The news this weekend from Nepal compels me to write another entry to this blog.  In the wake of a magnitude 7.8 earthquake, Kathmandu and more rural settlements to the west have suffered major damage.

A doctor I worked and prayed with while in Nepal is living out of doors in a tent with her elderly parents, and last night the heavy rains added to their misery.  AS the New York Times headline announced today "Everyone is Scared."

Please join me in supporting the people of Nepal by donating to World Vision's relief efforts.  Link is here.

Back Home

I want to thank all of you who've followed my Summer of Service.  I returned back home on Saturday August 30th and am acclimating to life in the US.  I'll continue to share reflections on the summer and follow ups on my Google Plus page, but a few thoughts for my final post on this blog:

• your talents, not just your money, are needed in the struggle to improve global health
• find a way, however small, to get involved - in your local community, or in the global community

Take care, and thank you!

Women: Appreciate Yourself Day!

We have a day in Kathmandu before we leave for home.  We decide to start the day at Swayambhunath, the monkey temple, which gave us wonderful views of the city after we climbed its 365 steps.  It was a trip down memory lane for me, since Sandi, Maggie and I visited this temple together back in 2001, when Maggie was a little girl of 7 and we were living in Singapore.

  Left, the monkey temples main resident, right, the stupa at the top of the steps

Kathmandu (just a small part of it), seen from the monkey temple

Buddhists believe that prayers inscribed on wheels spin off into the universe when the wheels are turned.

As we entered Kathmandu Derbar square we started to see throngs of women, of all ages, dressed in red, on line to purchase offerings and dancing in groups in the square. Today turns out to be "the festival of the women."  The hallmark of this festival is that women come together and dance in groups.  The dance is unique - while the women dance together, the dance is individual, not coordinated.  As I think you'll see in the video, the women seem to be appreciating themselves on their special day.  This culture puts a big burden on women, so having at least one day to celebrate themselves seems like a good idea to me!

After being in throngs of women for 40 minutes or so with loud music and quite a bit of shoving, I needed to, well, have my head examined...watch the video:

Then we did some shopping.  Since we three guys were on our own to shop (and we couldn't really consult any of the women around - they were busy) we may have made some questionable purchases.

I was tempted...

Good-byes, or total tikka

Monday was our last full day in Achham at Bayalpata hospital.  It was a week of goodbyes, first to our hospital director, Dr Cam Bopp, who left for Liberia to set up a hospital in the Ebola zone, and now us.
The acting hospital director, Dr Sampurna, informed the staff that there would be a program in the afternoon.  We gathered together after a really hectic day trying to complete last minute tasks in the operating theater and the inpatient ward, and were surprised to find Dr Sampurna in a speech making mood.  He very kindly and movingly spoke of our time in Achham, how we had become friends, and how helpful the work we had done was.  Jess Kribbs from the US, who leads finance and HR functions, thanked us for making her life easier, and integrating into the operations of the hospital.  Dr. Deependra, surgical head, thought the staff should take a lesson from the fact that we didn't have a boss here to look over our shoulder, but got good work done anyway (hint!).  We impressed on the group how very talented and capable they are, and that carrying on the improvements and recommendations we've made is now in their hands.

The final good-bye ceremony was the application of tikka to the foreheads of each of the three of us, by about 40 members of the staff.  By the end of it our faces and much of our clothes were covered!

We ended the day with chicken momos (Nepali steamed dumplings), some chalk drawing and a bit of football (Nepali style).

Tuesday morning we said goodbye to our home and friends of three months.  Thula, 13 years old, pictured below, got a lot of hand me down used clothing and gear from the three Merck fellows.  While I feel like a part of me remains in Achham, and I already miss the place, I am SO looking forward to coming home!  We passed through Dhangadhi and are in Kathmandu, leaving for home or next destination at the end of the week.

 Dr Sampurna applies tikka to my forehead during the going away program

Thula (right)

Thoughts on Leaving Achham - Gratitude, Limits, Love

We have one week to go in Achham, after which we make our way back the way we came, to Dhangadhi, Kathmandu, and thence to USA and the Netherlands.

