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Posted by Lindsey Youngquist

Nyaya Health: Village work

The most intensive phase of rice harvest is the pounding. Women and girls are the ones responsible for using wooden pestles to pound the outer husk from the rice grain, which is then ready to be cooked. These Achhami sisters (ages 12 and 15) take turns driving the poles into the mound of grain. They play a crucial role in food production for their family as they most likely spend days in the fields planting and harvesting as well.

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Lindsey Youngquist is a Rotary Ambassadorial Scholar studying Community Health in Nepal.  She recently volunteered at Bayalpata Hospital in Achham.

Posted by Ryan Schwarz

When I’m not working for Nyaya, I spend my days working as a resident physician in Boston (United States). In the USA we attend medical school for 4 years, after a previous 4-year bachelor’s degree, and then complete our “residency training” in our specialty of choice – for example, general surgery, primary care, ophthalmology, etc. During our residency we are required to work under the supervision of an “attending physician,” or a more senior physician who has already completed his or her residency. Having just completed my first year of residency – the so-called “internship” – I can say that an attending physician is crucial to ensuring effective and appropriate care. We as interns are not yet qualified and even as we become more senior residents we still have much to learn; our “attending” accompany us to ensure that their experience informs both the care of our patients and our education.

In contrast to where I train in the USA, in many developing nations around the world, and especially in rural areas within

Bayalpata Hospital Medical Director, Dr. Bibhusan Basnet, teaches staff about psoriasis during a recent morbidity and mortality conference.

developing nations, young physicians such as myself often have no backup support. This week while working with our clinical team at Bayalpata Hospital, it was hard to not be cognizant of the fact that our physicians, and in some cases even our Medical Director, have more or less similar clinical training to what I have now, yet we normally have no attending-level physicians at Bayalpata. This is the case throughout most of rural Nepal, where physicians often work by themselves, without any senior-level oversight or support.

We’ve written elsewhere on this blog about the rural and impoverished area our team works in. Similar to the limited resources in the area, there is a dearth of senior physicians. Job postings in rural areas are extremely challenging due to limited resources and limited clinical capacity, and living in such environments is equally if not more challenging. As a result, the large majority of physicians working in rural areas are young and less-experienced physicians, as those with more experience typically choose to work in more urban and affluent areas. This is not only a challenge we face daily in Achham, but it is also a problem dealt with globally in both developed and developing countries.

This dynamic leads to many health facilities in rural and/or impoverished areas – whether they are smaller health posts or district-level hospitals such as Bayalpata – being overseen by junior-level clinicians early in their careers. This blog post by no means aims to criticize such physicians; indeed, they are the backbone of health systems the world around. Nonetheless, as managers of health facilities ourselves, a critical question for human resource development quickly becomes how best to help support junior-level staff.

First, I will say that from a personal perspective it is deeply impressive, while at the same time concerning and disappointing, that clinicians with only limited experience and training oversee so many health facilities world-wide. I, having just finished my internship and with the equivalent training of some of our doctors, do not feel appropriately qualified to oversee a district-level hospital, yet this is precisely how we operate Bayalpata, and how thousands of other facilities operate globally. In fact, for likely more than 5 or 6 billion of the world’s 7 billion people, seeing one of these junior doctors is the best they could reasonably hope for; in many cases, people around the world (and indeed, here in Achham) do not even have access to one of these physicians, much less a senior-level clinician with decades of experience or specialty training.

Secondly, from a managerial and systems-level perspective, my time here after finishing my first year of residency has underscored the critical importance of continuing medical education programs, or “CME.” CME programs exist globally to enhance the education of licensed clinicians. In many countries doctors, nurses, and allied health professionals are required to attend lectures, workshops, or courses to fulfill a certain amount of CME “credit” each year. This ensures that clinicians maintain knowledge gained in their training, while also continuing to gain new knowledge and current updates on what they have previously been taught.

In many health facilities globally, and in particular facilities in rural and impoverished regions, such CME programs are non-existent, given limited resources and small numbers of faculty, often including only junior-level clinicians. Unfortunately, it is precisely these facilities that stand to benefit the most from such programs – both for the clinicians, and for the patients they serve.

Currently at Bayalpata Hospital we employ two Bachelor of Medicine, Bachelor of Surgery (MBBS) physicians. One has ~1.5 years of experience following medical school, and as our Medical Director, oversees a clinical staff of 8 health assistants and 8 auxiliary nurse midwives. Our second physician started last week, immediately after graduating medical school.

Nyaya’s team has a daily calendar of teaching sessions including lectures, interactive rounds, and M&M conferences.

To help support our clinicians as they care for upwards of 200 outpatients and 25 inpatients daily, we have developed several educational initiatives, including a morning teaching session, formal inpatient rounding twice daily, and additional weekly and biweekly lectures. Currently we are also privileged to have an attending-level doctor from the USA volunteering with us who helps to oversee these initiatives while also supporting clinical care on a daily basis. In the future we hope to maintain an attending-level physician as a volunteer to ensure continued CME and clinical quality oversight.

We are nonetheless not able to provide our clinical staff with the educational resources of a larger clinical facility, and are similarly unable to provide our patients with the experience and clinical acumen that comes only from clinicians who have worked for many years. It is humbling to imagine the challenges our clinical team faces, and a crisp reminder that we, as the next generation of global health implementers, must prioritize continued medical education for our clinical staff, to ensure both their own career development, and the best care possible for the patients we serve.

