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Posted by Duncan Maru

A middle-aged woman presented with abdominal pain, bloating, and vaginal bleeding.  A few years ago, she had had some gynecologic surgery in India where her son was working.  They had no records of the procedure, nor did they know of what

Mass detected on transabdominal ultrasound

precisely the surgery had entailed.  She had suffered no fever or weight loss.  Our Health Assistant, Uday Kshatriya, performed an internal exam and assessed her uterus/cervix, which had a hard mass.  Upon exam, her abdomen was quite tender with some fullness of the lower quadrants.  She had no lymphadenopathy, she was not pregnant, and she was HIV negative.  He called me to view a transabdominal ultrasound of her cervix and uterus (shown aside). He saw the large fluid-filled mass shown in the image, within her uterus, near her cervix.  Neither Udayji nor I were particularly qualified to assess gynecologic masses, but we both felt that her case was most consistent with some form of endometrial, cervical, or ovarian cancer.  The nearest gynecologic surgeon is fifteen hours away in Nepalgunj; it would be best for her to go back to the original hospital she had visited in India, but she did not have the funds for that.  Even in Nepalgunj, care for women with cancer of the reproductive system is quite minimal and modest.  I doubt, at this juncture, that a cure is possible, but she will make the long trip south with the hope that something can be done.   As she and her husband left, I looked down at our cold, dark concrete floors, feeling the shame of yet another patient for whom our services are so inadequate: no screening for cervical cancer, no gynecologist, no operating room, no chemotherapy.  When people tell us that such necessities are too bold and advanced for the Far West, let her story be a call to action, and let us together fight for a better hospital.

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Duncan Maru, MD, PhD is the 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 Dan Schwarz

Nyaya’s team is composed of an impressive array of over 100 staff members in Achham, and countless volunteers around the world.  Our Country Director, Gregory Karelas, acts as the fulcrum for all of our operations in Achham, coordinating the work of both our Achhami staff and international volunteers.  Despite this, his day-to-day life remains an enigma to many, so we thought we would spend a day documenting just some (though not even close to all) of the activities that occupy his time.

Please see below a slideshow that documents a usual day in Gregory’s life from dawn until (well past) dusk.  Our hats go off to him for his continued dedication, and the passion that drives his work for the people of Achham.



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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 Richa Pokhrel 

Bouda dai, our very loyal groundskeeper, enjoying a fire near the staff quarters. A few times a week, Bouda dai creates fires to burn trash around the hospital. He very much enjoys making fires and watching them.

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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 Ryan Schwarz

Nyaya Health was started by a group of Yale students 6 years ago.  It began when one of our founders, Jason Andrews, traveled to the Achham region and learned about the dearth of healthcare in the region, and the injustices faced daily by Achhami citizens.  Over the last six years our work has grown immensely, and our team continues to have many Yale affiliates in its ranks.  We have benefitted greatly from multiple mentors in the Yale community who have guided our work and made it possible.  This week’s issue of Yale Medicine has a feature article on Nyaya—you can read more here about Nyaya’s beginning at Yale, and its work since as “an NGO of the 21st century.”

Click image to view article

 

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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 Duncan Maru

We in the development, global health delivery, and social justice businesses seek to change current conditions that produce poverty, injustice, and ill-health.  On the one hand, our vision is often ambitious and over-sized for our levels of experience both as practitioners and visitors in communities that can remain unfamiliar even after many years.  On the other hand, our implementation is more modest; for those of us who work to deliver healthcare services, we literally make our impact one patient at a time.  That impact is tangible for our patients—if anyone argues that medical care is a “band-aid,” remind them that is probably not what they themselves experience when they or their family members fall ill—but its significance is more modest in the larger socioeconomic sense.  So we work onwards, trying to facilitate dignity within the suffering around us, yet holding onto a larger vision.  When does that vision become a dream forever deferred, and we become technocrats, having forgotten the underlying social and economic factors creating the problems we aim to solve technocratically?  Alternatively when does that vision even matter?