Feelings are mixed on my part, and I think that of my teammates as well.  We're really looking forward to seeing and talking to our wives and many other loved ones, having a real mattress and a flush toilet and dining without flies.  But we'll miss the hospital, the doctors, nurses and administrators, and those of the patients and community members with whom we've managed to communicate and form a bond.  We feel we've been privileged and blessed to have an opportunity to make an impact here.  The truth of that came home a few evenings ago in the Emergency Department when a 14 year old girl with a collapsed lung needed a piece of equipment that was right where it was needed, which was an improvement, but nobody knew it was there. We solved the problem so the girl's care wasn't impeded, but we learned, again, that we still have work to do.

We've made recommendations on the management of the hospital - who does what, how it gets done, how communication at various levels can be improved.  Several of these have been implemented, with good results, to our delight.  We reorganized the way medicines are procured, stored and distributed, how inventory is tracked and managed.  We've instituted a standard formulary so everyone knows what is supposed to be in stock, and uses the same name to refer to each item.  We designed and installed storage units for the places where medicine is dispensed, and trained personnel on keeping stock.  We've installed and configured a stock management software system and trained the staff.

We've helped the hospital to get the ball rolling on the purchase of a new generator so power will be less of an issue in the future, and we've laid out a strategy so the hospital can ensure quality of its medicines while simplifying and streamlining the procurement process.

Yet every day we realize we could do more.  There are the young men in the stock room, Min, Purna, and Dinesh (from left), who we could train just a bit more.  There's the Procurement Officer, a position we recommended and which was filled three weeks ago by a young man named Nabin (right), who I'd love to have another few weeks to coach.  There are refinements to processes and improvements to procedures we'd love to implement, but these things will have to be left to others.

As a good friend periodically reminds me, Mother Theresa once said "We cannot do great things.  We can only do small things with great love."  While I am called to do my part with diligence, it is God who gives sight to the blind, makes the lame to walk...

So I'm back to the theme of a previous post - limits.  My time here is limited; my talents, foresight, and plans are limited, so my contribution will be limited.  I am coming to peace with that again in a new context.  One aspect of this reflection has been the realization that my limits have changed; they've been explored, scouted, and in some cases pushed back a bit.  I know with greater clarity what I am good at, and what I'm less good at.  I have a better sense of where to contribute, where to put my gifts to use in the service of global health. Somehow, I have these insights more readily when I'm well out of my comfort zone, as I think is true for many of us.

The last reflection I'll share is that the Bible teaches that love is a verb.  It's not just a feeling.  Caring for the basic needs of our fellow men is an act of love which the people at Possible do every day.  It was a privilege to join them in their work.

Hike to the Buddha Tree

Yesterday was our second-to-last Sunday in Achham.

Ever since we got here, I have been admiring a huge tree at the summit of the hill across the valley from where we are staying.  It's massive, appears to be perfectly round, and is positioned at the very crest of the hill.  It seemed to be calling me.  I learned from my friend Umanga that these trees are called "Buddha," "Bodhi," or "Pipal" trees, and have been planted for thousands of years for people to sit under.  They are remarkably cool and are thought to have antihistamine properties.  This type of tree is sacred to Buddhists as it is said that it was under such a tree that Buddha achieved, or received, enlightenment.

Nardi pointing at the Buddha tree on the far slope

Yesterday Nardi and I set out to walk up to the Buddha tree, which we learned is in the village of Nawathana. What a great adventure we had!  We set out at 11:30 AM and walked down the hill to the river that feeds the Buddha Gangi for the first part of our trip.

Once in the valley, we had to walk across rice paddies.  Nardi took a little spill and his camera wound up in the rice paddy, but we're hoping the pictures can be salvaged and the camera is covered by insurance.  We had to cross the stream, which was running much higher than our last hike in this direction a few weeks back.  During the crossing, Nardi lost a shoe (which was recovered by a little boy who was bathing downstream) and a sock (which wasn't).  So my intrepid hiking partner walked the rest of the hike in a wet shoe and one sock.  What a trooper!

