"I've a feeling we're not in Thamel any more"

After a few nights in Kathmandu, we managed to buy some last minute supplies and get over our jet-lag as best as we could. Being aware of the rural conditions that would welcome us in Achham, each of us spent a few extra minutes enjoying the hot showers and air-conditioning. With all our bags packed we piled into a taxi and headed for the airport. 

The trip to Bayalpata Hospital is not an easy one. A fact that we can all attest to after arriving here late last night. The remote location of the hospital is the root cause of many of the hospital's major obstacles. Virtually every piece of equipment that the hospital requires needs to be transported both by plane via a flight to Dhangadhi and then a 10-12 hour jeep right through numerous hills and mountains. The remote location also makes it difficult to recruit trained staff and doctors from Kathmandu.  Yesterday we had the opportunity to experience the journey first-hand.

When we landed in Dhangadhi, it didn't take long for us to notice the stark differences between life in the urbanized Kathmandu valley and life in the Far West district. Water buffalo roamed freely across the dirt roads and the sounds of birds singing replaced the cacophony of car horns. 


When we began our ascent through the mountains it became clear to us why traffic accidents    are recurring problem in all parts of the country. The 10 hour ride to Achham consisted of non-stop hairpin turns on one lane dirt roads that serves motorcycles, cars and trucks alike. We were happy to put the worst of the trip behind us by nightfall. From there it was smooth sailing, no rain, no breakdowns. 

Close to midnight we pulled up to the home that we will be staying in for the duration of our internship. Our beds were a very welcomed sight.

Now with the travel behind us, we are ready for the work that lies ahead! 

We flew in to Dhangadi airport from Kathmandu.  The plane was small with room for about 30. At first I thought I would be terrified, but as it turns out it was an incredibly smooth ride.

We got very lucky that there was no rain during our 10 hour jeep ride. Things went relatively smoothly, considering the constant hairpin turns. 

The view  from the was gorgeous, and we could just see the snow capped mountains peaking out over the clouds.

After a quick hour the plan landed. I remember thinking that it was really odd to hear the familiar tune of an iphone starting up; something I just wasn’t expecting to be the first noise I heard when we arrived. 

After a short struggle with getting all of our luggage up onto the jeep Bhinnata, Greg, Alon, Micah, and I prepared ourselves for the long 8 hour drive up to the hospital.  About five minutes into the drive our driver stopped abruptly.  At first we were very confused, but then we realized that there was a water spigot nearby, and the driver had pulled over to cool off.

  A few minutes later we were on the road again. After a few hours, we stopped again to get some dinner at the last place that would be available before the hospital.  As is usual in Nepal, we lost power about 15 minutes after arriving, and no one even blinked because it happens most days.  

Hi everyone!  Just making a quick post to let everyone know that we all arrived in Kathmandu last night.  We will spend a few nights here before heading to Achham on Sunday.  We spent the morning exploring Thamel so I thought I would share a few of the pictures that I took!

Hello from Dubai!!!!

And we're off! (almost)

Welcome to the start of the Tufts GROW 2013 Blog!

Malina, Greg and I (Alon) have our bags packed and are only two days away from the start of our internship with Nyaya Health.

In the weeks leading up to our flight date, the three of us have been pouring over journal articles, manuals and other materials to prepare us for the work we will be doing as members of the implementation science team. We have been thoroughly briefed by the Nyaya Health International team regarding our assignments and are both excited and anxious about what awaits us in Achham Nepal.

During our time at Bayalpata hospital we will be working on a wide range of new and ongoing projects. Our projects cover topics such as reproductive health, respiratory health, mobile health technology, febrile illness, and health post strengthening, among others.

We are going to Achham as representatives of Tufts GlobeMed and hope that our blog, pictures, and work will enable us to share our experience and knowledge with our chapter back home, as well as with friends, and family.

Throughout the length of our internship, please do send us questions, thoughts, and suggestions so that we can foster a continual dialogue. Help us share this experience with you.

Wish us luck!

Light on the Hill

"For if Tufts College is to be a source of illumination, as a beacon standing on a hill, where its light cannot be hidden, its influence will naturally work like all light; it will be diffusive."
~Hosea Ballou , Tufts’ first president

As our jeep wound through Achham, we kept glancing back at the light on the hill. The floodlights of the hospital that has been our home for the past two months are a visible sign of hope – hope that the patients might live another day, hope that they might have a better life, hope that our generation can do something to combat the injustices in the world.