For someone such as myself, primarily concerned with the technicalities of healthcare delivery, these concerns can occasionally feel like idle ruminations.  But if every act is in essence political, particularly when you are working in resource-denied settings, then these questions do matter.  The problems we face in getting the right drugs and diagnostics to our patients are fundamentally social, economic, and global.  So, a global health delivery organization’s “theory of change” should address these problems to some extent.  Ted Constan, COO of Partners in Health (PIH), reminded us of this in an insightful talk he delivered to our Global Health Equity Fellows orientation recently.  He outlined PIH’s theory of change, and I found it instructive.

Their theory of change is focused on three actors—PIH, Brigham and Women’s Hospital, and Harvard Medical School, who work together to achieve four goals: Service, Training, Advocacy, and Research (STAR).  The service is the mandate of PIH, and it is the grassroots core that makes the other elements possible.  Training and research are both activities that Brigham, being an academic teaching hospital, and Harvard, being a biomedical education and research institute, are well-equipped to engage in.  For advocacy, PIH is a grassroots organization with connections to local community organizations and organizers, to national politicians, businesses, and government officials.  They have extensive ties within the international activist community with groups like Healthgap, ACT UP!, and Physicians for Human Rights.  These activists can leverage PIH’s research and examples to build compelling policy and political arguments.  We have seen this work with some impressive successes with HIV and TB.

Back to Nepal.  Let’s face the fact of life of our patients: the Far West lacks surgical services.  There is no infrastructure to house clinical services, or more precisely, clinical providers.  That is the problem.  My instinct, as is most of the Nyaya team’s is to ask the question: how do we fix that?  Build an operating room.  We can do that in alignment with a certain vision—free services provided in a government building and paid, at least partially, by the government.  We can pursue this technocratically, through supplies chains management and quality improvement initiatives and staff trainings.  But of course that is not all that is going on in the Far West with respect to why citizens are not getting the care they need.  Supplies don’t come on time partly because of trucking syndicates that the government can’t seem to break.  Doctors don’t stay long because there are no schools or opportunities for their families.  Public infrastructure is lacking because of small national budgets of which even smaller amounts get apportioned to the politically-marginalized Far West.  What can be done?

As it stands, we at Nyaya have not proved ourselves to achieve results in this realm of advocacy.  We are too consumed with trying to get care for our patients, for good reason.  Our patients in the immediate term cannot wait for large-scale political and economic transformation.  While the lack of surgical services (or any public goods or services, for that matter) is fundamentally a political and economic problem, we approach it technically.  In economically and politically powerful places, the technical problem of access has largely been solved; if Achham had power, they would have plenty of surgeons.  Of course, in the (only slightly) longer-term, the people of Achham are literally dying awaiting such broader change.  We do act with purpose: free services, building a government-owned structure, and working within the government’s existing community health worker network, but if the roots of the problem are political and economic marginalization, then we are ultimately missing the boat.

Nyaya has historically had a vision of direct service and local action that, through transparency and dissemination, could facilitate global change.  Achieving that vision has been a challenge, though we have had successes.  Currently, we are in the midst of refining that vision.  Here is one draft attempt:

That is, the work that we do on the ground in Achham has a vision about delivering healthcare in resource-denied environments: working to achieve community-level ownership over the health system, collaborating with the government, collecting ongoing data to evaluate our impact, actively revising our systems through quality improvement.  Subsequently, this work feeds into our broader work as a participant and leader in the global health equity movement, through collaborating directly with similar groups, through pushing the field to be more transparent, through global advocacy, and through scientific research.  The impact of these parallel activities on each other runs in both directions: our local healthcare delivery directly impacts our contributions to global health equity, and victories in global health equity facilitate generating resources and ideas for our on-the-ground work.  There is much work to be done…

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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 Tess Panizales

Huijan Kamal, Health Aide talks to an elderly patient outside the outpatient department (OPD). Huijan's role in the OPD is to maintain order and organization as the volume of patients presenting to the department and waiting to be evaluated builds up outside the waiting area shed. The OPD sees approximately 150 patients per day. The Nepali woman wanted to know when she will be seen next considering that she missed her prior months routine appointment.

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Tess Panizales is the Quality Program Manager of the Department of Surgery at the Brigham and Women’s Hospital Center for Surgery and Public Health.

