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Posted by Ryan Schwarz

When I first joined the Nyaya family in late 2008, our annual revenue was $76,631.  After all calculations were tallied earlier this year, our annual revenue for 2011 turned out to be $552,333 — quite the jump.  But what was even more obvious than our growth thus far, was still how large the gap in health services is that we aim to fill, and how much our budget will continue to grow.  Rough calculations at the beginning of 2012 suggest we have approximately a 1 million USD funding gap for the next 18 months.

In medicine, the term “development” describes how things form and grow.  To many in industry, “development” describes the growth of business, if not globalization.  In the non-profit world we talk about “development” as we talk about fundraising: building the financial resource base to implement the programs and services Nyaya has promised our patients.

Since mid-2011, when Nyaya brought on our first full-time Executive Director, our team has grown immensely.  While there is always a lag in growth of programs after a growth in organizational resources, we plan for 2012 to bring an equally large growth of services for our patients.  And with that growth comes the need for a similar, if not larger, growth in our development (fundraising).  Over the last few months I’ve had the privilege of working with several members of our team in Nyaya’s Boston office to rethink our approach to development, and to determine how we plan to raise $1 million USD in the next year and many more after that.

The process maps shown here outline our new, more rigorous and robust approach to development at Nyaya (Note: “development@” signifies an email listserv that we use to facilitate this process).  While Nyaya does now have a full-time Executive Director, we still lack other full-time staff including, for example, a Director of Development.  Thus, much of our work in these domains is conducted virtually via online communication.  Creating more formalized processes like these will help us to remain lean, continuing to collaborate across a broad and largely volunteer team.

We’ve had significant success over the last seven years raising money for Achham, but our approach has lacked a degree of rigor and process that we know will be necessary if we aim to not only maintain programs we’ve begun, but continue to grow them.  We hope these process maps are of interest to our colleagues doing similar work elsewhere and, as always, welcome any feedback on our approach.

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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.

Posted by Minoo Ramanathan

Every Saturday morning, community health worker leaders (CHWLs) meet with volunteers in their village development committee (VDC) to discuss different topics related to health. At this meeting in Bagheswor, the women discussed the treatment of burn injuries and turned in data about their weekly patient follow-ups.

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Minoo is a recent graduate of Brown University.  She is currently the Executive Assistant for Nyaya Health.

Posted by Ryan Schwarz

While the Achham district has become more developed since Nyaya began its work in 2008, there are still very few roads, a poor system of reliable and affordable transportation, and limited healthcare infrastructure.  Practically-speaking, for those living in Achham and surrounding districts, this means it can be exceedingly difficult to reach a health facility.  This challenge is especially apparent to those who are ill, when frequently the closest health facility is not able to provide the care they need.  The Bayalpata Ambulance service has met a critical need in this regard, bringing patients to Bayalpata Hospital, and when even higher levels of care are required, transporting them up to 15 hours further to hospitals that are better equipped.

Bayalpata Hospital (BH) began its ambulance services over two years ago and has had an immense impact on access to healthcare for our patients.  Recently I did a brief audit of our ambulance services for The Rubin Foundation, one of Nyaya’s longest and most consistent supporters, and a funder of our ambulance services.  Since beginning 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!

 In addition to The Rubin Foundation, many of you – our supporters – around the world have helped to make these services possible for our patients in Achham.  Thank you for all that you do; we look forward to working with you more this year to improve healthcare access globally.

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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.

Posted by Laura Harvey

Lara Harvey is a volunteer with Nyaya Health. She recently visited Bayalpata Hospital and took pictures of “A Day at Bayalpata Hospital.”  Attached are a series of pictures which capture day-to-day life at the hospital through the eyes of a volunteer.



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Dr. Lara Harvey is an Obstetrician and Gynecologist Resident at Beth Israel Deaconess in Boston MA and volunteers with Nyaya Health.