Nyaya combats these injustices every day with clear, tangible results. One of the organizational values we appreciate most about Nyaya is the constant focus on the purpose of using resources and on the outcome of our actions for the people of Achham. It’s not simply a consideration of return on investment – it’s a moral responsibility for each of us working to achieve global health equity and it is active citizenship at its best. 

Active citizenship is a process that requires pragmatic solidarity – the commitment and actual actions of working as partners towards shared goals. The solidarity component of this equation is clear: Our shared goals focus on the concepts of health as a human right, public goods for public health, and health as an investment for economic development. These goals are interrelated and at times indistinguishable. A common thread throughout each of these is the inescapable complexity and the need for multi-sectoral solutions. 

The pragmatic component is the more difficult as it calls into question the sustainability of running a hospital that provides an entire, impoverished region with 100% free medical care. Nyaya Health provides the structure that facilitates actual accountable progress, the front-line care that addresses at least one of the fundamental inequities the people of Achham face, and the persistent hope that we can achieve our goals. Ultimately, however, the question is turned to you – our friends and our allies – to ensure that the light on the hill remains alive. 

Thank you to our readers, our supporters, to GlobeMed at Tufts, to everyone who made this summer possible, to the people of Achham, and especially to Nyaya Health. We will miss our Nyaya family but know that we will continue our work in solidarity together as partners in the pursuit of justice.

Hero: Greg

We have saved this final “hero” post and penultimate blog post for Greg, Nyaya’s Country Director. Although we will try to express our deepest gratitude and admiration for Greg, we will not be able to fully capture the positive, long-term impact that Greg has had in Achham or for us. 

Greg is supportive of new initiatives as long as there is a demonstrated need and the initiative is created for the direct benefit of the community.  From the first, Greg encouraged us to find an area we were passionate about and to make it our own. Greg has given us countless opportunities this summer for personal growth. He included us in senior level meetings and allowed us to take advantage of our positions swinging between departments to truly take on the systems at the hospital. It’s not often that interns are given such an opportunity to take on as big of a scale of projects as they want, but it is completely indicative of Greg’s leadership style. He empowers his staff to improve the hospital through their own initiative, all the while motivating, guiding, and providing the necessary management to ensure that the people of Achham are always the top priority. 

Greg leads by example. One of the days that most inspired us was when we had the hospital clean-up day. He requested that anyone who could come to the hospital on their one day off to paint, move furniture, and put the hospital back together after some intense construction in time for the VIP guests. Essentially every single staff member showed up and spent up to 10 or 12 hours performing tasks well outside of their job descriptions from the “hero” list. Throughout the day, you could see Greg participating whether he was - painting alongside Buddha dai, the groundskeeper or carrying a heavy patient bed up the hill to the inpatient department. 

When the inevitable challenges come up, Greg calmly handles the situations with poise, respect, diplomacy, and fairness. Greg can take even potentially adverse situations and turn them into opportunities for hospital growth. A telling example was when a patient’s family member accidentally broke the mirror from the hospital’s only ambulance. After establishing the situation, Greg asked the man to provide a small sum of the money (and only this after confirming that it would not cause the patient’s family to go hungry) as collateral until the man would have time to come do some gardening work for the hospital. It's this type of long-term thinking and relationship building that sets Greg apart.

Greg truly cares about the staff and about patient outcomes. He reaches out to staff physically and emotionally to encourage and to show appreciation for the work people do. At the beginning of each day (and often several other times throughout the day), Greg goes around to every department and checks in with the staff. His first inquiry is always how the staff members are doing –and he cares very much about the answer. Greg is also incredibly inclusive and always listens carefully to the staff’s opinions. Around Greg, you feel that your work is meaningful and that you are valued as an individual. 

Dedicated cannot even begin to cover how much Greg pours into his work. More days than not, Greg will return to his host family for a brief dinner in the nearby community and then return to the hospital to continue working throughout the night with only a few hours of sleep on a cot in the office. The dedication pays off. Greg gets things done. In Greg’s year in Achham, Nyaya has grown tremendously and he has ensured that the hospital’s systems have kept up. It takes at least two days for anything to get from Kathmandu to Achham yet just in the short time we were there, the hospital underwent a complete transformation and the entire staff’s motivation even doubled in the process of putting in countless extra hours. This would not have been possible under the leadership of anyone who is not quite as incredible, far-sighted, and well respected as Greg.

