This is Nyaya Health’s highlight of the week:
1. Meet Bhinnata Piya, new Assistant to the Country Director
A Week’s Work
Oct 5th, 2012 by Nyaya Health
How to Make Patients Happy
Oct 3rd, 2012 by Nyaya Health
When I had headaches and some health problems during my childhood, my mother used to give me medicine to make me feel better. I thought medicine did the job, but I now realize it was my mother’s love that cured most of my illness. Now, as a medical doctor, I try to apply the same principle of curative love to my patient care, along with medicine to make them heal faster. Most of the time when I am in public places or outside the hospital, I hear people talking about the doctor’s approach towards them…sometimes good, sometimes bad, and sometimes exaggerated. I feel that all the complaints and dissatisfaction from the patients provide a learning curve for clinicians like us. In today’s world, everyone is very busy and is always in a hurry. Doctors are no exception. A clinician in a hurry has less time to spend with patients in outpatient and inpatient departments, as well as during counseling. A simple smile toward a patient, or a gentle touch and some sweet words can make a large difference in patient care. Medicine that is prescribed to them certainly does its work, but it is our job to act catalysts to cure the illnesses of our patients. In settings like ours, here in Achham, people sometimes say that we are just keeping patients in the wards and providing no treatment at all. I was actually confused to hear that we are not treating the patients. The point is that the people do not realize that many medications are given intravenously, and they think medications taken orally are the only treatment being given. I have come to the conclusion that there are four mantras to make patients happy: medicine plus love, care, and proper counseling.
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Dr. Roshan Bista graduated from the Institute of Medicine, Kathmandu with an MBBS. He is currently the Medical Officer at Nyaya Health.
Picture of the Week from Bayalpata Hospital
Oct 2nd, 2012 by Nyaya Health
After Lindsey served as a community health volunteer at Bayalpata Hospital she painted these watercolors from her photos of Achhami people. The paintings were auctioned at the Nepal + Ball in Boulder to raise money for the continued work of Nyaya Health:
Kesari
Kesari is a 43-year-old subsistence agriculture farmer focused on rice, potato, maize, and garlic production. She has two sons and two daughters, but treats every guest in her home like her own child. Here she pours two glasses of milk, one for her, one for her guest.
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Lindsey Youngquist is a Rotary Ambassadorial Scholar studying Community Health in Nepal. She recently volunteered at Bayalpata Hospital in Achham.
Thank You for the Remarkable Campaign
Sep 28th, 2012 by Nyaya Health
Dear Blog Readers,
Last week, you redefined ‘possible.’
You helped us, a small but tenacious and growing team, win 8th place of over 7000 organizations in the national Chase Community Giving contest by inspiring 20,254 votes in favor of health care for Nepal’s rural poor. That is no small feat, considering organizations with annual budgets of up to $10 million were competing. And as a result, we now have $100,000 more to invest in our work.
Nyaya Health team members celebrate at Bayalpata Hospital in Far-Western Nepal.
The data behind the campaign show exactly how ‘possible’ came to be redefined by your efforts.
In 2 weeks, 20,254 votes were cast, there was a 626% increase in those subscribed to our Facebook page, and remarkably, your efforts sharing our work over Facebook alone (not including Twitter and traditional media) reached 861,449 unique people.
But perhaps most telling was the diversity of support received, from partners like the Yale School of Medicine and GlobeMed to Nepali Ambassadors like Miss Nepal Shristi Shrestha and Ramon Magsaysay Award winner Mahabir Pun to world-renowned health care leaders like Dr. Paul Farmer and Howard Dean.
And finally, we want you to know that hundreds of votes were cast, against extreme technical barriers, directly from our home in Achham District of Far-Western Nepal. Those votes were cast out of a gracious and humbling faith that Nyaya Health will deliver on our promises, and more importantly, out of a belief that progress is possible in rural Nepal.
Thank you for sharing that faith in our delivery and in progress. We will not take your redefinition of ‘possible’ lightly. We will deliver. Because that is the essence of ‘nyaya’ — not merely talking about justice, but realizing it.
