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Posted by Shefali Oza, as told to her by Dr. Jhapat Bahadur Thapa, MBBS

We recently had a 35-year old female come to our clinic for an antenatal clinic visit. She was pregnant with her seventh child. Of the previous six, only the first had survived. Four others were stillborn and one died on the third day of life. Such loss should be an inconceivable exception, yet is far from unusual in this area where maternal and child mortality is among the highest recorded in Asia.

When we tested the patient’s blood, we found that she was B negative (blood type: B, Rh: negative). This meant there was a risk of Rh incompatibility, which can arise if the mother is Rh negative and the father is Rh positive. Rh incompatibility, a condition that is easily prevented with proper medication, can lead to miscarriage or death of the newborn. When we tested the father’s blood, we found that he was indeed Rh positive. We conducted a preliminary ultrasound scan and the results were normal. Our staff counseled the couple of the probable Rh incompatibility diagnosis and the high likelihood that the baby may not survive. We recommended that they go to a health center better equipped to handle such cases, since our hospital expansion is still being initiated.

In wealthier countries, Rh incompatibility is rarely a problem because a medication called RhoGAM is given to the woman 28 weeks into pregnancy and again immediately after birth. This will both keep the fetus safe and remove the risk of Rh incompatibility for the next pregnancy. Unfortunately, in poor areas like Achham, RhoGAM is rarely an option. Since our clinic does not have RhoGAM, our pharmacist immediately called Dhangadhi, the capital of a nearby district. They told us that there was no RhoGAM in the entire city.

The Nyaya Health Clinic delivery suite.

The Nyaya Health Clinic delivery suite.

Two weeks later, at 5 AM on a Tuesday, the patient returned for delivery. Gauri, one of our auxillary nurse midwives, evaluated her and called me to come to the Nyaya Health clinic. Upon arrival, I found the patient had a breech presentation, meaning that the fetus was positioned to come out feet first. A quick ultrasound scan showed that the breech was the only abnormality. At 7:30 AM, I performed an assisted breech delivery and delivered a 3.5 kg female baby. We tested the cord blood and found the baby to be O positive and that she was not anemic, though close.

We ordered RhoGAM from a pharmacy where it is available and it arrived at our clinic at 6 AM on Wednesday, so we could inject the mother within 72 hours. Thus, in case of further pregnancy, the mother will be protected from Rh incompatibility. In this case, our patient would likely have lost her newborn daughter if she had not arrived at the Nyaya Health clinic for a skilled delivery.

The mountainous region, alongside the lack of roads, make safe deliveries challenging but not impossible in Achham.

The mountainous region, along with the lack of roads, make safe deliveries challenging but not impossible in Achham.

This story highlights several important features of our work in Achham. The maternal and neonatal (death within the first month of life) mortality rates here are astounding, as are the number of stillbirths. Attenuating the factors that negatively affect pregnancy and delivery is critical for reducing these rates, particularly for mothers and neonates. While many complex realities influence pregnancies, the presence of a skilled birth attendant at birth is known to greatly reduce the likelihood of maternal and neonatal death, as well as stillbirths. Yet, a remarkable number of deliveries in Achham and similar settings continue to occur without these skilled birth attendants. As we expand our Community Health Worker program, a key goal is to monitor pregnancies through the district and provide safe deliveries. This is necessary since the difficult terrain and large distances can make travel to the clinic, especially for women in late pregnancy.

Since high-risk pregnancies can often result in emergency problems during delivery, our need for a hospital with surgical capacity is also clear. Our hospital will have rooms for such women to stay overnight so they are not forced to choose between difficult travel at the time of delivery and an unsafe delivery. Without our hospital expansion, for which we have initiated a capital campaign, we will continue to lose mothers and babies to tragic, and often preventable, circumstances.

The Bayalpata Hospital complex that Nyaya Health is aiming to renovate to expand its care operations.

The Bayalpata Hospital complex that Nyaya Health is aiming to renovate to expand its care operations.

Posted by Shefali Oza as told to her by Dr. Jhapat Bahadur Thapa, MBBS

A 12-year old boy from an area two hours walking distance from the Nyaya Health clinic was brought in after an abdominal injury. While looking after a grazing bull, the bull became aggressive and injured the boy’s lower abdomen. He arrived at our clinic at 6pm after being carried on a stretcher by his relatives.

During our initial observations, we found a 3 centimeter open wound in the lower abdomen (left iliac fossa) and the lining of the abdominal cavity was protruding through the wound. His vital signs were stable. We established intravenous access and quickly used the ultrasound to scan for free intraperitoneal fluid, which is an important indicator of dangerous abdominal trauma including hemorrhaging. The scan was negative. The ultrasound machine allowed us to check for this free fluid without requiring an on-site radiologist, since a trained physician can scan and interpret the results of the ultrasound image.

We then proceeded to close the wound. First, we gave the boy local anesthesia. We then extended the wound margins in order to have better access to the fascia, a strong connective tissue found throughout the body to support and protect the surrounding organs, muscles, and other body parts. We then closed this fascial layer, the overlying subcutaneous layer, and finally the skin.

Closing the open adominal wound with stitches.

Closing the open adominal wound with stitches.

