August 9 – Powerful Deterrents

So today, we went back to Patan Hospital to sign Dr. Bishnu’s training agreement. I also found out that Director Shrestha, while the Patan Birthing Center undergoes renovation, is working as coordinator of the night shift nurses. Unfortunately, that means that I have to show up either really late at night or really early in the morning. (I’ll be going at night, since there’s no way I’m waking up at 5AM).

To finally put some closure to the MDGP scholarships, I also went to NSI (The Nick Simons Institute) to sign our agreement with Dr. Zimmerman (and pick his brain about some clinic legal issues). One of the issues we discussed was medicolegal aspects of the clinic: how to deal with malpractice suits. Personally, I was curious about this as well, since I knew that Nepal was not a sue-happy place like America. Dr. Z enlightened me about the way things are done here: no doctors have malpractice insurance. The Nepalese don’t really sue in this department, and the law is somewhat loose as well. Apparently, until 15 years ago, medical malpractice had to be tried under assault and battery statutes. Even now, cases are seen more in the sense of consumer protection laws.

On the other hand, the Nepalese are more willing to take matters into their own hands. Should an egregious case of malpractice occur, threats, vigilante action, and out-of-court monetary demands are common. A more powerful deterrent is the press: families with connections can publish articles defaming physicians for their negligence. On top of being completely in the hands of the writers, such measures ensure humiliation and the fact that the doctor will probably be unable to practice in that city again.

That’s some scary stuff.

August 8 – Back in the Groove

After spending a day finalizing the agenda for my last week in Kathmandu, I got back in the swing of administrative duties, which was rather tough after the somewhat slow pace of life in Achham. Today’s agenda, however, took me through some areas that made me realize that there was inequity in the cities as well.

My first stop was the Nepal Medical Council, found all the way across town in Bansibar, Maharajgunj. For some reason, there was a massive traffic jam in central Kathmandu, so my cabbie made me a deal: he would work for a flat fee if he were allowed to take the side streets to save time. One of the rules of Nepalese city life (for foreigners, at least) is to go by taxi meter, but given the circumstances, I agreed. Doing so, he took the backroad (road is a relative term here—it was basically an unpaved rock path) that followed on the banks of the muddiest, brownest river I had ever seen. Trash literally made of several of the banks, and an overwhelming stench of waste (both industrial and human) hit me full-on. Nevertheless, hundreds of people were still making a living here. Young men waded in the shallows with nets, trying to catch something (I couldn’t believe anything could possibly survive in that river), while old women washed their clothes in the putrid water. Children splashed each other on the banks, shadowed by tin-and-cardboard shanties that looked like they may fall over at any moment.

“I asked to come this way because you told me you’d been in Nepal for a while,” said the cabbie, noticing that I was staring. “I usually don’t take foreigners this route.”

We then veered back onto the main road through a winding alleyway, and I was amazed by the sudden transformation. Bansibar is where many of the major embassies (French, Australian, Japanese) and organizational centers (Councils of Medicine, Nursing, Water) are, and the neat row of houses, sparkling government buildings, and shops were a stark contrast to the poverty omnipresent less than half a kilometer away.

Anyways, after doing some business at the Nepal Medical Council (okay, okay, I was getting documentation and applications so that we could bring in several expatriate doctors to work at the clinic) I took another cab to Patan Hospital to track down Rachanal Shretha, the director of the birthing center there (which is famous for reasons I’ve enumerated in a previous post). Nobody seemed to know where she was, so I took a stroll down the pediatric wards (for some reason, if you drop by in the afternoon, the security doesn’t seem to care if you just wander around the patient wards). In the words of Sachin, my pediatrician ex-housemate, “there were a lot of sick kids.” Many seemed quite cheerful though, and two with casts were actually playing with a ball in the courtyard.

This made me think that sometimes, I wish I could go back to being a small child. There’s a pure optimism kids have that we don’t anymore. Granted, as a young person, I’m still overly a glass-half-full person, but I can’t always believe that the best will come around. Bless them for it, I suppose.

August 7 - Rumors of My Demise are Greatly Exaggerated...

Home Sweet London Guest House. It's great being back in Kathmandu, with (more) consistent electricity, fewer insects, and chinese takeout.

That being said, if you've been following the news, there's been massive flooding in South Asia. Hundreds are dead across Nepal, India, and Bangladesh, and millions face suffering from waterborne diseases, displacement, and property destruction. In Nepal, the death toll is around 80, the last time I checked. Several tens of thousand are also in refugee camps because their homes are under several feet of water.

Fortunately (or unfortunately?) I was in the hilly regions (Achham) when the monsoon floods came, then made it back to Kathmandu, where the altitude is too high to flood (all the rain here went down into the valleys). Dangadhi was somewhat flooded on the way back, but it wasn't on the scale of a humanitarian crisis there. Nevertheless, it's been on the news and all over the newspapers recently, and my heart goes out to all the displaced people.

