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Posted by Gregory Karelas

Over the past few months, renovations have been underway to transform Bayalpata’s former Labor and Delivery Room into a

Bayalpata Hospital's Isolation Room

fully-functional Isolation Room with an external entrance.  This room provides a safe and comfortable environment for patients afflicted with communicable diseases, such as tuberculosis, who need to receive treatment separately from the standard Inpatient Department.  The hospital’s new solar power system provides electricity to the room, enabling the use of all necessary medical equipment.

This renovation enables confinement of communicable pathogens, to ensure the safety of all Bayalpata patients, while still guaranteeing a comfortable healing environment for patients in isolation.  As the hospital expansion progresses, we become equipped to better serve a variety of patient needs.  Over the upcoming months, we look forward to providing updates on more improvements and renovations.

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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 Mark Arnoldy

Nurse Urmila Basnet waits in Bayalpata Hospital’s (BH) ambulance prior to transporting a patient who had been involved in a 23 person bus accident. The patient was driven 14-hours for referral to a partner hospital in Nepal’s southern Terai belt. Since the initiation of the service in 2010, BH’s ambulance service has transported 843 patients, over a total of 88,141km (54,647 miles). The program has cost, overall, $23,307.90 (NRs 1864632), which shows that this frequently life-saving program has cost only $27.65 (NRs 2211) per patient!

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Mark Arnoldy is the Executive Director of Nyaya Health.

Posted by Bibhusan Basnet 

During one of our regular morning rounds, I saw an elderly lady carrying her two year old male child into the Emergency Department (ED).  They were waiting to be examined and looked a bit distressed.  I attended to the child.  The lady told me that he had fallen from the stairs and showed me his legs.  The child cried in severe pain even as I tried to check him over with caution.  Quick examination showed that his right thigh was badly swollen, and it was clear that he required proper pain management before anything else.  To relieve his pain, I ordered for some Ibuprofen syrup to be given to the child.  I then recommended him for anterior, posterior, and lateral x-rays of his right leg.

Some hours later his x-rays were ready.  “Right femur fracture,” Chanakya dai, one of our Health Assistants (HA) suggested as he examined the x-ray plate.  I looked at the x-ray to be sure.  He was right.  The fracture was running through the mid shaft of the femur.  Fortunately there were no displacements.  The patient had to be put in a hip spica (see image below) without question.  I asked Chanakya dai whether he had done such placements before.  He happily explained that two weeks earlier, two US volunteers and emergency physicians, Mark Goodman and Angela McKellar, had taught them to put on a hip spica.  However, neither he nor any of the other HAs in the hospital had independently done it before.  “We usually refer such cases to Nepalgunj Medical College for hip spica placement,” he told me, and asked if I have had any such experience.  Although I had assisted in placing hip spicas before, I could count the number of such procedures on my fingers.

Hip Spica

Chanakya dai quickly expressed that few other HAs had also seen the procedure done by Mark and Angela.  He sounded very eager to put the cast on the patient.  With only a few case experiences, I was reluctant to do the procedure in the beginning.  However, I knew that the economic condition of the patient was too poor and that the child’s family would never be able to afford him the trip to Nepalgunj for treatment.  It was a “do or die” situation.  If we couldn’t do the procedure in Bayalpata, the child risked living a crippled life.  Deciding to go ahead with the procedure in Bayalpata Hospital wasn’t even an option, it was a requirement.  The circumstances wouldn’t let us do otherwise.

I had mustered the courage to go ahead and was confident enough, but I also had my doubts as to whether I could actually make it happen.  The doubt kept me on my toes and brought out the best in me.  I gathered help from our other physicians, Dr. Ashok and Dr. Suman, to help me with the procedure.  Given the lack of experience of doing such a procedure in the team, they too were reluctant in the beginning.  But, given that we had no other options, we decided to have faith and trust in the skills of our team.  The long distance the patient had travelled to get to us motivated us further to spearhead the procedure.

