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Posted by Duncan Maru

We would love some discussion and feedback about a surgical implementation science protocol we just published on BMJ Open.  This research will evaluate our implementation of surgical services at our rural district hospital in remote western Nepal. As you all are acutely aware, surgical care is a severely neglected area in public health. Our theory of change, and indeed our motivation, for this research is the following: 1) pilot some methodologies for evaluation and planning of surgical services; 2) generate some baseline data; 3) provide motivation and background for larger implementation studies; and 4) advocate for increased funding mechanisms for implementation and research in global surgical and anesthesia care.

We would greatly appreciate some hard-hitting, critical feedback about the ability of this protocol to help meet these objectives. This is very much new territory for us, and the qualitative methodologies are currently still quite weak. We will be submitting this to NIH PAR-10-039 in the next cycle (which by the way is an excellent RFP for any implementation researchers out there).   You may also see discussion of the article on GHD online.

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Duncan Maru, MD, PhD is a co-founder and President 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.

Posted by Ryan Schwarz

Nyaya CHWs screen and provide treatment for malnourished children both at Bayalpata Hospital and in the surrounding communities

Malnutrition is a critical health issue for children throughout Nepal, and in Achham where Nyaya works, nearly 1 in 5 children are qualified as malnourished. Bayalpata Hospital conducts a malnutrition screening and treatment program for all children who come to the hospital, and in the coming year will be expanding its program out into nearby communities. This week IRIN Asia featured an article on malnutrition in Achham after they visited the Achham district hospital, the only other hospital in the district. Their article sheds more light on the enormous challenges behind malnutrition programs and highlights the need for further support. Nyaya is proud to work on this program with the Ministry of Health and hope that in the coming years the statistics where we work will not be nearly as grim.

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Ryan Schwarz, MD, MBA, is the Vice President of US Operations for Nyaya Health. He is currently a resident in the Harvard Brigham and Women’s/Children’s Hospital Medicine-Pediatrics Residency program

Nyaya Health’s Chief Operating Officer, Dan Schwarz, was recently quoted as part of PRNewswire’s press release that unveiled 21 global health case studies for open access to the public that were produced by the Global Health Delivery Project and Harvard Business Publishing. These case studies have previously been used as the core of Harvard’s Global Health Effectiveness Program (GHEP) which is a product of collaboration among Harvard Medical School, Harvard Business School, and the Brigham and Women’s Hospital. Both Dan Schwarz (’09) and current Nyaya Executive Director Mark Arnoldy (’10) are graduates of the GHEP, and these cases have benefitted them immensely in their programmatic and organizational decision-making at Nyaya over the last two years. Nyaya Health would like to applaud and celebrate the release of these case studies, for open-access is a fundamental value of our organization, and we wish to encourage partners and other implementers in the field of Global Health Delivery to access them through this website.

 

Nyaya’s partner organization, Hope Through Health, has posted the following proposal for a new job opening in Togo. Hope Through Health has been doing inspiring work for health care equity in Togo since 2004, and are currently advertising for their first full-time Program Director position. We are honored to spread the word about this important position and hope that our readers will forward it along to anyone that might be interested in supporting the mission of this tremendous organization. You can read more about the position here.

 

 

Along our journey, Nyaya has been blessed to find support from all corners of the world, and among all our supporters, the dedication of our friends in Norway continues to humble and inspire us all. As has been written about on this blog twice before, we have received an incredible amount of support from our Scandinavian contingent, and we are excited to now report on yet another initiative from Oslo!

The Hollies

In 2010, Knut Skyberg and Borgny Ween organized a concert by British rock band The Hollies . This concert was part of a fundraiser celebration for Knut’s 60th birthday. The concert was a smashing success.  Subsequently, Knut and Borgny and several other friends came to Bayalpata Hospital to learn more about our work. Inspired, they returned to Norway and launched an aggressive fundraising and advocacy campaign to raise even more money and awareness about Achham in Norway. Borgny had big plans: for her 59th birthday, in September 2011, she wanted to repeat the Hollies concert in Oslo.  However, this year Borgny and Knut went one step further and organized two shows in two different Norwegian cities, with 100% of the proceeds going directly to the people of Achham – an incredible sum of over $40,000 in total!