The boy was admitted for overnight observation and received maintenance intravenous fluids as well as ceftriaxone and metronidazole, which are two antibiotics that, when given together, provide a simple and cost-effective treatment against abdominal infection. The following day the patient passed urine and had good bowel movements. He was also started on oral fluids.

On the 3rd day after his injury, the boy was discharged with oral antibiotics and his family was advised on wound care and to return for a follow-up visit. We were pleased that we were able to treat this child for an injury that was dangerous, particularly if left untreated.

The patient after his wound was closed and dressed by the Nyaya Health staff.

The patient after his wound was closed and dressed by the Nyaya Health staff.

Posted by Duncan Maru

Peptic ulcer disease, a condition in which the lining of the stomach is damaged, is commonplace throughout the world. If left untreated, peptic ulcer disease can lead to severe disability and, if an ulcer ruptures, death. Helicobacter pylori is the bacterial cause of this condition. H. pylori is also a definitive cause of stomach cancer and is classified as a group I carcinogen by the International Agency for Research on Cancer. Infection is related to sanitary conditions, with infection rates several times higher in developing countries than in developed ones. Over half of the world’s population is infected.

Mid-level providers such as our health assistant Uday Kshatriya are at the front lines of addressing h. pylori

Mid-level providers such as our health assistant Uday Kshatriya are at the front lines of addressing h. pylori

A public health strategy of testing and treatment can effectively prevent most of the damage that the microbe causes. A two-week course of antibiotics and antacids can be as high as 90% effective in curing h. pylori infection. Nyaya has just initiated a helicobacter pylori control program that involves screening of patients who present to the clinic with gastric complaints for infection and then treating those who test positive. As with all of our programs, we focus on simple-to-use clinical forms integrated with our electronic patient database. We use this for program monitoring and evaluation. The English-language form is available at this link:
http://nyayahealth.org/Library/nyaya_form_pylori.pdf
Our screening protocol is available at this link: http://nyayahealth.org/Library/nyaya_protocol_gerd_dyspepsia

For testing for infection, we are using Quidel corporation’s rapid serum test kit. This tests for previous infection by assessing the presence of antibodies that the body has produced to fight the infection. This technology is not available in Nepal, and we are relying upon Quidel’s genereous donation of 1800 kits, which should be sufficient for the first year of our program. At the end of treatment, we ask patients about their symptoms to assess cure, since presently we do not have access to the test-of-cure technology. This technology is based on detecting antigens, or components of the h. pylori itself rather than the body’s response to infection. We hope to add this test on once resources become available.

This program is part of Nyaya’s overall “diagonal” strategy of building a comprehensive primary care system by adding on disease-specific programs to our general healthcare infrastructure. The problem with exclusively “vertical” programs, where disease-specific programs for TB, HIV, maternal care, and vaccinations run largely independent of each other, is that they fail to build an integrated health system capable of meeting a population’s evolving health problems. The benefit of such programs, however, is that they have well-defined budgets and public health outcomes. Fully “horizontal” programs, on the other hand, where a generalist primary care team is expected to address whatever comes through the door, are plagued by wasteful expenditures on conditions that are not necessarily public health priorities.

The Nyaya Health model is to incorporate condition-specific programs into general primary care

The Nyaya Health model is to incorporate condition-specific programs into general primary care

H. pylori is an excellent test case for our model, since h. pylori is a readily testable and treatable condition and it is associated with a very common symptom– dyspepsia. In the first several months of our clinic’s operations, dyspepsia was an exceedingly common condition for which we spent large amounts of money– 20,000 nepali rupees (about $260) on antacids in the month of august alone. The bulk of these prescriptions, while providing some symptomatic relief, would not alter the course of patients’ underlying conditions or achieve any public health benefit. As a free clinic, this did not make economic sense. After reviewing our pharmaceutical expenditures, we decided to stop the practice of dispensing these medicines. But this strategy left many of our our group, interested as we are in healthcare justice and equity and wanting to provide meaningful clinical care to our patients, frustrated that we could not be providing effective treatment to at least some of the patients who were presenting with dyspepsia. Now that we have started to screen and treat for h. pylori, we can now provide meaningful, disease-modifying care to these patients.

Posted by Duncan Maru

Over the last year, we have renovated a grain shed into a clinic and employed the only allopathic doctor in a region of over 250,000 people. In this time, we have treated over 15,000 patients, established the only safe birthing center in the district, and deployed the first ultrasound in the region.  Click on the photo below to view a new documentary video about our work and to support our work:

Patients waiting outside the Nyaya Health Clinic

Waiting outside the Nyaya Health Clinic

Now we are ready to expand our reach, and we need your help. Over twenty years ago, a hospital was built in the village of Bayalpata in the district of Achham in the Far Western region of Nepal. Poor, rural, and without government services, the district was without any major health facilities. But Bayalpata Hospital was never opened. Owing to bureaucratic entanglements, the hospital was never staffed. Over the subsequent years of war and severe poverty, the hospital remained largely vacant. Now, together with the Ministry of Health, and your support, we are working to finally open Bayalpata Hospital.

Staff heading towards the abandoned Bayalpata Hospital

Staff heading towards the abandoned Bayalpata Hospital

The situation is critical. The nearest ventilator, essential for providing breathing support to seriously ill patients, is 14 hours away by vehicle. The nearest blood transfusion center and functioning operating room is over 10 hours away. This is an impossible distance to cover by walking, which is how the majority of Nepalis in the area travel, for those in need of such medical services. As a result, preventable illness and death are commonplace. For example, maternal mortality is extremely high in Achham, with a rate nearly 100 times greater than in the United States. Our clinic has begun to address the lack of health services, but we are already treating 140 patients a day and demand is steadily increasing as our community health worker network expands.