We then started to prepare for the procedure.  Dr. Ashok looked for a video online on how to put a hip spica, to familiarize ourselves with the real procedure.  At around 3 p.m., sitting by the emergency desk with our team of HAs (Chanakya dai, Ram bhai, Khadak bhai and Kriti ji), we (the three staff physicians) watched the video of putting on a hip spica.

After the video, we divided our jobs, gathered the 15-16 packets of 4 inch pop casts, and then asked the patient to move to the procedure room.  We first made a support for the abdomen in order to prevent disturbance to the abdominal muscles and to facilitate smooth respiration.  We wanted to give the patient the best care that we could afford with our limited resources.  We didn’t want to leave any room for risk.

Our team proceeded with real energy and passion.  We remembered to align the hip flex and to externally rotate to allow room for digression.  With care and attention we made sure that the child could poop and pee without spoiling the spica.  It really took us about half an hour to complete the procedure.  It was indeed a very sweaty task.

After putting on the spica, we monitored the child’s vital signs frequently and checked for movement, color, sensation, and warmth in the child’s toes.  We also taught the grand-lady to put some emollients on the genital area and told her about regularly changing the child’s position to avoid the dreadful bed sores.

We then ordered an x-ray once again to see if the bones were displaced.  Luckily, the femur had no displacement and the child had no problem with respiration.  It was an amazing and awesome procedure for us all.  Chanakya dai was genuinely the happiest among us all.  “No more referrals for hip spicas!” I heard him exclaim.  I took a sigh of relief.  He was right.  Besides our team, the credit all goes to Mark Goodman and Angela McKellar, who were so awesome to have taught our HAs, this important procedure.  If it had not been for their training, the child would have just been another case of our referrals that would have never gotten treatment owing to poor economic conditions.  At the end of the day, it was an amazing success for our clinical team.  The lady was also more than happy to have a definitive treatment for her grandson and it was written all over her face. Such successes are vital for motivating the staffs, and patient satisfaction is a crucial ingredient to keep adding fuel to continue our noble efforts in Bayalpata.

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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 Mark Arnoldy

Nyaya Health’s Country Director, Gregory Karelas, and Accounts Officer, Chanakya Upadhyay, assist local laborers in moving the new door frames that were custom built for Bayalpata Hospital’s surgical center. The surgical center is currently under construction, and is scheduled to open in June.

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Mark Arnoldy is the Executive Director of Nyaya Health.

Posted by Shwetha Sridharan 

This is a cross-post from yodesh about the author’s experience in Achham at Bayalpata Hospital. 

A group of Nepali women leaving the hospital.

I realized quickly, after just having traveled to various villages in rural India, that distance is relative. Hailing from a city like San Francisco, going even a few hours outside of town is far – but twelve hours outside of a major city? I half expected to run into another country.

This remote place in mention is Achham, a tiny hillside region in Far West Nepal. Sitting like a giant amongst the lush green terraced mountains of Achham, is a hospital named Bayalpata. Once an abandoned building, it has been revived by the committed NGO Nyaya Health. I had the opportunity to visit this hospital last month and see the vision of Nyaya Health’s staff—free quality medical services and health equity for the residents of one of the poorest districts in Nepal.

The site of Nyaya Health's work, Bayalpata Hospital.

Achham’s population is about 250,000, but unfortunately its socioeconomic statistics are nothing to boast about. Bayalpata Hospital’s main cases are deliveries, in a region where the maternal mortality rate is 800 per 100,000.  By comparison, the U.S. mortality rate is 8 per 100,000.  Looking further into Nyaya Health’s collected baseline surveys reveals an even more troubling picture:

  • The average daily per capita income is $0.50.
  • 92-95% of homes don’t have electricity.
  • The average level of education is 1-1.5 years of schooling.
  • 60% of children are chronically malnourished.
  • 50% of households have a member working seasonally in India.  Not coincidental to these circumstances, this district is believed to have one of the highest rates of HIV and labor migration.
  • 55% don’t have access to safe drinking water, two and a half times the national average.