Over the past year, Knut and Borgny have worked tirelessly to achieve broad media coverage of the event. Knut was interviewed on national radio, there have been press releases (see here and here), newspaper articles local radio ads, a feature in the Norwegian Medical Association Journal, flyer distribution, and poster advertisements throughout their community in Oslo. The concerts have been widely advertised online with email campaigns, a Scandinavian event website on Facebook (accessible in Scandinavia only), and an informative Norwegian Wikipedia site. Ticketmaster Norway has run front page web ads for several weeks and they also sent out a very nice email announcement to their 300,000 subscribers underlining the purpose of the shows.

Ticketmaster Norway has been widely touting the benefit shows on their website and in email campaigns.

The two shows, scheduled for September 10th and 11th in Oslo and Trondheim, as of this week, are completely sold out! All proceeds from these two shows will go directly to support Nyaya’s work in Achham, with an incredible sum of at least $40,000 raised!

The Hollies fundraiser concerts for Nyaya’s work have been widely advertised over the past seven months, raising over $40,000 in ticket sales.


Nyaya would like to take this opportunity to extend its profound gratitude, on behalf of the people of Achham, to Borgny, Knut, and all of our friends in Norway who have worked so hard to support our work. It is an honor to have such inspiring and tireless advocates, and we are excited to continue working with them to provide the highest quality health services possible to the people of Achham.

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Dan Schwarz is the Chief Operating Officer of Nyaya Health and a member of the Board of Directors. He is a student at the Brown University School of Medicine and has also completed his MPH from the Harvard School of Public Health.

After two years of fantastic growth under the leadership of Jon Shaffer, the GlobeMed National Office is looking for its next Executive Director to guide it through its second phase of movement building.The next Executive Director will have the opportunity to significantly advance the mission of GlobeMed, leading the vision and work from our national office. We would be delighted to hear from anyone with an interest in engaging university students to improve global health equity across the world. Recent graduates are encouraged to apply. Applications will be accepted on a rolling basis until the position is filled. The job will remain posted until that time. The first deadline will be Friday, July 29, with first-round interviews taking place during the first week of August.
Please see the job description below and the GlobeMed website for more information.

If you have any questions at all about the role or the application process, please email us at:  globemed(dot)edsearch(at)gmail.com.

All the best,
The GlobeMed National Office Team

Core Responsibilities:

  • Develop and oversee the implementation of GlobeMed’s strategic plan (10%).
  • Develop and implement fundraising plan, raising more than $325,000 annually.  Cultivate relationships with donors including individuals, corporations, and foundations and represent GlobeMed to various stakeholders (50%).
  • Recruit, train and manage 2 full-time staff.  Support staff in recruiting, training and managing another full-time staff member and 10 volunteer student staff /interns (20%).
  • Develop and manage budget, financial/legal policies, and other administrative responsibilities as needed (10%).
  • Report to and work with the Board of Directors (10%).

Required Qualifications:

  • High level of initiative and passion for GlobeMed’s mission
  • Collaborative leadership style
  • Experience leading highly effective teams and in fundraising or sales
  • Minimum 2 year commitment, though longer commitments are preferred
  • Willingness to relocate to Chicago area (Evanston, IL office is 13 miles north of downtown Chicago near Northwestern’s campus)
  • Bachelors degree minimum

Preferred Qualifications:

  • Experience in student leadership development and proven ability to engage and work with students; willingness to meet students outside of normal business hours
  • Knowledge and understanding of global health trends
  • Experience living or traveling in resource-poor settings

Benefits:

  • Salary commensurate with experience
  • Competitive health benefits package
  • Travel to college campuses across the United States, with potential opportunity to travel internationally
  • Travel to global health conferences where GlobeMed is often a visible peer engaged in conversations with corporate funders and other significant supporting organizations
  • Opportunity to shape a young, exciting organization engaging students and communities around the world
  • Great leadership experience within a supportive community

Application and Interview Process:

Applications will be accepted on a rolling basis until the position is filled.  The job will remain posted until that time.  The first deadline will be Friday, July 29, with first-round interviews taking place during the first week of August.