Just One Nepali Virus Away from Target Weight
Sep 19th, 2012 by Nyaya Health
Posted by Jeffrey Kaplan
As I sit in the airport on my way home, I can only reflect on how randomly fortunate those of us who just happened to hit the “lucky dog club” (being born in a 1st world country) are. Our personal commitment to sharing our fortune of high quality, readily available healthcare and the directly related overall safety is often only reinforced by bearing witness to the efforts of those who courageously step into the ring day after day in extremely challenging environments to save lives and in turn combat the inequity that exists outside the comfortable walls of our homes.
It took 28 hours to get from JFK to my hotel room in Kathmandu. A long journey by some standards, but in reality, a relatively comfortable one which includes shelter, safety, nourishment, and healthcare if needed. After a short hiatus in KTM, we headed to Achham, which took another 28 hours including stopping for the night. Those same comforts from my prior trip were not as evident if somehow things went wrong on this 2nd leg.
Fortunately we arrived safely, and all seemed in order. Nyaya’s Bayalpata Hospital was not the typical rural poor hospital that I had seen in the past in other under-served countries. No, it wasn’t NYU Medical Center and even without a medical background I could see that there was much to be done at this young oasis, but there were seemingly adequate staff, basic supplies, pharmaceuticals, a strong sense of hygiene, a commitment of growth (to bring a full toolbox of basic health needs to the citizens) and an unwavering standard of a dignified approach of providing healthcare to its patients and their families regardless of the seemingly impossible circumstances for both provider and patient. Some or all of these are almost always lacking at rural health facilities in Nepal and elsewhere. And all of this under the position that healthcare is a human right and that unpayable user fees will only serve to deter patients who have no other options from seeking medical assistance when they need it most. Everyone is welcome here, and no fees apply. Although some may argue that user fees are the only way to build long-term, sustainable healthcare facilities (and they may be correct), with the average income in Achham district at about $0.50 USD per day, user fees today will only result in one thing at this time – no healthcare at all for those in need. The region would return to the same situation that existed before Nyaya Health, and that would continue to exist today without it. Say it with me…unacceptable.
I was looking forward to watching the hospital run for the next 4 days, to see for myself how the different departments ran, how the staff handled the long hot days, who showed up for treatment, how important this facility was to the community, what Bayalpata could handle capacity-wise, what needed to be referred out and how difficult those referrals would be to actually implement, etc.
But as it turned out, things took a turn for me and my aspirations. After about 3 hours in Achham, I started to feel ill. Some bug left me with heavy sweats, weakness, and upper gastric symptoms. Then the massive heat, combined with no electricity and a respectable case of diarrhea led to a dehydrating state. The combination of the virus and the dehydration resulted in a bed-ridden me. In our world, this is a temporary inconvenience. Under the worst case, you hit the Emergency Room at your local hospital, get hooked up to an IV, and then move on with your life often within a day. Lucky for me, I was at a hospital with adequate care when this happened. But for those billions of people without access to Bayalpata or another adequate facility, the results can be much worse. 2.2 million people die each year due to diarrhea, almost all in developing countries. If it weren’t me, if I hadn’t been at that hospital, if the team from Nyaya Health had never embarked on this venture, I had could have actually died from it. People all around the world are suffering from and dying of preventable and treatable disease. Say it with me …unacceptable.
And then there are the heroes. Personally I felt honored to get a glimpse. I wasn’t going to die, and because I had adequate care, my condition was considered minor in nature. But I watched the team in action and I was one of the beneficiaries. In my room late at night, in complete darkness (no electricity) were 7 Nepalis, all working to change my IV. A simple task, maybe, but we are always at our greatest risk when we are most confident, and in the dark in another language without optimal equipment and without light, there is always risk. And without this hospital, without these workers (95%+ of the full-time workers are Nepali, I might add), the risk is much higher.
And then there was the rest of the Nyaya Health team – Duncan, Ryan, Gregory, Mark, and Sindhya, who all sacrificed their own comforts for that of the visitors and the patients – all of whom made sure to care for me not only under their respective oaths, but also in the spirit of accompaniment that we have all been taught by our sensei, Dr. Paul Farmer. Dr. Farmer made this journey with us to see Nyaya’s successes and challenges, and was also part of my medical care, bringing his expertise and wisdom, his love, and his humor as he always does.