Despite these heartbreaking statistics, inspiration can be found in the phenomenal work that Nyaya Health is doing in this region.  An entirely Nepali medical staff, the hospital is slowly gaining parts to its whole. While we were there, we saw the beginning of a brand new surgery ward; the new toilet received its final touch with a fresh cover of tiles; a mason fitted new window frames for the entire hospital.

The busy office of Gregory Karelas, Country Director and administrative staff.

The Country Director, Greg, went on with his work approving funding for expanding staff and volunteer quarters –even as 20-30 people went in and out of his office with inquiries. And all this was happening next to the most expansive view of the region –a majestic valley before us, the mountains and the riverbed below appeared to carry a postcard-like quality. It was only the economic reality of this beautiful region that quickly brought us back to attention. About 200 adults and children filtered through the outpatient department that day. The waiting room was packed.

Nyaya Health was created in 2005, when they began setting up the organization, doing research and putting together staff. By 2008, Nyaya was up and running, providing medical services to the community.  It was originally started by three medical students from the United States but has been pushed forward by the Nepali staff in Achham with a support team in Boston.  One can imagine how rapidly things have progressed here, given the location: from Kathmandu, Achham is a two hour plane ride and ten hour jeep ride up and down a one lane largely unpaved mountain road.  From the plane, we saw the Himalayas clear and close; while from the jeep we experienced them firsthand, not knowing when the jeep might slip on a bend. From the terraced hillsides to the tall grass fields a perfect blend of green and yellow, I have never seen a landscape so breathtaking.

The terraced mountainside, characteristic of rural Nepal and the view from Bayalpata Hospital.

Nyaya has their work cut out for them though, as they recently lost 3 key members of their staff who demanded higher pay raises. Without a medical director, it is really hard to run a hospital. But somehow, the staff has persevered, tackling issues like a broken X-ray machine through an 8 hour Skype call with customer service in Spain; or dealing with prior accusations of illegal supply purchases, quelled through transparency of expenses.

Everything related to Nyaya Health is open source. From staff photos to budgetary allocations to board meeting minutes; it is all out there for donors and visitors to see. And in the non-profit world, this is a gift when oftentimes decisions are made based on political, regional, and economic variability.

If I had not seen it with my own eyes, and returned back to tell the tale, I would have thought my visit took me to the end of the earth. But the journey that we made was more than physical – if so many corners of the world could galvanize solutions like this to address inequity, it gives me hope that we can we rally together and carry them through.

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Shwetha Sridharan has spent the last two years working on water and sanitation issues in India.  She visited Nyaya Health to further her ongoing interest in local solutions to WASH delivery in rural areas.

Posted by Duncan Maru

I recently unearthed the following short piece, which I had written in the wake of residency work hours changes over the last two years and ultimately never published.  The work hours changes had tightened regulations on how long physicians-in-training could legally work in hospitals in the United States.  I turned back to this piece after attending a meeting among staff at a community health center in Boston where I serve one half-day a week as a resident physician.  My Nyaya colleague Ryan Schwarz (who is in the same position as myself) and I found it remarkable that the physician to non-physician provider ratio is 2:1, whereas at Bayalpata Hospital this ratio is approximately 1:10.  Much of the discussion at the clinic focused on how to better involve non-physician providers—“task shift” is the buzz-word—but both Ryan and I were struck by how this fundamentally inefficient human resources structure was hampering the functioning of the clinic.  This odd inefficiency—too many doctors vis-à-vis other non-doctor providers—is a cruel joke to our colleagues at Bayalpata Hospital who have to spend an inordinate amount of energy recruiting doctors in order to maintain even a 1:10 doctor to non-doctor provider ratio.  Doctors in Nepal just have so many greener pastures than our humble hospital in Achham.  By necessity, we must constantly innovate to figure out how to incorporate non-physicians into roles in the United States that physicians often fill; “task shifting” is not a human resource strategy but a human resource necessity.  Yet in so doing, I do think that our work in Achham has much to offer places like my health center in the United States.  This is one of many examples of how the experiences of resource-limited settings have much to offer here, since teams involved in global health delivery, such as Nyaya Health, have so frequently had to search for innovative solutions in the face of constant human resources crises.  The below touches on legal changes specific to the American education system, but I do believe the issues both inform, and can be informed by, efforts in places such as Achham, Nepal.

