Week 1 in Far Western Nepal: Remote Doesn’t Begin to Describe It

After my 23-hour New York-Doha-Kathmandu flight, I was lucky enough to have two days to decompress in Nepal’s capital. It reminded me of Delhi with its traffic congestion; where scooters and bicycles make 6 lanes where 3 should exist, and the unavoidable baseline level of smog. It does have magnificent historical sites though, and I managed to visit an ancient Hindu temple dedicated to the lord Shiva, as well as a Buddhist stupa called Boddnath. I fortunately also ate lots of momos — a Nepalese dish that looks and tastes like Chinese dumplings — my diet since then has consisted of rice, lentils and vegetable mash.

On day three, I began my travel to Achham, where Possible is based (it was called Nyaya Health previously: after the Sanskrit word for justice). One must fly from Katmandu to Dhanghadi (only about an hour away), and then take a jeep ride the rest of the way to Achham (which is in the far western region). Locals told me the name originated from Achha Aam ‘good mango’ in Hindi, and I can confirm that they are great. The domestic flight on Buddha Air treated me to sweeping views of the Himalayas (not Everest though, which is in the opposite direction). Though only a few hundred miles, the drive from Dhanghadi to Achham ended up taking 10 hours. The roads were fine for three quarters of the way, despite consisting of blind turns on un-barricaded sheer cliff-fronts. The final stretch was tremendously muddy, unpaved and bumpy; with semitrailers screeching down winding mountain roads in the opposite direction to us. Arriving in Achham at midnight I was greeted with modest accommodation consisting of a mat on a concrete floor (but thankfully with a ceiling fan). I was also somewhat agitated that standing in the bathroom/toilet was impossible because the ceiling was 5’5. I was annoyed at myself because my temporary ‘problems’ were clearly trivial compared to the struggles of the patients we serve. Welcome to Achham, where we are making ‘healthcare possible in the world’s most remote places’ (that is Possible Health’s philosophy).

Bayalpata hospital sits atop a hill (mountain by my standards). It was a government facility that was closed for many years, until Nyaya Health and it’s young founders rehabilitated it six years ago. It now operates as a partnership with the Nepal Government- has a coverage area of 45 000 patients, an inpatient ward that has 30 beds, and sees around 250 patients a day in outpatient clinic. The hospital has treated more than 170 000 patients since it opened. Health assistants (the mid-level providers in Nepal) do the majority of outpatient clinic, with the MBBS doctors doing the ER and inpatient wards, and two MD-GP docs doing amazing things like C-sections, skin grafts, toe amputations, and anything else that is thrown at them. We do not have general surgeons here, and complex cases are referred to a larger tertiary center back in Dhangadhi.

One of my first days here I decided to join one of the American co-founders of Possible on a walk back to my room down the mountain. He assured me it was shorter than the 5km road, only 20 minutes and ‘through the jungle.’ It ended up taking nearly an hour, in 38-degree Celsius heat (100F for you Yankees), down a challenging rocky incline (both of us in business attire and entirely incorrect footwear). I definitely was not keen to do that again, but being a motorcycle passenger the next day going down the mountain without a helmet was terrifying. I requested to be moved on campus and the Possible Health team graciously agreed. I now live in a dorm with the three young M.B.B.S. doctors who I serve as supervisor, clinical adviser, coach and educator for. The freshly minted MBBS docs look like they’re 16, but have a far superior book-knowledge than I did at their stage of training. They lack experience in real-life medicine though, so this is similar to July 1st in the U.S. when interns take over the old guard every year.

Patients here share in the misery of millions of others around the world. They have inadequate access to healthcare facilities, and are forced travel far across mountainous terrain to get any sort of medical attention. Two days ago I wandered into the ER and saw a health assistant suturing the hand of an infant. As I approached closer I realized what he was really doing. He was removing 10-15 writhing maggots from the remnants of the poor child’s limb — which was black and had been scalded by hot cooking oil eight days ago (sadly a common accident in remote areas where cooking is done in single room abodes). The parents had tried herbal remedies at home for two days, then gone to a health post where they were told nothing could be done. After this, they walked 10 hours to a bus stop, and took the half day journey to get to Achham. Now that we had disinfected the mangled limb, bandaged it, given the child pain medicine and antibiotics, there was nothing to do but arrange transport to a larger center. There was no escape from the harsh reality that the hand would have be amputated. As if the child had not been born into enough challenges…

Much remains to be done to ensure people around the world have access to the healthcare they deserve. In the end, the success of organizations such as Possible relies on local professionals providing this important service. There can be no global health without local staff. Possible has so far done an excellent job of employing and retaining Nepalese physicians, health assistants, nurses, and community healthcare workers. The system definitely does not rely on the presence of outsiders such as myself. Locals have options too, and could have found higher paying jobs in Kathmandu. Instead, they are here — where their patients need them, doing their job, and living in modesty. No matter how much ‘hardship’ outsiders experience in working outside our comfort zone, the reality is that eventually we get to go back to privileged lives back home. ‘More action, less applause’ — that will be my mantra over the next 12 months — much remains to be done.