1)  Send a cover letter and resume: 

Please email your cover letter and resume as attachments to:

GlobeMed
Selection Committee
Globemed(dot)edsearch(at)gmail.com

The letter should explain the relevance of your professional and educational experiences, address the requirements and responsibilities of the position, and include other important information that would make you a good fit for the position of Executive Director.  Letters and resumes should be kept to 2-pages or less.

Applicants will receive a response from a selection committee member upon receipt of materials.

2) Interviews for finalists: 

Finalists will be chosen for second-round interviews taking place in early August. Further information such as writing samples may be requested at that time.

Candidates are encouraged to apply as soon as possible.  A decision will be made in August.

Posted by Ranju Sharma

Bayalpata Hospital Staff listening attentively during a Mortality & Morbidity (M&M) Conference (brief introduction to the M&M program)

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Ranju Sharma was previously the Program Coordinator at Bayalpata Hospital. She recently completed her BSc at Mount Holyoke and is currently a volunteer with Nyaya Health.

Posted by Ryan Schwarz

Recently at the 2011 Skoll World Forum on Social Entrepreneurship, social justice leader Archbishop Desmond Tutu joined others for a panel discussion entitled Deep Leadership: Interior Dimensions of Large Scale Change (video here). The panel was filled with great lessons for all of us in the social justice and global health fields, but one particular line of Tutu’s struck a chord with recent discussions we’ve been having as the Leadership Team of Nyaya: “All of us want, quite desperately, for someone to say, ‘this is worthwhile,’ all of us.”

Over the past year Nyaya has undergone significant changes to its organizational structure. On paper, much of this is easy to change, however in praxis, to change the culture of an organization requires significant time, effort, and commitment. One particular aspect our Leadership Team has discussed recently is the need to move towards a “culture of positivity.”

What is a “culture of positivity“? It’s an environment in which each team member feels supported by their peers, directors, volunteers; an environment in which each team member is inspired and empowered by their teammates, and one in which they can feel day after day that what they’re doing is the right thing to be doing. It’s a culture that inspires and produces the goals its organization sets out to achieve: for Nyaya, it will be a culture that helps us work for health equity, with each team member bringing their absolute best to the table, and being met at that table by all other team members with warmth, encouragement, empowerment, and their own absolute best.

And why is this important? Well, quite simply, if we don’t function well as a team then we are nothing to anyone else – not Achham, nor other global health organizations – and we will fail in our mission. As Nyaya’s Leadership Team we cannot hope to lead our own team of volunteers to work for Achham if we cannot create a culture of positivity and inspiration for both them and us.

So, how do we get there? There is no protocol to attain such a culture of positivity; instead it is a continued process which all team members must commit to striving for. However, there are a few concrete and integral elements that go into developing this culture:

  • Inspiration – each of us takes our inspiration from those around us, whether our leaders or our volunteers, our team is a critical part of what inspires us to action;
  • Encouragement – this isn’t easy work, and some days it can be downright tedious and frustrating. We gain power from those around us to push on in spite of these frustrations because it is our teammates who remind us, in those moments, of our goals;
  • Validation – all of us, as human beings, like to get a pat on the back every now and again, and there is nothing wrong with this; it’s fuel to keep going, to know that what you’re doing is right and helpful and productive, and it’s an ego boost which helps you push through the challenging moments.