By renovating the abandoned hospital, we will be able to expand outpatient services; provide inpatient beds; implement a blood transfusion program; and roll out an essential surgical program. The construction and three-year operating financial need for the hospital is $580,000. Since launching the campaign last month, we have raised $224,000 for this purpose. Your tax-deductible donations will go a long way towards our goal.  Support our work by visiting the following link:

http://www.nyayahealth.org/donate

The Nyaya Health Clinic and surrounding area in Achham

The Nyaya Health Clinic and surrounding area in Achham

Posted by Duncan Maru

One of Nyaya Health’s main objectives is to develop a model of evidence-based rural healthcare delivery. For a clinic providing free medicines, it is important to carefully define the scope of pharmaceuticals that are offered. This is necessary for efficient management of patients, but also because local community members, foreign donors, and governments want to know that their investments are used in a cost-effective manner. To ensure this, prescribing practices should be data-driven.

Over the last several months, we have been experimenting with different strategies for rapid input, analysis, and presentation of pharmaceutical data. These data already are helping to drive the type and quality of the clinical care that we provide. You can read more about these data on our wiki by clicking the link below:

Screen shot of our pharmaceutical tracking map

Screen shot of our pharmaceutical tracking map

We have used these data to refine our clinical practice. One example is in the prescription of symptomatic therapies. Medicine as practiced in Nepal and throughout much of the world is focused largely on symptomatic treatment. Many of the medicines prescribed in rural Nepal do not alter diseases. Some common examples are acetaminophen/paracetamol (e.g. Tylenol), non-steroidal anti-inflammatory drugs (NSAIDs) like aspirin, PPIs/H2 blockers for gastric reflux, and anti-histamines for cold symptoms. Rural “quack” practitioners often earn a hefty income, since they provide services to both diagnose the patient and prescribe these treatments.

Patients eventually come to expect such treatments. Even well-intentioned providers will prescribe these symptomatic treatments because patients often travel several hours for care and clinicians feel a need to provide them with something, even if the therapy does not alter the disease course. However, doling out analgesics for anyone with vague, non-specific pains is not an effective and sustainable public health strategy.

Infant who received four antibiotics (metronidazole, cefixime, cephalexin, cefpodoxime) for cough and fever from a private pharmacist before coming to our clinic

Infant who received four antibiotics (metronidazole, cefixime, cephalexin, cefpodoxime) for cough and fever from a private pharmacist before coming to our clinic

During our ongoing evaluation of our operations, we noted our clinic spent 23,000 Nepali Rupees in August on NSAIDs alone. In order to streamline our prescribing procedures and more efficiently manage patients, we subsequently instituted protocols to manage syndromes such as lower back pain. By November, our monthly NSAIDs costs had plummeted to 2,200 Nepali Rupees.

Our long-term goal is an integrated primary care system that rigorously addresses the wide array of syndromes for which patients seek our care. Such a comprehensive system requires rigorous protocols, extensive follow-up, as well as on-site physical therapy and counseling services. In the short term, we are focusing our efforts on more treatable conditions with measurable public health outcomes, such as malnutrition, tuberculosis, pregnancy, abscess, and pneumonia. But in parallel, we are starting to build a strong organizational foundation required to efficiently build the long-term comprehensive system needed for adequate health care in this area.

Nyaya Pharmacist Tara Man entering data

Nyaya Pharmacist Tara Man entering data

Posted by Duncan Maru

Nyaya Health has recently updated our Budget page on our public-access wiki to provide our line-by-line budget that is accessible to all. This, we believe, is fundamental to our mission of creating testable, scaleable, and accountable models for the rapid scale-up of comprehensive health services in areas affected by poverty, isolation, government neglect, and war.

The public can view both aggregate and line-by-line data updated monthly on our wiki. We do this as follows. Our Achham team exports data from our accounting database (Quickbooks) and sends it over to our data management volunteers in the US. The US team then posts them into templated online spreadsheets.

For example, the following chart provides a summary of our expenditures that we have made in capital costs (equipment purchase, renovations) and our operating costs in the first-year to date. To achieve maximal impact in Nepal, Nyaya’s directors, US-based volunteers, and Kathmandu staff are all volunteers and we do not pay expatriate travel expenses. This is done so as to achieve maximum investment and impact locally in Achham. By clicking on the image you can view it on our budget wiki page:

Snapshot of our budget chart from our wiki

Snapshot of our budget chart from our wiki

The below timeline provides a history of our expenditures. Since many items are capital and inventory expenses, there are several jumps in expenditures on big capital purchases that do not reflect our actual month-to-month costs. Still, this provides a a look at the financial requirements of rapidly scaling up acute and primary care services in a rural resource-deprived region. Again, clicking on the image will take you to our budget wiki page:

Snapshot of the budget time series on our wiki

Snapshot of the budget time series on our wiki

Most importantly, we provide a line-by-line, searchable budget available here:
http://spreadsheets.google.com/pub?key=p-TJjzE7A-O7vvlOQZMrgCw

There are three main reasons why we are doing this. The first is that we fundamentally believe that our supporters deserve to know where we are spending our money. They can both better understand the context of their giving and also provide us with feedback and insight. The second is that we hope that our colleagues working in similar situations throughout the globe can benefit from having timely raw data to help guide their work. Finally, it makes management sense. Our board of directors is all-volunteer. While we aim to have 2-3 board members on site at all times, our leadership when they are outside of Nepal want to stay updated. Having our data on our wiki in a straightforward format and open access for all is simply the most efficient way of collaborating.

