so many patients whose inspiring and tragic stories tell us every day that we are failing in so many ways and that we need to grow effectively and rapidly—to deepen and improve upon our existing clinical and outreach services, and to expand both in the clinic and in the community.
Duncan Maru, MD, PhD is the co-founder of Nyaya Health. He is currently a resident in the Internal Medicine – Pediatrics program and fellow in Global Health Equity at Brigham and Women’s Hospital and Children’s Hospital of Boston.