Nyaya from Afar

Posted by Dick Katzman MD

Several years ago I was asked by colleagues from the America Nepal Medical Foundation to see what I could learn about an organization called Nyaya Health, which had contacted us looking for financial support.  Nyaya was based at Yale Medical School, a young NGO created by students there, and since I was from Yale it seemed reasonable for me to get involved.  I remember wondering if Nyaya would actually manage to make something of their mission, turning their passion and youthful skills into real work on the ground.  I recalled my days as a student activist in the 1960s, working without cell phones and social networks to make health care a human right, not just a privilege.  So began a relationship which I felt was likely to last when Duncan’s twins began to know me as Katzman Uncle.

Several months ago I set off for Nepal with high hopes, ready to champion the start of a clinical teaching program at Bayalpata Hospital, a collaboration between Nyaya and the Patan Academy of Health Sciences.  It was a period of considerable difficulty for the team in Achham; timing with PAHS wasn’t right, and the project never got off the ground.  In the aftermath, I went to Gorkha district, toward Manaslu, and ended up with severe illness and loss of vision that forced me to leave Nepal well before I had planned.

Since then, with time to reflect on the work of Nyaya, its momentum forward and its challenges, and now several days since vision restoring surgery (making it apparent why people in the hill country think of ophthalmologic surgeons as miracle doctors), the impulse to share a few thoughts has become irresistible.  Perhaps it’s just the clearer light and brighter colors I see, perhaps the muddy roads and melting snow up in northern New England.  Here’s what’s on my mind:

  • The clinical consultations and exchange of information done over the internet has been an important part of  why I continue to support and care for Nyaya from afar.  It is extremely rewarding to sense that one can help in even small ways from a distance, and in the process continue the lifelong learning that makes medical work always challenging and interesting.  Reaching out to colleagues for advice with images and clinical cases to consider has likewise been fruitful in and of itself, and has been a great way to expand the network of interest and enthusiasm for Nyaya’s model of health care.  Nurturing this aspect of the work among staff in Achham as well as clinicians, leaders and volunteers elsewhere can and should continue.  Tools of modern telemedicine would serve us well, and support is readily available.  Consider, for example, what the Swinfen Charitable Trust has to offer, or Dr. Carrie Kovarik’s American Academy of Dermatology Resident International Grant program in Botswana, which I referenced in a note late last year, combining internet, mobile phone, and live telepathology systems for interpretation of biopsies and teaching.
  •  Staff turnover, though not surprising, and likely to remain a concern when the hospital becomes a surgical center, has always made me anxious—not only for the morale of the hard working people I have never met, but also for the stability of their efforts to bring equitable and high quality care to the people of Achham.  I envision a strong, well-trained and paid force of community based health workers as the best guarantee of that long-term stability.  This would create a buffer against the vagaries of politics, funding, and the remoteness of the district, and would provide care that is attuned to the culture and sensitivities of the community, in an ideal position to provide continuing primary care and education.   A straightforward example of what could be done by such a team throughout the villages of the district includes: diagnosing, treating, and following nutritional anemia using the battery operated, hand held, needle free anemia scanner now available from India. 
  • The latest figures from WHO underscore one of the dark sides of much of our work: the growing problem of multi-drug-resistant infectious disease, in this case tuberculosis.  In countries like Nepal, nearly 2/3 of treated patients end up with resistant strains, as a result of inadequate or incomplete first time treatment.  Just under 10% of resistant cases are now extensively drug-resistant.  India and Iran have reported patients with totally drug-resistant TB.  Malaria and HIV are growing concerns.  And those are just the big three.  Other bugs announcing their disdain for our antibiotics include Staph aureus, Pseudomonas, Pneumococcus, Klebsiella, E. coli, Enterococcus, Enterobacter, Gonococcus, Acinetobacter, and Influenza.  I started medical school in 1967, when the US surgeon general is reported to have said that “it is time to close the book on infectious disease.”