New Residency Work Hours: Time for Training Leaders in Medicine

Ever since the Flexner Report compelled American medical education to integrate the training of doctors with scientific inquiry, scholarship, and the university [1], a key component of residency training has been to foster doctors who will innovate and advance the practice of medicine.  Although not a stated goal of the expanded work hour regulations, the recent ACGME recommendations [2] provide a critical moment to return to these roots.  While debate over residency work hours has appropriately centered on issues involving rigor of residency education, patient safety, and transitions of care, a central question persists: how residency work hours will impact the training of leaders in medicine.   The impact can be beneficial, but significant work lies ahead.

The need for doctors to serve as managers, scientists, and leaders has never been more important, given the explosion of medical technology and large complexities within the healthcare system.  The forms of leadership that our current residents take will be varied.  They may expand access to healthcare in a rural town by more effectively using nurse practitioners in a private primary care practice.  They may sit on boards of public health, or lead large non-profit organizations, or drive quality improvement in public urban hospitals, or write policy that changes the care environment.  They may innovate in biomedicine or basic science or clinical epidemiology.  They may write popular press articles and books that communicate new ideas about health to the public.  Central to being a member of the medical profession in the modern era should be about injecting our society and our health institutions with creative energy. Over-worked residents whose worlds become defined by narrow roles in the hospital do not leave postgraduate training programs well-prepared for these roles.  Furthermore, current residency training fosters an ethic that being a doctor is about simply putting in time rather than about being an effective leader and innovator.

Achieving sufficient operation volume, experience with diagnostic complexities, and challenging management decisions while maintaining attention to work hours necessitates that programs re-think the role of the resident.  Training should focus on managing complexity.  For example, clinic patients that are not of sufficient complexity should not be primarily seen by residents and should not count in accreditation numbers.  On the inpatient wards, much of the coordination and discharge planning that are done by residents should be delegated to administrative personnel and mid-level providers.  Inpatient rotations should be assessed by the level of complex management decisions that residents themselves are responsible for.  Short-term single-day, weekend, or afternoon coverage (“day float”) of inpatient wards, i.e. work in which the covering resident is not involved in critical decision-making, longitudinal care, and morning rounds, should not be covered by residents, since there is little educational value and much time lost in such work.

These changes may mean that residency programs become longer even as they become more focused on research, innovation, and managing complexity.  The ACGME should consider “Leadership” as a seventh core competency [3].  Evaluation metrics should be developed to assess residents’ success as leaders.  Are they capable of making independent, autonomous decisions on patient care questions of clinical, social, ethical, or biomedical complexity?  Are they demonstrating innovation in aspects of biomedical, policy, clinical, or healthcare management work?  Adopting standard metrics for these will not be easy, and holding residency programs accountable for the leadership skills of their residents, but this is central to ensuring that our healthcare system has effective managers and innovators at the helm.

The central challenge is to identify ways to staff much of the critical work that residents are currently compelled to perform.  Fundamentally, we need an infusion of well-trained mid-level providers who can manage much of basic clinical care, counseling, and patient-follow-up, and we are going to have to be willing to pay for it.  Changes in the regulatory environment to further capacitate these providers will be necessary [4].  Routine, less complex elements of health care delivery should be delegated to those with the proper training to administer those tasks.  We are already seeing this with the growth of nurse practitioners on the wards and in clinics [5,6].  Further expansion of the role of mid-level providers will cost teaching hospitals money (since they are more expensive than residents), but will, in the long-run, make for a healthier, leaner, and more dynamic healthcare system.  For its part, the federal government should be more willing to subsidize hospitals to train leaders and complexity managers than to subsidize basic hospital operations that should be managed by mid-level practitioners.  In fact, in the long-run, we cannot afford not to make this investment.