In discussing this with fellow team member Bibhav Acharya, he brought up the critical distinction between honoring and rewarding, in contradistinction to a true culture of positivity. And this actually gets more to the core of a what a culture of positivity is – it is not a culture in which every now and again a few team members are honored for their extra efforts or for being “the best volunteer of 2011,” for example. Instead, a culture of positivity is one in which all team members feel that their efforts are supported and met with appreciation. This is a critical distinction – in a true culture of positivity, each and every action a team member takes should be met with positive support, engaging questions, validation, and further encouragement. It’s not a culture of “rewarding” or “honoring” the two or three best volunteers only at certain times (i.e. when what they do really just far exceeds the norm). Instead, it’s a culture in which all of us acknowledge each other’s efforts, we appreciate our persistence, and we let each other know that by communicating it overtly. Further, it’s a culture in which the constructive criticism we offer, and should absolutely offer regularly, is equally balanced with positivity.

There is an enormous amount of great work to be done throughout the world – whether it’s in Achham, or Transvaal, South Africa (where Tutu calls home) – there are many groups doing critical work for human rights. But one key aspect that sets successful organizations apart from those that wither is the culture they nurture. Tutu’s comment, after 79 years of social justice work in many countries, reminds us that to accomplish our mission as Nyaya, or as members of the global health field, we must remain positive, and support those we work with in a similarly positive way.

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Ryan Schwarz, MD, MBA, is the Vice President of US Operations for Nyaya Health. He is currently a resident in the Harvard Brigham and Women’s/Children’s Hospital Medicine-Pediatrics Residency program

 

Bull Hit!

Posted by Ruma Rajbhandari

It was around 7pm on a weekday at Bayalpata when our nightguard, Naresh dai, came running to fetch the doctor on call, “Bullit, bullit!  Dr. Saab.”  At first, we all thought someone with a bullet injury had come to the hospital.  On further clarification, we learned that a woman who had been hit by a bull had been brought to the Emergency Room and needed immediate attention.   Naresh, who had previously worked as a waiter at a fancy restaurant in Bombay and had picked up a fair bit of English, was actually trying to say “Bull Hit!”

Dr. Amir and the health assistant on call, Taraman, immediately left for the ER.  Thankfully, the woman was in stable condition—her blood pressure and pulse were stable and she was conscious and able to converse.  She had no signs of an acute abdomen or internal bleeding. Her urine was clear without blood.  X-rays of her pelvis revealed no bony injuries.

She had been grazing her animals about four hours ago and was about to tie up her bull.  As she was putting the noose around its neck, it went wild and attacked her with its horns, injuring her pelvis and causing a large wound.  Her daughter-in-law who was at her side in the ER chimed in, “One should never tie a bull from the front, particularly this bull.  It has attacked other people before.”

Dr. Amir Bista, Bayalpata Hospital's physician, performing the surgery

The pelvic wound was massive—about 20 cm in length and deep with subcutaneous tissue and fat clearly visible.  It was shaped like a “V” with a large flap of skin and soft tissue in the middle.  Once sutured, it would look like a botched-up C-section.

Dr. Amir, an aspiring surgeon, immediately prescribed some broad spectrum antibiotics, a tetanus booster and pain medications and then, proceeded to clean the wound with normal saline and betadine.  After injecting sufficient local lidocaine, he placed catgut sutures and expertly aligned the deeper muscle tissue.  As he was about to start suturing the skin, we lost electricity due to a power outage—a frequent occurrence in Achham.  Naresh dai quickly brought in a lamp with rechargeable batteries and the suturing continued.

Stitched wound

Once the mini-operation was over, the patient was able to slowly lower herself from the procedure table and walk over to her bed in the ER.  Her wound was cleaned and dressed daily to avoid infection.  She went home in a few days on oral antibiotics and returned in a week to have her sutures removed.

 

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Ruma Rajbhandari is a physician at Brigham and Women’s Hospital, Harvard Medical School, Boston.  She volunteers with NSI and Nyaya Health


Posted by Ryan Schwarz

Nyaya’s President, Duncan Maru speaks at the Harvard Kennedy School

President and Co-founder of Nyaya  Health Duncan Maru spoke recently at the Harvard Kennedy School about Nyaya’s work and challenges moving forward. Following his talk there was a panel discussion with Ryan Schwarz, Nyaya’s Director of Operations, and Bibhav Acharya, Nyaya’s Executive Vice-President. You can view Duncan’s talk here:



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Ryan Schwarz, MD, MBA, is the Vice President of US Operations for Nyaya Health. He is currently a resident in the Harvard Brigham and Women’s/Children’s Hospital Medicine-Pediatrics Residency program

 

Posted by Ranju Sharma

School girls in Sanfe

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Ranju Sharma was previously the Program Coordinator at Bayalpata Hospital. She recently completed her BSc at Mount Holyoke and is currently a volunteer with Nyaya Health.