45 years later, the book is still being written by the invisible microbes that rule our world, and by whose grace we somehow carry on.  I urge everyone on the ground in Achham to think very carefully when prescribing antibiotics, and to prepare for the inevitable difficulties to come.  A real surveillance system in the community and at the hospital needs building, the first step being the creation of the basic microbiology lab.  Providers need to decrease inappropriate use of antibiotics, restrict their use, rotate and combine medications when appropriate, and treat only as long as necessary with the shortest effective course.  Everyone can help reduce the transmission of resistant bacteria at the hospital by following hand hygiene and contact isolation protocols.  Whether problems using antibiotics in Achham turn out to be a local event or a reflection of the global spread in resistance genes, this is no time for complacency.

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Dick Katzman is a family doctor in Vermont and a clinical assistant professor at the University of Vermont College of Medicine. He is a volunteer for Nyaya Health and acts as a liaison with the American Nepal Medical Foundation.

 

Posted by Minoo Ramanathan

Clinical and data staff worked very hard, late into the night, to successfully assemble Bayalpata Hospital's first infant warmer. This piece of equipment will enable Bayalpata Hospital to provide care for premature or unstable newborns, which is hoped to reduce infant morbidity and mortality in the region of Achham.

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Minoo is a recent graduate of Brown University. She is currently the Executive Assistant for Nyaya Health.

Posted by Ruma Rajbhandari

The Morbidity and Mortality (M&M) Conference Program at Bayalpata Hospital is unique for two reasons: 1) it takes place in a small hospital in an extremely resource-poor area of the world, and 2) it involves all levels of hospital staff, from clinical to administrative and managerial.  Further details of the program can be found here.

The following M&M describes the case of a young pregnant woman who was found to be Hepatitis B positive.  The discussion of the case delves into the hospital’s struggle to provide better Antenatal Care and to prevent Hepatitis B infection in the neonate.

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

[NOTE: This report is a part of our “Morbidity and Mortality Conference Program” initiative, which is aimed at cataloguing and reflecting on the underlying causal pathways in cases of excess morbidity or mortality. This work is supported in part by grants from the Lovejoy Foundation at Children’s Hospital Boston, Massachusetts, USA, and from the Partners Healthcare Center of Excellence on Quality and Patient Safety.]
 
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Ruma Rajbhandari is a physician at Boston’s Brigham and Women’s Hospital.  She volunteers with the Nick Simons Institute and Nyaya Health.

Posted by Richa Pokhrel 

The jeep on the trip back to Achham from Dhangadi encountered a malfunction. However, Ramesh, the driver, fixed the problem. The trip from Dhangadi to Bayalpata Hospital lasts 10 hours. Although the views are breathtaking, the car has to travel on meandering mountainous roads. Most of Nyaya's medicine comes from Dhangadi. During the monsoons, there are very frequent land slides and road blocks, which delay the delivery of medicine and important supplies to hospital.

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Richa was born in Nepal but grew up in Iowa.  She is currently the Director of Evaluation and Research at Nyaya Health.  Richa has a Master’s in International Development from the University of Pittsburgh.

Posted by Dan Schwarz

In line with Nyaya’s vision of being a leader in data-driven and transparent operations, we have recently been working to develop a more formal research and evaluation strategy for our work in Achham.  To that end, we have formalized several new volunteer and full-time positions, and have recently posted a new vacancy to hire a new Achham-side Director of Research and Evaluation .  Moreover, we have finalized an organizational research strategy, including formal research project design, approval, and implementation protocols, to ensure both high-quality research and high-quality service delivery to our patients.

We are intimately aware of the risks of research and service delivery overlapping and competing for resources, which is detrimental to the quality of both domains.  Our new research strategy addresses these and other concerns, and will push our staff on both sides of the world to adequately fund and staff both service-delivery and research operations, as independent, but critical, entities of our larger work.

Today, we present our new 2012 Nyaya Health International Research Strategy here . We look forward to working with all of our supporters and colleagues around the world to continue to push the envelope for high-quality health services and operations research for populations who have traditionally been marginalized from both.