Sadly, this event has had some political ripples as well. Refugees in rural areas have been picketing at many locations due to the parliament's poor handling of the situation. In one town, the government imprisoned a political leader because they believed he was using the flood to disseminate anti-government propaganda. The consensus, though, is that he had always been critical of the current establishment, and the citizens have been protesting his arrest vigorously (despite the fact that they don't even have homes now).

We've concluded the political questions from earlier, and have decided to stick with the clinic in Sanfe Bagar. We will, however, put ourselves on the fast track to moving to Bodelgata, and hope this will work out soon.

Also, thanks to Brad, Erin, and all of you for being concerned about me in the floods. I'm dry as a bone, though I would have liked to provide some relief for the victims. It's good to know that I have awesome friends who care about my safety abroad.

August 5 – Big Changes

As encouraging as my trip with Dr. Sedhain was, our arrival in the village of Bayalpata added a layer of confusion to the Nyaya Health plans. We were intercepted by the local council, who took the opportunity to present their argument: we shouldn’t be working in Sanfe; we should look to restore the abandoned Bodelgata hospital. As explained earlier, the Bodelgata hospital was a 15-bed facility constructed 15 years ago that was never staffed and stocked. To this day, it has never seen a doctor. (See the video for more details.)

Apparently, the residents of Bayalpata had been putting political pressure on the central government to begin work once more on this hospital. They were working to bring electricity and water to the structure within the month, and noted that a road connecting Sanfe and Bodelgata would be built within the year. They wanted us in Bodelgata.

Though our goals as an organization are to eventually bring this hospital to full operative capacity, we had never planned to do it this soon. The timeline had actually been for the migration from Sanfe to Bodelgata over the course of 5 years. Bishnu, however, seems to advocate the Bayalpata route over the current Sanfe project, in which we have invested a considerable amount of time and money. Politics were in play once more.

Shortly after our return to Sanfe, we were approached by yet another coalition, this time from the Airport side. Their mission: to convince us one last time to relocate the hospital to the airport bazaar. After some discussion, they were placated by the concept of the clinic being at Bodelgata… despite the fact that the current clinic was only 20 minutes away (as opposed to a 1.5hour uphill climb to Bayalpata). The rivalry between the two sides is apparently that powerful.

We also finally met with Rajan, whose bus had been stalled in Nepalgunj for the past two days. He confirmed our suspicions that Rajan’s uncle had not been entirely upfront with us. The 40,000 Rupee work was actually a cost he had not yet paid previous builders before our arrival (i.e. he was trying to make us foot the bill for structural work he had done on the building before Nyaya even leased the clinic). Politics once more.

Duncan apologized to me when I returned to Dangadhi for having to watch things get ugly, but I think it has been the exact opposite. This trip has taught me that international health relief is not just about a fairy tale Paul-Farmer-saves-the-world-with-love-and-cutural-understanding scenario. I’m actually quite glad that I’ve had the chance to see the difficulties inherent in working with human societies.

August 4 – The Man on the Mountain, Part II

After our meeting, Dr. Sedhain informed us that he would be traveling to Sanfe today on his way to Kathmandu. As such, he dropped by to pick us up at the Mangalsen Guest House at 6AM. The trek was downhill almost all the way this time, and resulted in an extremely pleasant, insightful journey, completely unlike the grim uphill battle of yesterday. Since he had made the trip many times before, Sedhain also showed us the easiest, most picturesque of the routes.

As we passed by riverside Chettri hamlets and cliffside cornfields, he showed us the land to which he was so dedicated. An amateur movie-maker, he would stop at lengths to shoot some footage of a humming woman washing clothes and early-rising children making their way up the mountain to go to school. Everywhere he passed, residents would go out of their way to say a salutation to him. It was clear that Dr. Sedhain is very well-liked by his community.

“Life is hard in Achham,” he said, while watching a woman old enough to be my grandmother carry a bundle of firewood twice her size down the mountain. His eyes grew sad as he watched her hunched form totter down the rocks.

Part of the problem was the lack of roads and the difficulty of travel. Due to the difficulty of getting from villages to clinics, more than 80% of births in the region are performed at home, often without the aid of a midwife.

“This is why PMTCT (Prevention of HIV from Mother to Child) training needs to be deprofessionalized.” Sedhain notes. “What use is it to have a few highly-trained PMCT doctors if the nearest birthing clinic is hours away? Nobody will go.”

As such, Dr. Sedhain often brings the hospital to the people. Every few months, he holds health camps at the most remote villages. Hearing that the DHO was passing through, local authorities even came out to our travel party to ask Sedhain to see some patients. With Dr. Bishnu, Dr. Sedhain observed a gaunt man, his eyes yellow and his tongue extremely swollen. “It may be TB… Maybe even AIDS.” Even as we were eating, an elderly shopkeeper came to beg the doctors to see his wife. She had had a series of epileptic seizures this month that had never before occurred.

