We're Back!

After three incredible weeks traveling the world, Team Nepal is back in the States. We had an amazing trip, filled with truly unforgettable experiences- like the time we ordered 90 momos, the time we met a monkey at the airport, and the time we hiked through rice paddies in a monsoon to reach a community health post.

We'd like to thank everyone who made this trip possible. In particular, we are so grateful to Laerdal Global Health for our grand Norwegian adventure and for sponsoring our work in Nepal as well. Thank you for a once-in-a-lifetime experience!

We are also indebted to Jhpiego staff for their support and guidance. Lindsay, thanks for jamming into countless tiny cabs with us and providing much-needed advice about field work and public health. Sheetal, thanks for all of your work adapting our trip at a moment's notice and for spending extra time hanging out with us outside of our global health work. Dr. Kusum, thank you for your time, your connections, and for making us laugh and think hard about our purpose here. Everyone at Jhpiego Nepal was so welcoming, and we wish we could have spent more time with all of you!

Now that we're back in the land of clean air and drinkable tap water, we are hard at work trying to wrap our minds around everything we have seen. We have less than nine months to come up with some way to truly make a difference in the lives of people living in places like Nepal. It's an enormous challenge, but we're ready to take it on.

Namaste,
Team Nepal

The Mystery of the Missing Preterm Babies

Coming into this trip, I expected to see lots of babies. For the most part, that's been true. I've been overwhelmed by the number of adorable infants I've gotten to "observe" (read: oggle over and wish I could adopt). However, Aaron and I have run into a perplexing problem. 

"We don't have preterm babies."

Nearly every facility has told us this, and we have only seen a handful of visibly premature babies in our eight site visits. This should be good news, but considering Nepal has the 20th highest rate of preterm deliveries in the world, with 14% of all babies born before 37 weeks gestation, we should be seeing much more of them. So where are they?

We have a few hypotheses, with each of them posing unique challenges. 

1) They have all been referred to other facilities. 

This is the most common explanation we receive. Lower-level facilities refer women in preterm labor to tertiary care facilities with neonatal intensive care capabilities. If a woman delivers a preterm baby and they do not have the necessary equipment (for example, and incubator or a ventilator), hospitals will also refer the newborn. 

There are a number of issues associated with this system:

a. Tertiary facilities are limited, and even the government facility with the second-highest delivery volume in the country refers babies to nearby private hospitals because they do not believe their facility has the proper equipment to handle premature infants. This leads to overcrowding in many facilities. One primary health facility said they once had a nearby hospital refuse to admit a 1 kg baby born in the primary facility because they did not have room. The baby soon died without intensive care. 

b. As we have discussed in previous posts, this means that women in labor or unstable babies may have to travel many hours over dangerous roads to reach quality care. Ambulances are rare, and they aren't equipped with special technology to stabilize babies in transport. 

c. Lack of equipment in all facilities is a serious problem. From the primary hospital in Waling to the regional hospital in Pokhara, nearly every place wished for more ventilators and more incubators. Equipping the lower-level facilities could limit some of referrals, but cost and maintenance are major issues. A low-cost technology that breaks, or one that can't withstand monsoons and variable power, will not make a difference in the long run. 

d. Interventions at the lowest level that could prevent the need for intensive care are lacking. For example, many babies can get all the warmth they need from skin-to-skin care, but instead, they are referred to hospitals with incubators. Early delivery of surfactant can prevent babies from needing to go on ventilators, but surfactant is expensive and rarely available. 

2) Preterm babies are not being properly identified. 

How do you spot a preterm baby? It's actually harder than you might think. 

a. Gestational age estimates can be unreliable. Ultrasound equipment is expensive, and the mother's own estimate can be off. The difference between a 34-week baby and a 37-week baby can be dramatic, requiring very different levels of care. 

b. Another marker of prematurity, low birthweight, is hard to measure when you do not have a scale. Female community health volunteers use their own estimates to tell if babies are small-but in a country where stunting is prevalent, there's a chance that many babies get overlooked as being "average" when they are actually small. 

c. Skilled birth attendants in lower-level facilities that do not see as many preterm babies might fail to notice the distinctive physical characteristics of preterm babies when they do arrive. 

3) Preterm births are happening away from where we can see them. 