Dr. Bikash Gauchan

Originally from Kalopani, in the Mustang district of northern Nepal, Dr. Bikash Gauchan has served as Bayalpata Hospital’s Medical Director for the past year. This week marks a bittersweet milestone for Nyaya as Bikash heads to Dharan to complete a residency in general practice and emergency medicine. “Bittersweet” because Bikash has played such an enormous role in Bayalpata’s development and caring for the patients of Achham, and he will be missed dearly. Simultaneously though, we are extremely happy for Bikash, and for the people of Nepal, who will benefit from having such a compassionate and skilled physician serve them for many years in the future.

Bikash graduated from the B. P. Koirala Institute of Health Sciences, in Dharan, Nepal, in 2009 with his MBBS degree. Subsequently, Bikash stayed on at BPKIHS and worked as a medical officer in anesthesia. Then, in mid-2010, Bikash joined the Nyaya team to oversee our medical services and the development of programs at Bayalpata.

Dr. Bikash Gauchan in the Emergency Department

Just last week our team got an email from Bikash announcing that Bayalpata had seen it’s 40,000th outpatient in Bayalpata’s outpatient department. While this achievement in and of itself was humbling, overseeing our outpatient services (not to mention seeing dozens of patients each day) has been just one part of Bikash’s job as Medical Director. Bikash has also helped spearhead a more community approach to medicine for Nyaya, both by ensuring clinicians are reaching out to the community, and by helping to develop Nyaya’s Community Health Worker program. Over the last year Bayalpata has also begun to partner with other organizations to host health camps, including camps for eye health, mental health, and even plastic surgery for cleft lips. Under Bikash’s direction parallel programs like the Safe Motherhood Program and Nyaya’s Morbidity and Mortality Conference have also been developed and become integral components of Nyaya’s services.

The past year has been one of great success for Nyaya, but without Bikash’s dedication and leadership, none of this would have been possible. As Nyaya looks ahead, we’ll miss having Bikash at the helm but feel blessed he will remain a critical member of the Nyaya family. Please join us in offering our best wishes to Bikash during his residency and congratulations for his amazing work as Medical Director of Bayalpata Hospital.

 

Posted by Duncan Maru

Recently, a 17 year old man fell about 10 meters from a tree, sustaining fatal injuries.  After three hours in transit, he was brought almost certainly dead on arrival by our ambulance.   Our medical team performed basic cardiopulmonary resuscitation on this gentleman, though we were sadly unable to bring him back to life.  As part of our morbidity and mortality conference program, our team reviewed his case.  Although there was probably very little medically that we, even if we had advanced medical facilities, would have been able to do, reviewing the case helped us to identify key gaps in our treatment of emergencies.  For example, we identified shortages or expiries of medicines to help restart the heart, misplacement of ambu bags for providing rescue breaths, and misplacement of beds (which had been removed from emergency owing for re-painting).    We also discussed the question of when and whether the declaration of death can be performed in the field.  Our health assistant Uday ji summarized well the key lessons learned from the case:

“We need to have well managed and stocked emergency area. In this particular case, AMBU bag masks of all sizes weren’t readily available. We found an adult one after some effort but was covered in dust. We need to be well stocked with masks of all sizes not just the AMBU bag. Beds should be available at all times for emergency cases. We should hire a paramedic for the ambulance. Health education in the community is essential.”

Please see the full text of the mortality and morbidity review here.