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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 Program at Brigham and Women’s Hospital and Children’s Hospital of Boston.

Posted by Roshan Bista

When I was in medical school, my professors used to have medical rounds in the mornings and evenings.  I was very happy to do rounds with them, and wished to do the same in the future.  Despite the best efforts by our professors, however, the patients and patient parties were not fully satisfied with the service they received.  I used to hear the patients and their caretakers complain that there was not enough time given to discuss their illnesses.  These were things I used to hear while working as an intern during medical school.  I came to the conclusion that their dissatisfaction was in part due to a communication gap between the doctor and the patients.

I learned my lesson from that very moment and now, as a medical officer here at Bayalpata Hospital, I want to do something new to bring smiles to my patients.  Today I began a new practice: making rounds with the patient parties.  This morning, I called all the patient parties to the chautari (gathering space) near the hospital, and asked them to talk about the patients’ illnesses, their improvement or deterioration, and any difficulties they and their relatives are facing.  It made all of them happy to have such organized meetings with the doctors, in such a way that the mutual relationship between the doctor and patient was maintained and there was no miscommunication between them.  In return, I explained to each of them about the illnesses of the patients, their prognoses, and the need for referrals.  This was a relatively new approach that I wanted to try, based on the lessons I had learned from my medical school.  It made me very happy to see that the patients’ relatives found it very helpful to know about the recent developments of the patients’ illnesses.

Nyaya Health is teaching me new lessons every day and this was one that I learned today: making morning and evening rounds, plus rounds with the patients’ parties, establishes even stronger bonds between the doctor and patient.  Following this morning’s meeting, I was happy to know that patients are very much satisfied with the services Nyaya Health provides for them.

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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. 

Posted by Lindsey Youngquist

Nyaya Health: Sunset in Achham

Bayalpata Hospital rests on a remote hillside in the Far Western region of Nepal. While the rural nature of Achham presents challenges for road systems, access to medicine and technology, food security, and education, the region does exhibit beautiful scenery. Sunrise and sunset magnify the raw landscape, which lies at the foothills of the Himalayas. Here, a glorious fiery sun drifts behind the far hills beyond one of the hospital staff quarters.

 

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Lindsey Youngquist is a Rotary Ambassadorial Scholar studying Community Health in Nepal.  She recently volunteered at Bayalpata Hospital in Achham.

Brothers in Arms

Posted by Bibhusan Basnet

Raviman, Bayalpata Hospital’s Pharmacist, reminds me of one of Chad Kroeger’s songs: “and they say that a hero can save us.”

Raviman (our pharmacist) reading though the patient booklet and preparing the medication list for the patients waiting outside his pharmacy window.

He is the ultimate hero at Bayalpata Hospital (BH).  Without him, the care and service we provide to the patients would be incomplete to say the least.

He is always busy in the pharmacy, where we supply free drugs to all of our patients.  Starting early in the morning, patients line up at his window with their patient booklets and medication prescriptions.  He is busy from then until the end of the day.  Undaunted by the heavy traffic outside his window, I find him distributing the medicines patiently, with full care, and without complaints.  Even when busy, he takes the time to draw circles on the blister packs to help the patients easily remember their correct doses, and carries out drug counseling in a local Achhami tone.

At first impression Raviman comes across as a young man just starting his professional career, but upon closer observation one is mesmerized by how a man this young can have thoughts so mature and actions so efficient.  It is amazing how Raviman singlehandedly makes it look so easy to do work that demands precise mental and physical presence for at least 8 hours a day.  In just two years, Raviman has developed expertise that usually only comes after years of professional exposure.  The passion with which he approaches his work is very telling of this young man.

The stocks in the main pharmacy are kept well organized and stacked.  He is always vigilant that the medicines are readily available in the pharmacy, and regularly fills up forms for the weekly procurements from our store.  Following our recent procurement meetings and quotations from medications vendors, we have started ordering bulk monthly procurements of medications for the hospital.  He was extremely sensitive towards choosing the best drugs within his knowledge from certified, trustworthy drug companies.  Raviman seems totally satisfied with the new procurements, and exclaims with pride that “now the patients can have the best drugs and best care.”  His care is clearly reflected in the type of counseling that he gives to the patients.  He has added to the trusting relationship we have with our patients.

Patients waiting outside our pharmacy window to receive the quality medications we supply free at Bayalpata hospital. .The shade of a roof outside the pharmacy is indeed important in improving the quality of our care.

Ravi empathizes with the patients and expresses the procurement needs based on the problems they face.  A few weeks back, he came up with the idea of building an awning in front of his window, where the patients queue for their medicines.  The shade of a roof outside the pharmacy is indeed important to improving the quality of our care.  The construction plan has been in the pipeline since then, and once built, the shade is sure to relieve the patients from the scorching sun and heavy rainfall they currently have to withstand while queuing up to get medications from the pharmacy.

Distributing medications to more than 150 patients per day is not an easy task.  There are 3-4 medics in the regular outpatient departments daily for examining patients, with only a single person in the pharmacy to distribute the prescribed drugs.  But Raviman does not complain, as he enjoys his job and interacting with his patients.  Sometimes we find his window crowded with patients waiting for drugs, making Raviman confused or hasty.  Yet when we go there he always welcomes us with his broad smile and asks what he can do for us.

