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.

August 1 – Things Get Tough

We finally figured out the whereabouts of Rajan today—by asking his cousin, we discovered his mobile phone, and managed to talk to him. Apparently, his child had fallen suddenly ill (jaundice and blood in urine, apparently), and he left for Nepalgunj immediately. Unfortunately, heavy rains the previous night had destroyed the road back, and he would be taking another day to get back.

Though Rajan wasn’t around, we had some immediate business to do. It is impossible to get internet in Sanfe, especially not the standard wireless connection we use, called CDMA. By bringing in some awesome US technology (a Yagi antenna and internal amplifier) we hoped to pick up on the weak signal found in this valley. The result: failure.

Bishnu took a photo of me that pretty much sums up this IT nightmare: I’m clutching my laptop, sweating profusely in the blazing Nepali sun, a disgruntled look on my face from seeing “Signal Level Not Sufficient” for the umpteenth time. We tried the antenna (which was theoretically supposed to work) at multiple locations and a multitude of ridiculous positions, but all to no avail. I had brought this clunky apparatus all the way from Connecticut to rural Nepal, and now I was going to have to take it back to the States. What to do…

Anyways, Rajan’s uncle (from whom we are renting the place) gave us the key to the clinic, and we had our first look inside. Due to Rajan’s son’s hospitalization, all clinic work had stopped. Nevertheless, the building didn’t look half bad, considering it was only half done.

An unforeseen logistical problem resulted, however, from the fact that the clinic is apparently a bit further from the projected housing than we thought. Bishnu was quite clear about the fact that if he were to be expected to make night calls, the current housing was not an option. He would need to hike 10 minutes from the SEBAC house to the river, cross a rickety suspension bridge, hike up the side of a hill, then pass Haat Bazaar at night in order to get the hospital (which is right in the middle of a rice paddy). None of us had ever thought about this before.

While we contemplated this development, Rajan’s uncle came to meet us and tried to convince us that it was he who had shut down the clinic work (despite the fact that he has absolutely no control over this process whatsoever). Apparently, he had put 40,000 Rupees of his own money into the project, of which he had not received any from Rajan. In addition, he claimed that Rajan had been overselling the clinic as something much greater than what it actually was (advertising it as a posh medical facility with high-tier lab and fancy radiological equipment). How much we wanted to believe him was difficult, though. For some reason, Rajan’s uncle had always opposed the work of Nyaya, seeming to have his own agenda when he leased the location to us. Little did we know that the nagging nape of politics had begun to rise from the water.

July 31 – Getting There, Part II

Dr. Bishnu and I spent the night in Silgadhi, the district headquarters of Doti (the district adjacent to Achham) with Dr. Prakash Thapa, alumnus of Bishnu’s medical college. Apparently, the two were extremely good friends back in school, so Prakash took amazing care of us and showed me photos of the two doctors (partying) during their college days. Sigadhi, perched on the mountaintops (“hilly region” by Nepali standards) has a much milder, pleasant climate than the pressure-cooker environment of Dangadhi. Anyways, we made arrangements with Prakash to meet again in Kathmandu the following week and continued on our 9-hour jeep ride into Sanfe Bagar.

Travel there was interesting, since we traversed some of the rockiest passes in the region. The road was winding and twisted, and was full of oozing mud and jolting potholes. We wound our way around the mountains, experiencing major climate change from cold evergreen forest to sweltering jungle (then back again). We passed dozens of tiny mud houses and thatched straw huts, watching as disheveled children hopped in and out of the thick mist.

Eventually, our jeep drivers (who insisted on blasting Hindi pop at deafening levels and spitting chewing tobacco out my window at regular intervals) announced that we were nearing the village. The road then promptly proceeded to end. We got stuck in some thick mud, and ended up having to walk the remaining half-hour into town.

The trek offered us an interesting view of the town, though. First, we passed through Haat Bazaar, a precarious assortment of small tin shacks in which many Bagarians ply their wares. Considered the poorer side of Sanfe, Haat is populated with younger people and seems to have a fair crime rate. The Haat side ended when we crossed an iron suspension bridge for which Sanfe is named. The bridge spans the Seti River, one of Nepal’s largest rivers, and is the result of an early American development project. The name Sanfe Bagar is actually somewhat of an inside joke among Achhamis, which I don’t understand but the locals find hilarious. Here’s my best attempt at explaining this:

Originally, the village was divided in two by the river, but the US project promised to link the two sides. Unfortunately, the project moved along rather slowly, and the Achhamis began to joke that it would never happen. As such, they named the village “Napnu Bagar,” which roughly means “where the river reaches its banks.” Due to the peculiar local dialect, the name soon became “Sapnu Bagar.” And since humans are lazy, the people eventually defaulted to a simpler pronunciation of the word, “Sanfe Bagar” (say it out loud, it’s easier to say). Think of it as a country drawl, only Nepali.

Anyways, crossing the bridge leads us to the Airport Bazaar side of town. This name comes from the fact that there was once a small landing strip laid on this side of the river. It hadn’t seen much use, though, and what remained of it had been destroyed in the Maoist rebellion. The airport side of Sanfe is believed to have older, more established community members, and the fact that the houses are a bit nicer reflects this claim. Our lodgings were at the SEBAC House, a nice guest house on this side of the river.