It was a site to see Duncan and Gregory (both 6 foot+ tall) sleeping together side by side on a thin twin-sized blanket (no mattress) in my room to make room for others, and so that Duncan and Ryan could check on me multiple times during the night after their typical 18 hour workday. These are educated, highly seasoned professionals (Duncan and Ryan being residents at Harvard Medical School), choosing to spend every one of their waking moments completely dedicated to these people on the opposite side of the world. Trying, failing, learning, trying, failing, and learning over and over again. Taking punch after punch and never wavering. Not for money, not for power, not for fame, but to put justice into action – for “Nyaya.” We can only hope that our children grow up to have the strength, love, and dedication of these young people.
On the second morning of our visit, Dr. Maru told me of an 8 year-old boy that had come in with what seemed to be a bowel obstruction. They were doing more tests including a simple enema to see if maybe it was just a bad case of constipation, but if he needed surgery he would have to be referred to a hospital 16 hours away via jeep. In this case, there would be a low chance of this boy surviving. After some more tests, it turned out that he had a severe case of intestinal worms, an affliction that is both preventable (for pennies, I might add) and easily treatable if caught early, but a late stage case also calls for surgery which would require referral to that same hospital. I’ve thought about that boy and his family since. And of course, due to the dedication of the Nyaya Health team, the surgery center at Bayalpata is opening and hopefully one day soon will provide surgeries like this one. What is more important? I cannot think of it.
It has always been clear to me that that even if a single life is saved, it’s all worth it.
And then there is the spirit of the Nepalis themselves. I didn’t get to spend enough time with them due to my bedrest, but I got the distinct feeling that these are people who see life as a privilege as opposed to a right. Such wisdom from the East should be taken with us every day.
I left hopeful. The people of Achham have a dedicated group of young people from both the East and West who won’t stop until they have set in motion a sustainable system for those who need it most. We came across powerful Nepalis, some of whom are working hard to improve things for their fellow citizens, and are welcoming this group into their country with open arms. Another set of ideals that could be better called on in our home country.
With excruciating need, internal local support, and an outside group of deeply dedicated experts that have adopted this region as their own, it seems clear that capital – both financial and intellectual – will continue to flow in. All we can hope is that it happens fast enough to save that single innocent life.
As my 14 year-old daughter Andrea recently told me, “it will all work out well in the end – and if it hasn’t worked out yet – that just means that it isn’t yet the end.”
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Jeffrey Kaplan is a Partner at Deerfield Management, an investment firm with a focus on healthcare that manages money for foundations, endowments and others. Jeffrey joined Nyaya’s Board of Directors in March, 2012.
Nyaya Health Needs your Vote before 9/18
Sep 16th, 2012 by Nyaya Health
Dear Blog Reader,
We write today to make a special appeal for a tiny 30-second favor before 9/18 that will deliver big results.
Nyaya Health is remarkably close to winning a top prize of $100,000 in Facebook’s Chase Community Giving contest, and your 30-second vote is desperately needed to secure our top spot and allow us to expand health care to some of the poorest in the world in Nepal.
Here are your options for voting:
- You can vote directly here: http://bit.ly/
votenyayahealth . (NOTE: this may not work on mobile phones but the link will work on computers). - If you need voting instructions, find those here: http://bit.ly/how2vote4n
yayahealth . - If you are a Chase customer or employee, you can also visit this page and vote an extra time by using your Chase customer login information.
Finally, if you’re really committed, there is a special way to actually get 2 votes for Nyaya Health that is explained in this photo.
Please share this message with anyone you believe would vote. We are in the top 10 of over 7000 organizations, and if we stay there, we will get at least $100,000 of support and propel the work of our team into the national spotlight — which will have innumerable ongoing benefits.
With thanks,
The Nyaya Health Team
8 Year-old Boy Makes his Own Diagnosis
Sep 13th, 2012 by Nyaya Health
[The following patient story was adapted from our medical@ listserv, which provides a forum for collaboration between medical professionals at Bayalpata Hospital and around the world.]
An 8 year-old boy presented with periumbilical pain for 4 days, which was non-radiating, with multiple episodes of vomiting and the inability to pass stool and flatus for same duration.
Besides these symptoms, he has no history of headache, loss of consciousness, abnormal movements of the body, chest pain, diarrhea, joint pain, or rash.