Every expenditure is recorded, such as this water filter that our health aide Chandrikaji is using

Every expenditure is recorded, such as this water filter that our health aide Chandrikaji is using

Posted by Shefali Oza

The Singapore Internet Research Centre (SIRCA) has generously awarded a two-year $17,800 grant to Nyaya Health for research on information and communications technology for development (ICTD). The grant, commencing in January 2009, will be used to develop, implement, and evaluate a program to investigate the application of telecommunications technology to healthcare outreach efforts in the region.

Disparities in access to quality healthcare services are among the greatest humanitarian injustices present in today’s world. Exemplifying this problem is the district in which we work. Achham has some of the highest maternal and child mortality rates in South Asia. The complex problems of this district are similar to those faced by poor, rural communities throughout the world. Achham thus provides an ideal testing ground for developing programs to provide appropriate technologies for healthcare delivery.

Since our inception, we have trained several of our staff members to utilize the technology and communication devices available at our clinic, including patient databases and the internet. Through this model, we are able to efficiently manage patients and data, rapidly evaluate our programs, and retain an easily accessible institutional memory in order to improve our work. Through our SIRCA-funded research, we will be able to expand our technological reach to the more distant communities in our catchment area by providing our community health workers (CHWs) with communication technologies. Community health workers are the critical front-line providers in the remote villages. Connecting them to the central clinic is vital to maximizing their effectiveness. This proposed health worker program is an important complement to our current model of using technology in the clinical setting.

Nyaya Health ANMs Radha and Urmila entering patient data

Nyaya Health ANMs Radha and Urmila entering patient data

The key objectives of our proposed research study are to:

  1. Develop a system capable of establishing and sustaining a) communication systems between CHWs and other health professionals, b) data collection and management tools for surveillance, c) communication systems linking CHWs to timely medical information, and d) an integrated, sustainable training system.
  2. Create a sustainable, scalable healthcare delivery system capable of addressing the most critical and immediate medical needs in Achham. Within current CHW models, CHWs typically work alone, often travel great distances, and rely completely on their own knowledge and the most basic of resources which they carry with them. In operating under these rudimentary conditions, only a small fraction of the potential for CHWs to impact their communities is realized. This proposal will equip CHWs with innovative technologies tailored for local communities.
  3. Enable CHWs to input longitudinal data on their patients and communicate with the central clinic staff. This will improve the effectiveness of home-based care for chronic diseases such as tuberculosis, HIV, diabetes, and chronic obstructive pulmonary disease.

Following an initial assessment of available services and population health status, we will begin a pilot study, which is divided into the phases of technology installation, CHW training, program implementation, and scale-up. We believe that the knowledge gained from this research will provide an essential link between information technology and provision of healthcare, and a model that can be applied in rural settings worldwide.

Community Health Workers at the Nyaya Health Clinic

Community Health Workers at the Nyaya Health Clinic

Posted by Dr. Aditya Sharma, MD

A 35 year-old female from a village in Achham was carried to our clinic by stretcher. She was brought here by several family members, including a healthy husband, just after the outpatient and delivery services had ended for the evening. During the previous two weeks, she had significant weight loss, abdominal swelling, and persistent vomiting.

Two auxiliary nurse midwives (ANMs) quickly obtained the patient’s vitals, which were worrisome because she had a high fever (103F), abnormally low blood pressure, and an unusually high heart rate. She appeared to have extreme physical wasting and was unable to lie flat on her back because of immense pain in her abdomen. We quickly inserted a large-bore IV and began early goal-directed therapy for sepsis with fluids and antibiotics that target a wide range of disease-causing bacteria. As her vitals improved, we carefully examined her markedly distended abdomen. We found a large semi-mobile mass, about the size of a volleyball, surrounding the entire circumference of the navel. Using our recently acquired ultrasound, we discovered that the mass was actually multiple pockets of fluid.

Ultrasound image of the fluid pockets that made up the abdominal mass

Ultrasound image of the fluid pockets that made up the abdominal mass

We tapped this fluid, revealing a thick yellow-white substance which was likely to be pus. Our provisional diagnosis was that the patient had an abscess in the abdominal area (or specifically, an intraperitoneal abscess).

While interviewing the patient, we learned that the she had burned her abdomen several months ago and had chronic secondary open wounds, which were left untreated. Given how superficial the mass was, it is possible that that the abscess was actually a large infected collection that resulted from the initial untreated burn.