If not for his right-sided sternocleidomastoid muscle hypertrophy, due to him addressing patients on his right for hours, he

Raviman (our pharmacist), left and Tilak Rawal (our Medical assistant), right, busy during the OPD hours distributing the medicines as prescribed.

would be content doing the job alone.  After a trial of muscle relaxants and with our Country Director, Gregory’s advice, we added a new job responsibility for our Medical Assistant, Tilak Dai, so that after 1 p.m. he would be with Raviman in the pharmacy to distribute medications.  The pharmacy seems to be more relaxed and coordinated since we have the brothers in arms.  The consistent pain in his neck muscles has resolved.  Raviman seems happy these days and he says that “it’s not just because he has a helping hand, it’s mostly for the reason that from now onwards the patients can have better counseling along with the best drugs we supply 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.

Posted by Lindsey Youngquist

Nepal has some of the highest maternal and infant mortality rates in Asia, particularly in the rural areas. In Achham, 99.5% of babies are born in homes and cattle sheds, and the presence of skilled birth attendants during delivery is rare. Bayalpata Hospital offers financial incentives for mothers to deliver babies at the hospital. With the help of our nurses and midwives we can conduct safe deliveries, deal with complications, or refer cesarean section patients to another hospital. Within a couple of months our Surgical Ward will be completed and we will be able to conduct cesarean sections at Bayalpata Hospital.

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Lindsey Youngquist is a Rotary Ambassadorial Scholar studying Community Health in Nepal.  She recently volunteered at Bayalpata Hospital in Achham. 

Posted by Gregory Karelas

Almost one year ago, I wrote a piece for this blog titled “The Transformative Power of Paint”. Its purpose was to elucidate how small gestures can make great change. It was a pleasure to write and depicted beliefs that I still hold true. Thus, when the experience of touch emerged as a theme for further writing, a reflection of its transformative power seemed fitting.

Nima (name changed for confidentiality purposes) is a 24 year old woman, who came to Bayalpata Hospital’s Emergency Room four months ago for hand contracture and severe burn injuries across her face and body. Nima suffered from epilepsy and had fallen into a fire while seizing, causing the burns and contracture that brought her to us. It was not the first time that she had endured this unfortunate coupling of space and disorder. Nor was she the first patient we’d treated for similar injuries caused by those same events. Widowed and without children, Nima had no family. Her father was alive and seemed to be her only support beyond our hospital. But he was a migrant worker, who spent most of the year in India and had likely not seen or spoken to Nima in months, if years prior to her accident. Thus, when Nima settled herself into our Inpatient bed, she perhaps unknowingly took our staff as her family and our hospital as her home.

Loneliness is a curious feeling. I don’t reference the kind that comes from missing companionship. I mean the kind that comes from feeling forgotten. One Thursday evening a member of our Nursing staff unfortunately yelled at Nima for shaking another patient. The nurse meant well and ultimately protected the patient in Nima’s grasp from physical or emotional harm. Yet, to Nima’s dismay, the nurse never accepted her explanation of why. Nima had tried to help the patient by mimicking traditional healing rituals that she had surely seen and likely undergone before. But her justification was lost on an understandably shocked nurse. Explanation seemed futile. Hurt feelings painted the room. And the young woman with epilepsy and a burned body–the one who had so eagerly made her home within ours–decided to run away.

In two months at our hospital not a single person from Nima’s village had come to visit her. From her bed in our Inpatient Unit, she had once felt special among our staffs and patients. And, as has happened to so many of us in the past, in a swift turn caused by misunderstanding, she felt completely alone. Or so I gathered.

Word quickly spread that Nima had tried to leave the Hospital. Our staffs took out their torches and began to canvas Hospital grounds with hopes of finding her hiding as opposed to halfway down the night-veiled hillside beneath us. Luckily, Nima shared that hope with them. I found Nima twenty minutes later, sitting in the dark next to our water tanks, crying to the consolations of Tulla and Dr. Payel. It seemed that Nima had never intended to leave the hospital. But she had every intention of sharing her sadness with someone.  Dr. Payel and Tulla sat on Nima’s one side. I sat on the other. And the three of us took turns between holding the flashlight and rubbing Nima’s back.

Yet it wasn’t until Raviman arrived, Bayalpata Hospital’s charming young pharmacist and Nima’s crush apparent, that she began to smile again. His own smile radiated and seemed to brighten her night with playful questions regarding her post-escape plans and how she could consider leaving without saying goodbye. Although aware that they were friendly, I was surprised to see that the two knew each other so well. And despite my foggy idea of their discussion’s details, I did know that Nima stopped crying. In fact, she began to laugh. And we all did in return.

So why couldn’t I stop crying when Raviman reached over and touched her face? There was nothing unique about it. The two had been laughing about something and then paused. Raviman invited Nima to take dinner with us all in the staff canteen that night, since her staged escape had run past patient mealtime. And, despite her resistance, she was clearly tickled by the uncommon invitation. Yet right before we stood up to walk to dinner, Raviman reached over–as if toward a sister or recently rediscovered friend–and touched the burn on the side of Nima’s face. It lasted only a moment and seemed perfectly natural. And I don’t know if Raviman even realized the effect that his gesture had on me or, hopefully, on Nima. But it was powerful. And it moved me enough to write this post.