Upon examination, the patient appeared ill. His pulse was 120 beats per minute, with a respiration rate of 30 breaths per minute, temperature of 99ºF, and blood pressure of 110/70 mm Hg. He exhibited signs of dehydration, but showed no pallor, icterus (yellowing of the skin), lymphadenopathy (swollen glands), clubbing (enlargement of the fingers), edema (accumulation of fluids), or cyanosis (discoloration of the skin due to oxygen insufficiency). Upon abdominal examination, the patient’s abdomen was distended, firm, tender, and warm to the touch, but there was no organomegaly (enlargement of the internal organs). Examination of the chest, cardiovascular system, and central nervous system were unremarkable.
With this history and examination, I came to the provisional diagnosis of acute intestinal obstruction. We ordered lab tests, with the following results:
Hb: 11.1
WBC: 17,000
Platelets: WNL
Urea, Creat, Na+: WNL
K+: 2.9
Plain X-rays of the patient’s abdomen, both supine and erect, showed multiple air fluid levels and the features (valvulae conniventes) of a small bowel obstruction. With these investigations, I got the impression that the boy’s acute intestinal obstruction was most likely due to volvulus (intestinal twisting), though I also considered the possibility of paralytic ileus (paralysis of intestinal movement).
We decided to keep the patient NPO (nothing by mouth), inserted a nasogastric tube, which drained 1.5 liters of bilious aspirate, and began treatment with Metronidazole and Ceftriaxone. We are taught that we “don’t let the sun rise in case of a small bowel obstruction,” and I thought of referring the patient to Nepalgunj (a 12 hour bus ride from our Hospital). I counseled the patient accordingly, but the mother was unable to take the poor boy because of financial reasons. In lieu of referral, we tried an enema for the child, and luckily he passed some stool and flatus the same night he was in the emergency room. We were all a bit relieved.
The next morning, when I went to see the patient at 8 a.m., the mother held a cloth with a worm about 15-16 cm long that the child had defecated. We had found the cause of obstruction. When I shared this finding with Drs. Paul Farmer, Duncan Maru, Ryan Schwartz, and Payel Gupta, and Executive Director Mark Arnoldy, Dr. Farmer said: “the poor guy made the diagnosis for you!” Indeed, the boy had made his own diagnosis. We proceeded to treat him with Ivermectin immediately, and the boy is doing fine now. Thank god.
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Dr. Roshan Bista graduated from the Institute of Medicine, Kathmandu with an MBBS. He is currently the Medical Officer at Nyaya Health.
Harvard University’s Global Health Delivery Partnership
Sep 8th, 2012 by Nyaya Health
The vision that ultimately led to Nyaya’s founding began in 2006, when 3 students at Yale decided to work with the government to establish better healthcare in Achham, Nepal. Our team has largely been comprised of younger volunteers including students and young professionals. Initially we had little formal mentorship, were certainly not experts in health delivery, and had little opportunity to engage those with more experience than ourselves. Since then we have been privileged to work with mentors in both Nepal and the United States. In particular, our programs and patients have benefited greatly from outside expertise through our relationships with Harvard University and Partners In Health.
Recently, Harvard University established The Global Health Delivery Partnership (GHDP), formalizing the longstanding collaboration between the Harvard Medical School, Brigham & Women’s Hospital, and the non-profit organization Partners In Health. The mission of the GHDP is to work together to enhance the implementation of effective strategies in the global health field, with each institution contributing its own experience and excellence. The GHDP will focus on:
- training of medical professionals and strengthening of health systems,
- identifying new and innovative models for medical education and training in resource-poor settings,
- fostering a research base focusing on best practices in global health delivery, and
- creating communities of practice for those working in the global health field.
Nyaya Health is humbled to be a supported partner through the GHDP. Having recently had the privilege to host Paul Farmer in Achham, and also having the opportunity to work with multiple faculty members at Harvard through the GHDP (including Chair, Joe Rhatigan who also directs the Global Health Equity Residency program I am a fellow in), we wanted to take time to reflect on our excitement about the guidance and support the GHDP offers, primarily in three key domains:
1) Technical advising: Throughout Nyaya’s ongoing challenges during the development of a health system in rural Nepal, further technical advice from the GHDP will help steer us away from “re-inventing the wheel,” and will instead help us to employ best practices identified through their experience.
