The patient was of a young woman who presented to the Emergency Department (ED) with rectal bleeding for the third time this month. I watched our doctors go through preliminary check-ups and interventions with her at the end of the work day, and then left for my office, confident that all was under control. When I emerged for dinner that evening, our clinicians quickly pulled me into the ED. Given limited technology, they were unable to perform a colonoscopy and concerned that the patient would need a blood transfusion before the end of the night. Moreover, they had spent the last three hours defending themselves against a barrage of criticism from the patient’s family, accusing them of ineffectiveness and spitting advance blame for any devolution of her condition while in our care. Worst of all, and paradoxically, the family refused to allow referral for potentially life-saving transfusion services that our hospital could not provide.
In the interests of saving time and with hopes of convincing the family otherwise, I got on the phone with colleagues across the region: hospital directors, surgeons and lab specialists at four different medical centers between Mangalsen and Dadeldhura. Due to lack of transfusion services or lack of responses to my then “late night” call, we found no outside technical support. We did, however, reach a senior Nepali physician whom I had once interviewed for a position at Bayalpata and called that night in a moment of resource-seeking amidst withering options. He was a voice of support and reassurance when we needed one, informing us of transfusion options that we could access before morning. We thanked him. And then returned to the waltz of harassment and hurt that awaited us with the patient’s family.
My two hours of subsequent intervention did little. I could hear the shouting before I entered the ED and took the patient’s mother-in-law to my office, away from the commotion around us. She had been the primary perpetrator of abuse against our clinicians and the driving force behind her son’s decisions for his sick wife. We spoke. And she cried. But she never wavered. I then spoke with her son privately in the ED call room. But after thirty minutes of progress by inches, the furthest we got was “I need to talk to my mother.” Our staffs were tired and frustrated, and the hope of winning this debate had begun to feel beyond reach.
Ultimately the patient spent the night. Our staffs had fought hard and wanted to keep going. But we decided to stop. It was after 10p.m. And the best we could do was to make sure that the family didn’t return home. As our parties parted ways, I brought the family a jug of water and asked the night guard to send immediate word if the patient tried to leave the hospital.
Two days later, the young woman with rectal bleeding returned home alive. She left with no real diagnosis and no visible fear that she would likely return to our ED soon.
So, yes, the patient was healed enough to go home. And yes, the night was a remarkable example of teamwork, resource identification and die-hard perseverance. But it was hard. It was hard to watch people refuse care for a woman who needed it. It was hard to see her suffer throughout the mayhem around her, completely powerless and subject to the rhetoric of her husband’s family. It was hard to watch our staffs, whom I admire and care for in endless ways, take such a beating as reward for their altruism. And it was hard to fight and lose…
People have said that life is cheap in Achham. And maybe that’s true. Maybe that’s why we do the work we do. To honor the lives that others don’t. Or to set a model of compassion and grit that defies the skeptics of free healthcare and the challenges of survival in this forgotten fold of the Earth. So we keep trying, fueled and impassioned by the toils that brought us to Achham in the first place. Perhaps hoping that the bruises we invite bring us closer to our vision.
Gregory Karelas is the Country Director of Nyaya Health. He graduated with an MSc in Medical Anthropology.