 

Posted by Agya Poudyal

Doctors in Achham are God.  Ask the woman with a sick ten month old baby waiting outside the outpatient department (OPD) at Bayalpata Hospital and she will convince you that they are.  As one of our doctors and his clinical staff walk the long path to the OPD, a horde of patients runs to them, trying to sneak in an early checkup.  The woman with the baby hovers around the doctor, hysterical.  “Dactar (Doctor) Saap please save my child, I have been waiting since ten in the morning,” she hollers, with all the air in her lungs.  On a Sunday, the desperation of many other patients is similar if not the same.

The woman’s child looks pale and sick.  For her and those around her, Bayalpata Hospital (BH) is the only place in Achham that has given them hope to live, to save lives, and to prevent diseases.  “My in-law wanted to take my son to the witch doctor, but I know that the best way to treat him is to bring him here.  For us, the doctors here are incarnations of God,” she says, holding the young child in her arms.  She had fought with her in-law to bring the child to BH.  BH is a haven, where sick patients walk for days from places as far flung as Bajura, Khaptad, Ramaroshan, and Doti in order to see a doctor.  On a Sunday, BH sees more patients than the Government hospital in Achham’s headquarters of Mangalsen.  Sometimes, the number exceeds three hundred patients a day.

In Achham, BH has become a recognized health service provider.  Even the rival medical practitioners in Sanfe and Bayalpata bajar have started to refer their patients to BH.  Still, most visitors to BH find a lot of room for improvement.  Most are quick to notice the flaws that, in other facilities, could be taken care of in a matter of hours.  It is indeed hard to comprehend why things as simple as cleaning the hospital premises or keeping the patients in a queue can be hard.  You know you’re in BH when reaching a person over the phone can be a process that might take you hours, if not days.  But working in Achham is not easy.  It is more than a test of time.  If you work here, you understand why complaining cannot make things work, why the internet keeps failing, and why the people never seem to understand what they ought to do.

In spite of all these flaws, there is a charm to BH that both the patients and the staff acknowledge.  There is something that makes working in Bayalpata more appealing every day, that keeps them here, that makes it more fun, and that makes you feel at home in the middle of nowhere.

Survival is the basic human instinct.  In Achham, it is all that really matters.  Regardless of whether you are providing healthcare or receiving it, being able to live is a blessing.  Achham is not for the faint-hearted.  BH is all about standing still amidst the wind, rain, chill, and heat, both metaphorically and literally.  But despite all of the problems faced, BH never fails to shower warmth, love, and affection.  The grim social realities pertaining to politics, development, poverty, and war are simply not excuses for people to be rude and unfriendly.

BH is full of contradictions.  So close to death yet so full of life.  You fight your battles, but remain cozy in BH’s cradle.  It suffocates you in despair to see the aspirations and dreams that lie above the clouds.  It shatters your expectations, only to show you the possibilities that lie within the impossibilities.  You sprain your ankles but not enough to stop you from climbing the mountains of life.  You feel abandoned, but it is secretly cradling you in the cushions of love.  Before you start questioning whether you love it or hate it, you realize that you have become stronger because BH is the way it is.   You are who you are only because it taught you the hard way.  It is strikingly amazing how the place where you came to contribute has given you so much more than you could have given it.  You are thankful for what it has taught you and, as you look towards the beautiful green valleys from the staff quarters, you are amazed at the endless possibilities it has in store both for Achham’s development and for your own.  It is beautifully strange how this place has transformed me in five months, and has became a part of me in less than that time.

BH has become synonymous to hope, for patients and for staff.  It isn’t for nothing that patients walk hours and even days to reach BH.  Being able to survive is one thing; giving the hope of survival is quite another. Doctors aren’t god but giving hope for life is definitely akin to godliness.

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Agya Poudyal is the Community Health Director at Bayalpata Hospital. She graduated with an MA in International Relations.

Posted by Dan Schwarz

This past week, Nyaya Health Nepal received a further allocation of 30lakh rupees (approximately $35,700 USD) from the Ministry of Health of Nepal.  As part of Nyaya Health Nepal’s public private partnership with the Nepali Ministry of Health to administer services at Bayalpata Hospital, the Ministry has made the strong commitment each year to augment Nyaya’s finances with its own fiscal support.