2) Research support: The “Research Core” provides guidance and support to the GHDP for research activities ranging from study design, development, and implementation, to analysis and ultimately reporting and dissemination. Such guidance is particularly crucial to early-career professionals and/or young organizations with minimal support. Through collaboration with the GHDP, all partners may continually identify and share best practices in global health delivery.
3) Accompaniment: As our team continues to expand programs in Nepal, we are also challenged to identify career pathways that tie social justice and global health work to our developing careers. The GHDP offers an important opportunity for each of us, accompanying our team and others like us by working to create a community of like-minded, social-justice oriented professionals. Such community is critical to maintaining perspective, inspiration, and dedication to this work.
The GHDP promises to bring great benefit to patients around the world, and Nyaya is grateful for the support it continues to offer our team and patients.
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Ryan Schwarz, MD, MBA, is a former director of Nyaya Health and is currently on the Board of Directors. He is a resident physician in Harvard University’s Internal Medicine and Pediatrics Program and fellow in the Global Health Equity Residency Programat Brigham and Women’s Hospital and Children’s Hospital of Boston.
Make $250,000 of Progress Possible
Sep 6th, 2012 by Nyaya Health
Dear Blog Readers,
Between now and September 19th, we have an extraordinary opportunity ahead of us. Nyaya Health has been nominated to win the $250,000 grand prize in the Chase Community Giving contest hosted on Facebook. If we together can bring the most votes, we will be able to expand our work to 5 clinics in 2013.
Our campaign is built on an idea you already believe in — that progress is possible for Nepal. But we need your voice to turn that belief into votes on behalf of our patients.
Please help us win this competition by taking the easy steps below.
- Voting directly at http://bit.ly/votefornepal (if you get diverted to a general page, just search for “Nyaya Health” and then vote).
- Liking the Nyaya Health Facebook page.
- Sharing the top post on Nyaya Health’s Facebook page. (NOTE: ‘Likes’ are okay but ‘shares’ are great).
If you are a Chase customer or employee, you can also visit this page and vote an extra time by using your Chase customer login information.Rarely do we have an opportunity to change health care at such a large scale with such a small action. Please join us in making this a bit of advocacy you can look forward to every day between now and September 19th. Our patients need your best ideas, networks, and more than anything, your friends.
With gratitude,
Mark Arnoldy
Executive Director
@markarnoldy
Barriers to HIV Treatment in Achham
Aug 31st, 2012 by Nyaya Health
I recently had the opportunity to meet several Achhami women who were receiving services from a local non-profit organization with which Nyaya partners. All of the patients are HIV positive and receive support services at home through our partner organization. The organization provides much-needed assistance in a number of psycho-social domains to these patients, however does not provide actual HIV treatment, which in Nepal is relegated to certain government-approved treatment centers.
Prior to meeting these patients, we had a very interesting conversation with our partner organization about the services offered, and heard about the important support the ~500 patients they serve receive throughout the Achham district. Nyaya’s part of the partnership is that we are one of the two government-approved centers for HIV treatment in the district, and some of these patients receive their treatment at Bayalpata Hospital.
What was impressive about the afternoon’s meeting however, was not hearing about the excellent support services our partner offers, nor meeting the truly dedicated team that carries out the work (indeed we’ve met on numerous previous occasions). Following our discussion with the support team, we spoke to the patients, and as has happened many times before, were disappointed to find that what we and our partner were providing was in gross misalignment to what our patients told us they needed.
When we asked what challenges these patients faced in continuing their anti-retroviral (ARV) treatments (the drugs necessary to treat HIV infection), we heard three primary concerns:
1) Transportation to visits: Achham is a district of 75 village development committees (i.e. villages), yet there are only two government-approved treatment facilities in the district, both of which are in the northern part of the district (see map – “H” for hospital where the two treatment centers are). We heard from one patient that she had to walk 3 days to get her HIV medications, and despite the support services offered to her at home, there was no transportation or stipend available to get her medications.
2) Frequency of visits: Patients are required to come to one of the two treatment facilities once each month to get their medications. For women who have full-time jobs tending their fields, while simultaneously taking care of their children, further complicated by the great distance many have to travel, this is frequently an insurmountable barrier to getting effective and consistent treatment.
3) Lack of poverty mitigation: Support services aside, when patients are forced to choose between spending their time putting food on their tables or traveling to a clinic on a monthly basis, in an area with such endemic poverty, basic needs often make regular travel to clinics impossible.
