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‚Äôll 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‚Äôs 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‚Äôve 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.
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.