Note: this report is a part of our “Morbidity and Mortality Conference Program” initiative aimed at cataloguing and reflecting on the underlying causal pathways in cases of excess morbidity or mortality. This work is supported in part by grants from the Lovejoy Foundation at Children’s Hospital Boston, Massachussetts, USA and from the Partners Healthcare Center of Excellence on Quality and Patient Safety.

Duncan Maru, MD, PhD is a co-founder and President 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.


June 2nd, 2011

Posted by Micheal Polifka

This post was written by Dr. Michael Polifka, Nyaya team volunteer, as a personal journal entry during a recent trip to Bayalpata Hospital in Achham, Nepal.

The varying amounts of moisture in the air (from a lot to more) coupled with the winds that circulate around the hilltops makes for constantly changing mood of the view of the river valley and surrounding hills in both the early morning and setting sunlight that is ever beautiful. Today, the fog extends up the hill from the river bed  so that little of the mountains across are visible.  The swallows are still seemingly happy as they chirp and do their sharp aerial acrobats right outside my room while several sitting on a wire just outside my open shutter wonder what my tooth brushing is all about.  This morning while having my usual breakfast of roti that I fill with a aromatic chick pea stew, Amir, one of my Nepali colleagues, brings an  xray for me to look at while I am waiting for my chiya to cool down enough to take a sip.  A six year old  girl was brought by her father into the ER this morning after walking for five hours having fallen and landed with her body weight on her flexed left elbow a day and a half ago.  Looking up at us from a bench the father is  obviously stressed from his daughter’s pain and a long walk through the night.  The xray unfortunately shows that the child has shattered her elbow and is at real risk to a life long disability from a non-functional joint without operative management, available only a 15 hours bus ride away.   Amir explains the needed referral to the father, who responds that he doesn’t have the funds for such care.  And so Amir and I discuss the best way to cast her elbow knowing that likely it will be frozen in that position for life.  ‘Fortunately’ it is her left, unclean arm (people eat only with their right hand here) .  As the father mulls over and over the long term dilemma he will face when his daughter is at an age for marriage and she is less than fully functional and the guilt he must feel of not being able to provide even basics for his young daughter.  The emotional stress is so clear in his right eye; you see quite awhile ago he was traumatically blinded in his left one. He has been through a similar circumstance before.

Rounds start with Bikash, the other Nepali physician, thereafter first in the four bed ER then to the six bed inpatient ward.  First is an elderly woman with chronic lung disease, from a life long combination of exposure to cooking fire and cigarette smoke, who has acute pneumonia.  In the next bed is a small one month old infant also in respiratory distress but more severe.  The mother, legs crossed, sits on the bed holds the swaddled infant in her arms.  Obviously malnourished, the tiny child’s chest retracts with each rapid breath, it’s face completely covered by the oxygen mask.  As Bikash is talking with the parents, I notice the handle of a small sickle sticking out of the back of her sari.  Taraman, the PA  explains that she keeps it there to ward off evil spirits from the child.  Seeing how terribly sick the infant is, I think quietly he’ll need all the help he can get.  I am surprised that the next bed is empty.  Yesterday a drunk young man fell from a thirty to fifty foot height and was brought in by a friend.  His left leg was both numb and weak; and his xray showed a spine fracture.  Desperately his family had taken him from the hospital in the night and were planning on taking him to a hospital in India, at least 30 jarring hours away by bus, where they hoped they could find him advanced care.

Next is a middle aged woman with pneumonia and dilated heart failure who is improving; she has classic deformity of leprosy of her right hand, fortunately the only permanent defect before being treated; that  her current problem would be so straight forward to treat.  Then a 14 year boy with abdominal pain, a 20 year woman who delivering a healthy child in the hospital several hours ago will be observed and discharged in a few more hours, and last a 40 year woman gored by her bull in her genital area two days ago that she was attempting to feed grass.  She had more stitches than one could count by Bikash two days ago and is now on large doses of antibiotics to try to prevent a secondary infection.