Nyaya has worked for the past 4 years to expand access to HIV treatment as well as a community health worker network that might be able to assist patients by delivering medications to their homes (instead of patients coming to the hospital). Nonetheless, neither Nyaya nor the other government services in the region have yet been able to expand services enough to address these barriers to care.
While the treatment services Bayalpata Hospital provides has more than doubled the HIV treatment capacity in the region, three years of asking our patients what challenges they still face has underscored the barriers that persist, and that frequently make the treatment we offer an irrelevant option.
As the meeting ended, we said our thank yous and goodbyes, and walked out. As I was leaving, I noticed that one of the patients was picking up the left-over biscuits from the meeting’s refreshments, and was passing them back to the other patients behind her. Each patient had a small plastic bag that they were filling with the biscuits and crumbs – a harsh reminder of how far indeed we still have to go before our treatment programs will be truly effective.
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Ryan Schwarz, MD, MBA, is a former director of Nyaya Health and is currently on the Board of Directors. He is a resident physician in Harvard University’s Internal Medicine and Pediatrics Program and fellow in the Global Health Equity Residency Programat Brigham and Women’s Hospital and Children’s Hospital of Boston.
Picture of the Week from Bayalpata Hospital
Aug 28th, 2012 by Nyaya Health
We met these brothers at the Bayalpata Hospital patient check in area. The younger one was coming in to get the dressings on his head bandage changed. In Nepal, young children are largely responsible for the care of their even younger siblings. This is because parents must work long hours in the fields or tending to their shops. However, the lack of parental supervision can also be a cause for childhood illness and injury, including preventable falls, ingestion of non-edible items or unsanitary food or water, or feelings of neglect.
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Lindsey Youngquist is a Rotary Ambassadorial Scholar studying Community Health in Nepal. She recently volunteered at Bayalpata Hospital in Achham.
What if?
Aug 26th, 2012 by Nyaya Health
Posted by Laura Corlin
The other night, a live baby girl was born. She wasn’t perfectly healthy; she needed oxygen. In the United States, otherwise healthy newborn babies receive oxygen all the time. It’s very easy to administer and relatively cheap. Even here, we have oxygen. But what we don’t have is consistent power, and oxygen can’t be administered without power. Just as the jeep pulled up to the hospital with the inverter that would fix the hospital’s solar energy allowing for 24 hour power, the baby girl died. The team had gone to extraordinary lengths to try to save her without oxygen. They did everything they possibly could –even trying to hook up a computer battery to power the oxygen. But it didn’t work. Possibly the worst part was that her father slept nearby not showing that he cared at all that his daughter was dying. If it had been a son, he might have reacted differently. It’s absolutely unfair that this baby girl died. She could have lived. She should have lived. If this were not one of the most remote and poor regions of the world, the baby girl would have lived.
For me, this speaks to the structural violence that ravages Achham. Living here can seem peaceful – the people are wonderful and generous human beings, the views are absolutely stunning, and there is no shortage of dedicated hope in Bayalpata Hospital. Yet, the structural violence is still here.
While accompanying Dr. Paul Farmer and his team to Sanfe, a nearby community, we stopped for tea at one of the local shops. Young boys, no more than 12 years old, were serving us. We asked the manager whether they went to school and were told that they “didn’t want to go to school.” Of course, I’m not sure I’d want to go to school either if it meant walking 2 hours each way and then returning home to spend several hours helping in the fields and with the household chores.
I can’t help but think “what if.” What if someone had said that about Dr. Roshan Bista, the absolutely incredible Achhami doctor who serves Bayalpata Hospital? What if the family of the clearly anemic and severely malnourished young girl I met the other day earned more than $1 a day? What if there was a clean and consistent source of water so children weren’t so at risk of developing typhoid? What if the government decided that health should be a human right? What if we, as people with more than enough, decided to distribute this wealth just a little bit more equitably?
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Laura Corlin is a senior studying Community Health and Biopsychology at Tufts University. She is a Co-Founder of GlobeMed at Tufts and is the Community Health and Communications Intern for Nyaya Health.