To me, the transformative tenderness of touch is its ability to make people feel loved. Anthropologists have long devoted hypotheses and studies to touch’s therapeutic value as a vehicle of healing through connection.  For who can deny the feelings of comfort engendered by a loved one’s hug, the bond created by a reaffirming handshake or the enthusiasm shared by an energetic high-five?

Yet touch clearly has the ability to hurt as well. Physical violence and inappropriate contact are sadly prevalent in the lives of so many, and especially in Achham. Fighting among drunkards brings too many patients to our Emergency Room. Sexual assault is frequent enough that our Hospital does not allow female staffs to walk home alone after nightfall. And domestic violence is common enough that no one flinched when one staff member took leave last month to escape the beatings she claimed her husband had taken to giving her.

The tenderness of touch is inspired by compassion and defined by grace. It’s what moved Raviman to reach into Nima’s sadness and remind her that she is human, that she was not forgotten, and that neither the losses in her life or deformities on her face and body would ever change that. It offered human connection to a person in the throws of emotion I cannot fathom. And perhaps it’s what Nima needed most of all. Raviman touched a side of her face that was deformed, marred by burns and still bandaged after two months of treatment. And while I marvel at how a single moment of connection was able to suspend feelings of neglect and isolation, I was inspired by its simplicity and cried for lack of knowing any other response.

 Nima joined us for dinner that night in the staff kitchen. She sat at the head of the table, next to Raviman. And she returned to her Inpatient bed soon after.

May this account of human emotion and simple exchange forever remind us of the importance of tenderness in all we do. In a place like Achham, where life is hard and work is defined by challenge, it becomes easy to fall into survival mode; to protect oneself with a thick exterior and to mistake aggression for fortitude or gruffness for honesty. But we need reminders. We must always remember that the truth of our work lies in human connection. And that the courage to overcome injustice lies in a single moment of connection. May our work forever promote our ideals. May our commitment to caring for a people forgotten only strengthen in time and practice. And may our work always seek connection over forgetfulness, patience over speed and tenderness above all.

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Gregory Karelas is the Country Director of Nyaya Health.  He graduated with an MSc in Medical Anthropology from Oxford University. 

Posted by Ashma Baruwal

Nyaya Health Staff participate in the Community Mass Campaign on May 12th, 2012 in Ridikot to promote Menstrual Hygiene and Personal Hygiene. The event was held at Bayalpata Bazaar; with people attending from Ridikot as well as the neighboring village development committees (VDCs) of Ganjra, Chandika, Bhageswor, and Janalikot

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Ashma Baruwal is a MPH graduate from Chulalongkorn University,Thailand. She is currently the Associate Director of Community Health for Nyaya Health.

Posted by Gregory Karelas

The gentleman sitting in my office believed he was helping us, or so I like to think. He was from the Nepal Red Cross Society (NRCS), visiting our hospital to discuss the NRCS’s criteria for Blood Banking Center approval –an approval necessary to begin any type of blood transfusion or storage services in Nepal.

His soliloquy on the advantages of hospital user-fees was unoriginal. Yet he delivered it with a passion, the likes of which I had rarely seen before. He waxed poetic about how Nyaya Health’s free-healthcare model was unsustainable, about how patients who paid for service would appreciate their care more than others, and how charging women for blood transfusion services—mid-child delivery and in need of an emergency C-section—could be the perfect opportunity for Bayalpata Hospital to begin a new and surely advantageous user-fee model.

After forty five minutes of our guest’s reflections, I politely intervened. I had noticed that three of our staff members—all of whom held high ranking posts and were in some way related to the conversation—began to support our guest’s idea with enthusiastic nods and comments like “Gregory, we really need to think about charging patients if this hospital is going to be sustainable.” I listened. And I waited for the conversation to end. But it didn’t. So I gave our guest a rather pointed ten minute monologue driven by the following three ideas:

  1. Nyaya Health is committed to serving the poorest of the poor.
  2. Nyaya Health plans to stay in Achham permanently.
  3. Neither Bayalpata Hospital nor I would tolerate someone coming into our home and telling us how to manage it.

The meeting ended shortly thereafter.  Our guest and I agreed to continue the conversation in a formal meeting with community representatives the next week. With community buy-in, we both felt we could determine how to proceed with our proposed partnership. And we left with a handshake before our guest went to our hospital’s Outpatient Department to request a user-fee free medical examination.

As our guest left and I began a recap discussion with staffs present, I realized that the NRCS’s favorite word seemed to quickly become our own. “Sustainable”. How could an organization of any sort ever hope to survive if it did not charge for service? “It was simply not sustainable.” The gentleman from the NRCS seemed to believe it. Some of our staffs seemed to believe it. Perhaps even more than some. This was hardly the first time that I’d heard this logic. But it was the first time that I’d witnessed someone actually try to enforce it.