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Dan Schwarz is the member of the Board of Directors and a medical student at Brown University School of Medicine. He completed his MPH at the Harvard School of Public Health

Posted by Sheela Maru

The sun penetrated deep into our chilled bodies as we talked on the lawn outside the delivery room of Bayalpata Hospital.  We found our first study participant there, with her 6 hour old infant, basking in the hot, therapeutic rays.  She answered our foreign questions meekly with a slightly confused look.  We were probing her decision to deliver in the hospital.  She had delivered her first 5 children at home, about an hour and a half from here.  All were uncomplicated vaginal deliveries.  In a village near her home, one year ago, a mother died in labor.  This changed her perspective on the safety of delivering at home.  With the encouragement of her family, she decided to make the journey to Bayalpata Hospital to have her baby.

I had left my roti and tharkari breakfast to attend both her and my first delivery at Bayalpata.  A few agonizing pushes released the chubby infant from the narrow birth canal.  We asked her about the quality of the care she received, was there anything that we could have done better?  I ran through the things in my head that I thought could have been better—the cold, dark delivery room where no visitors were allowed, the metal pegs with fragmented foam that served as stirrups, the battering tone of voice that was customary for nurses to use to keep her on her back with knees in open-book position.  With a half smile, she answered no, she said she felt relieved.

It was ironic then, that in her safe haven, I experienced raw fear.  As her placenta was delivering, a second laboring patient presented.  A 32 year old woman, carrying her fifth pregnancy, had been in labor since the night prior, when her water had broken.  She contracted all night, and by morning there was still no baby.  She decided to come to the hospital.  For the hour and a half prior to arriving at Bayalpata she had been pushing.  All of her other deliveries were at home, and her sister-in-law, who had accompanied her there, described them as simple.  This time was different, something was wrong.  Bayalpata Hospital had also sprung up in the time since her prior delivery, and she had somewhere reachable to come to. She arrived at 9 a.m., and in my mind the stop-watch was ticking.  Her allotted 1 hour for her second stage of labor was already up.  What could we do for a prolonged second stage?  We could try an assisted delivery with a vacuum, but what if that failed?  Getting her a cesarean section meant referring her to a hospital 5 hours away by ambulance.  If she delivered on the way, there would be no skilled personnel to take care of her or the baby.

Her cervix was fully dilated and the baby’s head was at +1 station when she arrived.  The fetal heart rate was reassuring.  We moved her into the freshly cleaned delivery room.  She climbed onto the waist-high rubber-clad table and was ordered to lie on her back.  The contours of her grimace deepened as her contraction intensified.  I slid two fingers in her vaginal canal to evaluate her push.  I felt the baby’s moldable skull pressed against the bones of her pelvic outlet.  A soft skull cap of swelling on the baby’s head bulged.  A few grunts were all that she could manage.  As the minutes passed, my pulse quickened with fear.  In obstetrics, the contingency plan is a core principle.  The partograph tracks the progression of labor hour to hour and alerts the provider to any deviation.  A series of actions can be taken, and there are a variety of tools, but the penultimate solution is abruptly ending labor and delivering via the knife. In most cases, cesarean section secures the baby and the mother from any further harm the pregnancy and labor is committing.  In the US, doctors rely so heavily on this safety net, that it has now become dangerous.  With a cesarean section rate of more than 30%, rare complications are not rare enough. However in Nepal and in other nations with limited access to cesarean section, this factor is largely responsible for high rates of stillbirth and infant mortality.  My presence at this delivery was happenstance; I was here on my elective to do research, not direct clinical care.  I thought about these nurses, with a two month training in skilled birth attendance working daily with no contingency plan.  I wondered how many infant and maternal deaths they had seen.  They seemed appreciative of my presence, though I had no further tools to assist them with, only my standards from another world—a world with an OR steps away from the delivery room, with anesthesiologists, ObGyn attendings, banked blood, continuous fetal heart monitoring, and where death during childbirth was truly rare.