Visceral Leishmaniasis at Bayalpata Hospital
Aug 24th, 2012 by Nyaya Health
It was Friday, and as usual, we were having our grand rounds in the inpatient department. The patient from bed number 6 was a 9 year-old female child who had presented to the emergency department (ED) yesterday with fever for 4 weeks (recorded up to 104 degrees Fahrenheit in the ED), which was associated with chills and rigors. She had not traveled anywhere recently; the fevers all occurred while she was in our district of Achham. Her fever has spiked again this morning, and she was admitted with a diagnosis of fever under evaluation. She was given injectable antibiotics, fluids, and some antipyretics to soothe her fever discomfort.
Taraman dai, one of our Health Assistants, went up to examine her. On examination we found her to be jaundiced (showing signs of liver inflammation) with an enlarged spleen. She weighed 17 kgs. No edema (swelling of the tissues due to water) was found on evaluation. She did not complain of any pain with urination.
Her lab tests showed pancytocytopenia (low numbers of different types of blood cells) and negative exams for malarial parasites. We suspected her of visceral leishmaniasis (Kala-azar) and sent for an RK 39 test, which is a rapid test for antibodies to the Kala-azar infection. It was around 11 a.m. when our lab technician came up to me and showed me that the RK 39 test was positive, effectively diagnosing her with Kala-azar (although occasionally there can be “false positives,” or tests that incorrectly indicate that the diagnosis is positive). Also, the HIV test was found to be non-reactive, or negative. Here, we had a case of visceral leishmaniasis at Bayalpata Hospital (BH). This was the third time we had recorded any cases of Kala-azar at BH. The previous two cases were diagnosed at BH and referred to higher centers, but both patients expired despite consistent efforts. These cases are very concerning because Kala-azar is a disease that is transmitted by a particular type of insect, which is supposedly not endemic to our region. Thus, we were seeing a series of Kala-azar cases in a non-endemic region.
In the past, one of our leishmaniasis patients had died, despite our best efforts. We had to save our patient with leishmaniasis this time. “How can we help this patient?” was the question on my mind. Firstly, the idea of referring the patient to a larger hospital with specialty services (in another area of the country, over a day’s travel away) came to my mind, as we had neither Miltefosine nor Amphotericin B (the drugs for treating Kala-azar) available at BH. Also, the ongoing bandh (political strike) in Nepal was a major obstacle in our referral because the roads were blocked and people were not able to move around the country freely. Even ambulances were vandalized at many places and referral seemed impossible. Dr. Payel Gupta (our Director of Clinical Operations) was in Kathmandu those days for some official meetings. I called her up and informed her about the case. She assured me that she would bring the anti-leishmanial medications back to BH from Kathmandu when she returned in one week’s time.
Meanwhile, on the third day of admission, along with the daily spikes of fever (>101 F), the patient started to have a few episodes of epistaxis (bleeding from the nose). We controlled the bleeding with anterior nasal packing and also sent for her lab studies for complete blood counts and other hematological tests. Her lab reports showed profound anemia, with a hemoglobin concentration of 5.2% and platelet count decreased to 40,000/mm3; this nearly shook me up.
The patient needed an immediate transfusion of platelet rich products, which was only available in Kathmandu. There was also a possibility of recruiting donors from the community in the district capital, who might be able to provide fresh blood to her. This was in Mangalsen, which was a 1 hour bus-ride from BH. We had to prevent any hemorrhagic manifestations and buy some more time until Dr. Payel could come from Kathmandu with the Amphotericin B. We called the district hospital in Mangalsen and arranged for blood donors from the community, and then the patient was sent on our ambulance for blood transfusion. This was a challenge for us, but we decided to take it.
The Kala-azar patient returned back to BH after successfully receiving two pints of blood transfusion over a period of two days in Mangalsen Hospital. In Mangalsen, she had continuous fever despite regular antipyretics and had vomited some blood in the morning. My hopes were still high that we could save our leishmaniasis patient this time. Several days later, Dr. Payel returned from Kathmandu with our wonder drug, Amphotericin B, amidst the bandh (strike). This added fuel to our hopes. We taught our nurses how to monitor for the side effects commonly associated with Amphotericin B administration, and get ready with hydrocortisone, chlorpheniramine and paracetamol injections for combating the “ampho-terrible” side effects that the patient would experience.