While we have the utmost admiration for Greg as a leader, we have even more respect for him as a person and friend. He is kindhearted, humble, generous, welcoming, and fun. You always walk away from an encounter with Greg smiling. He just makes you feel awesome about yourself. Some of our favorite memories from this summer were our conversations late into the night where Greg would give us life advice, ask our opinions about new ideas he had, or simply share stories with us. We know Greg is someone with whom we’ll stay in touch for years to come.

Greg is our hero.

We are so honored, humbled, and inspired to have been able to work with Greg, and with all of the others who make Nyaya what it is. Thank you from the bottom of our hearts.

Heroes: Buddha Dai and Min, Kitchen Staff (new and old), Health Aides, All of the other wonderful staff

There are countless others who toil every day and night to serve the communities of Achham. We are so thankful for all of the crucial services they provide. These are the people who make it safe for patients and staff to be at the hospital all hours of the day, the people who cook three meals a day for the entire staff, the people who ensure there are clean and hygienic facilities, and the people who are willing to do whatever it takes to make the hospital function. 

Buddha dai, the groundskeeper makes sure that patients are directed to the correct parts of the hospital, chases cattle off of hospital grounds (after all, we run a hospital, not a farm!), and will do anything that’s needed to maintain the hospital. He works with determination and with a fondness for the community. Buddha dai has been employed by Nyaya longer than any other staff members. He, and his bright 11 year old son Dula (who often translates for the ex-pats, loves math and is a leader among his peers), are well loved by all of the staff. 

Min, the night watchman, quietly volunteers to do any job needing to be done around the hospital on top of dependably protecting the patients and hospital each night. He has an incredible work ethic and is among the most committed staff member we have met. The very kindhearted Min is an integral person to Nyaya.

Dili, the ambulance driver, safely navigates the winding mountain roads bringing patients to our hospital and others when they are referred. There was more than one occasion where he had only a brief rest between 10+ hour drives but he still was determined to get our patients to the appropriate medical facilities in the least time possible and likely saved multiple lives through this determination.

Deepa, Laxmi, and now the new canteen staff have the daunting task of cooking all meals for the entire hospital. They carefully prepare the food and will always brighten your day. They work earlier and later each day than the majority of staff but never complain. Now, Deepa and Laxmi join the health aides in ensuring that the hospital and staff quarters are kept hygienic, that patient beds have clean sheets, that the toilets are kept clean, and that the clinicians have the necessary supplies. Without these fabulous people, our hospital would not be able to provide quality services.

These individuals, and each of the other staff members who make the hospital function, are heroes.

Heroes: Each of the Health Assistants, Nurses, Pharmacist, Lab Technicians, and Patient Registrar

After walking between 20 minutes and several days to reach the hospital, our patients interact with an entire team of individuals each time they visit the hospital. This team registers the over 200 daily patients, takes vital signs, provides the diagnostic and therapeutic services, runs lab tests, distributes medications, and supports our patients and their families through difficult times. We feel privileged to have interacted with each member of this team. Each of them has gone out of their way to welcome us into the Nyaya family and to show us how the hospital actually operates. 

The health assistants tend to be among the longest-term employees of Nyaya Health. They have truly help shape the organizational culture and many provide insiders’ perspectives on life in Achham. Each day we see them passionately treating patients for a wide variety of conditions. Whether Taraman is explaining how the hospital treats and tracks TB patients or we’re meeting with Mahindra to discuss the new HIV initiatives or Uday is following up with a patient who has a severe mental illness, we know that each of the patients receives high quality care because they are in the health assistants’ hands.

The nurses provide many of the hospital’s primary services such as ante-natal care and in-patient care. These women are among the kindest people you could ever meet and are incredibly attentive to the patients. The nurses also always look for ways to improve the quality of service they can provide. Asha, the Nurse in Charge, recently initiated a continuing medical education program for all of the nurses. During the session David and I led on epidemiology, the nurses leaned in for a wonderful and insightful discussion. 

The pharmacist, Raviman, lifts the spirits of every patient and staff member as an outgoing member of the Nyaya family. Raviman always is around to make you laugh but he also takes his responsibilities very seriously. Not only does he care very much that the patients are provided with the correct drugs and dosages, he also cares that they are provided with adequate instruction and counseling to maintain proper treatment plans. He has great insight into the ways the systems can be improved at Bayalpata Hospital.