Ultimately these changes may mean that, as in Flexner’s day when the Report led to the closure of dozens of unqualified medical schools, residency programs need to become smaller even as training programs for mid-level providers vastly expand.  To meet the needs of our patients, the demands of healthcare reform, and the integrity of our profession, we may not need more doctors.  Rather, we need a cadre of physician-leaders who are ready to drive the push for newer technologies and expanded access to better healthcare services.  We need smarter, more creative, more balanced leaders in medicine.  The new work hour regulations are a welcome call to action to inject an emphasis on managing complexity, on innovation and on leadership into graduate medical education.

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Duncan Maru, MD, PhD is a co-founder of Nyaya Health. He is currently a resident in the Internal Medicine – Pediatrics program and fellow in Global Health Equity at Brigham and Women’s Hospital and Children’s Hospital of Boston.

 

References

1. Flexner A. Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching, Bulletin No. 4., New York City: The Carnegie Foundation for the Advancement of Teaching, pp. 346, OCLC 9795002.
2. Nasca T, Day S, Amis E. The new recommendations on duty hours from the ACGME Task Force. N Engl J Med. 2010;363(2)
3. ACGME Outcome Project [Internet]. [updated 2010/09/14; cited 2010/09/14]. Available from: http://www.acgme.org/outcome/comp/compmin.asp
4. Pohl J, Hanson C, Newland J, Cronenwett L. Analysis & commentary. Unleashing nurse practitioners’ potential to deliver primary care and lead teams. Health Aff (Millwood). 2010;29(5):900-905.
5. Naylor M, Kurtzman E. The role of nurse practitioners in reinventing primary care. Health Aff (Millwood). 2010;29(5):893-899.
6. Reines H, Robinson L, Duggan M, O’brien B, Aulenbach K. Integrating midlevel practitioners into a teaching service. Am J Surg. 2006;192(1):119-124.

 

Dear Blog Readers,

Sunday is a special day for the mothers in our lives. Yet we know so well that showing appreciation one day a year isn’t fair tribute to all the nurturing care and support they provide. That’s why our team in Nepal is committed to make this Mother’s Day matter well beyond Sunday.

We calculated exactly what it takes to support Nepali mothers in two of our most meaningful ways — making certain they bring their child into the world safely and providing employment as a community health worker to care for families in their village.

 

This year, please join us to send an email gift card to the mothers in your life, and forward this email to friends so they can do the same. It is an honest gift (100% will go directly to Nepal), and it is one that matters.

Thank you, and have a happy Mother’s Day.

The Nyaya Health Team

 

Posted by Mark Arnoldy

Madan Kunwar, Health Aide, installs Nyaya Health's new and improved 1 Mpbs internet at Bayalpata Hospital after a lightning storm destroyed the previous system.

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Mark Arnoldy is the Executive Director of Nyaya Health.

Posted by Gregory Karelas

Having literally spent years working up to this moment, it is with great gratitude and relief that we have finalized the first bulk order of pharmaceuticals for Bayalpata Hospital.  Since the establishment of the hospital, medications have been ordered as they became necessary, due in part to difficult accessibility, limited funding, and the ongoing process of protocol development.  This former system of “ad hoc” ordering, though largely effective, did not guarantee timeliness or cost effectiveness of treatment.

With the new arrangements for monthly bulk ordering through Dhangadhi distributors, Bayalpata will be able to stock essential medications, track pharmaceutical usage, and benefit from the reduced prices of bulk ordering.  This event marks yet another milestone for Bayalpata, on its road to building a better system for the patients of Achham.  We want to express our thanks for all who helped make this possible: the newly established Procurement Team, Bayalpata staff members, and everyone who works tirelessly to support the hospital and all of its endeavors.