Partly to hydrate her and partly to demonstrate our efforts to help, we “opened her vein” to start IV fluids.  We gave her some oxytocin in the IV bag to make her uterus contact more strongly, even though we had no evidence that she needed it.  We pushed back her heels to extremely abduct her hips and open her pelvis.  We encouraged her and reprimanded her.  She finally delivered an hour and a half after presentation.  The fetal heart rate was reassuring at random checks, though it was difficult to tell if danger signs, like late decelerations were present.  We did not use the vacuum because once the head of the baby was low enough to use it, it became apparent that she was delivering this baby on her own.  As she delivered, one loop of cord was loosened from the baby’s head by the midwife.  She gave forceful downward traction to deliver the anterior shoulder and then the little boy squeezed out.  The cord was wrapped tightly around the baby’s neck three times.  We unraveled his limp and silent body as we gave commands in urgent tones to call the doctors for neonatal resuscitation.  With aggressive stimulation and removal of mucous and meconium from his mouth and nose, he finally let out a feeble cry.  Once the local doctors arrived, I kept myself occupied with the placenta still lodged inside the uterus.  There was no infant warmer and we could see our breaths in the delivery room.  They called for a hot water bag, an electric space heater and swaths of thick cotton to wrap the infant.  In the meantime, the warmest spot for the baby was on the skin of the body that had just run a marathon.  She muttered that she wanted him off for a moment, I think only I heard.  One of the midwives gave intramuscular oxytocin and I held downward traction on the cord.  A gush of blood and the large jellyfish of a placenta slipped out.  The baby let out a few more cries and was wrapped and moved to a side table where the doctors watched him breath.  They decided to administer antibiotics and monitor the baby closely for a couple days.  I felt good to know that she would rest and not start her journey home in the usual six hours after delivery.

In a few hours, mother and baby were sitting out in the sun, and he was suckling without difficulty. What had happened, why did it take her so long to deliver?  Was her uterus infected and not contracting effectively?  Was there a component of cephalo-pelvic disproportion that resolved with McRoberts leg positioning?  I knew that this prolonged second stage gave her an increased risk of urinary incontinence and her uterus falling out down the road.  She probably will not have access to corrective surgery.  This may mean a lifetime of discomfort and social shame.  What if we had referred her on arrival to the hospital?  She would have likely delivered in the ambulance.  The baby would likely have not survived. We sat down to interview her, our second study participant.  She said she was completely satisfied with the care she received.  I was not satisfied.  I was disturbed.  My fire to work on global disparities in healthcare was re-ignited.  But I appreciated the futility of assessing “satisfaction.”  It all depended on the immediate outcome—they were both alive.

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Sheela Maru is a resident in Obstetrics and Gynecology at the Boston Medical Center.  She is currently a volunteer for Nyaya Health.

Posted by Richa Pokhrel 

President of Nepal, Dr. Ram Baran Yadav, made an appearance at the spring festival in Baijnath Temple. Baijnath Temple is very close to Bayalpata Hospital. A few Bayalpata staff members attended the ceremony to provide minor medical services for the spectators.

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Richa was born in Nepal but grew up in Iowa.  She is currently the Director of Evaluation and Research at Nyaya Health.  Richa has a Master’s in International Development from the University of Pittsburgh.

Posted by Gregory Karelas

Friday was indeed a triumph. Of course the program started forty five minutes late. But as I told the Local District Officer while we waited alone for the first invitee to join us, “It’s ok, Sir. In Achham, everyone is right on time.” In other words, forty five minutes late was no stress to local chronometers, their bearers or to me.

The meeting’s purpose was to rally formal support for Nyaya Health’s new funding request to the Ministry of Health and Population.  Its primary tool was a presentation that explained our services and expansion plans, highlighting Nyaya Health’s unique contributions to healthcare in Achham and specific features like the free care it provides to 26,000 patients every year.  The team included Bayalpata Hospital’s Medical Director, Community Health Director, Accounts Officer, Data and Technology Officer and me. The invitation list included twenty five of the leading government, political party, media and community leaders in the region, as well as the Regional Health Officer and a representative from the National Planning Council in Kathmandu via speaker phone.  The plan was to begin with introductions. I would give the presentation. Our team would host a Q & A together. And then the big moment : we would ask each attendee to sign a letter of recommendation advocating for a tripling of Nyaya’s government funding from thirty lakhs (approximately $37,500) to one karod ($125,000).  The letter would accompany our request to the Ministry.  And we would personify persistent advocacy until the Ministry reached a decision.