 Nardi in the river that ate his sock.  The boy to his left retrieved his shoe.

The shoe rescue made the river warrior band quite proud.

As we gained height on the opposite slope, the way became steeper, the sun stronger, and the hospital gradually came into view.  What a wonderful perspective we had on our little community!  We passed two homes with enough English to confirm that we were on the right track, although the path at times was so steep we weren't sure we were going the right way.

After several rest stops and more climbing than we had counted on, we made it to the Buddha tree. The views were astounding!  We saw our home for the past three months, Bayalpata hospital, from a completely new perspective, we shared great conversation, and we had a great workout.  The hike to the summit took about 4 hours, and we hiked back down to Sanfe Bagar in about 2 hours.

Bayalpata hospital from the Buddha tree - the hospital is in the clearing on the opposite slope

 The Buddha tree

Panorama from under the Buddha tree

2nd Merck Blog: RTC Fellows at Work and Play in Nepal

Here, dear readers, is my 2nd Merck blog:

In my last blog I promised that I’d use this post to explain what we’re doing here at Bayalpata hospital in Achham, Nepal, in a bit more detail.  I’m also going to share another fun part of our Richard T Clark Fellowship experience with you – our four day trek in the Annapurna Conservation Area.

The first draft of our work plan for Possible Health was refined in a series of meetings with the CEO and one of the founders of the NGO before we left for Nepal.  There are two main work streams: improvement of the internal and the external supply chain.  Internal supply chain improvement includes clean up and organization of the hospital’s stores, and implementation of a software system, business processes, and Standard Operating Procedures to track inventory of pharmaceuticals and supplies.  External supply chain involves the development of a comprehensive strategy for sourcing of medicines and medical items with the goals of ensuring quality, lowering cost, and improving service.  While all three of us worked in both areas as needed, we decided it would be helpful to have a leader for each workstream.  I’m leading the external supply chain strategy development and implementation. 

We hit the ground running on the way into Nepal.  During our first week in country, we benchmarked external supply chain best practices at several large hospital systems, and met with government and private suppliers in Kathmandu and Dhangadhi, the closest big city to Achham.  Armed with a better understanding of the Nepali pharmaceutical business and regulatory context, we came up with an improvement strategy for the hospital.  In a nutshell, the new strategy involves consolidating procurement to a few larger, trusted generic pharmaceutical manufacturers and arranging to negotiate terms directly with the manufacturer.  Last week, we met with the sales divisions of each of four large Nepali manufacturers, as well as an importer for Indian and other international manufacturers.  We also visited and inspected three Nepali pharmaceutical factories.  The purpose of the site visits was both to assess fitness of the manufacturer to become a long term supply partner for the hospital and to provide improvement suggestions to the factory staff.  We were pleasantly surprised at the state of equipment and procedures at the manufacturers’ sites and at their willingness to be a partner in executing the hospital’s strategy.  We’re now awaiting quotations.

The three of us have also had the opportunity to assist Possible Health in a way that was not in our original work plan.  Our experience with team and project management, as well as the business acumen we’ve developed at Merck, has enabled us to be effective management consultants to the NGO’s senior leaders.  We’ve made recommendations related to roles and responsibilities, division of labor, and work flows and talent management which have been accepted and quickly implemented, to our delight. 

After working for six weeks on all of the above with only two days off, we needed a break!  On our one week leave, two of us (Bryan and me) went to Pokhara while Nardi visited with his wife in Kathmandu.  While in Pokhara, Bryan and I embarked on a four day trek in the Annapurna Conservation Area.  We were truly blessed to have clear morning views of the snow-capped Himalayas, an unusual sight during the monsoon season.  Four days of vigorous hiking, including an elevation gain of more than 6,000 ft, was also a great workout!  Here are some pictures that give you a flavor of our wonderful four day trek:

                          

Bryan (left) and Philip (right) and two friends we made on the way up Poon Hill at 4:30 AM for a sunrise hike.

Annapurna South (left) and Himchuli (right) from Ulleri on Day 2 of our trek