We took her baseline complete blood count, renal parameters, and electrolyte parameters before starting the drug to monitor its side effects. Every day, we paid special attention to her in the morning rounds and also tried to explain to her father each day about the disease and treatment. The emotional toil of caring for patients suffering from rare and unnecessary illness is not easy, as I learned with this patient. On day 7 of treatment, the size of her spleen had regressed (improved). She had re-gained her appetite. The child had no spikes of fever for 24 hours, and no signs of heart symptoms. Lab reports suggested that her bone marrow was recovering slowly. We also had added some fortified feeds to her diet, hoping that it could help her to gain some weight. Dr. Payel and I were both excited and crossed our fingers that she could recover completely.
Her kidney function lab tests were within normal limits but her electrolyte reports showed decreasing potassium levels and ensuing hypokalaemia which somewhat worried us. We tried to look for any bananas from the surrounding villages, but could not obtain any because of the growing season. Nor could the patient’s father from home. So, we had to start a potassium intravenous infusion along with the regular Amphotericin B until the electrolyte parameters could be maintained within range. We monitored the electrolytes daily to look for the progress, and finally we had it within range. There was more hope.
On day 14 of the Amphotericin B treatment, she had had no fever for the past few days. Her spleen size had regressed to normal on clinical examinations and she had gained her appetite. The bone marrow had recovered. The patient was better, and every one of us was satisfied; a sigh of relief was seen in the eyes of our whole team. Finally we were able to discharge our leishmaniasis patient from the hospital. It was with great pride and satisfaction that we assured the child’s father that the disease has been cured and she would be safe now. We asked him to be in constant follow up at the hospital to look for recurrence.
A rare case, with local unavailability of medicine, regular transport strikes, and difficult-to-access blood transfusion facilities – but as the old adage says, “if the god persists, all of us will be blessed.” It was made possible at Bayalpata Hospital. The whole Nyaya team did a great job to make this difficult treatment accessible to the patient and family. I feel immense satisfaction when we are able to treat our patients at BH.
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Dr. Bibhusan Basnet , MBBS graduated from B.P Koirala Institute of Health Sciences,Nepal. He has a special interest in Emergency Medicine and Psychiatry and is currently the Medical Director for Nyaya Health.
Picture of the Week from Bayalpata Hospital
Aug 21st, 2012 by Nyaya Health
This Achhami woman has a similar routine to most rural women in Nepal. She wakes around 5 am to make tea and daal bhat (lentils and rice) for the family, tends to livestock, cleans the house, then sets out by 7 am to hike into the forest and collect firewood and leaves. It generally takes five hours for her to walk into the forest, gather her collection, and then walk back home with a full doko basket suspended on her forehead. The woven bamboo baskets can weigh up to 80 pounds when full. Many women come to Balaypata Hospital with back and neck pain. With consistent and heavy labor, the lifestyle of an Achhami woman presents many opportunities for illness and injury.
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Lindsey Youngquist is a Rotary Ambassadorial Scholar studying Community Health in Nepal. She recently volunteered at Bayalpata Hospital in Achham.
Dr. Paul Farmer: The Source of Inspiration
Aug 18th, 2012 by Nyaya Health
Posted by Roshan Bista
My third day in the office at Bayalpata Hospital was a special day because it was the third anniversary of the hospital, as well as the inauguration of our new surgery block and microbiology lab at Bayalpata Hospital, Achham. It got even better when Dr. Paul Farmer arrived in Achham to be part of our celebration. Before I met him I “Googled” him to read about his life, and I was immediately impressed by the way he has devoted his life to helping mankind. He is a true source of inspiration to all the people from different sectors around the globe. I agree with his principle of JUSTICE IN HEALTH, and I am happy to be a part of a similar nongovernmental organization (NGO), Nyaya Health in the district of Achham. As a new Medical Officer, I have much to offer to Nyaya Health and to people of Achham. I grew up in a remote village of Achham called Totkesaal, and I remember how hard it is to live in a remote place like this. Now I have come here as a doctor to offer the best care I can provide to the people of Achham. It was a great moment today to meet Paul Farmer and to talk to him. It was really encouraging to walk with him during medical rounds and to learn from him. I dream to follow in the footsteps of Dr. Farmer and to help Nyaya Health provide Justice in Health throughout Nepal.
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Dr. Roshan Bista graduated from the Institute of Medicine, Kathmandu with an MBBS. He is currently the Medical Officer at Nyaya Health.