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

Posted by Mark Arnoldy

An overhead view of Bayalpata Hospital during a late Spring morning following snow in the surrounding regions. Nyaya Health is making significant investments in phase 2 renovations at Bayalpata Hospital to accompany the building of the hospital's first surgical operating theater and Far-Western Nepal's first microbiology laboratory. These include increased water capacity, a grounded electrical system, 1 mbps wi-fi enabled internet, and new windows and flooring where needed for safety and cleanliness. Bayalpata Hospital serves as the hub of Nyaya Health's operations in the country, in contrast to the more standard route of excessive and expensive investment in Kathmandu-based offices and facilities.

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Mark Arnoldy is the Executive Director of Nyaya Health.

Posted by Duncan Maru

This Easter Sunday, I sat with my family at The Paulist Center in Boston, my mother’s Catholic Church.  The pastor in his sermon told the story of Bishop Oscar Romero, the Salvadoran Bishop, who spoke out against his militant government’s violence, and whose visionary voice was silenced when he was assassinated in 1980.  Ultimately, his vision did lead to a more peaceful El Salavador and an end to that repressive government.  The world continues to remember Bishop Romero as a great champion of social justice and peace.  His is a story of resurrection, of a rebirth of peace and justice from tragedies and structures of violence and repression.  He teaches us the core value of Easter: a firm, resolute belief in the possibilities of resurrection in a harsh world.

 

In a modern world that is so violent, wasteful, and unjust, what are the possibilities of resurrection?  My thoughts, as is often the case, turned toward the hills of Achham.  Our patients and their families teach us of resurrection, walking for hours and even days on fueled by the hope of health.  Community members teach us of resurrection as they go about rebuilding a society only six years out of a brutal Civil War.  My long-time colleague Bibhav Acharya eloquently and perceptively documented this on our blog several months back.  I try to remember these possibilities of resurrection in moments, such as the last past week, of disappointment.  Nyaya was rejected from two good-sizedsizeable grants that we were very close to getting.  The laboratory and surgical renovations have been stalled, and our first surgeries and microbial cultures, long-since promised, remain elusive, far-off goals.  Wrong tiles, wrong laborers, wrong timings, wrong prices.  Still no surgeon in sight willing to work in Achham.  Untimely and unfortunate departures of two of our physicians.  Team members over-worked, over-tired, over-stressed.  Seeming impossibilities of effective communication across languages and time zones.  Six years in to this work, and we continue to hit the same roadblocks, cross experience the same interpersonal conflicts, confront the same internal, psychological, and spiritual demons, and commit the same mistakes.  That is, of course, the nature of the work.  The possibilities of resurrection do not make the art of resurrection easy.  Resurrection is not inevitable nor an act of grace.  In fact, part of the resolve that we try to find within ourselves is in seeing the challenges, the apparent impossibilities in the possibilities of resurrection, and knowing that if we don’t continue to fight, those possibilities will not be realized.

 

At the level of individual patients in the practice of doctoring, the transformative power of medicine, rests on possibilities of resurrection.  It is the idea that an illness can be intervened upon and an individual’s health can be restored.  This is one of the most exciting aspects of medicine.   Diabetic ketoacidosis (DKA), a condition in which high levels of glucose and acid build up in the bodies of undiagnosed or otherwise uncontrolled patients, is a deadly disease, conferring 100% mortality if not treated promptly.  When I am not working in Achham, I am a physician in Boston.  Recently, working at Children’s Hospital Boston, I admitted a five year old boy with DKA.  Children’s Hospital has an amazing electronic system that informs all providers, from nurses to doctors, about precisely what tests, and medicines, and intravenous fluids to dispense.  This includes electronic order sets that reminds us about expected complications, the best management based on current medical thinking, and safety mechanisms in case we forget to order the right tests or medicines.  There is nothing inherently routine about DKA, but the system at Children’s systems puts things in place to make resurrection the near-absolute rule for this deadly condition.  That is the power of effective healthcare management systems.  We’re not there quite yet at Bayalpata Hospital, though, thanks to one of our wonderful physician-volunteers, Dr. Michael Polifka, we do have an excellent DKA protocol.