During the laboratory examination, we found that the patient was HIV+. She and her family were unaware of this. Using the I-Stat machine which was recently donated to us, we also diagnosed the patient with hyponatremia, a condition in which the plasma sodium concentration is low. We proceeded with treatment to slowly correct her hyponatremia. At this point, it was clear that she needed urgent referral for both complete drainage of the large abdominal abscess and additional management for septic shock. We informed the family of the need to transfer the patient. They were initially reluctant because they believed she would be fully recovered once evaluated and treated by our clinic staff. However, they agreed to the transfer as we explained the urgency of her situation and advised them to immediately take her to the nearest hospital for complete management. We also instructed the patient and her family to return to our clinic upon their return from the hospital so that we can begin the relevant outpatient services for her, particularly regarding her HIV+ diagnosis.

Due to the ultrasound and I-Stat machines, we were able to correctly diagnose the patient and quickly find the optimal treatment for her. This case also demonstrates the multiple difficulties faced by many of our patients and the urgent need for the hospital renovation we are aiming to complete in the coming year so that we are able to provide our patients with necessary surgical services.

posted by Susan Warren

The Ella Lyman Cabot Trust has generously awarded $19,900 to Nyaya Health for the development of a Women’s Center in collaboration with Architecture for Humanity Boston.The Women’s Center is an innovative project that combines two complementary strategies to improve health: 1) implementation of evidence-based architectural features in the design of patient facilities, operating rooms and inpatient units that have been shown to improve health outcomes but have yet to be utilized in resource-deprived settings, and 2) community-based programs for reproductive health education to reduce maternal mortality and help women achieve excellent physical, psychological and social health. The Women’s Center will be part of Nyaya Health’s plan to expand existing outpatient services through the renovation of the abandoned Bayalpata Hospital.

The Womens Center will be integrated with the hospital expansion project which includes renovation of a nearby abandoned hospital

The Women's Center will be integrated with the hospital expansion project which includes renovation of a nearby abandoned hospital

Nyaya Health and Architecture for Humanity Boston jointly presented our ideas for this center at the “Disparities in Surgical Care: Research to Practice” conference poster session. We received valuable feedback on our research design from surgeons, nurses, and others who have worked at clinics and hospitals in remote areas around the world.

Our intervention will begin with the recruitment of a local program director to coordinate the human resources and organizational components of the project. We will develop a leadership group that will include male and female community members and local healthcare providers to ensure local ownership of the Women’s Health Center. They will address some initial obstacles including transportation, community reluctance about institutional services, and consult on the introduction of evidence-based design features within the cultural context in Achham.

For the reproductive health education program, we will hire five group facilitators and train them in community-based participatory educational techniques. We will test our overall strategy through a six-session pilot program with specific user groups. We will also assess curriculum and educational methods, and elicit participation in creating a program and facility that will address user needs.

Together with Nyaya Health, Architecture for Humanity Boston, teams in the U.S. and in Nepal, and under the leadership of local community members, we will construct the Women’s Health Center and begin to provide services in June 2010. This creative model, which brings together medical, architectural, educational and psychosocial disciplines in a rural setting, can be scaled up to address maternal mortality and women’s health in other communities throughout the region.

posted by Aditya Sharma

An 18- year old male from the district of Bajura was injured while hunting with family members. He was accidentally shot from behind at an oblique angle, which created a bullet tract from the lower right abdomen, through part of the abdomen, transecting the genitalia, and exiting through the left thigh. We found no exit wound for the second bullet, and it is likely that this bullet is lodged inside the patient’s abdomen.

The patient’s family carried him for 10 hours to the Bajura hospital, where no doctor was available. They were told that he should be transferred to another center for care. The army was stationed nearby and arranged for a military helicopter to transfer the patient from Bajura to Sanfe, which was the furthest distance they could manage. The patient was transported along with two relatives. The group then waited two hours at the airport while others tried to find a stretcher to bring him to the Nyaya Health clinic. Unfortunately, they could not find a stretcher so he was carried from the airport to our clinic.

On arrival, the patient was pale and shivering. His systolic blood pressure was around a low 60 mm Hg. He also had two small-gauge intravenous (IV) catheters in his wrists which had been inserted during his earlier journey. We quickly replaced these with two larger ones for more rapid infusion. Upon examination, we found that the patient had frank peritonitis, or inflammation of the membrane lining the abdominal cavity. We treated this with a combination of two antibiotics (ceftriaxone and metronidazole). With these steps, the patient slowly became more comfortable.

Initial treatment by Nyaya Health staff of patient with bullet wounds

Initial treatment by Nyaya Health staff of patient with bullet wounds

He began to slowly ooze bodily fluids, followed by stool, through the entrance wounds. At this point, we decided he needed an urgent transfer from the clinic to a proper hospital setting. We decided that his best option would be to first go to the TEAM hospital in Dadeldura for re-stabilization and re-evaluation and then be transferred to the Nepalgunj Medical College Hospital, which is approximately 10 hours away from our clinic by auto. There, he would be able to receive appropriate care based on need, including intensive care management and an exploratory laparotomy, which is a surgical procedure to examine the abdominal organs.

Unfortunately, no member of the patient’s immediate family was available to agree to our transfer plan. Given the lack of policy for medical decision making within the larger framework of medical ethics in Nepal, we were forced to keep the patient at the clinic until his older brother could arrive and agree to our plan. We were informed that the brother was coming by jeep and would arrive within hours to take the patient to a center that provides more extensive services.