We all go then to the outpatient area, where there are 150 patients to be seen.  Here I move from provider table to table, to discuss the wide variety of cases that present to them.  A woman with malaria she caught in India was only partially treated now recurring, we discuss why;  an 18 year boy with clinically apparent mononucleosis, we discuss the physical exam findings;   a 35 year man with a lemon size benign tumor on inner thigh, that I lead Amir through surgical removal tomorrow afternoon.  And then an elderly woman with a large abdominal mass, almost certainly a cancer, whose almost cheerful response to a clear but simple explanation radiates a long and simple life kept in balance.   Most cases are straight forward though some are frustrating because of the limitation of resources here in this remarkable outpost that attempts to bring up to date medicine to the rural poor.  Just before lunch Bikash asks me to see an 18 month old girl who 3 days ago drank from a stream and now has a leach deep in her nose (this is a new one for me).  So I brain storm a bit and figure out a non traumatic way to get it out.  There are big smiles all around when it actually works.

As I am leaving for brief lunch, I return and see Amir and Megha doing CPR on the little one month old that we saw earlier on  rounds.  After ten minutes we stop, efforts were that futile even from the start.  The parents response is universal when told; tragically this is the second child that has died, the first was at 3 months of age.   Their agony is expressed in a sing song wailing chant that is joined in by a dozen family relatives who were waiting just outside.  Under the metal roof of the hospital the noise is deafening, perhaps it drowns out the agony of the parents momentarily.  I stay on the far side of the room silent and tearful trying to absorb some of this aspect of their culture.  After ½ hour they proceed out, the child’s uncle holding him, of the back door and down the hill.  The room now suddenly quiet, I notice the mother’s small curved knife on the now otherwise empty hospital bed; I guess the evil spirit wasn’t deterred.

As I am waiting for the food to be served, I look out of the kitchen window.  There are 6 bare foot boys who had been playing cricket; their game came to a grinding halt when 10 or so cows obviously weren’t able to tell the difference between a grazing area and a make shift cricket pitch.  The cattle responded very slowly to their yelling and pushing, apparently the grass was greener on this side.  Smiling to myself at the scene, I couldn’t also help but be aware of the contrast to the tragedy just minutes before.

The afternoon was as busy as the morning and went by in a flash.   First, we review a chest xray with finding of TB.  Then we review the thankfully negative HIV test of the 9 month old who had been breast fed by an HIV positive mother. (Virtually all HIV positive women here contract their illness from their spouse who have been to India to work for extended periods.  Typically they learn of his illness only when he dies of AIDS).  I am delighted to see a patient with rheumatoid arthritis that I had seen six months ago.  She was the first patient that was started on a protocol for disease remitting therapy and is doing really well.  Later is a 14 year boy who is two months into treatment for leprosy, he too is doing well, without any more clinically apparent disease.  There are many others with less complex problems, but I always try to find some relevant clinical point to review.  The last of the day is a 12 year boy who at 1 ½ years had head trauma and was left with a seizure disorder, untreated since then.  Three years ago during one of his daily three to five seizures he severely burned his dominant right hand. Untreated and now with severe contractured  scarring,  Amir and I are impressed by his positive spirit.  He proudly writes his name with both hands in both English and Nepali.  We discuss his seizure treatment, Amir will arrange for the boy to see a plastic surgeon.

In the early evening I stand outside my room and watch across the valley as a storm  moves in.  Lightening above the clouds, moonlight behind me, the wind picks up as clouds darken the sky. As I go inside the wind suddenly increases, and seems to be blowing inward  from the two windows and door, each being on a different wall of the room.  I close the shutters and climb into bed as the rain begins to pound, but in spite of the storm outside, I am peacefully content about today’s work and am soon asleep.   Some work days stand out more than others; this was one of them.

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Dr. Polifka is a physician volunteer who recently worked at Bayalpata Hospital, Accham.

 

Posted by Ranju Sharma

Hospital Administrator Nandram Gahatraj interacting with the Community Health Workers from the Siddheswor VDC at one of their meetings.

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Ranju Sharma was previously the Program Coordinator at Bayalpata Hospital. She recently completed her BSc at Mount Holyoke and is currently a volunteer with Nyaya Health.