Once we settled ourselves in, we decided to call up Rajan Kumwar, a young local political leader and our chief ally in town. Rajan, who went to school in Kathmandu and speaks solid English, was one of the first people to help out the clinic efforts, and is currently overseeing renovations of our clinic. Unfortunately, Rajan wouldn’t pick up his phone. A brief questioning of the residents confirmed our fears—he had unexpectedly left for Nepalgunj, a 14-hour drive from Sanfe. Nevertheless, he plans on returning tomorrow, and we will hopefully see him then. The majority of our business in town involves communicating with him about the status of infrastructure.

July 29 – Getting There

This may be the last internet contact I have in a bit, since I’ve begun my travels to the clinic site in the village of Sanfe Bagar, Achham. Since the more interactive (and less administrative) part of my trip begins now, I suppose this requires some more background.

Nyaya Health was originally conceived of by Jason Andrews, a Yale undergraduate. Through all his college summers, he traveled to Nepal to do medical work in the Kathmandu valley, where he helped secure HIV/AIDS resources for IV drug users in the capital city. This vision followed him into med school (at Yale again) where he formally created the NGO. During his travels, he met Kathmandu-ite Roshani Dunghana, a young Nepali filmmaker. The two ended up getting married, and their confluence of interests (Jason for AIDS relief and Roshani for using film to progressive action) inspired them to travel to far western Nepal. There, the two saw the deplorable condition of health and development in general, exacerbated by the recently-ended Nepali civil war. Particularly depressing was the fact that the national government had constructed a 15-bed hospital in nearby Bayalpata, but the clinic was never staffed and never stocked. To this day, it is an abandoned building. Upon returning to Yale, Jason contacted two friends, Duncan Smith-Rohrberg Maru and Sanjay Basu, and the three decided to begin an effort to rectify the problem. Duncan and Jason traveled to Achham, one of the western districts, in May 2007 and while there decided to establish a PHCC (primary health care center) in the village of Sanfe Bagar. The Nepal Health Equity Initiative was born.

Currently, the clinic building, a non-inpatient facility, is undergoing renovation and outfitting to become a suitable health center. In addition, agreements are being finalized with domestic agencies, other NGOs, and the staff. Much of my work in Kathmandu has been managerial, and I’m now shifting gears and going to Sanfe with our prospective medical director, Dr. Bishnu Kattel.

Our travels at this point have taken us from the capital to the southwestern city of Dangadhi. The town is just 10km from the Indian border, and is in the heart of the Terai, a sweltering jungle. Apparently, the region used to be almost devoid of inhabitants due to malaria falciparum. (In fact, Dr. Bishnu tells me that when he was a child, the prevalence of malaria and leprosy was so great in the Terai that his parents would joke about how your finger would fall off if you even pointed towards the forest). The few people who did persist in the Terai, the Tharus, were considered magical since they enjoy some measure of immunity to the disease. Modern development of the area via swamp draining, DDT spraying, and aggressive prophylactic measures, however, has wiped out falciparum (though vivax still stubbornly remains) and the region is one of the fastest-growing districts in Nepal. The place is still a breeding ground for mosquitoes though, and last night alone I was bitten over twenty times— while wearing a blanket. I’m paranoid about these things, so I've been making sure to take my doxycycline prophylaxis. Interestingly, none of the Nepalese finds malaria at all worrying, and Dr. Bishnu actually rejected my offer of doxycycline (which is understandable, since the drug has some minor GI side effects). The only person who has shared my worries about malaria is Chris, and he's in Kathmandu, where malaria is not present.

As for the climate, it's more humid than anything I've ever encountered in my life. Merely standing is good enough to get you sticky, and life is an endless quest to stay cool. In addition, it stormed (rained by Dangadhian standards) last night, and now the streets are a sea of brown water.

Populationwise, Dangadhi is interesting due to its proximity to India. Whereas I could blend in easily with the Gurungs and Rais of northern Nepal, I stand out pretty clearly here, since the majority of people are darker. This leads to a fair amount of staring and pointing. For the first time since coming to the country, people have been approaching me and asking if I’m Chinese or Japanese. This is facilitated by the fact that most people travel slowly. Poorer and more rural than Kathmandu and Pokhara, Dangadhi is largely an unmotorized city, with no taxis and only the occasional motorbike. As such, our (and everyone's) main means of transportation is rickshaw. The town is small enough that rickshaws will get us anywhere in good time, though, and the open-air travel is strangely refreshing.

A highlight of the journey, however, was meeting up with Dr. Japath Thapa and his friends, Dr. Krishna and Dr. Patan. The trio of young doctors (all in their mid-twenties) has been working at Seti Zonal Hospital for the past few months following the completion of their internships. They are also alumni of Dr. Bishnu and Bijay. As such, they’ve really gone out of their way to take care of us, offering us food, lodging, and even Tuborg Strong (the 15-proof local beer). In our quest to find them, however, I was afforded a unique view of the “medical district” of Dangadhi.

Nepal’s state medical system is broken up into several tiers. At the very top are a few national hospitals largely affiliated with universities. Most are in urban areas. Below them are zonal hospitals, set up to service a collection of districts. The next level contains the district hospitals, which serve individual districts. Following them are primary health care centers, which function to varying levels of capacity in villages. Lastly, there are health posts, which are irregularly-staffed clinics run by HAs (Health Assistants) or ANMs (Auxiliary Nurse Midwives), not doctors.

Anyways, I’m out of time, since the jeep that will take us to Doti, the neighbor district of Achham, is here. There, we will most likely stay at the home of Dr. Prakash Thapa, who is working at Doti District Hospital and interview our clinic’s potential ANM. More to come.