However, the entire night passed and the brother did not arrive, nor did we receive further news about his whereabouts. In the morning, we decided we needed to urgently mobilize the community and government to support an immediate transfer given the lack of family consent. We called the District Health Office (DHO) and were given permission for the transfer. The head of the DHO called the district police headquarters on our behalf to support the transport. In the meantime, we used our local connections in Sanfe to arrange for a jeep to transport the patient to the Nepalgunj Medical College. By 2pm, over 36 hours since the injury, the local police, community members, and our staff helped the patient into the jeep.

Community members help transfer the patient from our clinic to the jeep.

Community members help transfer the patient from our clinic to the jeep.

We left the two large-gauge IVs with lactated Ringer’s solution, which is used after blood loss due to trauma, in his arms and arranged for the jeep to stop at every hospital along the way to Nepalgunj to have the fluids replaced.

Despite the significant length of time since the injury, we were relieved that the patient responded quickly to our management and seemed stable before transport. He is expected to do well if he receives surgical care soon. For us, this situation helped demonstrate the ability of a mobilized community to assist with urgent access to health services. We will write an update once we receive news about the patient’s condition.

Posted by Duncan Maru

The Child Health Foundation has generously awarded a $5,000 grant to Nyaya Health to combat malnutrition in Achham. From our grant proposal summary:

We are developing an innovative program to combat childhood malnutrition through female community health volunteers (FCHVs). FCHVs are women from within local communities who serve as indigenous paramedics and public health providers. These FCHVs already form a part of the government of Nepal’s health infrastructure, but they typically are under-trained, under-utilized, and under-supported. If sufficiently trained and supported, however, they can have a significant and sustainable impact on child health. From our community base in Achham, Nyaya Health is developing a scaleable, culturally-appropriate, equitable, and effective model to train and support FCHVs. They will be supported by each other, through our existing social networks, and through our telemedicine program that connects villages to each other. FCHVs will specifically deliver the following interventions: 1) education of mothers on nutrition and breast feeding; 2) routine height and weight monitoring and nutrition interventions for identified cases of malnutrition; 3) distribution of vitamin A, iron, and anti-helminthic medicines; 4) Screening and treatment of diarrheal diseases. This model will be applicable not only to rural Nepal but throughout rural South Asia and beyond. As we do with all our programs, we will make the results of this work freely accessible to the public via our website. This will enable rapid dissemination of our innovations among poor communities throughout the world.

Nyaya Health Community Health Worker Kamala Koli assessing nutritional status

Nyaya Health Community Health Worker Kamala Koli assessing nutritional status

Please download our third quarter report here:
http://wiki.nyayahealth.org/f/Update2008Quarter3.pdf
To our supporters:
This quarter marks the 30th anniversary of the Alma Ata Declaration — a compact signed by world leaders in 1978 to bring “health for all” by the year 2000. Alma Ata brought inspiration to many, even if its target was not achieved. But over the past three decades, the definition of “primary healthcare” has narrowed. Today, primary care in poor countries is often said to be a “minimum package” of health services, such as vaccines or simple treatments. Certainly, these basic ingredients are essential. But when someone involved in an accident goes to a primary care clinic operated under this philosophy, they are turned away, because care is defined so narrowly that laceration repair is no longer considered an essential health service.

We can do better. (Yes, we can.)

At Nyaya Health, the community of Achham in Far Western Nepal has been teaching us that narrow perspectives often undermine the quest of communities to attain truly enjoyable livelihoods free of disease and disability. We’ve been taught that reaching across disciplines as varied as architecture and epidemiology can help us to develop creative initiatives to integrate traditional public health measures, novel poverty-relief programs, and local capacity-building for long-term health.

We have been lucky to achieve so much success in preventing and treating disease in Achham. Our latest health indicators and medical outcomes show that we’ve become a strong resource for a population previously denied service. But our work requires that we continue to develop systems to maintain community accountability and challenge poverty.

This quarter, we have initiated a hospital-building project to address Achham’s highest-priority needs, as determined by members of the community and as witnessed in our own clinic (http://wiki.nyayahealth.org/SurgicalServices). As always, we are working with the local government to ensure the long-term success of our operations; this includes the gradual integration of our training and service work into a new federal healthcare system, which is currently non-existent in the region. We hope you will join us in continuing our venture to expand a transparent, community-based, comprehensive model of healthcare delivery. Read our third quarter report here:

http://wiki.nyayahealth.org/f/Update2008Quarter3.pdf

Sincerely,

The Nyaya Health Team

Nyaya nurse midwives Sangeeta Nepali, Kamala Sharma, and Urmila Basnet,

Addressing malnutrition requires a community-based team approach

Posted by Jennifer Guo

We have recently deployed a new I-Stat machine that was donated by Abbott Laboratories.  With this technology, we aim to further expand the reach and quality of our laboratory, already the highest quality laboratory in the entire region.  Our overall goal, as with any device we deploy, is to develop and test models of delivery in areas affected by poverty, war, and isolation. In piloting the I-Stat as an essential tool in resource-deprived areas with nascent health systems, we are focusing on monitoring potassium among severely malnourished children. Following an initial pilot phase, we have begun implementing the following additional programs with the machine:

