There is a new HIV diagnosis in the outpatient department for a man whose wife is dead, an infant in respiratory distress in the emergency department, an inpatient unit whose patients seem to be bathing in flies. Another child in the emergency department fell on her elbow from a few feet and probably needs an x-ray, but the x-ray has not been charged. The grid has been out for too long and the solar power, despite all that it has done for this hospital, is not enough for all our electrical needs right now. There are two patients with likely multi-drug resistant tuberculosis, without community health workers in their villages and no good way for following them up. The delivery room, for some reason, has blood that has not been cleaned off the floors. There are expired medicines, rat-eaten equipment, broken light fixtures, and busted windows. The entire hospital needs to be tiled. The head of the district just stopped in. There is a question about an ultrasound for a post-partum woman with abdominal pain; patient toilets are overflowing with feces. The month is December and if we don’t raise $200,000 this hospital will shut down. Oh—and the man with the new HIV diagnosis? He also has herpes zoster over the right side of his face and possibly herpesopthalmicus which can cause blindness. This warrants treatment with IV antiviral medication and an ophthalmologist’s expertise. But neither can be found for over twelve hours.
One of the core skills we learn as physicians during residency is how to effectively triage. It is impossible to do just one thing at a time. But the nature of the job also forces us to flip from one task to another. This need for rapid task alternation is compounded when we try to be both physicians and implementers, leaders, and managers. My role here in remote rural Nepal is as a leader, to work with our team to generate technical and financial resources to improve this hospital. This largely consultant role is much easier than actually being a manager. And yet at times I have felt paralyzed. This is a moral paralysis. There is no question about the need for action. Our patients are suffering and dying needlessly. What I can do is ponder and focus back on fundamental questions: where can we take small steps forward on our systems for the future? How can we offer tangible acts of compassion and quality care in the present? I can see this paralysis at times in our own staff and volunteers. We often talk so much and yet weeks later nothing has been done. We have no shortage of wonderful ideas, but we are lacking in their implementation. I have become impatient with the round-and-round talk over cups of tea about what we can improve. I crave concrete, small steps with implementable work plans. But that is not always the necessary process. Admittedly, I am finding my writing somewhat ironic in that it is reflective rather than action-oriented.
I do see progress. There have been moments of compassion, care, and cure. I am proud of what we have accomplished here; proud of the skill with which our team places intravenous catheters, performs simple interventions, revives children with pneumonia and sepsis, and fixes lacerations, abscesses, and broken bones. Our staff work hard and operate as a really inspiring team, even when facing the harshest of circumstances. But every fly I see hovering around our patients, every broken window, every patient who needs an EKG, an oximetry reading, or a lab test and who doesn’t get it, hurts. Our patients walk hours to get care, wait in lines, suffer the greatest of indignities, and often die needlessly. They deserve much, much more. They deserve actions, not ideas. They deserve for us to overcome our paralysis and act with moral certitude.
Being a clinician is a blessing because a particular patient can bring back your focus and awake you from your moral slumber. When one child comes in with a correctable problem that we can treat or refer appropriately; when we can perform organic fixes for concrete diseases that don’t require our floors to be tiled, our medications to be dispensed via air-tight quality control mechanisms, or tests that we don’t have. These patients inspire us and bring us back to the task at hand: identifying small, concrete steps to build better systems. The diagnosis—moral paralysis—has a singular cure: the eyes, brows, hands, and hearts of those people who walk up this hill, hours from their villages, asking of us that we do better.
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.