The program took a solid but reliably turbulent beginning. Almost all invitees had arrived. The presentation went well and met loud applause upon conclusion. The first question came from a local journalist, asking about allegations of corrupt purchases at Bayalpata Hospital before my time in Achham. As explained in a previous publication on this site (please see The Road to Healing), our hospital had been accused of illegal supply purchases roughly 9 months prior, resulting in a staff strike and the ultimate dismissal of almost all of Bayalpata Hospital’s senior leadership personnel. The reporter wanted to know why the government’s formal Investigation Report on the matter had not yet been released and what it said. The scandal at our hospital had left virile rumors in the community and questions like these on the tip of every reporter’s tongue. I thanked him. And then answered with every ounce of information I could, as recent dealings with the press had taught me that holding back any detail would generally herald more headache.  All parties seemed satisfied. We moved on.

From there, the questions turned to the subjects of strategy, funding logistics, and similar groundball queries amidst welcome platitudes and thanks for providing necessary care to Nepal’s poorest of the poor. Our team welcomed audience questions, vacillating between Nepali and English replies, and seized every moment to praise Nyaya Health’s audacious model of free care amidst the resource deprivation of Far Western Nepal. Our answers matured to monologues; and Nyaya’s vision found the limelight. Our momentum could only build. Until, Mr. Arjun (name changed to respect privacy), a prominent member of the Bageshwor Water Committee, raised his hand to speak.

Almost two years ago, Nyaya Health made an agreement with the Bageshwor Water Committee to provide certain priority services to residents of the Bageshwor community in return for use of a water pipeline that ran through Bagheswor property lines to Bayalpata Hospital. Among them was the agreement to provide special consideration to Bageshwor citizens applying for Hospital job vacancies within a specific stratum of staff qualification. At 11pm on Christmas day this past year, a Bageshwor resident visited my office to wish me a happy holiday and inform me that his community would cut the Hospital’s water supply in eight days for alleged non-adherence to our hiring agreement during a recent round of staff recruitment. In defense of our hiring practices, I met with Mr. Arjun and other Bageshwor leaders in the days to follow, receiving speedy reassurance at a dinner chez- Monsieur Arjun that our talks had clarified all misunderstandings and created a reinvigorated partnership between all parties.

Thus, when Mr. Arjun began his thirty minute diatribe regarding the same issue, I was surprised. But knowing how things often happen in Achham, I wasn’t surprised at all. With the attention of a newfound audience, he began to condemn the hiring practices of our Hospital and then criticize its lack of willingness to provide Bageshwor residents services such as free helicopter travel and all-expenses paid treatment in Kathmandu. His rhetoric quickly turned to ranting, and his vehemence seemed to take a tone of reproach. Our team looked annoyed. Many guests looked confused. Mr. Arjun continued.

From the podium where I stood, I took the liberty of recounting my Christmas-time meetings with Mr. Arjun and the Water Committee, specifically noting the evening when we buried the hatchet over a handshake and rice dinner. My response was simple, yet thankfully effective enough to quell Mr. Arjun’s concerns and satisfy our audience. He quieted quickly. The crowd seemed satisfied. I continued. Yet my broken trust and questions surrounding Mr. Arjun’s impetus hovered. Our Q&A session progressed. And our conclusion ultimately found crescendo in my promise that Nyaya Health would continue to create a model hospital, redefining healthcare delivery and its systems for all of South Asia. All participants signed our letter of recommendation, and smiles became the room.

There is little more to tell from that point forward, except that Mr. Arjun became remarkably car sick during the 90 minute jeep ride that he asked of us on the return from our presentation to the Hospital. I do not believe in karma, especially when it comes to the suffering of others. But I did find the coincidence of Mr. Arjun’s perceived sabotage and his patent illness thought provoking.