  • Blood tests among post-operative cardiac surgery patients receiving community-based care
  • Tests to evaluate acute dyspnea who may have chronic obstructive pulmonary disease, congestive heart failure, or pneumonia in a setting where X-Ray services are less widely available
  • Hematologic tests to assess patients with severe hepatic derangements secondary to viral hepatitis
  • Sodium and potassium monitoring in patients receiving medications in the course of community-based care for cardiac conditions
  • Physiological monitoring for the management of severe sepsis, renal failure, meningitis, and pneumonia
  • Rapid tests of blood status in post-partum hemorrhage patients
Lab technician Santosh using the new i-Stat Machine

Lab technician Santosh using the new i-Stat Machine

Posted by Dr. Aditya Sharma, MD

An 18 year-old female from neighboring village of Mastamandu was carried by her family to our clinic.  She came in with headache, blurry vision, and high blood pressure–the ominous signs of pre-eclampsia, a medical condition that affects a significant number of pregnancies and can be life-threatening if not managed promptly.  She then progressed to eclampsia–generalized (whole-body) seizures with loss of consciousness.  Eclampsia is a major cause of death among pregnant women in resource-poor settings. Untreated, the risk of death from eclampsia is extremely high.   In Achham, where 199 in 200 women deliver birth at home, few women survive long enough to reach health care facilities.   Our team rapidly administered the appropriate therapy for this condition–intravenous magnesium–which broke the seizures.  But her condition was still very critical.  Without urgent delivery of the child, the mother would likely seize again and the mother and child’s lives would be in danger.

Given the severity of her condition and the need for emergent cesarean section, we discussed with the family and decided to refer her to the a mission hospital in Dadeldhura about seven hours away that could perform the surgery.  The family acquired transportation means within thirty minutes. Before she left, we injected magnesium sulfate to provide basal level of magnesium sulfate during transport. At the hospital, the patient was medically induced.  She and her baby returned to the clinic in excellent health one week after hospitalization.  Nyaya Health covered the 2300 NRs (~32$) charges for her medical care the hospital.  While this woman narrowly avoided significant disability and possibly death, other women have not been so fortunate.  Her case highlighted the dire need for local surgical services.  To put this into perspective, imagine living in Boston and having to travel to Washington DC to gain access to essential obstetric care, and over treacherous mountain roads.

Woman in labor being brought to clinic by her family

CHW Pabitra performing outreach in the community

Posted by Bibhav Acharya

Sanfebagar area as seen from the roof of the Clinic

Sanfebagar area as seen from the roof of the Clinic

Dr. Jhapat Thapa (Nyaya’s Medical Director) and I were summoned to Mangalsen, the district headquarters of Achham, to attend a district-wide meeting of NGOs and government bodies to tackle HIV. Mangalsen is a 7-hour hike from Sanfebagar and our trip started at the far left of the picture above and we traveled toward the right, across the river, up the mountain you see and 2 others that are not visible in this picture.

As we walked down the main street of Sanfebagar at the beginning of the trip, we watched a group of people digging to build a dirt path across the mountain at the far left of the picture above. Humidity was above 90% and temperature above 90 degree during the month that it took them to build the dirt path you see in the picture below.

Humidity and temperature were both above 90 every day of the month or so that it took them to dig the dirt path you see

Humidity was above 90% and temperature above 90 degree during the month that it took a group of people to build the dirt path you see

Almost all the arable flatlands in Achham, which has a population of 250,000, are what you see in the first picture above. Famines are common here and are made worse every year due to global rise in food prices and the sheer neglect that the Far-Western Region of Nepal suffers at the hands of national and international power centers. Beside the flatlands, people farm on terraces on mountain slopes. Terrace farming may look beautiful but has a very low crop yield so the people heavily rely on supplies from outside of Achham.

Terrace farming on the slopes of mountains may look beautiful but has a very low crop yield so the people heavily rely on supplies from outside of Achham

Terrace farming on the slopes of mountains may look beautiful but has a very low crop yield so the people heavily rely on supplies from outside of Achham

We walked by what used to be buildings owned by the Nepal Food Corporation (NFC). The Nepal Government owns and operates NFC with the stated goal of supplying food at heavily subsidized rates to famine-struck regions of Nepal. NFC in Sanfebagar (right above the settlement seen at the left side of the first picture above) has been non-functional for about a decade. During the Maoist war, it stopped supplying food and was used by the Nepali Armed Police as a military base instead. The Armed Police were driven out by the Maoists during a deadly attack in 2002 and the ruins that remain have never been renovated.

Remains of what was the Nepal Food Corporation in Sanfebagar

Remains of what was the Nepal Food Corporation in Sanfebagar

Through a window in Nepal Food Corporation in Sanfe

Through a window in Nepal Food Corporation in Sanfe

Foxholes and trenches dug during the War at the Nepal Food Corporation site

Foxholes and trenches dug during the War at the Nepal Food Corporation site

After we passed the ruins of NFC we prepared to cross the river (at the center of the first picture above). During the monsoon, which can last for about 5 months, the rivers become difficult or impossible to cross, often stranding people and vehicles carrying essential supplies including food. At the peaks of the food crises every year, tractors carrying supplies wait for weeks by the rivers as people in rest of Achham wait for food. When the water level drops, they quickly cross and wait at the next river. Since you have to cross 2 rivers without bridges and go through 3 mountains on an unpaved road, it can take weeks for emergency supplies to reach the district headquarters.

