I had dozed off, I think, when the jeep pulled over. The door opened and our young patient and her mother got into the back. It was pitch black, where the new moon had ceded the night stage completely to the stars. Suddenly, mayhem seemed to break loose. The child’s father, afflicted with a developmental disorder rendering him severely intellectually disabled, was crying and trying to enter the jeep. An uncle was drunk and saying that we were stealing his niece for her organs. Several other men had gathered around. The child’s mother sat steadfast in her seat. Agya calmly explained again that we were going to see the cardiologist in Kathmandu. Ultimately, the men stepped away and we began our long, winding journey through the darkened hills.
Achham has taught me that accompaniment is both a philosophy of leadership and a way of life. I had heard our colleagues and mentors at Partners In Health use the term, but have only begun to realize its power through the guiding hand of Achham and its people. Accompaniment is the commitment to be present with patients and family members in the midst of suffering and injustice and stupid, unnecessary deaths. It is the commitment to be present with our staff and volunteers as we make mistake after mistake, as we fail and fail and fail, and then as we learn and evolve and fail again. It’s an undying belief in our vision and an unwavering hope in health and justice. I have seen Achham break the spirits of many of us, where the lesson we take away from the deaths and the bandhs (strikes), the expired medicines and faulty equipment, is one of defeatism and nihilism, retreat and paralysis. In Achham, learning accompaniment is not merely an act of compassion or good leadership, but one of necessity, of survival. And ultimately, those acts of accompaniment are what draw us back to Achham time and again.
So it was with Agya Poudel, a young woman raised in Kathmandu who joined us last year after seeing Achham several years before, towards the tail end of the civil war. She had recently received a Masters degree from a prominent German university and was compelled to put her education, experience, and passion to work in the Far West. The subsequent year would bring huge, intense, personal challenges. She weathered a staff crisis that brought her personal threats. Being the only leader of a community health department that, within Nyaya, only receives a tiny fraction of our operating budget, yet is charged with delivering some of our most impactful and far-reaching initiatives. Many of our objectives were not met; our follow-up program, community malnutrition initiatives, and expansion, were all delayed or incompletely met. That is the nature of the work; we aim, we experiment, we fail, and then we evolve. Throughout these struggles, the Agya I witnessed was someone with a gentle and accompanying presence for the families we serve. Despite her life and world as an educated woman from Kathmandu being gulfs away—politically, economically, socially, culturally, linguistically—in so many ways from life in Achham, she listened and accompanied. It was in those moments of human connection, like when she sat by our patient’s strong mother and helped her bring her daughter to get evaluated for cardiac surgery, that Agya provided such inspiration and impact.
Accompaniment is about identifying each other’s strengths and bringing them to bear for health and justice. Agya demonstrated this with the child and her mother. The mother had been married at the age of seven, is illiterate, and lives in dire poverty with her four children. Yet she shares that most powerful force of hope in her daughter’s future. Her daughter is attending school and will get a cardiac surgery to repair her damaged mitral valve. Agya saw and appreciated this strength and supported it at a time of intense fear and doubt and danger.
She is moving on now, but her impact and spirit will persist, and she will bring the lessons and struggles, the failures and evolutions that she has learned from Achham, to all her future endeavors. And, like all of us, she will one day return to these powerful hills.
Duncan Maru, MD, PhD is a 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.