My experiences in Achham have taught me that there are no rules here. As in many parts of the world, and surely in those most destitute, there is no need for them. Days are hard. Life is a struggle. And nothing is guaranteed—especially not support for anything outside of immediate individual gain. Yet we persist. I often find it difficult to understand the connection between the poles of selflessness and villainy that the people we serve use to define us. But we persevere. We were not invited by this community to serve it. Yet we have treated over 80,000 of its members in four years. The answer is grit. We’re not perfect. And our product is far from it. But with compassion as fuel and temperance as a mantram, we greet the challenges we never expect to see, especially when they come from the sources we expect the least.

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

Posted by Richa Pokhrel 

An amazing thing has happened here at the hospital, something I didn’t think would happen in my first month here.  When I first arrived at the hospital, I noticed that Buddha dai, our groundskeeper, never ate with the rest of the staff.  I was very confused by this because he lived and worked at the hospital like the rest of us.  He was the only staff member who worked every day and didn’t eat lunch with us.  He was also one of our most loyal staff members, and has been with Nyaya Health for many years.  My thought was that perhaps he did not eat with the rest of the staff because he is from the lowest caste.  Of course, this is merely speculation and I have never asked Buddha dai what his caste is, but my inclination says that this may be the main reason.  He is not the only staff member who we have here that belongs to the Dalit caste.  The organization is very adamant about hiring staff from all different castes and backgrounds.  The caste system is a staple of the Hindu religion.  In history, the caste system was defined by what roles or jobs people held in society.  Members of the highest, or Brahmin caste, are the only ones who are able to be religious leaders.  However, the lowest caste, known as the Dalits have historically held jobs that other people do not want to do, and unfortunately the Dalits have always been discriminated against.  While this discrimination is not as severe as it used to be, it still exists today.  This piece is not to pin one group against another, I don’t want it to come off as US verse THEM.  Let it just be said that cultural traditions and practices are ones that don’t change overnight, and it takes everyone’s collaboration to make progress happen.

My original idea for this post was to write about discrimination amongst the staff.  However, after recent changes in the eating policy, this post will address discrimination a bit, but will also focus on Buddha dai and his two children, Laxmi and Tula.  Both of his children live with him.  I just want to make clear that Buddha dai and his family are not being oppressed by this organization.  The organization has provided them with a free room and gives Buddha dai a nice salary.  His daughter also has been provided a part-time job.

In getting to know Buddha dai, there was something else that I didn’t like or understand about his situation.  Buddha dai and his two children live in a little room next to the kitchen.  The painful part is that their room has no door.  In the winter months, like right now, I can’t imagine how cold it must be.  One night I was talking to Buddha dai and he mentioned that it is very hard for him to sleep because of the cold.  I went into his room once and saw that 3 people only had 2 blankets between them.  There was a push for them to get more blankets.  The next morning, after using their new blankets, Laxmi and Buddha dai told me they were so warm that they overslept.  We will ask the carpenter to build doors for their room, not only for more privacy but also to protect them from very cold nights.  Things are changing here at Bayalpata Hospital and we are making progress.  However, this does not mean that things are always peachy and that staff are treated with the respect they deserve.  There is still room for improvement not just for this family, but also for other staff members.

Buddha dai is from Bajura district; his village is about a ten to twelve hour walk from Sanfe Bagar.  He came to Sanfe in the early days of our clinic.  He used to sleep under the steps of the clinic, until the organization gave him maintenance responsibilities.  He came on his own but later his small children accompanied him.  Unfortunately, his wife drowned when his children were very young.  He never remarried.  His young daughter had to take charge of caring for her brother and father.  She did what a wife would do: cleaned and cooked.  She made sure everyone was all right.  Currently, his eleven year old son, Tula, is going to school.  He is in first grade and his favorite subjects are English and Nepali.  The former Community Health Director and the former Country Director enrolled him in a private English school and paid for his entrance fees and other fees. He is a very sweet boy who likes to play soccer and speak English.  His sister Laxmi, on the other hand, is a bit more shy. She is a great cook and has beautiful black hair.  She helps in the kitchen as a part-time staff member. Once you get to know her, she is more open to talking about herself.  Unfortunately, she has not been able to go to school.  I am not sure if it for financial reasons or family reasons, perhaps it is a mixture of both.  However, some of the staff members are passionate about her learning.  There was an idea of putting her into school but it would very uncomfortable for a late teen to start in grade one.  There was another idea of hiring a tutor that could come to the hospital and teach her for a few hours a day.  Right now, we have not found anyone to be her tutor but there is hope that in the near future she will be able to read and write.

