Our last two days in Nepal were spent at the medical colleges. James, Matt and I went over to Kathmandu Medical College (KMC). On the first day our contact Dr. Kirka assigned two interns to show us around the hospitals. The medical education structure is a bit different then in the states, students enter medical school right out of high school, studying for 5 and half years towards there bachelor’s (making them MDs), the last part of their bachelor’s study is an internship which is equivalent to an internship in the US system. They can then specialize in what is called “post-graduation”, the US equivalent of residency.

The interns were extremely friendly and excited to show us around. KMC is a private hospital with a variety of well-equipped facilities; they have a 64 slice CT scanner, ultrasound equipment, and even perform minimally invasive signal port surgeries. We actually had the opportunity to meet the premier laparoscopic surgeon in Nepal, who recently had visited JHU and saw Dr. Cameron perform a whipple.

We were able to get into surgery on the last day, seeing a vaginal hysterectomy and an elective C-section. While they didn’t have the resources and cutting edge equipment that Hopkins has, KCM is still able to provide top-class care to their patients. It is amazing what they can do and how resourceful they are with their limited supplies.

After surgery we meet with a physician who was very knowledgeable about the Nepali healthcare system. He was able to clarify and crystalize for us the capabilities and skills at the different level of Nepal’s healthcare system. Needless to say it was the perfect conversation to end our clinical emersion on.

Hey everyone, we recently got back from a very productive trip to Chitwan, with a little fun thrown in as well. Chitwan is a southern district located near the Indian border and home to a vast wildlife reserve. We headed out early Tuesday morning at 6AM, a little groggy, but soon perked up as we headed out of Kathmandu and the scenery changed. Leaving the valley, we were greeted with breathtaking views of the hills region of Nepal. Five hours and a tasty mid-trip breakfast later, we arrived at our hotel in Chitwan ready for the day. There we met up with our translator, Saroj, who stayed with us during our field visit to help bridge the language barrier.

First off was a visit to the District Public Health Office to meet with officials there and clear our permissions for our various visits. Once we had the OK we headed to Bharatpur General Hospital for a tour of their lab facilities. Dr. N.K. Singh explained their various capabilities at the lab and we were able to get some great input on the point of care diagnostic device. Everything from urine sugar to hemoglobin, we captured all the tests that would be useful for expanding the platform. After the hospital, we took in some of the local culture with a visit to a peaceful temple located nearby. After crossing a rickety bridge and a local cow attempting to maul Matt we made it to the temple where two Hindu deities, Ram and Sita, once lived.

The second day had us back at Bharatpur General Hospital for meetings with the hospital superintendent and hospital matron. After explaining CBID’s mission and the purpose of our trip we dove right into getting feedback on the JHPIEGO needs as well as getting some ideas for other potential projects. Dr. Kiran, head of OB/GYN, was brought into the meeting and provided us with a lot of help, especially on the partogram. I think she will make a valuable contact in the future as we work on our projects, having significant research experience.  Next we visited the primary health care center in Shiva Nagar to gain a better understanding of how things work in the rural setting. Seeing a PHCC firsthand gave us the exposure to the potential setting where some of our projects could end up. After this it was back to Bharatpur and to their maternity ward. Unfortunately we missed out on the deliveries that day but were still able to get some useful information from a tour and some conversation.

The third day of our visit started with a visit to the Bacheuli sub-health post which got us in touch with the roots of healthcare delivery in Nepal. Here they are faced with a lot of constraints surrounding healthcare including availability of materials and especially of skilled labor. We got an in-depth overview of the female community health volunteer’s responsibilities which helped us understand how best to deploy our potential technologies. Overall it was a great trip to see the lowest level of healthcare which services so much of the population.