 

In other settings, the transformative power of medicine is not about fixing problems, its but is more generally about deeply valuing life.  These are some of the most profound moments in medicine.  Recently, I’ve been working in an inpatient hospital setting at Children’s that takes care of children with severe developmental disabilities from cerebral palsy or genetic syndromes.  Many of these children are blind;, most are non-verbal;, most receive their nutrition through a tube in their stomach.   Caring for these children is an immense privilege.  As a parent myself, the parents of these patients teach me about commitment and advocacy.  Every parent, everywhere, needs to fight tooth-and-nail for their children, for the best quality of life.  Their children, against all odds and disabilities, attend school, participate in sports, work, and live meaningful lives.  They teach us about the daily, personal process of resurrection, of waking up each morning and fighting for a healthy day for ourselves and our communities.

 

I admitted a fourteen-year-old boy with severe cerebral palsy a few weeks ago.  It was two o’clock in the morning when he arrived to at our ward at in Children’s Hospital.  What immediately struck me was his finely parted hair.  The nails, skin, teeth, hair of any child, or adult, who is dependent on the twenty-four hour care of others provide a window into the amount of love and attention they are receiving.  These children are at risk for bad dental disease, skin ulcers and infections.  Their parents, to ward off these maladies, have to, in the words of one, be “dragon parents: fierce and loyal and loving as hell.”  His mother, dressed in a Pan Mass Challenge fleece (the PMC raises money for Dana Farber Cancer Center – another hospital in Boston), almost certainly up all day and night caring for her son, still seemed sharp and positive and ready to advocate.  She described to me with pride the ins and outs of his feeding regimen, his daily activities, how he expresses pain and pleasure despite being unable to speak or write.  As I often do for these parents, I thanked her for the amazing care of her son.  Somewhat hubristically, I took the liberty in his admission note—an unusually bland medico-legal document describing my findings as a physician to my colleagues—to sprinkle.  In describing his physical examination, I called him a “gentleman with finely parted hair” with “impeccable skin”.”    In my social history (details of the patient’s home, work, daily life), I talked of the “exquisite care” provided by his mother.  Usually, we do not use such flowery terms in our admission note, but, selfishly, I felt compelled to document and articulate the inspiration I gained from this boy and his mother.  They reminded me again of the possibilities of resurrection which we can experience every day through love and hard work.

 

The relative health of this child also stood in stark contrast to the status of individuals with disabilities in rural Nepal.  The love of parents is universal; their capacity to provide the care their children need, however, is sadly so often dependent upon economic and political forces far beyond their control.  At Bayalpata Hospital, we don’t see fourteen year olds with severe cerebral palsy; most have died of medical complications within one year of life.  That, to me, represents one of the possibilities of resurrection posed by our work in Nepal: that we can be part of a transformation that enables families with food, medical, and economic security to provide the care for their children they so desperately desire.  That transformation, in Nyaya’s view, is not one of traditional paternalistic charity, but rather one of creative problem-solving with communities, of solidarity and bearing witness to injustice, and of building new infrastructure and systems.

 

And so it is that we look towards our leaders, teachers, parents, and patients who show us that another world is possible.  That was the meaning of resurrection I took away from Easter this year.  I hope that, in moments of doubting about the direction of our world and dismay at the intense, seemingly intractable suffering of our communities and patients and families, I can call upon the strength to believe in the possibilities of resurrection and fight, like Oscar Romero and Dragon Moms, to help realize those possibilities.

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Duncan Maru, MD, PhD is a co-founder of Nyaya Health. He is currently a resident in the Internal Medicine – Pediatrics program and fellow in Global Health Equity at Brigham and Women’s Hospital and Children’s Hospital of Boston.

 


Posted by Mark Arnoldy

Nyaya Health Community Health Worker Leaders (CHWLs) and Director of Community Health Agya Poudyal. Nyaya Health uses CHWLs as a critical bridge between Bayalpata Hospital and a network of 73 Community Health Workers (CHWs) who oversee more than 17,000 people. They are elected within their communities to take on this increased responsibility and oversee the training, data reporting, and payment of the CHWs in Nyaya Health's system.