With the recent expansion of the lab services at Bayalpata Hospital, Bishnu Kunwar as the lab technologist and Dorna and Rajendra as the lab assistants have their work cut out for them trying to run labs in a matter of a few hours each day before the patients have to begin their treks home. However, the lab team can be found in the lab well into the night or on their day off running tests to ensure that our patients are diagnosed properly. They are quite excited to offer the most up-to-date lab tests, including several tests that are exclusively offered at Bayalpata Hospital in all of Achham.

These individuals, and each of the others who interact with our patients each day, are heroes.

Heroes: Netra, Chanakya, Chet Raj, and Pradip

While the doctors are working to save the lives of patients, the administrators are there, working in the background, to keep the entire hospital afloat. They may not always get the most attention when it comes to the care that Nyaya provides, but without them, Nyaya would offer no care in the first place.

Pradip is Nyaya’s Kathmandu Administrator. He was the first person we met upon arriving in Nepal, and we can honestly say that without him, we would never have made it to Achham or back home again. Every day, Pradip hits the streets of Kathmandu, going from store to store to acquire lifesaving medications, securing supplies for the hospital, purchasing plane tickets for staff members to get them to Achham, meeting with government offices to get our paperwork in on time and forge partnerships. He is the hospital’s bridge to the capital. Pradip though, goes above and beyond his duties. He spent his entire day off taking us souvenir shopping, and taking us sightseeing to places like the Monkey Temple, all because he wanted to show us a good time in Kathmandu. He is incredibly hard working and honestly one of the kindest people we have ever met.

Netra is the Administrative Director of the hospital. As such, he is in charge of pretty much everything. He works long hours to make sure the hospital is moving smoothly, and that the staff are doing what needs to be done. He is Greg’s right hand man and so much more. He is phenomenal at coming up solutions to all different problems that arise, and is incredibly kind and patient in doing so. He knows how to run a hospital. While some of his talent likely comes from his business degree, he is a truly natural leader who knows how to work with others. He is incredibly kind hearted. Netra always is interested to hear about what you are working on and to offer any help. When we had some time to kill in Dhangadi, he put us into contact with his family and friends who showed us around the city all morning. His wife opened their home to us, and fed us an incredible feast. We are indebted to him for his kindness, and will definitely be staying in touch.

Chanakya is the hospital’s financial officer. He spends all day making sure that all of the hospital’s payments are delivered on time and that all of our budgets are balanced. Chanakya is a relatively quiet guy most of the time, going about his work in the admin office without fanfare. However, if you give him a mic or music to dance to, then you see a completely different side. He loves giving speeches and acting as the MC for events and ceremonies. He is also incredible on the dance floor, dancing hours without rest, and is definitely the best dancer in Achham. We’ll miss our time spent with him working away.

Chet Raj, or CR as we call him, is the Store Manager. The store is the heart of the hospital as all pharmaceutical and non-pharmaceutical supplies must first go through CR for processing and distribution. Over the past couple of weeks, I have come to know CR through our major project with him completely re-organizing the store and to updating the baseline inventory. To help us finish this daunting project, he has spent numerous evenings working well into the night and his entire day off making sure our database is up to date. Without this work, we could not hold ourselves accountable for the resources we acquire or hold ourselves to the highest quality of patient care with ample medical supplies. 

Netra, Chanakya, Chet Raj, and Pradip are heroes.

Heroes: Ashma and the Community Health Workers

Since taking on the role of Associate Director of the Community Health Department just a few months ago, Ashma has taken the program by storm transforming the clinical follow-up program, helping get the WATSI program off the ground so that even our poorest patients can receive life-saving treatments from the tertiary care units in Nepalgunj and Kathmandu, and helping implement the mobile health technology platform that our community health workers now use to report their data. Through the numerous hours we have spent working with Ashma, she has become a close friend and a respected colleague. 

Ashma has also quickly earned the trust of the community members. One Saturday when we accompanied her into a nearby village for the weekly community health meeting, one FCHV told us about a man in her ward who had HIV, TB, and asthma. The FCHV told us that the man’s health status had been deteriorating but he was not willing to go to the hospital because he had formally had a negative experience with clinicians during the course of one of his many visits to different medical centers. After the meeting, we went with Ashma and the FCHV to the man’s house, along the way passing families out in their fields preparing their rice patties in the heat of a Saturday afternoon. There, she spent well over an hour patiently discussing the situation with the family. The wife had literally carried her husband to all of his medical appointments throughout Nepal and India and just could not keep doing that while also raising their several young children. Ashma promised the family that she would personally see to it that the man got treated properly and only then would he agree to come. We then accompanied the man to the hospital where Ashma saw to it that he was received properly by the clinical team. 

