It was Wednesday, and I was sitting under the merciless Nepali sun, my pasty Irish complexion slowly roasting to a crisp red, chatting with the ladies of grade eight by the football field. Just as I started to contribute to the turning of the Bhalchandra School rumor mill by inquiring about a hush-hush puppy love courtship among two of the eighth graders, one of the younger players howled; I turned to see him stumble toward the edge of the field, a limp hand dangling awkwardly from an outstretched arm. Nick, stopping the play to address the wailing, sat him down on a shady stone and asked what had happened. He continued to moan, the slack hand was becoming more apparent. The sleeve of the sweater (yes, he was wearing a sweater playing soccer as I sit on the sideline sweltering) was sheared to expose the damage: a grotesquely apparent, shouldn’t-be-there kink contorted his frail forearm.
Pre-Break: Ominous walk to the soccer field.
I turned and trotted down the main/only village road, looking into all the local tea houses hoping that I would stumble upon Kriti, the closest medical care provider. Kriti is a 21-year-old Auxiliary Nurse Midwife (ANM) in training, completing her On-the-Job training of five months under PHASE while living in the village. We had shadowed her days before at a nearby outreach clinic that she mans on a weekly basis, a sparse but clean and efficient one room medical office in which she saw patient after patient, most of them older men and women who came for follow-up visits to refill medication and track symptoms. No emergencies to be seen that day. We later learned that some of them had to walk significant distances to reach the outreach clinic, despite their age and ailments. The outpost is of great value, as the next provider, a larger medical post, is about a half hour walk up the road. Stumble upon Kriti I did, discovering her in the canopy of a tree off the side of the road about a third of a mile away from the incident. She was hacking away at the highest branches.
“KRITI, SOMEONE BROKE THEIR ARM IN HALF.” My rushed and slapdash-shouted English was hard to follow (even more so than my usual quick diction).
She continued to lop off branches.
“KRITI,” more slowly this time. “SOMEONE BROKE THEIR ARM IN HALF.”
I pivoted and ran back, with Kriti (I assumed) following. It was her last day in the village, as she had just completed her training, and was set to return to Kathmandu the next morning. I arrived back at the scene to find that a crowd had gathered around the broken boy. Several of the onlookers decided to take a more hands-on role in the situation, and one woman (who we later found out to be the aunt of the boy) was massaging the break. As Nick and I tried to disperse the crowd and prevent any more fracture-kneading, I asked if anyone had called an ambulance. There were a few confused nods, confirming my suspicion that no, no one had called an ambulance. While in the states, there would be no question as to whether an ambulance would have been called, or at least a car prepared to take the boy to the hospital, it was a question without any definite answer in Rayale.
This, upon reflection, sheds light on the true meaning of the frequently discussed community health buzzword of accessibility. In places even as rural as the small village of Manadhova, which, thanks to it’s proximity to Kathmandu and the frequent buses to the nearby city of Panauti, is not considered very rural by many standards, accessibility is simply too limited to ensure quick care for real medical emergencies. We were in luck to be close to the main road and within a 5-minute walking distance of Kriti and her house full of supplies. While the boy was soon whisked away by motorcycle to a hospital about an hour away, the time elapsed between fall and arriving at the hospital was, as precisely as I can remember, a very, very long time. While there is an ambulance that services the area, it takes, at minimum, half an hour to arrive. Having traveled to some of the students’ homes higher in the hills of neighboring villages, it’s clear that a more immediate medical emergency in a harder to reach area (of which there are very many) could not be handled as straight forwardly and as quickly.
Before the boy was tossed atop the bike, Kriti soon arrived, looked at the arm with a empathetic mien of pain upon her face (precisely the same face as Nick displayed upon seeing the arm) and took a (painfully) bumpy walk with the boy to her nearby place of residence as she held a make-shift notebook-and-string splint. There, she quickly addressed the arm with a expertly-applied sturdy cardboard splint and a gauze sling.
The broken-arm incident naturally made the idea of the lack of healthcare accessibility a very clear one. While, in places like the U.S., financial barriers are often the ones preventing needed care from being received, we witnessed a situation where the geographical obstacles were the more immediate concern. Even without a single thought to the financial aspect of care, the boy probably could not have received care any more quickly. Of course, in places like this, both financial and geographical barriers are hinderances to receiving proper and needed care.
Nick, what do you got there?
A few days later, Nick and I trudged up a steep and rocky hill not without difficulty a ways away from the football field to the home of the boy; it was certainly not an easy walk. His hand and fingers were shades darker and clearly very swollen on the broken side than on the non-broken side, and he told us he didn’t feel any better and that the pain hadn’t subsided. He would be out of school for two months due to the injury (it was his writing hand, and, moreover, the walk to school was not a short one). In the same room, his incredibly petite and very elderly grandmother lay bedridden and unexpectedly talkative, a outmoded-looking green tank providing her oxygen through a nasal cannula. As I sat on the bed by her, I wondered how they got the tank, and her, down and up the steeply rugged path to the house; yet another medical concern exacerbated by the hard journey to the closest provider.