The community meeting was the following Wednesday. Our Administration fulfilled its promise of organizing the event, delivering invitations to local leaders and reserving the requisite tea and biscuits that all meeting attendees typically expect at such gatherings in Achham. Our two guests from the NRCS were hardly strangers, and arrived in high spirits. The lankier gentleman was the one described above. His burly counterpart was the Regional Manager, whom I had met on several prior occasions. We shook hands and walked into the room together, taking seats on opposite ends of our circle of plastic chairs.

After our meeting’s thirty members had completed their introductions, the NRCS began with its opening comments. Our burly guest began with descriptions of the purpose of this meeting, the necessity of NRCS approval before any blood banking could begin at Bayalpata Hospital and the importance of the community in developing those services through blood donations and general awareness. Then it came. Despite my neophyte Nepali skills, I heard the word again. “Sustainable.”

Why was everyone obsessed with this word? And perhaps more importantly, why was everyone so sure that our Hospital was in peril without charging less than $4 per blood transfusion? My questions were rhetorical and to myself. So I stayed quiet and continued listening. The Regional Manager continued for close to an hour, growing more confident with every dramatic pause he took. Then he stopped. He took a seat. And it was our turn.

My response was simple. It began with the first two points recounted above. It found its stride with “…and Nyaya Health is committed to working twice as hard to make sure that its patients never have to pay for service.” And it ended on “…thus it seems that there are really only three things that need to happen before Bayalpata Hospital can begin providing blood banking services : 1. The community must support the idea; 2. Nyaya Health must commit to covering all service costs; 3.The NRCS must approve it. It appears numbers 1 and 2 have been completed…”The crowd gave that faint but genuine applause I’d come to hear at so many of these events. And we knew we had sealed the deal.

The burlier of our two guests quickly walked over to me and requested in my ear that we finalize these discussions in my office. I agreed under the condition that his organization promise to grant our Hospital blood banking status in front of the community members present. And he did.

Is Nyaya Health’s model of free healthcare sustainable? To me our organization has flourished on the sleeplessness, brilliance, commitment and shameless funding requests of an international team of heroes. For an organization as young as we are, we have grown in leaps and bounds. In less than six years we have expanded from free blood pressure screenings in the local bazaar to a District-level hospital, whose staff of 54 will treat over 30,000 patients this year and provide community health outreach to nine districts. Our most recent board meeting confirmed that our budget for the next fiscal year will have to raise close to $1 million to cover in-country costs alone. And we still have our eyes on growth.

So is it sustainable? Or is Nyaya Health approaching its Icarus moment? How long can we beat our chests with the battlecry of “no user-fees” and “serving the world’s poorest” without any income to fuel them? If the most recent financial crisis has taught the non-profit industry anything, it’s that most donors view charity as akin to luxury good spending and will, understandably, close their wallets when a dollar in Nepal might also be put toward a harrowing mortgage payment.

The truth is that I don’t know the answer. There are times when I believe with every ounce of my being that we must continue to provide free health care, name brand medicines, x-rays, lab and community health services among others; that our efforts defy the “impossible” and will someday change healthcare across Nepal. But there are also times when I wonder “How in the world can we keep this up?”  How in the world will we be able to raise $1 million next year? And will that even be enough? I’d lie if I said these questions and their myriad derivatives didn’t keep me awake on a regular basis. But I’d also lie if I said that I thought we should change our model; or at least before we have to.

It’s true that there may come a day when Nyaya Health must ask its patients for money. Perhaps that day will come in the form of a community health insurance model, or asking patients to purchase medicines, but not treatment. Perhaps it will never come at all.

But for as long as Nyaya is still driven by the sleeplessness, brilliance, dedication and shameless funding requests of its international heroes; for as long as Nyaya is able to recruit international heroes like the ones it has to date—ones of like mind and arguably nonsensical commitment to the ideal of justice through healthcare–for as long as Nyaya can afford to repeat figures like $1 million per annum with a straight face and glimmer of excitement, it should hold on. There is no question in my mind that every board member, visitor to Achham, or witness to the abject health that is this place would agree. We are committed to serving the poorest of the poor. We are committed to working extra hard to ensure healthcare for every last person here that needs it. Because, in Achham, we all need care. We need the efforts that have come to define Nyaya Health. And we need hope.

So we do what we do until we can’t do it anymore.

And that is sustainable.

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Gregory Karelas is the Country Director of Nyaya Health.  He graduated with an MSc in Medical Anthropology from Oxford University. 