We have seen eight different districts in Nepal, but there are still 67 we have not explored. In addition, the home birth rate is still high, for a number of reasons. 

a. Women live too far away. Would you want to trek several days through the mountains to reach a hospital?

b. Hospital births can be a negative experience. Facilities are crowded, care for complications can be expensive, and every delivery we have seen so far has looked extremely painful for the mother, with episiotomies happening under limited and diluted local anesthesia. 

As we have come to realize, this one simple question- Where are the preterm babies?- has revealed so many complex issues that I would have never even considered prior to this trip. It's a bit ironic that not being able to find what we set out to find provided some of the best insight, but one point of these trips is to turn all of our assumptions upside down-and this trip has definitely succeeded in that!

Gestation, Gems, and Jenga

On Wednesday, we had the chance to visit a local government hospital, called the Civil Service Hospital of Nepal. Government employees can go there to receive discounted care. It was clearly a popular place, with the line for admission looking intimidating and very long.

We began our day by sitting in a classroom for an hour or so, receiving what I call "the India treatment." Back when we were traveling through Delhi, we were told to sit in a waiting area for "a few minutes" before we could change gates. Those few minutes stretched into more than an hour. A similar thing happened at this hospital. It made sense, really. The hospital was waiting for the right administrator to receive us before taking us around the facility. It only seemed strange because our team is used to being able to go anywhere we want in the Hopkins hospital. I've realized what a privilege that freedom is, now that we're in a country where our reputation is not established and hospitals understandably want to keep an eye on us.

Still, in this case, as in all the others, we were warmly received once the chief nurse arrived. Despite the weirdness of foreign engineering students asking to see labor rooms and deliveries, the hospital personnel here have been obliging, and both MIS and Preterm have been fortunate to have opportunities for both observation and interviews.

She showed us to the OB/GYN ward, where we got to see quite possibly the most stylish delivery beds ever. Unfortunately for us, we did not get to see anybody use those beds, since the hospital has a lower volume of births and did not have any women in labor that day.

This visit allowed us to see how mothers are cared for along every stage. We got to see the antenatal checkup rooms, the labor rooms, the delivery room, the post-natal ward (babies!!!), and the exam rooms where infants receive vaccines and mothers receive family planning counseling. This illustrates the problem with trying to pin a high preterm birth rate on one factor. There are so many different aspects of maternal and neonatal care that are vital to ensuring that infants are born full-term and healthy.

After our tour of OB/GYN, we got to speak to two out of the three biomedical technicians in charge of repairing all broken equipment at the hospital. Their perspective was important to understanding design considerations for any device we make. They mentioned that machines with complicated instructions (sometimes in foreign languages!) and lots of moving parts often remained broken once they failed. I was impressed with the equipment they had managed to repair, but listening to challenges they faced reinforced the idea that devices must be serviceable for the long term.

As we were heading out, we ran into Dr. Vikal, the head of the surgery at the hospital, who has eight years of experience doing minimally invasive surgeries. He met with us and provided feedback to the MIS team. We soon found out he had no formal training in MIS, but he had been to workshops and bought a box trainer to practice his skills and train his juniors. He invited the MIS team to come observe his procedures the next day.

We left the hospital in the afternoon with a little bit of free time, and Sheetal graciously agreed to provide local shopping advice. We navigated the bustling traffic (both cars and cows) to go to New Street, known for its many jewelry shops. 

Sheetal pointed us to the most reputable places, and also directed us to the restaurant with the best momos of the entire trip. Considering we have eaten hundreds of momos these past few weeks, that is saying a LOT!

That night, we used our usual restaurant selection strategy (wander around until we find some place that looks interesting) to arrive at The Electric Pagoda. I only add this because this restaurant had Jenga to play while we waited for our food! Jenga got so intense that the entire table of European tourists next to us, plus the cat that lived in the restaurant, could not take their eyes off of the game. Then again, the cat may have just wanted Lindsay's tacos. Cats are enigmatic like that.

All in all, Wednesday was a fun mix of work and play, with a hospital visit that helped both teams, and a chance to see more of the city. We're really thankful we have been able to get so much out of our hospital visits while getting to experience what Nepal has to offer!