After this we headed to Tiger Camp for our quick Chitwan safari getaway. Thursday afternoon we took a relaxing canoe ride down the Narayani river before starting our three hour jungle trek. We were on the hunt to spot some of the local wildlife which includes tigers and rhinoceroses, but ended up mainly seeing some of the local deer and a few tree monkeys. Nonetheless, it was spectacular scenery and a great chance to get in touch with our inner conservationists. After a scrumptious dinner we headed into town to watch the locals perform their “stick dance” cultural show which was great and performed excellently. We hit the sack early after that for we had exciting morning plans: elephant riding. These guys were huge, and our first time seeing them in person, but we quickly got the hang of it. Each elephant had a platform strapped to their back which we got to sit on as the local “driver” directed the elephant. We headed into the jungle in an elephant caravan and were quickly having the time of our life. Not only did we get to march through the jungle, but we even got to scope out a rhino and her babe up close and personal. While Shoval and Sean had the larger elephant, Elias, Matt, and I rode the most feisty beast, at one point letting out an ear-shattering roar to ward off some nearby wild boar. Almost two hours later, it was over and we were hoping for more. A quick feeding of bananas kept the elephants happy and we parted ways.

We hopped in our van and headed back to Kathmandu for what turned out to be a seven hour ordeal due to some traffic issues on the mountain roads. Despite that, we made it back to Kathmandu and the KGH in time to relax Friday night. Check in later for more pictures on our Chitwan trip

-James

First off, I must apologize for the gap in recent posts from the Nepal crew.  It’s hard to believe how fast the days have been stacking up, but I think that only means we’re filling the days with valuable clinical feedback.  Also, unlike the 2-hour scheduled power outages, internet availability was much harder to predict during our time in Chitwan, which I’ll touch on in a bit.  First, I wanted to touch on what James and I have been doing at the Teaching Hospital, apart from the other three CBIDers at the Maternity Hospital.

Heading out in rickshaws Sunday morning.  I let our driver know I knew a few things about bicycles, and he was easily persuaded to let me pedal for a few miles.

As Sean mentioned, James and I did have an interesting trek up from our meetings to the Teaching Hospital, which was about as far across town as you could get.  We hiked for a few miles with our trusty city map through back streets, miraculously ending up on a familiar main road.  We bargained a price with a taxi (unaffected by the strike?) to take us the remainder of the distance.  After a quick lunch, we met Dr. Mita Singh, our primary contact throughout our visit, who had coordinated a small time slot for us to give a presentation at their weekly departmental meeting.  While we were expecting a smaller group, James and I arrived at a board room occupied by about 20 residents, and 10 physicians and staff nurses.  We jumped at the opportunity to spread the word about CBID and our five main projects, and opened up the floor for discussion.  One resident, Dr. Poudel, was particularly vocal in voicing new ideas and we plan on keeping up with him through Skype.  After 15 minutes of insight, the meeting resumed to its original business of covering activity for the past week, so we were able to pick up some first-hand stats and special cases.  For example, there have been 6 cases of postpartum hemorrhage this month.  Following the meeting, we headed to the maternity ward and were hard-pressed to find much action (most business occurs in the morning and it was already 2 pm).  Still, we used the downtime to our advantage and interviewed three nurses about our projects.

Once we got back to the guest house, we met up with the rest of the crew, Dr. Acharya and Dhananjay included, to digest our past days’ work and discuss the state of each project.

Monday was also a productive day.  We saw Dhananjay off after breakfast, knowing we were losing a huge asset in the short term, but gaining a major lifeline for our projects in the long term; then, we hit the hospital.  James and I began with a tour of the Family Planning clinic and were given several helpful demonstrations about the currently available contraceptive methods.  We also had the chance to observe an IUCD placement.  Then, we migrated back to the maternity ward where things had picked up from yesterday.  There was a C-section underway, but we were unable to observe due to a lack in surgical gown supply (a potential need?).  Instead, we observed the general workflow in the ward and had a very nice conversation with a student of one of the three nurses we met yesterday.  She provided some social and economical commentary on contraceptives to go along with the functional training we received earlier on in the day.

It was hard to believe, but our time at the Teaching Hospital had come and gone and we said our good-byes and presented Dr. Singh with a parting JHU gift.  She was able to accommodate us so well over the three days, and we definitely look forward to remaining in close contact with the Teaching Hospital as we develop the global projects.

The rest of the day we took to meetings with the rest of the group.  The first was with the Nepal Society of Obstetricians and Gynecologists.  Due to heavy traffic, the meeting was strapped for time, but it was clear that the women knew their fields well.  I thought their adamant attitudes showed through well to provide pushback and pertinent questions to our projects, especially the e-partogram.  They really challenged us to think about the target user of the device and how we thought it would fit in at the middle and lower levels.  Very good feedback.  The second meeting with Nepal Family Health Program (NFHP II) was less clinical but expanded our knowledge of the healthcare system.  Information about the availability of drugs at the lower levels, as well as price points of contraceptives were only some of the tidbits that came out of this meeting.