Posted by Ashma Baruwal

It was Thursday and I had just returned from my day off (my “weekend” falls on a Wednesday).  After attending the update meeting I headed back to my office, making mental notes of the things that needed to be done.  The waiting area for the patients was not too crowded, which is normal as the week comes to a close at Bayalpata.  Nevertheless, the hustle and bustle of patients and staffs, the heart of Bayalpata Hospital, is always there.  This is something that I have come to love in the two weeks that I have been here.  I was going through some articles on HIV that I had downloaded, when Agya came in to tell me that our follow up patient was here.  With so few staffs in the department, we have a simple follow up system.  Patients who need to come back to the hospital for further check-ups are marked as “follow ups,” and their details along, with contact information, is provided to the community health department.  We then follow up with the patient on the dates specified.  It is our job to make sure that the patient is at the hospital for his or her check-up on the specified date; this is usually done via phone or through patient notification by our efficient team of Community Health Worker Leaders (CHWLs) or Female Community Health Volunteers (FCHVs).
The patient, an eleven year old girl from Markhu, is one such patient and perhaps the dearest one to the hospital.  I was meeting her for the first time and was very excited about it, as I had heard of her often from Agya.  The girl had first come to the hospital a couple of months back with her mother, and had been diagnosed with Rheumatic Heart Disease.  Dr. Sizan and Dr. Micheal did their best for her then and asked her to come for a follow-up visit.  The patient and her mother came right on time.  This time, Duncan too examined the case and decided to take her to Tribhuvan University Teaching Hospital in Kathmandu right away.  In Kathmandu, the girl had an appointment with the celebrated Dr Bhagwan Koirala, who determined that she wasn’t old enough for surgical correction of the disease, and that the surgery couldn’t be performed until she was 14 years old.  Until then she was to come to the hospital every three weeks to get her penicillin shot.  So there she was on the 3rd of May ready for her medication, which was her lifeline until surgery.  I went out to see her and Agya introduced me to both of them.  I found her mother to be a cheerful person while the patient on the other hand was a shy young girl.  Initially she came across as any other kid who has not been feeling well.  But then as she answered questions with slight nods and a couple of answers here and there, her light colored eyes and innocence got to me.  As we proceeded through the checkup, penicillin shot, and electrocardiogram (ECG), I found myself falling in love with her innocence.  I was getting to know the reason why she is so dear to Agya and Duncan, and let me tell you I am not a bit surprised.  There is something about the girl that just pulls you to her.  Her calm nature during the penicillin shot surprised me.
While we were waiting for the ECG report from Dr. Bibhusan, we got to talking with the girl’s mother.  Her life story is another struggle.  She was married at the age of 10 and her first son was born at the age of 12.  Yes, you heard that right.  It was kind of normal in those days for women to be married at such an early age.  And here I am not talking about the 19th century or even 50 years ago for that matter.  This was commonplace somewhere around 20-30 years ago.  The practice is changing, but early marriage is still very prevalent in the area, and Nepal definitely has a long way to go in regards to such social issues.  Anyway, coming back to the mother’s life story: she has five children, with our patient being the third one.  Life has been difficult for her, as she has had to fend for her family almost alone.  On asking about her husband, I came to know that he is disabled.  What was more shocking to learn was that he had the condition when they got married, and that her father thought that he was doing a good deed since no one else would be willing to marry one’s daughter to a disabled person.  So, she has had practically no help from her husband except for some household chores.  That was a heart wrenching story, and she would have continued further if not for the nurse who came to inform us that the ECG report was normal.  After counseling, they were headed back to their destination when we offered them some refreshments at the tea shop right outside our hospital (their home is 2 hours away).  Imagine an eleven year old child with rheumatic heart disease having to walk 2 hours for treatment.  That’s the reality in Achham, as well as in most of west and far west regions of Nepal.  However, that seemed a trivial matter for them. “The hospital has been like a God to us,” were her exact words.  She was equally grateful to Agya, and they sat together talking about Agya’s mom, who obviously holds fond memories for the patient’s mother, who had stayed with her while in Kathmandu.  The special bond they share was reflected in their conversation, and it was there while I sat listening to them that I realized how proud I felt to be part of an organization that was in a REAL way making a difference in the lives of the people in this little corner of  far west Nepal.
The girl comes to the hospital religiously every 21 days and she is so responsible that even before asked, she reminds us when her medicine dosage is about to finish.  For us and for Dr. Koirala, a surgery for the girl is inevitable.  Worries for her daughter’s life are all you see on her mother’s face, but little does anyone know what is going on in the mind of this little one, who just expresses herself in a few nods and smiles.

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Ashma Baruwal is a MPH graduate from Chulalongkorn University,Thailand. She is currently the Associate Director of Community Health for Nyaya Health.

Posted by Lindsey Youngquist

Nyaya Health: The Season for Wheat

The life of a Nepali villager follows the rhythm of the seasons. There is a time for planting, for harvesting, for monsoon and for festival. All elements are woven into synchronicity with the land and the climate. During the winter months of November to March, it is the season for wheat harvest and men and women work tirelessly to collect this grain for subsistence farming. Golden fields turn to flour through processes of threshing by hand and letting wheat grains dry in the sun.
Wheat flour is used for making flat breads called roti. The wheat straw is used for livestock feed and shelter.

Posted by Gregory Karelas

This morning, our nursing staff greeted me with a phrase that has become too common at Bayalpata Hospital: “Gregory. We have no pani.” Translation: “Water is out again. We don’t know what to do.”

As mentioned in previous stories and updates, water is a delicate and ever-unreliable commodity here at Bayalpata Hospital. Our need for it has only increased over the years. Yet its supply has dwindled in the last few months. Thus, I’d like to devote this post to examining the questions and ruminations that have helped me to deal with the greetings above.

The first question that comes to mind is “Why?”  Why has every day of the last few months felt less likely to have water than the last? Water exists in Achham. It’s accessible. In fact, it’s available from a public tap just 20 minutes up the road and at every tap on that same line for kilometers in either direction. Yet none of that water seems to be reaching our hospital, its staffs or the patients they serve.