Back in Kathmandu

So we're back in Kathmandu after having a great experience in Pokhara interacting with FCHV's (Female community health volunteers), medical officers and surgeons. Being in Pokhara was an amazing experience, not only because of variety of health workers we got to meet, but also because of the awesome views, and fresh air! We got to experience walking through rice fields in the rain to get to a health post (and I almost lost my shoes in a stream); which showed us the challenges that people in these rural areas must face to access healthcare. I must admit that although we're glad to be back, we did not miss the smog filled Kathmandu air.

Today was one of the most productive days we've had thus far! The team returned to Kathmandu Medical College to meet up with general surgeons and physicians in the OBGYN department. The MIS team observed a rare esophageal stricture removal, 2 cholecystectomies and a rectal prolapse procedure (all performed laparoscopically); while the Preterm team observed a delivery and got to see the NICU. Unfortunately, Allie was unable to join the us today due to a stomach bug which she acquired after drinking a glass of lemonade with ice last night at dinner. Allie's episode which lasted about half of the day just reinforced how important it is for us to order drinks without ice, or only those made with "mineral water" ice due to the poor quality of the regular Nepali water.

The MIS team met up with Dr. Thapa, a general/GI surgeon, who has introduced a number of different procedures including the use of the SILS (Single Incision Laparoscopic Surgery) port to Nepal. He is a very enthusiastic man, and was willing to answer all our questions and introduce us to his team of 6 surgeons. Dr. Thapa received his training in India and has since traveled to different countries including the United states to learn  how to perform other procedures by observation. Coincidentally, Dr. Thapa had recently received a SILS port from one of the CBID clinical mentors, Dr. Nguyen.

From our observations and discussions with the surgeons, we were able to gain insight into the training pathway to becoming a surgeon as well as the barriers to MIS specifically related to cost, and usability of the equipment. Most surgeons at KMC are confident in performing laparoscopic cholecystectomies, due to the amount of experience they have had over the years (in spite of their limited instrument set). They also perform several appendectomies, hernia removals, cancer surgeries and gyn procedures such as cyctectomies and prolapse procedures. Nevertheless due to cost limitations, surgeons have been forced to create their own innovations such as to use cheap meshes (or no mesh at all) with regular sutures instead of staples. The hospital relies on donated laparsocopic instruments, and is only able to purchase OM surgical tools from India

Because surgeons are paid a fixed salary of $500/month at KMC, Dr. Thapa and his collegues spend the afternoon working at Grande International hospital, a private profitable hospital in Kathmandu, which we were fortunate enough to visit.Unlike KMC, Grande hospitalis equipped with state of the art machines such as CT scans and MRI machines. The OR rooms are comparable to those at hopkins and satitation is taken very seriously, hence the team was not allowed into the NICU.

Our night ended with a wonderful diner and insightful conversation with Dr's Thapa and Dhiresh who have published a book and several papers on surgery together. Coincidentally, Dr. Thapa will be in the US later on this year and would love to speak with CBID students.

Here are some insightful quotes form our conversations with surgeons:
"We don't compromise on patient safety, we compromise on our comfort to reduce cost." Dr. Thapa
"Nepali people have a high immunity, that is why our infection rates are so low. I just change my clothes to keep the blood off, not because of infection." Dr. Thapa
"When your hands are free your mind is free."  Dr. Dhiresh
"When performing MIS, your mind and your assistants mind have to be in parallel." Dr. Dhiresh

The team with Sheetal from Jhpiego, and Dr's Thapa and Dhiresh from KMC after dinner.

Last Day in Pokhara and the Journey Back To Kathmundu

I woke up at the ripe hour of 4:30 to go to Sarangkot mountain. I shot out of bed excited to start the day with a sunrise. Then saw the time and fell back asleep for fifteen minutes. I was eventually shaken awake by Ian and shuttled off to the mountain. When we arrived at the peak of the mountain, the sun had just appeared on the horizon. It was mesmerizing.

Other people clearly like the spot as well. We even saw a wedding!