Since coming here, I have been very attached to this family.  I can say that Buddha dai is many people’s favorite person at Bayalpata.  He is very sweet and is always looking out for other people.  He will heat water for you so you can take a warm bucket bath.  He will also try to get you to eat more.  He likes to build fires and watch them from a distance.  He likes to drink tea in the morning and is always willing to share his glass of milk with me.  He says milk will make me very strong.  He likes to tell ghost stories around the fire and lets us know that light scares away any ghosts or creatures walking through the grounds at night.  Seeing him smile always touches many people.  His dedication to this hospital is incredible, and he is probably the hardest worker I and many other people know.  He never complains, and is very good at what he does.

Buddha dai overlooking a fire he started.

Hopefully all the changes I talked about earlier will have taken place by the time this post reaches the website.  I will be updating everyone on the progress.  If the changes mentioned don’t happen, you know that I won’t be a silent bystander. I will try to do what I think is right. Luckily for me, there are other staff members here who feel the same and are very supportive of giving this family a better life, whether it is an extra blanket or food during lunch. Seeing the smiles of these three makes my day better and for a moment of time erases any worries I may have.

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Richa Pokhrel was born in Nepal but grew up in Iowa.  She is currently the Director of Evaluation and Research at Nyaya Health.  Richa has a Master’s in International Development from the University of Pittsburgh.

Posted by Richa Pokhrel 

Taraman Kunwar, one of our Health Assistants, and his wife Sabita, with their child. This event marked their baby's Pasni, or rice feeding ceremony. The Pasni is celebrated between the ages of five to eight months, and marks the child's first meal of solid food.

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Richa was born in Nepal but grew up in Iowa.  She is currently the Director of Evaluation and Research at Nyaya Health.  Richa has a Master’s in International Development from the University of Pittsburgh.

Posted by Duncan Maru

An 18-year-old man presented recently with swelling and pain over his right forearm after a fall.  I was asked by one of our Health Assistants, Ram, to look at his x-ray.  About a week prior, he had been carrying a stone on his head for some

A swollen arm with liquid filled vesicles.

construction when he tripped and fell.   Curiously, in addition to a swollen, tender proximal forearm, he had a band-like area of discoloration over his forearm as well as liquid-filled vesicles.  His hand was also swollen.  He stated that these had arisen earlier that day and had prompted his presentation.  The day prior to his visit he had received a plant-based mixture over his arm as well as a rope tied tightly over his forearm by a traditional healer.  The x-ray was of overall good quality, although the lateral view did miss the posterior fat pad which is useful for assessing fractures of the elbow.   There did not seem to be any fracture, and his elbow was not particularly tender.  Our clinical team decided it was most likely some element of muscle injury, hematoma, and venous compression from the tightly bound rope.  The vesicles were from a contact dermatitis from a reaction to the healer’s medicine.  We suggested symptomatic treatment with diclofenac (an NSAID), gentle exercises, and elevation of the arm.  We asked him to come back in a few days if he did not improve.  I wondered whether, if we had missed something and he did not improve, he would return to us, or whether he would trust other providers—including the previous traditional healer.  Patients, here as elsewhere, truly do

X-ray of the patient's forearm.

vote with their feet.  How did he perceive the care that he received?  Did we treat him with compassion?  Did we provide him with good counsel?  Did we present him with a clean hospital?  I regretted not getting a second, higher-quality film of his elbow.   The more than one hundred patients presenting to the hospital daily and the women traveling long distances to deliver here give us a feeling of pride, though this gentleman demonstrates how much work we have before us to earn and build a deeper trust to ensure both timely presentation and reliable referral back to us.

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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.