This week, Country Director Gregory Karelas, Medical Director Dr. Preeti Bhandari, Chief Operating Officer Dan Schwarz, and Bayalpata Hospital Accountant Chanakya Upadhya, traveled to Mangalsen—the district capital of Achham—to meet with local health and government officials to finalize the budget for the Ministry’s 30lakh R for the coming fiscal year.  The meeting went very well, and Bayalpata Hospital was commended for its excellent service to the people of Achham.  The committee approved the proposed budget and will subsequently release the 30lakh R to our hospital’s accounts.

During the meeting, the Achham Local District Officer (LDO) and District Health Officer (DHO) both made individual commitments to advocate at the national level for the coming fiscal year budgetary process, with the goal of providing Bayalpata Hospital an increase from its current 30lakh R allocation to a full 1crore (approximately $119,000 USD).  They will both be meeting with Ministry officials and writing letters of support in the coming months as the budgetary planning and approval process commences.  We look forward to working with them to advocate for stronger health systems for the people of Achham, and to continually providing the best care possible for our communities.

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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 Tess Panizales

A school child plays the dhol (drum) during the Diwali/Tihar celebration. The ethnic Nepali music creates a festive mood and nurtures the local culture, which continues to embrace the community. Diwali/Tihar is the festival of light, which primarily honors Laxmi, the Goddess of Wealth and Prosperity. In addition, domestic animals and brothers are celebrated during the 5 days of merriment.

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Tess Panizales is the Quality Program Manager of the Department of Surgery at the Brigham and Women’s Hospital Center for Surgery and Public Health.

Posted by Duncan Maru

As I wrote in a recent tumblr post, since the early days of the Sanfe Clinic, energy has been a central challenge here in Achham.  Back in July, with assistance from both the Nepal Government and from the Monsanto Electronic Materials Company (MEMC) Foundation, our partners at Gham Power installed a solar system to provide more consistent electricity for Bayalpata Hospital.  The result has been impressive; even through two periods of complete grid black-out (one in July for seven days and one in August for nine days), the hospital electricity has not had a single significant stoppage in five months.  The solar system has successfully powered all of our clinical and administrative facilities throughout this time.  This has been fundamental to Bayalpata Hospital’s ongoing transformation.

In installing the system, we were concerned about maintenance and performance.  On both fronts thus far, the system appears to be performing well.  Performance and usage over the last four months of operation have been as follows:

 

Our excellent Night Watchman, Bharat Bahadur Rawal, has been following the energy checklist without fail, and the results have been impressive.  The solar panels, batteries, and inverter are all exquisitely well-maintained.  Henceforth, our new Research and Transparency Director, Richa Pokhrel, will be uploading the performance and usage data to the wiki for public and team consumption.

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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 Duncan Maru

In Boston, I often see patients bounced around from one hospital or specialist to another.  It is a bit surprising to see this

Large pleural effusion on ultrasound

happen here in Achham, where the main challenge is a dearth of clinicians and hospitals, rather than an excess of them.  A sixty year old woman had been sick for several months with cough and shortness of breath when she initially came to our hospital.  While here, a chest x-ray was read as pneumonia and she was treated with antibiotics.  A month or so later, not feeling better, she went to the district hospital a few hours away where she was found to have a pleural effusion (fluid around her lungs).  Some fluid was removed for basic analysis, no clear cause found, and she was referred to a hospital over fifteen hours away where a more extensive workup was performed.  Ultimately, she was diagnosed with tuberculosis and prescribed anti-tuberculosis medications, despite the fact that the hand-written, disorganized papers she was carrying in a plastic bag seemed to indicate a concern for malignancy and her tuberculosis tests had come back negative.  Her son explained, however, that upon discharge from the hospital two months later, they never received any anti-tuberculosis medications or follow-up.  She carried with her a small copy of her chest x-ray, and it looked similar, though less severe, to the one we did: a large pleural effusion, although now the effusion was so large that her heart was pushed over to the right side of her chest by the fluid.   She was so short of breath that

Microscopy of the pleural fluid.

we were concerned that she would collapse.  We elected to repeat the thoracentesis (fluid sample from the chest), and our Health Assistant Chanakya Timilsina performed it, drawing out 1.5 liters of fluid while using ultrasound to guide us.  The patient felt symptomatically better.  It was late at night, and our Lab Assistant Rajendra Dhami performed microscopy, conducting three AFB (tuberculosis microscopy) tests, and a protein analysis on her samples.   The tests were suggestive of malignancy versus tuberculosis, but most strongly of tuberculosis (lymphocytes in the pleural fluid, high protein).  We would aim to get sputum as well, but would start her on anti-tuberculosis therapy in the morning, as long as she was stable.