After seeing the sunrise, we went back to the hotel and took a small nap before we had a Skype call with Dr. Sanghvi. Patience, Ian, and I relayed to him what we have seen so far in our trip. The sterile area of the OT being tainted by people not using their face masks. The difference in laparoscopic equipment from cheap O.M. Surgical to expensive Stryker. How cholecystectomies where done open or MIS simply based on whether a certain doctor was there at a certain time. How the training was done fully through observation, or with a cardboard box to learn depth perception, or using animals for practice. Dr. Sanghvi nodded along to the information and challenged us to go further into technology, maintenance, procedure, and training. We had a lot to look at in the second week. After that we decided to tour Pokhara. We started with Davis Fall a beautiful waterfall with a dark history.

While the wording was a little off( as well as the random switch from Davis to Devis in every poster), it moved me nonetheless. We then went to Begnas Lake a much calmer source of water. After the experience gained by our first venture on a lake, we decided to row ourselves. Which proved aimless at first, but everyone quickly got the hang of it

After an hour of rowing, we were exhausted and ready to head back to the hotel. The next day we drove back to Kathmundu on the way we stopped for chai. We were serenaded with beautiful Nepalese hymns while ordering drinks.

We continued to Manakamana Temple a sacred religious spot located at the top of a mountain. I waited in line to circle the temple while the rest of the team hiked around the mountain. 

The temple was very interesting; it is said to grant the wish of any person who circles it. Many people brought goats and chickens to sacrifice as well. They would offer the blood to god then eat the animals, presumably, to add another blessing. After I went around the temple, the team got back together and took the cable car down to the base.

After this excursion, we continued on the road until we got to Kathmundu. Pokhara was a great city, and it was very fortuitous we were able to see it. Seeing the Female Community Health Volunteers, GMC, and Western Regional was extremely interesting and helpful. However, I was happy to go back to KMC and see a greater variety of laparoscopy procedures than what the previous hospitals had to offer.

Western Style

For our last clinical day in Pokhara, we visited Western Regional Hospital, which delivers  10,000 to 12,000 babies a year.  This caseload places it as the second largest birthing center in Nepal and means that up to 50 babies are being delivered in a day.

Entrance to Western Regional Hospital, Pokhara

One thing that struck me is how involved families are in the immediate post natal stages.   Given the lack of resources to keep babies warm immediately after delivery, babies are sometimes handed over to the family after they undergo post delivery care and drying.  The family's job is to care for the baby as the mother is being transported to a post natal ward to clear space in the delivery room for the next woman in late stage labor.  It really is like an assembly line, and when so many new lives are finding their way, the situation calls for all hands on deck.  Walking through the postnatal wards, it was not uncommon to see a room of 8-10 beds with mother, baby, and accompanying family sitting on the same mattress.  The saying goes that "it takes a village to raise a child."  I'd say that it takes more than a hospital to deliver a baby.

We had an interesting conversation with a group of Skilled Birth Atendant (SBA) trainers.  These trainers were responsible for modelling the correct techniques for natural and vacuum assisted deliveries, as well as evidence based care for the baby immediately after delivery.  In Nepal, SBA trainees practice their technique on real babies most of the time since adequate training models can be hard to come by.  Thus, SBA's sometimes start their formal roles with basic training plus lots of hearsay from their supervisors concerning more complicated cases of delivery or neonate care.

One of the main needs was more manpower.  Looking at paid staff, sometimes the patient / provider ratio could get up to 20:1.  Do you remember the last time you took care of 20 babies? I can't even imagine attempting it!

Talking to staff sisters in the NICU

Probing a bit deeper, we found that the ratio actually much better due to the fact that there are 10-11 additional  sisters (as nurses are called here) who help out each shift.  However, these additional sisters, even though they have completed their nursing degrees, are purely volunteers.  Many of them could not find jobs elsewhere but they still come to give of their skills.  The only compensation is for the sisters who volunteer for the night shift.  At least they get a snack.

As we feasted on Thali, the traditional Nepali spread at lunch,  I thought about how far these volunteer sisters were willing to go in order to ensure that each baby received their chance at life.

Thali with Dhindo-which feels like play doh- substituted for rice

At the end of the day, one question remained: how far am I willing to go?

Not Your Average Field Trip

*UPDATE: We had an awesome few days in Pokhara! Unfortunately, our internet and power were not quite as amazing. Stay tuned for more pictures and posts from our trip!*

I'd like you to take a moment to think about how long it would take you to get to a quality health facility in the event of an emergency.