-Matthew

P.S. I wanted to post more pictures, but my new computer is not compatible with my Sony camera.  I’ll figure this out when we get back and add pictures in where I had planned.  The pics I used are courtesy of James.

P.P.S. Sorry if this was too long-winded to be considered a true blog, but I decided our second clinical site merited a good bit of detail.  I’ll add our expedition to Chitwan tomorrow, after our meeting with Harshad from JHPIEGO.

Corny title, but too appropriate for me to pass up (more in a bit)

Britni arrived Friday night (the 13^th) with her friend Dan (Who’s also going to be taking pictures for Jhpiego…don’t worry, I don’t think he’s eligible for the picture contest). Saturday is the (only) weekend day in Nepal, so we had the day off. The other 4 CBID-ers and I took the opportunity and went on a special trip in the morning (I’m sure you can figure it out from the posted picture below…). When we got back, Stephanie and I had lunch with Britni and Dan as an orientation for those two. We got them caught up on the proteinuria study and went over the basics of living in Kathmandu. After lunch, the four of us headed over to the Maternity Hospital to show Britni and Dan the lab and to check some testing results from the day before (the Esbach test, our “gold standard” we are using, requires mixing urine with chemicals and letting it sit for 24 hours). Once we were finished, Britni, Dan, and I caught a cab back to the hotel to meet up with the rest of the CBID-ers and Dhananjay (the J&J rep spending a few days with us). With some free time to kill, we decided to go check out one of the nearby temples. Dr. Acharya had arrived by the time we got back to the hotel, so we all relaxed at the nearby bar until it was time for a traditional Nepali dinner with Stephanie.

Sunday (the 15^th) is when things got a little interesting. I’m not an expert on recent Nepali history, and I apologize if this account is not completely accurate, but from what I’ve gathered Nepal used to have a king and a parliament/prime minister until 2006, when the king was forcibly removed. The people of Nepal have been trying to draft a Constitution ever since, which has been difficult with many different political and ethnic groups vying to get their voices heard (Nepal has over 100 ethnic groups, and there are some who believe Nepal should be divided into different states for every different ethnic group). Some of the ethnic groups organized a transport strike for Sunday, which means that no cars or motorcycles would be allowed on the streets (not enforced by the government or anything, but the people of Nepal generally support these strikes and Stephanie told us a story of her friend who was driving to the airport at 4am during one of these strikes and had a brick thrown at her car). Without any taxis to take us to our meetings, the nine of us (5 CBID-ers, Britni, Dan, Dhananjay, and Dr. Acharya) got a few rickshaws (3-wheeled bikes with a two-seater in the back) together to get to our meetings at the Ministry of Health. We met with the directors of the Family Health Division and the National Public Health Library, who gave us a lot of good information on the 5 Jhpiego projects and a few other needs.

From there, Elias, Shoval, Britni, Dan, and I walked over to the Maternity Hospital (fairly close by, took about 15-20 min…I’m sure Matt and James’ journey was more interesting- their hospital was further away) for clinical visits and proteinuria study. I observed a birth in the labor ward while Elias and Shoval observed the Neonatal Care Unit. I also helped Britni with testing more urine samples. When we left the hospital there was a reasonable amount of traffic flow (this strike turned out not to be too strict- even in the morning there were a few motorcycles on the roads) so we hopped in a cab back to the hotel.

-Sean

Typical Saturday morning flight in Nepal.  Guess which one is Everest.