However, the story of the heroes of the community health program would not be complete without including the Community Health Worker Leaders and Female Community Health Volunteers. As we have had the chance to get to know the 9 CHWLs when they come to the hospital each week for trainings and to report data and the 92 FCHVs whenever we go out into the community, we have seen the dedication and kindness each woman brings to her position. While each woman has a different story for how she decided to become a CHW, every one of them brings a common desire to help their communities. The FCHVs are selected by their communities and are the true links between the population of Achham and all health services. These strong and wonderful women break down the barriers – geographic, cultural, and social – that the most vulnerable and marginalized Nepalis face in accessing care. 

Ashma, the CHWLs, and the FCHVs are heroes.

Heroes: The Physicians

Dr. Payel has provided us invaluable guidance throughout our summer and we have been inspired by her work to transform the hospital. As a bridge between the clinical and administrative departments in her role as Clinical Operations Director, Dr. Payel has spear-headed innumerable projects to improve the quality of care and create clinical systems that result in the best patient outcomes. She has a keen eye for places where the hospital could improve and constructively does something to address any concerns. In our first several weeks, we saw her lead the efforts to make the hospital into a more dignified, hygienic place. ­­ There was rarely a night when she was not in the ER or IPD overnight assisting in the heroic and often creative efforts of the clinical team to save a patients’ life. Her energy carries through the rest of the hospital as she encourages others to produce top-quality work. In an organization with a basic tenet that ‘good intentions are not enough,’ Dr. Payel embodies efficiency and effectiveness in getting things done.

Dr. Bibhusan is among the kindest, most visionary physicians I have known. As Medical Director, he has earned tremendous respect from the entire clinical staff as a skilled physician, excellent teacher, and an effective manager. However, I have been most inspired by my interaction with Dr. Bibhusan as a physician who makes a concerted effort to improve community health beyond the clinical space. After attending a training program on the government’s HIV initiatives, Dr. Bibhusan came to Ashma and me to discuss how we could fill in the service gaps of the region’s community and home based HIV care model. Through our conversations over the next couple weeks, we created a program that would bridge several of our departments and bring all of the community stakeholders together. This was not a theoretical exercise – within a week of our initial conversations, we were able to begin bringing community partners together. Dr. Bibhusan’s gentle leadership throughout that process fostered the beginnings of a very positive and productive partnership among a group of people who had never before been able to work together in a meaningful way.

Dr. Roshan’s constant optimism is infectious. I’ve never once heard him complain and he claims to have never had a bad day. People seek Dr. Roshan out to be reminded of why we do what we do and maybe to be tossed a mango or a wide smile. Dr. Roshan is a role model for everyone at Bayalpata Hospital with his love of learning and teaching. Even after a long day in the clinic, Dr. Roshan always finds time to teach anyone interested in learning. One night while I was in the ER for rounds, Dr. Roshan was looking at a patient’s xray. He paused when he saw Sindhya and me to thoroughly explain the patient’s history and the relevance of the xray findings. He then went on to explain the difference between a number of similar-sounding medical terms related to the next patient’s condition. The next morning in the daily continuing medical education lecture for the health assistants, he made sure to slip a few of those new terms in and looked over to Sindhya and me to make sure we had caught the terms. As he did so, I was reminded of just what makes Dr. Roshan so incredible – he naturally connects with and improves the life of each individual he meets, whether patient, co-worker, or friend.

Dr. Rashmi’s passion to improve patient outcomes drives her work. As one of the first female physicians in the region, she has quickly gained the trust of the many female patients who come to Bayalpata Hospital with Ob/Gyn concerns. Dr. Rashmi looks out for others. One night she came to us quite concerned about the quality of the blankets we give to newborns and expressing the desire for a project where we could perhaps provide infants with their first (and likely only) outfit that they will receive in their first days of life. She takes the lead in addressing any complications with maternal and child care. Dr. Rashmi also greatly contributes to the morale among the staff by helping to organize staff bonding nights and by being a friend to all those in the Bayalpata community.