If you're a relatively privileged person like me, the answer is likely less than thirty minutes. In fact, now that I'm at Hopkins, I can walk to two community hospitals in less than 15 minutes and ride to one of the best hospitals in the world in that same amount of time.

In rural Nepal, it's a little different. Women in labor and patients in need of emergency care have to deal with long treks to reach accessible roads, bumpy car rides in shared taxis, and the threat of landslides during monsoon season. 

We got to experience this journey for ourselves on Thursday when we traveled to a community health post. Just getting there from Pokhara proved to be an adventure. First, we piled into the car for a terrifying two hour trip over single-lane mountain roads. By single-lane, I mean the roads were only wide enough for one car, but still had everything from water buffalo to school buses traveling in both directions at once. We then turned off on to a dirt trail that had flooded so badly that our car eventually got stuck. Our driver managed to free the car, but we hopped out and walked after that. 

We had arrived in a valley of rice paddies nestled in the mountains. It was beautiful- and very, very wet. There had been so much rain lately that much of the dirt path was submerged. With no other choice, we waded through the ankle-deep water and then climbed a hill to finally reach the health post, more than three hours after we left the closest district with high-quality tertiary medical care. 

Nepal's rate of home births is shockingly high, at 64% of all deliveries. The government has an incentive program to cover the cost of delivery and provide transportation vouchers to women who deliver in a government facility. They also give new mothers baby clothes and towels, free of charge. What I realized on this trip, however, is that this is not merely an issue of mothers being unable to afford care. There are huge issues at play here, from transportation infrastructure to uncontrollable factors like the weather. 

After we arrived at the health post, we talked to female community health volunteers, or FCHV's. These are women in the community who devote up to several hours each day providing health education to dozens of families. They check in on pregnant women once a month during pregnancy to ensure they are attending their antenatal visits, and they visit newborns and their mothers to recognize when an infant requires special care. Still, there are limits on what they can do. The primary tasks of an FCHV are to inform and to refer, but they cannot provide much in the way of treatment. Women still have to travel to a health post to receive basic care and a hospital to receive specialized care. 

The FCHV's were inspiring to meet. Their willingness to devote their time to helping other women, without receiving a salary for doing so, has made a big difference in the state of Nepalese healthcare. When we asked them what they needed and what was challenging about their jobs, we found that their most common request was for a way to assess a baby's temperature, but many also wished for a way to ensure safety when they have to walk several hours through the jungle to reach remote families.

After talking to the FCHV's at the health post, we drove to a primary care facility where women with uncomplicatd pregnancies deliver their babies. We talked to more FCHV's as well as the medical officer who oversees most of the deliveries there. Over the course of the conversation, the medical officer's year of birth came up, and I realized that she was only three years older than me! I've witnessed eight deliveries this summer, which I thought was pretty extraordinary for someone my age, but I cannot imagine being in charge of all the deliveries in a rural area less than three years from now. 

We had a chance to walk around the primary care facility to see the very basic level of care they could provide. The delivery room was particularly shocking. The picture below shows a rusty table used for child births that makes the whole birthing process even more terrifying than (I think) it already is. 

Even so, the facility succeeds in delivering healthy babies. While we were conducting our interviews, a mother gave birth to twins. The babies were a little small, but full-term and healthy. When we visited the postnatal ward later that day, we asked her permission to take this photo. (Photo cred to Lindsay for this amazing shot!)

Seeing the twins was a reminder that even in under-resourced settings with equipment we would consider unacceptable, mothers and babies in Nepal are still surviving and thriving. Nepal has made remarkable progress on the maternal and childhood Millenium Development Goals, but much work remains to be done. Our visit helped us understand that global health issues are incredibly complex. Simply designing a low-cost technology will not solve any problems. A solution we develop will have to work in a way that is compatible with the capabilities of primary care centers and accessible to women living hours away from facilities. 

As we drove home that night on the same bumpy road, dodging trucks and avoiding the five landslides that had happened since that morning, I wondered how we could make this work. We're not just up against technology barriers-we're up against everything from politics to the weather! It's a daunting task for a few graduate students, most of us fresh out of undergrad. Still, I am convinced that with everything the Preterm team has seen on these trips, we are going to give this everything we've got. After all, we didn't wade through the rice paddies as just another field trip.