Since my adventures in Kathmandu have been a little different from the rest of the group, I thought I’d give a short summary of my time here. We arrived in the afternoon on Wednesday and settled into the Katmandu Guest House. While the rest of the group was out shopping and exploring Thamel, a worker from Jhpiego named Tharendra escorted me to the Maternity Hospital (also known as Prasuti Griha) where I will be working on the proteinuria study. At the hospital, I met another Jhpiego employee, Sheetal, who has helped to organize the study at the hospital and showed me the space that I will be working in. It’s a small side room near the pathology lab which has space for 2-3 people to work in (more than enough for us!). Sheetal has been nothing short of amazing. The space had been equipped with all of the supplies that I needed (including some that I had forgotten to mention!). Sheetal and her colleagues had also created a folder with all of the study protocols, the schedule for the entire two week study, and they even organized a research assistant to help us out for the two weeks! Afterwards I headed back to the hotel for our first meeting with Stephanie. When she arrived, we headed over to a nearby restaurant called the Factory and discussed our plans for the clinical rotations. The rotations were just as well organized as the proteinuria study! Stephanie gave us packets with background info on Nepal, directions to the hospitals and offices we will be attending, and schedules for basically every hour of our stay (including places to eat and approximate times we should leave from the hotel/hospitals/etc to get to the hospitals or our meetings on time). 

Thursday was a pretty exciting day. In the morning I headed out on my own to the Maternity Hospital. I had a meeting with Stephanie and Sheetal with Dr. Lata Bajracharya, the director of the hospital! It was only a short 10 minute introductory meeting, but again more than I was expecting. Afterwards Stephanie and I rode over to the NSI to meet the rest of the team for our meeting there (Elias previously talked about that…). We had lunch and while the rest of the group had their meetings with MIDSON and PSI, Anjana (the research assistant) and I started testing the first urine samples for the study. It’s too early to really tell, but the results are looking pretty good.

Friday morning I headed over to the Maternity Hospital along with Elias and Shoval. The three of us attended what we would consider grand rounds, where the doctors went over the cases in the different wards over the past 24 hours. After this we toured around with Dr. Kusum Thapa. She showed us the maternal ICU and a delivery ward. She knew about the potential projects from Jhpiego and was able to give us a lot of good information about the tamponade and the electronic partograph (how they are currently used and how they can be better). Around noon, I started testing the next set of urine samples with help from Anjana, Elias, and Shoval.

Right now I’m relaxing with the other guys in a hookah bar near the hotel, sipping on some Nepali tea, and listening to KE$HA. Britni (the design team leader for the proteinuria pen) is flying in tonight to help with the study.  I can already tell it’s going to be a little crazy running around Kathmandu for clinical rotations and this study, but it should be a lot of fun J 

And to Marybeth, Dr. Acharya, Dr. Yazdi, and everyone else who helped to organize this trip, I hope this can help put everything in perspective: I have been working on the proteinuria pen for two years and I sincerely believe I have learned more about healthcare in developing nations in the past two days than I did in the previous two years researching about it (and we haven’t even gone out to the rural areas yet…) 

 -Sean

 P.S Yes, I went for the sentimental send-off (I did mean it!)

 P.P.S For those that are unaware, “Seamus” is a nickname some of my friends came up with.

Our first day on the job began with a trip to the Nick Simons Institute (NSI), an organization dedicated to training and supporting skilled, rural health care workers. We caught a cab to a part of town called Jhamsikhel and miraculously only got lost once; a short phone call to our contact Stephanie got us to on track and promptly to our meeting.

NSI gave us an overview of health care structure in Nepal. Kathmandu and six to eight major cities constitute “islands of excellence”, areas where patients can receive high-end care such as open-heart and orthopedic surgeries. City hospitals are either run by the government or private entities, majority being privately run. Moving away from the cities towards the rural areas, the majority of health care is provided by the government. Rural health centers lack the equipment and personnel to adequately deliver care to these areas. Geography and Nepali terrain are some of the major challenges that have created this gap between rural and urban health care.

With a basic understanding of the Nepali health care infrastructure, the conversation turned towards specific challenges facing the NSI.  Maternal health, waste management and training health care workers were some the issues discussed, giving us a good foundation to purse these unmet clinical needs. 

Before heading off to our next meeting at the Maternity Hospital (Prasutti Griha), Stephanie took us out to lunch to a little Japanese place with a breathtaking view of Kathmandu valley. Even though it is monsoon season, the sky was crystal clear and the “hills” overlooking the valley made us understand why some members of NSI originally came to Nepal for a few weeks and ended up staying for 25 years.

