The road from Dhangadhi changes between a rough paved surface and unpaved. We weave past beach ball sized boulders fallen from the cliff to our left. Our wild haired driver accelerates in the straights before tapping the brakes and applying the horn in short jarring pumps all the way through the corners. The technique is customary on this road that’s just wider than a single lane. The horn warns oncoming traffic before we enter the blind curves. The only oversight by our driver is the blasting Hindi pop music drowning out any possibility of hearing a warning from the other direction. In this way we maneuver through the hills and into the night…

…Occasionally passing through small towns, clusters of tin three-walled shacks open to the front in between more permanent mud and wood constructed homes built into the hillsides. Approaching the tin fronts, the candle lit rooms transform into pantheons of packaged butter biscuits, cigarettes, and sundries for sale. Other fronts contain families sitting shadowed inside open kitchens with open hearths (in rural Nepal a family’s size is most accurately described by how many people eat in a particular kitchen). Burnt flour, chilly spice and manure pervade the air. To the right the road bends past the last home into darkness. To the left it is the same.

 

View from the jeep, a brief straight section before the next turn.

 

“It’s all about food and disease here,” said Dr. Bibhusan Basnet.  He smiled, but his humor was not far from the daily truth.  His life as Medical Director at Nyaya Health’s Bayalpata Hospital in Achham is composed of little more than eating, sleeping, and doctoring.  We chatted over tea sitting on a rock ledge built below a massive Peepal tree (pronounced like “people” and coincidentally the place where everyone gathered in the evening).  The ledge and the tree were at the top of a hill that overlooked a small village of tin structures including the cantina from which we ordered our tea, and further out on the ridge the hospital newly painted a pale yellow and earthen red in honor of the Nepali flag.  To the right and left the land fell away into the valley, and out beyond the last building of the hospital the grey and distant river soon to be swollen with Monsoon rain.

 

Inside Bayalpata's Emergency Room, (in the center Urmila Didi, Auxillary Nurse Midwife)

 

Our conversation dominated by the doctor was light and full of laughter.  About halfway through his cup of tea, and halfway through apprising me on the many ways in which I would eat the same meal each day in Achham, the doctor was called back to the hospital to make a referral for a Caesarian section (the hospital’s own operating room was a few weeks from complete). Within five minutes he was back with his tea in hand, further detailing the monotony of the diet in rural Nepal.

Dal Bhat: a massive pile of rice (sometimes USAID, sometimes from the People of Japan), a bowl or ladle full of lentil soup, and hopefully a small portion of curried vegetables…whatever is in season, or more commonly potatoes.  There are some differences in the techniques for consumption, but most often the components are mixed into an amorphous pile and eaten with one’s hand.

Chandrika, a long time Nyaya Health Aide at the ER's Nurse's Station.

For westerners the latter piece is a point of preference as spoons are generally available.  The lead trainer in Bayalpata’s community health office, Ranju Sharma, chided me at dinner one night, “rice does not taste as good when it’s eaten with a spoon.”

Ranju (a natural teacher), who was recently added to Medic Mobile’s team as Nepal Projects Manager, proved to be an amazing asset to implementing Nyaya health’s data collection project for which Medic Mobile would be supplying the mobile tools and training.  With Ranju acting as interpreter and trainer, Alex Harsha (Medic’s project manager and research coordinator) squeezed out every minute of internet access (down every time the hospital’s generator quit…which was often) communicating with the development team back in the states.  Most of the troubleshooting had to be done in very early hours of the morning which was good for having things ready for the mid morning trainings, but hard on Alex who rarely slept.  After a crash course in the project design, Ranju spearheaded the training of the Community Health Worker Leaders (CHWLs) on the application that they would be using to collect patient data via mobile phones.

 

Ranju and Alex leading the trainings of the CHWLs.

 

The SIM application will hopefully take the place of paper reporting forms, and store data to the central server where the information will be instantly available for the community health staff to analyze. The secondary purpose of the application will be for reporting on the status of local health posts.  A simple but critical question in Achham: is anyone staffing the post? Are the medicines and supplies that the Nepali government claims each post is stocked with actually there and available?  The real benefit in the implementation of Medic Mobile’s tools will be in the rapid availability of data that will give Nyaya Health a vital source for accountability in its continued work with the Nepali government, and within the government supported health system.

 

Watching messages arrive on the server, (left to right) Satya Sunar, Pabitra Kunwar, Tulcha Devi Khanal (Community Health Worker Leaders), Ranju Sharma, and Community Health Worker Leaders Kamala B.K., Sunita Kumal, and Lalita Khadka

 

It was clear from the moment that the CHWLs entered the small community health office that they were a unique group of women.  They all wore matching aquamarine saris, a blue that contrasted against their dark skin and complemented the bright crimson tika that most wore on their foreheads.  They were striking.  Intelligent and progressive, each Leader had walked at least an hour or two to attend the training, and did so as representatives of their own groups of female community health volunteers (FCHVs) that live much further away from the hospital.  The faces of the CHWLs filled with skepticism at the onset of Ranju’s instruction, and then with timidity and surprise as phones were placed in their hands and they began to work through learning how to use the application.  Constantly joking and ribbing one another, the group in the end seemed optimistic that they would be able to use the new mobile phones.

 

Community Health Worker Leader Satya Sunar testing out the phone.

 

Female Community Health Volunteers at their weekly meeting in Chandika VDC

 

At the end of the week in Achham we were able to visit a community health meeting in a village a few miles from the hospital that was being lead by one of the CHWLs that we had been working with days prior.  Sitting in a circle beneath a Peepal tree on a raised platform of earth a group of FCHVs received a brief training, and shared their weekly summaries for the CHWL to record on a paper report. Eventually this CHWL would be using the Medic Mobile phone to collect the summaries, and each FCHVs patient list would be instantly updated to the server where Nyaya’s Community Health Department could aggregate and analyze it to observe changes in the community health status.  The significance of the visit was getting to observe how and when the phones would be used once the project becomes fully operational.

 

Weekly community health meeting in Chandkia VDC

 

The CHWLs are continuing with weekly reporting and training using the phones at the hospital.  There have been (and will be) some difficulties, but with feedback from the Nyaya community health staff, namely Ashma Baruwal, Medic Mobile’s team has been working on improving the application. It is Medic Mobile’s first project in Nepal, and so the team is anxious to learn how to make it as easy as possible for the CHWLs to collect data and perform their reporting duties from the most basic phones.

Patients waiting at registration

Aside from the cows grazing past the latrines in the open center of the hospital campus, or the stray dog asleep on the shaded concrete floor of a hallway, things moved like they do at any hospital.  A swell of patients accompanied by family members grew each morning before the registration window, and by four in the afternoon that swell had passed through the hospital. The only evidence of its movement the low din of the various waiting areas rising in volume punctuated by the cries of infants getting weighed and measured. After seven in the evening dinner was ready.  The hospital staff, as well as visitors like us, sat down to eat.

 

 

 

Text and images by Lewis Feuer.   Lewis is a visual artist and poet.  He is currently pursuing a Master of Fine Arts degree in Creative Writing at UMass Boston. Please check back in the coming weeks for more installments in the series Artist in Arms.  Future posts will cover other projects beginning in Nepal.