People waiting to cross the river on the road to Bayalpata and Mangalsen. This river can get up to 50 times this size during the peak of the monsoon season

People waiting to cross the river on the road to Bayalpata and Mangalsen. This river can get up to 50 times this size during the peak of the monsoon season

A tractor carrying supplies to Mangalsen manages to cross the river when the water level is not very high

A tractor carrying supplies to Mangalsen manages to cross the river when the water level is not very high

Luckily, the river was not very deep that day. We continued uphill toward the Bayalpata Hospital. The “hospital” is on the mountain at the right side of the first picture above and is yet another glaring testament of the denial of resources that Achham faces. It was built 30 years ago by the Nepali government but not a single doctor has ever seen patients here. There are no medications, the buildings are falling apart and 2 government employees with little or no health training are stationed there essentially as caretakers of the dilapidated buildings. Nyaya is currently working with the government and the local community to renovate and operate this hospital. We are also lobbying the government to quickly build a bridge and pave the road to connect this hospital to the rest of the country.

The rocky trail to the Bayalpata Hospital. You can either take this trail or the longer and unpaved road shown below

The rocky trail to the Bayalpata Hospital. You can either take this trail or the longer and unpaved road shown below

The road leading to Bayalpata Hospital and Mangalsen remains non-functional for half of the year except for occasional off-terrain vehicles

The road leading to Bayalpata Hospital and Mangalsen remains non-functional for half of the year except for occasional off-terrain vehicles

All structures of the Bayalpata Hospital are falling apart and Nyaya is currently working with the government and the local community to renovate and operate this hospital

All structures of the Bayalpata Hospital are falling apart and Nyaya is currently working with the government and the local community to renovate and operate this hospital

We continued walking and after four hours, stopped for food at an establishment at the top of the second mountain we crossed that day. The husband and wife that run the business are in their 50s and appear to be in their 70s. They carry all of their supplies including water from the bottom of the mountain: a back-breaking 2-hour hike. A hearty meal of chickpeas or rice pudding costs Rs. 5 (7 cents). The water is free.

A photograph of the couple would have probably made a “great shot” (they wore colorful clothes and cracked smiles through wrinkles that are witnesses to their simple life of honest and hard work). We did not take their picture. There was nothing pleasing about this, nothing to romanticize. They know they are poor and don’t like the fact that they work harder than most people in Nepal (and the world) and still struggle to survive. Poverty was more visible than beauty.

The husband and wife that run this restaurant are among the few who have a regular source of income in Achham

The husband and wife that run this restaurant are among the few who have a regular source of income in Achham

As Dr. Thapa and I hiked up the rocky trails to Mangalsen, I told him that this was more difficult than the Everest Base Camp trail, considered one of the most challenging trails in the world. We talked about how things would be so much better if the roads were paved. Achammis have been told for years that it is going to be paved soon.

The only paved portion of the road in Achham ends near Nyaya’s clinic in Sanfebagar and it is the only road that connects Achham to the rest of Nepal and to India. During the monsoon, landslides are frequent and further disrupt transportation (and emergency assistance) by weeks at a time.

Passengers trying to push their Jeep out of a landslide on the only road that connects Achham to the rest of Nepal and to India

Passengers trying to push their Jeep out of a landslide on the only road that connects Achham to the rest of Nepal and to India

Landslide on the only road to several districts of Far-Western Nepal, inhabited by millions

Landslide on the only road to several districts of Far-Western Nepal, inhabited by millions

Maoist ex-combatants assisting travelers and clearing the same landslide from above as a broken Bulldozer sits on the left

Maoist ex-combatants assisting travelers and clearing the same landslide from above as a broken Bulldozer sits on the left

Landslides and their consequences are usually portrayed as unfortunate events. The government and others who could have helped prevent them before they occur and could provide swift help after they happen are portrayed as weak witnesses to an overwhelming natural calamity. Suffering is presented as a default state and no one is forced to take responsibility for causing it. This has bolstered the now common notion that people usually suffer because they happen to live in a “resource-poor” region. This paradigm neatly hides the fact that the state of resource deprivation is a consequence of an active process of resource denial.

There is no denying that certain geographic conditions (like beautiful, tall mountains) make a region more likely to experience landslides. But a landslide is caused when resources are either channeled to other parts of the country or pocketed by corrupt middlemen while they should have helped in scientifically managing the landscape to minimize mudslides and planting trees and grass. When a landslide does occur, the government agency responsible for disaster management sends an old bulldozer that breaks down before it gets to work as in the case above, cutting off millions of people from the rest of the world.

The lack of roads or their proper maintenance, the state of Bayalpata Hospital, the Nepal Food Corporation and several other similar institutions, the lack of bridges over rivers that can cause starvation of hundreds of thousands of people, and a tired, elderly couple hardly making enough to take care of themselves even after working 15-hour days are all examples of active resource denial.

We left Mangalsen at 5 am the day after our meeting. We arrived at the clinic at noon. After witnessing a series of examples of resource denial in Achham, it was reassuring to be at the clinic. About 60 patients were waiting to be seen by Dr. Thapa and he quickly got to work while I could barely stand up.

After a long day at the clinic, we went back to the staff quarters and heard news about a new aid package that the Japanese Government was providing to Nepal. Hundreds of thousands of dollars in aid had arrived in Kathmandu to build roads in Nepal. No reason for Achham to celebrate; it will remain beautiful. The money was going to be used to add two more lanes to a road to Surya Binayak in the Kathmandu area.