Despite the promise we saw in some these places, Dr. Sedhain noted, however, that custom and history was holding the region back.

“Achham almost exclusively practices Chaupati Goth.” He said. “Nobody knows why, but 90% of the families here do.”

Chaupati is the practice of forcing a menstruating woman to sleep in a cowshed. Unfortunately, even the cowshed is too glamorous. The actual structure the woman sleeps in is a 3.5ft by 3.5ft by 3.5ft hutch reserved for this occasion.

“The people believe that if the women are not separated, fire will burn down their homes or tigers will eat their livestock.”

“These are the types of problems we must deal with,” he noted. “There are many problems in Achham,” he mused. “They are not big problems, but they are complicated problems.”

August 3 – The Man on the Mountain, Part I

Rajan had still not made it back from Nepalgunj, so Bishnu and I decided to make the trip to Mangalsen, the district headquarters of Achham district. The daylong, strikingly uphill hike would have to be made entirely by foot on an unpaved rock path in 100 degree Fahrenheit weather with 20%+ humidity. The objective? To meet with Dr. Purosotam Sedhain, the District Health Officer.

I’d only heard stories about him, but Dr. Sedhain was supposed to be a soft-spoken MBBS-MPH with more than 10 years of experience. Sedhain was our best shot at understanding how health worked in this region, and his unadvertised field work (for example, he performed 4 vasectomies while passing through a small village once) were testament to this fact. He was also the man who could procure us our vaccines, ARVs (Anti-AIDS drugs), and some key lab equipment.

That said, the trek there was possibly one of the most miserable act of physical exertion I had ever experienced. The sun blazed, my legs ached, and the loose rocky trail repeatedly betrayed my footing. The weather was also unpredictable in the mountains. The Sun could go from shining to storming and then back again in minutes, adding to my despair.

It rained. I rained sweat. Repeat.
I had two liters of boiled water with me. I’m certain I lost all of it in perspiration.

For some reason, the fact that I was going there for business took all pleasure out of the otherwise-gorgeous trail (that wound through pine woods, mango groves, and tropical forest). Towards the end, my legs were spasming from the loss of electrolytes, and I was stopping at 15-minute intervals to catch my useless breath. Nine grueling hours in, we made it to Mangalsen. Another hour to the very top of the mountain finally brought us to the Achham District Hospital. Dr. Sedhain was waiting for us.

I felt rather silly as I stepped into his office, dripping sweat from my hiking attire. As I pulled my rain-soaked notebook from my muddy bag, Sedhain asked, “How was the trip?”

“Terrible,” I wheezed.

He laughed genuinely, but then he turned serious.

“That trip is a journey that hundreds of Achhamis make every year to get health care.” He gravely noted. “This is a problem.”

Over the next two hours, Dr. Sedhain then proceeded to describe the work of the District Health Office in trying to bring services to this unfortunate region. Achham is one of the remotest, least-developed, and poorest of the Nepali provinces. Unfortunately, it was also one of the hotspots of military conflict in the recently-concluded civil war. The war had left tens of thousands of Nepalis dead, and the structural damage (All of Mangalsen’s major government buildings were razed by Maoist forces—you can still see the burned-out foundations) was profound in a region that already lacks development.

Nevertheless, he provided us with some very encouraging news about the newly-implemented ARV programs and public health initiatives, and pledged his all to the Nyaya Health clinic. After that, he waxed contemplative for a moment:

“We don’t do this to print colorful brochures of all the great things we’re doing, and I hope you aren’t either,” he remarked.

“The problem with Nepal is that people are always talking, never acting.”

He then chuckled softly.

“Actually, even we are just talking right now.”

“But we are trying, aren’t we?”

August 2 – Strange Bathfellows

Today, while showering, I noticed that there was something large slowly moving about the tiny bathroom. Upon closer inspection, I realized it was a hairy five-inch long spider. My initial instinct was to panic, but the door to the shower opened up into the village square, so running out into the street soapy and naked was definitely not an option. The creature ended up being pretty chill, though, so after a few moments, I grew accustomed to its lazy lounging. I took my time and finished my bath, noting that my arachnid pal (sitting comfortably in my soap dish) seemed a little thinner than most American tarantulas. I then realized how much I had grown to appreciate the presence of it and its eight-legged brothers: Sanfe is bursting with flies, and without these guys, things could get really annoying.

Though the day was quite slow (still no Rajan), we managed to meet with the current clinic coordinator of HASTI-Nepal, an NGO working in rural areas as a VTC (Voluntary Testing and Counseling). The agreement was not in writing, but we will definitely be coordinating our resources in the coming months.