Drs. Payel, Bibhusan, Roshan, and Rashmi are heroes.

Hero: Deepak Bista

I’ve had the incredible opportunity to work alongside Deepak during my time here working in the Data department. He is the hospital’s Data and Technology officer. As such, he is in charge of all data entry and reporting in the hospital, and is also responsible for any task relating to technology that needs to be completed. 

Deepak is an incredibly hard worker. He works in a stifling office that has been affectionately nicknamed “The Oven” by other staff for its lack of ventilation and high temperature when it is warm out. Deepak spends hours at a time entering data into databases and spreadsheets, a task that could wear on anyone, but he always has a smile when he does it. 

What is truly incredible about Deepak is his knowledge and drive to continue improving the hospital’s data systems. He is like an artist when working with his spreadsheets, crafting them in a way that will ensure the most utility of the data and the highest accuracy. When data isn’t reported to him at time, he will go out and track it down, even if it takes talking to every single employee in the hospital. Deepak also has a genuine love for the work that he does. He enjoys seeing what the data holds, and is rarely without a smile when seeing it all come together.

Deepak also has an incredible degree of initiative. He is excited to continue working on the data communication plan, and offered many suggestions of his own in its design. After a long meeting discussing ways to improve the pharmacy and store system at the hospital, by the next morning Deepak had constructed an Access database out of scratch that was incredibly functional and has already replaced the hospital’s previous stock system. He can also often be found in his office on Saturdays (the only day of the week that people have off) chugging along in order to get our data reported on time.

Deepak is a great co-worker, always willing to drop what he was doing to lend a hand. You can hear his distinctive laugh even before you see him, knowing that he is either chatting enthusiastically about his work, or about the weather, or about the football game after work.

I’m honored that I’ve been able to work alongside him the past couple months, and will be sad to say goodbye.

Deepak is a hero.

Hero: An Introduction

As our time here in Achham is coming to a close, we feel the need to point out the incredible staff at the hospital that have impacted our experience beyond measure. The people that work here are an incredible group of people, who each have inspiring stories, and who each are doing a tough job on a daily basis, but continue to press onward in Nyaya’s mission of providing care to the people of Achham.

Over the next few days, we will post to this blog descriptions of some of these “Heroes” that we have been able to work with. While we cannot say everything there is to be said about each of these heroes, or express the full measure of our gratitude, we want to highlight the work that they are doing here. We also cannot write about every single person that works here individually, but our thanks and admiration goes out to the entire staff.

These inspiring people are heroes to us. We hope you will see them that way as well.

Data, Communicated

Data is everywhere. In everything we do, in everything we see, data can be found in any place in the world that surrounds us. It is this concept that has led to the rise of new “Big Data” initiatives to try and harness all of this information. The issue with data is that if you gather too much, the signal you are trying to evaluate can get lost behind all of the noise. More importantly, perhaps, is that all of this data that is collected amounts to nothing unless the actual steps are taken to communicate this data to others, and to put it to use. At Nyaya, we have been working to get to that point of data communication.

Much of my work here this summer has been working on a new Data Communication Initiative. Through all of our programs, we collect boatloads of data, however it is often difficult to use it, and it is rarely ever communicated back to the staff who collect it. With the recent work that we have been doing, this is all changing. Through a new plan we have been working on putting into place, every month, new data will be hung up in the hospital’s new Conference and Training center, as seen in the photo below.

Bulletin Board in New Conference Room

We presented the data at a data meeting which will now become a monthly event at the hospital. Since the bulletin board has been set up, dozens of staff members have taken time out of their busy schedules to come and check out the information, in order to help inform their actions moving forward.

Nyaya’s community health workers also collect a great deal of data from the communities they work in. As shown in the photo below, for the first time, Ashma, the Associate Director of Community Health, was able to show visualized data back to the community health workers, allowing for them to finally see the fruit of their labor.

Data Being Communicated to CHWs

Among these two projects, other plans are in place to provide weekly data to community health workers, to provide the clinical staff with data to supplement their daily lectures, and to use the help of our Globemed Chapter to write actionable reports on different data points.

Data may seem like an abstract concept, but it is real, usable information that can increase the care we provide to our patients, and the strength of our public health program.  All that needs to be done is to take the time to tap into its potential. We are on the road to do just that.