One explanation depicts a young shepherd walking his goats through the woods. He’s thirsty. As the sun beats down upon his perspiring head, he sees a green, plastic and rubber amalgam in the shape of a pipe. The shepherd realizes this pipe shape might carry water. He knows that water would quench his thirst and quickly gets to work. The shepherd removes the knife from his back pocket and cuts ever so vigorously into the pipe before him. Victory is soon his. Yet within six hours, Bayalpata Hospital’s water reservoir will be empty. At that time, it will be forced to send another staff member to collect six large buckets of water to float it (pun intended) until another staff member can walk the pipeline, identify the line break and patch it up.

Another scenario might include Naresh, a fictitious young Achhami gentleman, who walks by the Bagheshwor water source every day on his way to school. Whether Naresh knows that the Bagheshwor source supplies Bayalpata Hospital with over 75% of its water is debatable. But he definitely knows that the Bagheshwor source serves as a convenient receptacle for the plastic bags of the processed food snacks he eats en route to school every morning. And so, he throws. He is a child and likely doesn’t realize that that sack will lodge itself somewhere in the pipeline, blocking Bayalpata Hospital from the water it needs to wash its floors or feed its staff. Yet his throw follows that very trajectory and indeed makes an impact on countless staffs and patients that day.

In our third scene Ram, another fictitious Achhami resident, plays his hand at sabotage. One afternoon, after a couple glasses of local moonshine, Ram makes his way to the Hospital’s water source and develops a strategy fueled by the resentment he holds for Bayalpata Hospital it did not select him for the Health Assistant post he applied for last week. He decides to block the Hospital’s water line with rocks and any debris within reach. He knows that his efforts will not permanently cripple the Hospital. But he rests assured that it will cause some distress there while the Hospital figures itself out of another daily drought.

The above scenarios are real and happen often.

Moving on from the question of “Why,” one might ask: “What does the Hospital do when it has no water?” The first step is to find the Country Director immediately or, in rare cases when the Country Director is not present, wait until the Country Director is present and ask him to fix the problem. The next step is for the Country Director to send the ambulance driver and at least one groundskeeping staff member to fill as many large buckets of water as possible from a reliable source approximately two kilometers away. The third step is for the Country Director, or some other eager-to-help staffs, to send someone to walk the pipeline, clear its obstruction or seal the break releasing its water. There is usually a combination of ancillary responsibilities accompanying these processes to solve the problem. Yet, the steps outlined above are pretty standard. And, somehow, they work every time.

The third question one might ask is “How does the Hospital plan to fix the water problem permanently?” Its answer is, unfortunately, not as easily derived. To date, the Hospital has forged contractual agreements with the community to protect its water, hiring staffs to regularly walk and maintain our water pipeline and lobbying the district government to build protective walls for the Hospital’s water source. Each effort has been successful. Yet not a single one has ensured reliable water flow. New ideas include the installation of a metal pipeline, burying our existing pipeline in a 1-meter-deep ditch, supplicating the community through smaller meetings with its leaders, and radio announcements drawing attention to the Hospital’s water plight. Each suggestion brings its own advantages and drawbacks. But we plan to undertake all of the above until something works, because waiting for a magic bullet will get us nowhere.

I often wonder why the nature of Achham appears to be defined by patent destruction. There is no reason to cut our waterline. Everyone in the Region knows of our Hospital and everyone for three Districts seems to know which pipeline is ours. Yet our well-known Hospital has endured almost one half of the last month without water. Why? That’s what I ask when I hear rumors that the community had poisoned our Hospital’s campus dog. It’s what I ask when a local political party member screams accusations that our Hospital hates Achham’s citizens as he waits for his son to receive free treatment in our Emergency Room.  And it’s what I ask when staffs greet me on yet another morning with the announcement that we have no water.

A dear friend recently told me that behaviors like these are not exclusively endemic to Achham; that they’re a part of the world. Restricted water has spawned wars in Africa; no one would bat an eye with the news of a poisoned dog in West Baltimore; and white-collar politicians cram our airwaves every day with hypocritical condemnations of the systems that serve them and the people who sacrifice for them. Yet somehow in Achham it feels different. Perhaps it’s my eyes that too thoughtlessly blame these problems on a remote and formerly war-torn region of the world–allowing a part of the Earth with so many problems to absorb yet another; an association that I’m quite ashamed to admit.

I can attest to living in conditions where one’s neighbors deliberately destroy and regularly the Earthly staples I consider to be human rights. The explanations people give for that destruction run the gamut from “ignorance”, to “malice” to the development industry’s age-old favorite “poverty”.  Perhaps it’s all of the above. Perhaps it’s none of them. Perhaps Hobbes had it right, for if Achham has taught me anything it’s that an unsupported life is indeed nasty, brutish and short. Or perhaps the explanation just doesn’t matter, for nothing could make disregard for life acceptable.

Thus, until a day of universal empathy—one that defines political structures, drives human interactions and inspires compassion—people will continue to hurt, disappoint and disrespect the world around them, for we are all human and we are all flawed. Complimenting efforts to serve the poor is obligatory in most social circles. Yet truly feeling what that care actually means–deeply meditating on the toils of life without water or the efforts it takes to run a hospital without it—that is a more obscure compliment. And it is a more permanent solution.

We work with the hope that someday, someone might feel the meaning of their words when they say, “It must be so hard to work in such a remote area.” In fact, it’s what I believe will change the world.