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Mark Arnoldy is the Executive Director of Nyaya Health.

Posted by Payel Gupta

Drs. McKellar and Goodman teaching the Nyaya Health team in Achham (March 2012)

Ultrasound is an excellent and portable technique which allows healthcare professionals to identify abnormalities within the human body.  Ultrasound is used to visualize muscles, tendons, and many internal organs, as well as to capture their size, structure, and any pathological lesions in real time images.  It provides a great tool for use during various procedures.  Without imaging studies like CT scans and MRIs, the use of ultrasound is critical for the Doctors at Bayalpata Hospital.

The Health Assistants and Doctors at Bayalpata Hospital have learned many ultrasound techniques from various physicians who have volunteered in Achham.  They are currently using ultrasound on a daily basis for their obstetrics clinic and also in the emergency room.

 

The red screen shown inthis picture indicates abnormal functioning of the ultrasound machine.

For the next couple of weeks we are fortunate to have Dr. Angela McKellar and Dr. Mark Goodman here from the University of Utah to teach various ultrasound techniques.  Unfortunately, as we began our ultrasound lectures, we came to realize that the ultrasound machine we currently have at Nyaya Health is on its last legs.

We hope that it will at least last as long as Drs. McKellar and Goodman are here so that they can continue to teach ultrasound techniques and help to diagnose and treat patients with this incredible tool.   In the meantime, making sure that we have this useful machine in Achham is one of our highest priorities.

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Dr. Payel Gupta is an Internal Medicine/ Pediatrics trained Allergist who has a strong interest in global healthcare.  She is currently volunteering as the Director of Clinical Operations at Bayalpata Hospital

Posted by Mark Arnoldy

Health Assistant Prakash Madai refers a complicated head trauma case from a 23-member bus accident to a referral hospital located 12 hours away. To provide a higher-level of referral care in non-emergent situations, Nyaya Health has been selected as Watsi's first partner. Watsi has introduced the world's first peer to peer medical treatment funding model.

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Mark Arnoldy is the Executive Director of Nyaya Health.

Posted by Ryan Schwarz

In an unprecedented and historic moment, Dr. Jim Yong Kim was named President of the World Bank this week. As one of Nyaya’s long-standing inspirations and mentors, Dr. Kim is one of the founders of Partners In Health, the current president of Dartmouth College, and one of the world’s foremost experts in pro-poor healthcare development.

The World Bank – charged with the mission of reducing poverty and promoting development – was founded in the wake of World War II. Since, it has evolved significantly, and has often been the subject of great controversy, receiving frequent criticism of its approach and strategy. In this vein, the naming of Dr. Kim as its new chief is a moment of inspiration that opens enormous potential as he brings his innovative background and experience to its helm.
Throughout Dr. Kim’s career he has been a leader in health, human rights, and most recently, management sciences. In the 1980s and 90s, as one of the co-founders of Partners In Health, Dr. Kim worked to bring healthcare to marginalized communities globally, from the slums of Peru to the prisons of Siberia. In 2004, Dr. Kim was named director of the HIV/AIDS division at the World Health Organization, where he led the landmark “3 by 5” campaign to increase access to HIV/AIDS treatment around the world. More recently, Kim’s academic work has spearheaded the development of the global health delivery field – aiming to enhance the implementation and delivery of healthcare services in resource-poor settings globally – through which he co-founded The Global Health Delivery Project.

 Throughout his career Dr. Kim has been a tireless advocate for the poor and has pushed communities, politicians, governments and multi-lateral institutions to focus on poverty alleviation as one of the fundamental priorities of our time. He has again and again challenged the status quo, and pushed the field of global health and human rights forward to new horizons.

Dr. Kim has been a true leader and pioneer fighting for the poor and marginalized. His background and experience will bring a new and inspiring approach to the World Bank; indeed, Dr. Kim’s perspective is perhaps exactly what the Bank needs. It is with hope and inspiration that we offer our congratulations to Dr. Kim, and look forward to deepening our work in the context of a development field that has truly changed.

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