Collaboration to Stop an Epidemic

The burden of HIV/AIDS in Achham is among the worst in the world. Achham has the highest prevalence of HIV/AIDS of any district in Nepal, largely due to the number of men who seek work in India and come back infected. To respond to this challenge, there are numerous community-based organizations that try to prevent the further spread of the epidemic by reaching out to people living with HIV and AIDS. The government piloted its community and home based care (CHBC) model in Achham to expand the continuum of care beyond the medical treatment hospitals and health posts provide. Nyaya Health has also participated in efforts to combat HIV/AIDS as an integral part of our health care delivery model. We have recently become an HIV Center- authorized to initiate and maintain treatment for affected individuals. Our medical director just participated in a government training for the CHBC program and our community health program reaches out to affected individuals through follow-up visits. However, the efforts of all of these different organizations and providers have not been coordinated resulting in duplicated efforts and wasted resources.

A couple of weeks ago, I was asked to do some research regarding HIV interventions conducted in other resource-limited settings around the world and current efforts in our local community to determine what Nyaya could do to coordinate efforts and fill in gaps in the current services. As a result of this research, yesterday we held our first Community Partners Meeting with representatives of the organizations working to combat HIV in the region. The objective of this first meeting was to simply get everyone in the room together to share current programs, target groups, and successes. Nyaya also presented recent local HIV epidemiological information from our patient record database. The tone was quite friendly and the meeting seemed to be a success. By the end, everyone present was excited to continue the collaborative efforts through monthly meetings hosted in a rotating schedule by each of the organizations. Hopefully, future meetings will provide a way for the various organizations to collaborate in a more meaningful way.

The other successful outcome of the first Community Partners Meeting was the support the organizations present gave to Nyaya’s new idea of reaching out to caregivers of people living with HIV/AIDS - a traditionally neglected group in HIV care. From my initial research, I had ascertained that in Achham, there is not a structure that provides caregivers of people living with HIV and AIDS with support, guidance, or a community of peers. I proposed the idea of a caregivers’ support group facilitated by the community health workers in each village. We are drawing up the specific plans now and hope to reach out to other stakeholders and begin trainings for the community health workers prior to the next monthly Community Partners Meeting.

Representatives from a number of community based and government
organizations at the first Community Partners Meeting to combat HIV

Developing a Global Model of Health Care Delivery

Part of Nyaya Health’s mission is to develop and disseminate a model of health care delivery in resource-poor settings throughout the world. While this may seem a little audacious for such a young organization, the recent steps the Nepal team has taken to strengthen our operations do seem to be putting Nyaya on the right track to develop such a model health care delivery system. In July alone, Nyaya has taken on a wide scope of development projects from signing a new contract that ensures a consistent source of water supply to gaining permission form the Nepali Red Cross Society for the hospital to begin blood banking and transfusion services. Nyaya even had a field-analysis conducted of the waste output and elimination practices of the hospital as part of larger effort in creating a “green” waste management system to.

Looking at this list, I’m struck by the range of projects from building basic infrastructure to cutting-edge hospital management practices. But as we work day to day here, it doesn’t seem unreasonable. In fact, it seems absolutely necessary if we want to provide a reasonable standard of care where patients don’t continue to die of conditions that would be easily treatable elsewhere in the world. And this list of recent developments is really just part of a broader systems strengthening process.

This summer, much of our work has focused on helping with the implementation of the Medic Mobile program for the community health workers to gather their epidemiological data on an electronic platform and with the implementation of an inter-departmental medicine delivery system. We have also aided in the development of evaluation processes for the daily continuing medical education lectures and quality improvement measures for the hospital. In the next phase, Nyaya will be switching to an electronic medical records system which will integrate patient clinical data across the hospital departments, pharmacy and store-room inventory data, and community health data in a system that can provide a comprehensive base for evidence-based medicine and data-driven clinical and public health services.

“Making the impossible, possible” – This is something that Greg, the Country Director of Nyaya, claimed that the organization routinely does during one our chapter’s skype calls with him last semester. At the time, I thought it was very inspirational rhetoric. This summer, we’ve witnessed Nyaya Health actually making the seemingly impossible reality. 

August calendar of morning lecture topics for health assistants
GlobeMed at Tufts chapter members will be contributing to these lectures by using Nyaya's clinical and community health databases to find relevant epidemiological information for each topic. Topics were chosen by the physicians to reflect the high-prevalence conditions seen at the hospital.