So here we are.  At least seven months since the start of symptoms, through three hospitals, and only now would she get any sort of potentially curative treatment.  Her condition is incredibly tenuous and I don’t think she will survive.  While I hope we can help her, I’m fairly certain at this juncture, it was far too little (coordination and follow-up), too late.

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Duncan Maru, MD, PhD is the 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 Tess Panizales

Nyaya's Community Health Worker (CHW), Bhajan Kunwar and a child. Most, if not all, of Bayalpata's dedicated CHWs are female. The daunting task of meeting personal family needs such as child care, housework, and other family responsibilities requires commitment and work balance. The CHWs are the pillars and strength of health care delivery, especially in a resource constrained setting such as Achham.

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Tess Panizales is the Quality Program Manager of the Department of Surgery at the Brigham and Women’s Hospital Center for Surgery and Public Health.

Posted by Bikash Gauchan

I recently presented at the World Organization of Family Doctors’ South Asia Conference.

This conference was hosted by the Federation of Family Physicians’ Associations of India (FFPAI), and was held in Mumbai from December 16-18, 2011. I was the only presenter from Nepal to give a free oral presentation on my research, and had the opportunity to share ideas and learn from other presenters and practitioners at the event.  Please see my presentation below, and some photos from the conference:



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Dr. Bikash Gauchan, is currently pursuing his residency in General Practice and Emergency Medicine (Family Medicine) at the B.P. Koirala Institute of Health Sciences. He is the former Medical Director of Nyaya Health.

Posted by Richa Pokhrel

If you asked an average mother how much they care for their children, I bet the answer would be a lot.  It would be so much

Two beauties at Bayalpata Hospital. From left, the daughter of Dilli Nepali (Ambulance Driver) and the daughter of Dhan Bogati (X-Ray Technician).

that there would be no number value for it.  I ask this question because here in Achham we have come across some instances where human lives, especially those of children, are not valued as much as I had assumed they would be.  Before continuing this post, I would like to say that my observation does not reflect the sentiment of all mothers here in Achham, and it would be unfair to stereotype them all in one category.  It is known in rural Nepal that female children are not as cherished as their male counterparts.  This is not unique to Nepal, and happens in other countries as well.  However, I wasn’t aware that the apathy expanded to male children too.  For example, we recently had a mother give birth to a premature baby and while the doctors were frantically trying to save his life, the parents happily dozed off.  The doctors checked on the baby every hour while the parents showed no concern.  The parents left two days later with their dead baby in a plastic bag.  Another example includes a child with pneumonia.  The parents are very eager to take him home, but the clinical staff members insist that they stay until the baby gets better.  The parents ask often if they can go home; they even commented that if the baby was going to die then he should die.  We have mothers here who are okay with their children dying, they are okay with not giving them medicines.  They show no emotion when the child is suffering.  Being a non-mother myself, I always thought the connection mothers have with their children was something so powerful that it was indescribable.  Perhaps this kind of suffering is not new to the mothers of Achham; perhaps they have dealt with bigger issues.  Maybe it is their own society that prevents them from expressing their emotions, or possibly it is poverty that tells them that it is okay if the baby dies because they will no longer have to worry about feeding another mouth.  I keep trying to figure this out; I am trying to find the right answers.  It makes me angry because I want the system to change.  I can’t decide if education is the key or whether economic development is what we need.  Unfortunately, I do not think I will ever understand what these mothers go through and it’s unfair for me to judge them for not showing concern when one of their children dies.

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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 Tess Panizales

An empty packet of chewing tobacco. With increased access to roads, tobacco in various forms has reached Achham. With a large proportion of the population utilizing tobacco products, and significant air pollution, chronic obstructive pulmonary disease (COPD) is the most common diagnosis at Bayalpata Hospital. The use of chewing tobacco also increases the risk or various forms of oral and throat cancer. Not only do these products cause disease, but the trash that litters the roadside and villages creates a collective environmental challenge.

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Tess Panizales is the Quality Program Manager of the Department of Surgery at the Brigham and Women’s Hospital Center for Surgery and Public Health.