I interact with our patients briefly, in the context of a consultation by one of our clinical team members. For most of the patients with whom I consult, I will never know whether we had the right diagnosis or the right treatment. Without a clear mechanism for following up with our patients, I cannot know if they come back alive, if we helped or harmed them. These are such dedicated and courageous patients, and they deserve better. They travel for up to two days, some carried by their relatives, others by their own feet, by tractor, by bus, and by jeep. They are brothers, sisters, husbands, wives, sons, and daughters; the fabric of a society at the margins of economic and political power, trying to build a better community. And so it is that we owe them better mechanisms to ensuring adequate follow-up.
Indeed, the very moral heart of our work here in the remote Far West is following through. There are two distinct cultural forces that make following through so difficult for us: that of biomedicine and of international development. The biomedical culture is fairly universal throughout the world, especially within the Nepali medical system, which places much of the onus on presentation, diagnosis, treatment, and follow-up of patients. Within the international development community, promises are so often made without adequate moral commitment to do whatever it takes to follow through on those promises. As I’ve written elsewhere, ideas, criticisms, promises, and plans are epidemic; what is lacking is tangible follow-through and implementation. I am proud that our hospital does attempt to reach out, through provision of free services and through our community health worker program. But the norm is to dispense medicine without a clear plan for following up or following through.
Our healthcare team is morally committed. Yet translating that moral commitment into moral action requires better systems. In discussing these problems with our Director of Community Health Agya Poudel (who has started spending more time with patients at the hospital to better understand their needs), our current Medical Director Dr. Sizan Thapa, and others, we are pursuing three avenues to make Bayalpata a more accountable hospital, and improving our capacity for following-up with patients:
1. Patient follow-up program. We have started a modest program to follow-up selected patients with diseases in need of rigorous follow-up. These patients may come from the inpatient, outpatient, or emergency departments. Please see the protocol, register, and database at the following link.
2. Community Health Worker Referral system. We have formally started a card system for referring patients. This is a project that we had discussed several months ago and purchased cards for, and that we have now started to implement. The data for this will be tallied via our current CHW database.
3. Health post linkages. Over the summer, members of our team conducted initial surveys of five surrounding health posts (government clinics staffed by mid-level providers). We are formalizing this through monthly phone calls. This is primarily for maintaining good relationships with the health posts, and to engage them in helping to follow up patients through our patient follow-up program.
Now it is time for us to demonstrate that we can truly make that moral commitment, to following through on our promise of following up.
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.