Thanks to GlobeMed at Tufts from Nepal

Click here to hear Ashma Baruwal, Nyaya's Associate Director of Community Health, discuss the impact of the partnership between GlobeMed at Tufts and Nyaya Health.

Below is a picture of one of the new community health worker leaders hired as part of the expansion of the program that GlobeMed at Tufts funded. Lalita Khadka lives in Gajra, a community of over 1900 people who live almost 2 hours from Bayalpata Hospital.

Lalita Khadka became a CHWL to serve the needy people in her community – to counsel those who are in dire need and advise them to go to the hospital. She has a 7 year old son, Ashish, in kindergarten and an 8 year old daughter, Akriti, in 1^st grade. Her husband is a farmer. Lalita enjoys studying books, reading newspapers, and writing stories. She would like to study English and to learn how to use a computer.

Video Tour Part 2

The second part of a video tour of the hospital is now available at the link below. Hopefully there will be more soon on the way.

Video Tour Part 2

Video Tour Part 1

While our internet is quite slow here, we've managed to upload a video online for everyone to see. Follow the link below to see Part 1 of a tour of the hospital. We hope to get the remaining parts uploaded over the next few days.

Please forgive the short length of the video and the poor video quality. If it was anything larger or clearer, any upload at all would be impossible.

Video Tour Part 1

Reflections from our VIP Guest Dr. Paul Farmer

Check out Dr. Paul Farmer's impressions from his time here.

Dr. Paul Farmer with the community health workers

Hafsa Chaudhry, a Co-Founder/Co-President of GlobeMed at Tufts and current intern for Nyaya Health's US office, has donated her 21st birthday to Nyaya Health. To see how you can wish Hafsa a happy birthday, click here. 


If you're interested in donating your birthday to Nyaya Health, please let us know! Post a comment or send us an email at tufts@globemed.org.

Hardship in a Beautiful Place

It can be jarring at times when you are surrounded by beauty at one moment and the next you see a terrible tragedy unfold. Such is the way life is here in Achham. Green mountains surround the hill top that the hospital sits upon, yet the realities of living in such a setting are difficult to deal with.

Today we awoke to a beautiful mist shrouding the hospital. As the sun rose it dissipated, leaving a lush green day in its wake. This morning we also arrived in the hospital to witness a young child dying. A five year old girl had pneumonia. In the 3 minutes she was off oxygen to go to the bathroom, she grew much sicker and succumbed to her illness. Her mother’s cries rang through the halls.

With the start of the monsoon season, the land has seemed to have gotten a new life. The grass that was once dead is now vibrant with color. There was no haze by mid-morning leaving incredible views of the surrounding hills, and down into the valley that holds Sanfe, a nearby town. You could just sit for hours and stare off into the distance.

Just after lunch a young boy who must not have been older than 9 years old came in. He was experiencing a loss of appetite and was having spasms whenever he would try to drink water. He also had tingling and pain in his arm, around the site of a bite wound. It turns out that about a month ago he was bitten by a rapid dog, along with his father, but neither of them sought treatment. Now, it looks like the young boy has rabies. Even in the United States, once a patient becomes symptomatic to rabies without prior vaccination, their chance of survival is almost zero. The doctors gave him the vaccine as a post exposure treatment which might help as the symptoms are only in early stages, but even so, while he still looks healthy now, he likely will not make it past the next couple weeks.

Then later in the afternoon as we were sitting in the office we heard yelling from outside. We ran out to look and saw the most incredible rainbow we had ever seen. It stretched in vivid color up from a dip in the hills and rose high into the sky. From a distance back, it would appear that the hospital sat at the bottom; that Bayalpata was the pot of gold at its base. Opposite of it, the entire Sanfe valley was ablaze with light from the sun, creating what seemed like a glowing mist filling the land. There weren’t words to adequately describe it

There is so much beauty here. Beauty in the scenery, and in tricks of the light. Beauty in the wedding of two staff members, and all of the staff’s incredible commitment to the hospital. Beauty in the resilience of the patients who walk for hours in the morning to get their treatments, and then walk hours back at night to go work in their fields. Beauty in the son who stays by her mother’s side as she struggles through MDR TB, and in the kid that pulled through from a case of Kala Azar.

But there is also hardship here in Achham. In the patients who we can’t help and who don’t make it back home.

This is a land of beauty that deserves beauty. That is why we do our work.