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Gregory Karelas is the Country Director of Nyaya Health.  He graduated with an MSc in Medical Anthropology from Oxford University

Posted by Ashma Baruwal

Our Community Health Worker Leader, Pabitra B.K from Hattikot explaining the hand washing technique as a method of personal hygiene at a Community Mass Campaign.

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Ashma Baruwal is a MPH graduate from Chulalongkorn University,Thailand. She is currently the Associate Director of Community Health for Nyaya Health.

Posted by Jesse Brady and Bibhusan Basnet

 In the past 8 months, the month of May recorded the highest number of bandhs (strikes) due to an extension of time allotted for drafting the national constitution.  Many parts of the country have been reeling from the almost daily bandhs during the past few weeks, which have created a shortage of essential commodities like food, provisions, and medicines in many places.  The constitution has yet to take a final shape, but the country is already burning and there have been moments in which the entire nation has come to a standstill.

The Far Western Region of Nepal has been in the bandh for more than two weeks, due to people demanding an indivisible Far Western Region, and others demanding a Tharu Province within that region.  Bayalpata Hospital (Achham) and its services have also been affected lately due to the ongoing indefinite strike.

[The following post was adapted from a series of update emails sent from Achham during the recent bandh (strike).]

 Mark Arnoldy, Executive Director

May 13, 2012

Our Nepal team has been without internet and phone for the last 5-6 days, and just briefly picked up the ability to make a few calls.  The region is in day 16 of an indefinite bandh.  The report is that everyone is safe but there has been some violence and possibly a few deaths in Dhangadi.  Achham, some 10+ hours by vehicle from Dhangadi, has not been impacted by violence, but has disrupted supply chains and the inability to move out of the district (our ambulance included).

 

Bibhusan Basnet, Medical Director

May 17, 2012

The bandh has been continuous in Nepal and our services are very much affected by the strike.

We have medical supplies left just for 4-5 more days.  Recently our solar power has been out of order and we have had to rely upon electricity for our lab reports and X-rays.  We have electricity for just a few hours a day and no fuel supply for our generator.  Because of this, the patient reporting is not done on time these days.  We are short on food supplies and fuel for cooking.  The ambulance service is even being hampered by the bandh.  We have patients with suspected extradural hematoma, post-dated pregnancy in need of caesarean section, and traumatic subcutaneous emphysema in our inpatient department waiting for the ambulance services.  Our internet service was also out of order but recently we have been able to use our NTC internet, though the broadband is still out of order.  At least we are in touch to the rest of the world now.  The situation is bad but we still have hope.

 

Gregory Karelas, Country Director

May 18, 2012

1. The CDO has agreed to turn power on to our hospital for increased hours until fuel has arrived. He is making a special exception for our Hospital given the dire need and shortage of meds at BH.

2. Rumor has it that Dhangadhi strikers will open a window for vehicle passage to other areas of the Far West in the next 1-2 days, allowing petrol to reach Sanfe.

3. Our vendors are currently collecting a 1 month supply of our most commonly used and necessary drugs for release as soon as the bandh opens.

4. We have personally contacted the Storekeeper at the District Health Office in Mangalsen to release any medications possible. Since we do have diesel, the Ambulance has received approval for this pick-up right away.

Indeed, these are further iterations of the unexpected challenges we face in Achham.

With thanks to Dr. Bibhusan and all of BH’s amazing staff, who overcome these challenges daily. Their dedication is inspiring.

 

Bibhusan Basnet, Medical Director

May 24, 2012

Even during the bandh, we have been able to move some supplies during the night.  The medications have started arriving.  We have decided to procure extra medications for the next 10 days, and hope that the medications arrive tomorrow or the day after.

Regarding the cases that were in the hospital waiting for ambulance services:

-  The lady with post-dated pregnancy was induced, and had a male child who was treated for suspected neonatal sepsis and sent home a few days ago;

-  The boy with suspected extradural hematoma improved with mannitol, phenytoin, and prophylactic antibiotics, and was sent home after 7 days as an inpatient.  We are thankful that the child improved. He is on our CHW follow up list.

-  Sadly, the lady with subcutaneous emphysema passed away.

The ambulances are now able to travel for referrals.  Our ambulance will even be sent out of the district for service as soon as the ambulance is maintained and in order.  Until then, the ambulance is in service within the district due to the ongoing bandh.

We have electricity about 4-5 hours a day (8-11 a.m. and 3-6 p.m. inconsistently).  The electric plant in Achham does not have enough capacity to send us more electricity.  We can now run the hospital’s generator a few hours a day for laboratory and X-ray services.

Food supplies and gas cylinders have been supplied by our local vendor, so there is no food shortage at Bayalpata Hospital (BH) these days.  Despite the continuous bandh, BH has improved conditions and services, and life has gotten better.  I am inspired by the teamwork of the BH staffs, who work so hard under any circumstances.

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Jesse Brady is the Blog Editor of Nyaya Health and is currently pursuing her MS in International Medicine at Montana State University.

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.

Posted by Mark Arnoldy

Dr. Paul Farmer, Co-founder of Partner’s In Health celebrates the 3 year anniversary of Bayalpata Hospital; Opens the surgical center and Far West Nepal’s only microbiology laboratory.

Mark Arnoldy is the Executive Director of Nyaya Health