After delicious lunch we caught a cab over to the hospital where we meet up with Dhananjay from J&J India who would join us in our meeting with MIDSON (a Nepali mid-wife organization). We had a very productive discussion about several of the Jhpiego projects. We picked their brains for specific design inputs that would allow these devices to have the greatest impact in Nepal.

Our last meeting of the day took us all the way to the northern edge of town, to the footsteps of the Himalayas and perhaps the greatest view on the planet. Population Services International, an organization that deals with family planning as well as malaria prevention and safe water education, discussed the implantable contraceptive with us. It was another fruitful discussion that gave us a lot of good information about not only what value the implant would need to provide, but the innovative business model needed to make the implant successful and sustainable.

Armed with the knowledge from all these meetings, tomorrow looks to be an exciting day as we begin our clinical immersion and get to see the clinical needs of Nepal first hand.

Packed in on our way into town

Yesterday started very early for both the India and Nepal groups when we were up at the wee hours of dawn and off to the airport for our flights. The rest of the Nepal group and I flew out of Mumbai International with Jet Airways, and we were fortunate enough to all get aisle seats (thanks Marybeth!). Three hours later we were close to Kathmandu and it was awesome to see the foothills of the Himalayas (Fulchowki, Chandragiri, Shivapuri, and Nagarjun) as we approached.

Once on land, we collected our bags and headed through customs to make our way into the city. We ended up getting a van to take us and small doesn’t even begin to describe it. I’m not sure how we packed six people and our bags into this thing, but we managed for the short trip to Thamel and our lodging, the Kathmandu Guest House (KGH). This place is great and perfect for our needs for the next two weeks. It has an outside restaurant along with a few relaxing gardens, and to top it all off it sits right in the middle of the tourist district.

We had until the early evening to get settled, so after a scrumptious lunch of Indian and Nepali cuisine we headed into Thamel to see what the town had to offer. Shop after shop after shop was all you can see in every direction! From mountain climbing gear to hand carved Nepali trinkets, the streets were lined with everything under the sun. We poked around for a while trying to soak it in before we headed back to the KGH to get ready for our meeting with Stephanie.

The streets of Thamel!

Stephanie from Jhpiego met us at the KGH and we headed out to a local restaurant called the Factory to discuss our plans for the next two weeks over drinks. We all sampled the local tea selection which was delicious. We talked about local customs, crazy taxi drivers, and general etiquette as we prepared for our time in the local hospitals. Today we are going to meet several organizations based in Nepal which deal with providing healthcare to the local people. We finished up by discussing our plans to visit Chitwan, located in the South. After we broke we headed back to KGH for an early night to get ready for today.

Check in later tonight for how our meetings went…

Hey all,

Welcome to the gateway of information about all things CBID in Nepal!

For the past two days, we have been piggybacking off the Indian group.  We’ve been very fortunate to have such welcoming and knowledgeable hosts from Johnson and Johnson in Mumbai.  There really couldn’t have been a better primer for the rest of the trip, as we have been educated on everything from critical clinical areas of need to the specific market dynamics unique to Indian healthcare.

We’ve also been taking in some of the sights, sounds, and especially tastes that Mumbai has to offer.  Yesterday, we visited the Gateway of India and Cafe Leopold, and digested the day’s material over some authentic delicious cuisine.

Today, we began by meeting with a VIP exec from Johnson & Johnson India who took us in for a closer look at some of the emerging markets.  Diabetes, oral cancer, and other things we might see as “western lifestyle” diseases are very real in India, and in need of low-cost, far reaching solutions. 

Then, five of us who participated in the Radiation Oncology elective rotation at Hopkins took a trip to TATA Memorial hospital in Mumbai.  TATA is a trust hospital, or semi-government facility, backed by both the Indian government and the TATA corporation.  Here, we observed a very high degree of care and technology reaching those below the poverty line, who have very little or no means of paying for care.  It was a truly eye-opening experience to see the wall to wall expanse of patients waiting to see one or two physicians.  A very nice doctor was able to meet with us in order to discuss potential project ideas and future collaborations, and we’re eager to build many more connections.

It’s getting quite late, and I could go on for hours…but check back soon because tomorrow the need-seeking animals of CBID will be unleashed on Nepal!

P.S. Pictures soon!