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Posted by Duncan Maru

It was a straightforward task: to measure malnutrition in the areas served by our community health workers (CHWs).  In August, we mobilized our CHWs, who went out into their communities and recorded heights and measurements for over 1500 children.  Subsequently, however, all the surveys were left in a filing cabinet and were not analyzed until I asked about it.  When I started to go through the data with our Director of Community Health, Agya Poudel, we found that 17 of 90 of the first children were malnourished, with Z-Scores of -2 or -3.  These children should have been followed-up with nutrition counseling, supplementation, and regular assessments.  Yet their data had been sitting in a filing cabinet.  Furthermore, it was demoralizing for our CHWs, who had done a tremendous amount of work without any follow-up.

There were miscommunications about using the heights and weights instead of the mid-upper-arm circumference, about what a Z-score was, and about how to follow-up identified cases.  The disaster that was our community assessment of malnutrition demonstrates a basic moral challenge of Nyaya Health: can we follow up on the health of our patients with determination and rigor?  Can we make that moral commitment to our patients?  I’ll admit that finding out about this malnutrition assessment was one of the lowest and most demoralizing moments I have ever faced in Achham.  It suggested an organization whose morality and commitment only runs skin deep.  I as a long-time leader of the organization, bear direct responsibility for enabling or even fostering such a culture.  But to emphasize: this was a management failure on the part of Nyaya, not a personal one on any individual’s part.  We failed as a team to treat the children in our survey as our own.  We acted unethically.  It is not that we as individuals failed to care, it is that we did not have the appropriate management and communication structures.  Yet from every crisis comes an opportunity.  Better management is, after all, a moral imperative.  I spoke with folks on site about this, and I do think we identified some concrete ways to avoid this tragedy in the future.  Agya and her CHW Aarti will go through all the data and will follow-up with the children who had low Z-scores.

Beyond the basic task of finalizing those data and tracking the malnourished children down, we will be taking strides to prevent such lapses in ethics from happening in the future.  We have added the following insights to our wiki.

As a team, we’ve had some tough conversations about this, and I think we are ready to do better. Mistakes are inevitable in this type of work; the question is whether we can reflect and build better systems.  I have full confidence that we can.  We will.

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Duncan Maru, MD, PhD is the co-founder of¬†Nyaya Health. He is currently a resident in the¬†Internal Medicine ‚Äď Pediatrics program¬†and¬†fellow in Global Health Equity¬†at¬†Brigham and Women‚Äôs Hospital¬†and¬†Children‚Äôs Hospital of Boston.

2 Responses to “On Malnutrition and Mismanagement”

  1. Dr. Bikash Gauchan says:

    Dear Duncan
    Thank you for your very insightful post. Let me tell you whatever we are doing is great. The Community Health Program is one of best program i could ever imagine in the health care delivery. I admit there are challenges and areas where we can improve. At the same time, i believe that we can do better. I envision the Community Health Program to be run in collaboration with the clinical team of BH because many of the staffs are trained in Malnutrition management as for example Taraman Ji. As clinicians have better idea about how to diagnose, they can also provide training to CHWs. I am always ready to help from my side when need arises. Please let me know if i can help. Thank you once again for your continuous hard work.

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