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.

July 26 – This is for you, Nick Simons

Working in a developing country is interesting since you routinely encounter folks involved in a variety of development NGOs. We met today with Dr. Zimmerman (a *gasp* American) with the Nick Simons Institute. NSI is offering MD-GP (Medical Doctor-General Practitioner) scholarships for eligible MBBS doctors (Medical Bachelor/ Bachelor in Surgery). Though our current medical director is not interested, we hope this will be a sufficient incentive to attract future doctors to the Nyaya Health clinic. The problem with the program is that in the current Nepali system, a bachelor in medicine is usually sufficient to allow a doctor to enter the field. An MD-GP is nice, but unnecessary. In fact, most MD-GPs work in rural areas (with charitable intentions), since their additional training enables them to become proficient family doctors.

Anyways, you may ask “why a funny name like Nick Simons?”

The story gets interesting: According to Chris, Nick Simons was a wealthy young man who lacked a goal in life but enjoyed traveling to exotic places. During one such visit, he was trekking through rural Nepal. Somehow, something he saw here touched him so much that he decided to become a doctor and devote his life to serving the people of Nepal. Unfortunately, on the trip home, he stopped by in Indonesia, where he drowned while swimming in an atoll.

His parents, in his memory, decided to continue his work and have thus created the huge institute in Nepal to improve health in rural areas via MD-GP scholarships, nurse/midwife training, and improved clinical research methods.

With this in mind, Chris, Bibhav, and I went to the NSI offices—and were amazed. Though tucked away in a residential area, the NSI building is immaculate, A/Ced in every room, computer-enabled in every office (with wireless internet too!), and full of massive furniture. We actually joked with Dr. Z that we may consider working for him on account of the impressive setup. That aside, negotiations went well with NSI, and we’re well on track for signing a number of scholarships each year with the organization.

Upon leaving the building, Bibhav let us know that he had done his research. Apparently, Mr. Simons (father of the late Nick) is among the 60 wealthiest people in the world. NSI is actually just one part of the great charitable projects they’ve financed in this country. Patan Hospital’s birthing center (the model for all Nepali birthing centers and a fully-independent [no doctors] program that has seen only 2 technical complications out of the last 600 births) was built (and now being renovated) by a million-dollar gift from the Simonses. Sadly, the family has not been similarly blessed. Nick, the eldest, met his untimely end in Indonesia. The second son was killed in a car accident while riding his bike outside his home. The third son is apparently autistic. Though I haven’t had time to confirm these facts, they’re a grim, but encouraging reminder that philanthropy is an important and powerful factor in global development.

On a lighter note, Bibhav and I had pizza today. Chris is from Connecticut, so he remained a skeptical of Nepalese pizza-making, but I thought it was okay. Definitely no Peppe’s or even Papa John’s, but it was recognizable as pizza.

Power is the Problem, So We Go for Bananas

Chris and I woke up early today to get some business out of the way. After meeting with Mr. Dhungana to go over tax issues, we booked tickets for my flight with Dr. Kattel to Danghadi (the first stop on the way to Sanfe). The rest of the morning was spent doing research on a tricky issue with the clinic— power. Electricity is not consistent at all in Achham (Chris and Bibhav spent over a week sans energy during a blackout) so it’s absolutely critical we get a generator there. Alas, the 2.5kW diesel generator that we have in mind is nearly impossible to find. We took a list of procurement businesses off the web and went down them, calling everyone. I also took a hike through downtown Patan, stopping at every machine shop on the way back to the guest house. Ten phone calls and eight store visits later, we could sense a pattern: nobody carries diesel generators. Most stores seem to have petrol (gasoline) generators, though, so things are leaning closer to that end. There was a glimmer of hope for a moment, when Rajan called us to let us know that he had found a place—but they only sell larger industrial-grade generators.

In lieu of our disappointing morning, we met up with Bikram to go on the long-delayed sightseeing trip. First stop: Durbar. This square, bounded by the former palace of the royal family, was bursting with temples, buildings, and monuments. Particularly memorable was visiting the Kumari, a nine-year-old girl considered a living goddess (the only living Hindu deity). We weren’t allowed to take photos, but she did peek down from her window. “She doesn’t look very happy,” noted Chris.

“She does this every day for hours,” noted Bikram. “Who could be happy about that?”

Also worrying to the Kumari is the fact that her position is temporary: Upon the onset of menstruation, the reigning goddess is unceremoniously and literally thrown out on the streets. A new girl takes her place and the cycle begins again.

On the way out of Durbar Square, a little man solicited me to buy something from him. The plaza is bursting with peddlers, so I was prepared, but he presented an item I really wanted: a Gurkha knife (khukuri). The huge blades are traditionally made by the residents of the region by the same name and are symbols of Nepal. They also represent the Gurkha army. During the British wars of colonization, their defense of the Terai led to the two year Anglo-Nepali war. Despite the eventual defeat of the Nepalese, the English were so impressed by the Gurkha fighting force that they were regularly called upon in WWI and WWII to serve the queen. Their regiment ended up being awarded 13 Victoria Crosses, the highest British Military honor. In addition, Britain has designated one of its most feared dragoon units the Gurkha Battalion, despite the fact that there are no Gurkhas in it (and of which Prince Harry is a commanding officer). To this day, many Rai and Limbu men still have khukuris (which they always carried with them into war) tucked into their belts.

Anyways, back to this knife, it wasn’t as elaborate or decorated as most I see in gift shops, but when I pulled the sheath back, it had the stamp of the Ghorka Army, complete with a serial number. Needless to say, I made the peddler quite happy. If nothing else, it'll also make an impressive mango slicer for me in Achham ;)

Unfortunately, buying one item in Durbar makes you a salesman magnet. One man harassed me in an attempt to sell me a lock for almost 15 minutes as I repeatedly denied his attempt (not to mention he was asking 400 Rupees [$6+] for an inch-long trinket!). I had learned my lesson. From then on, I kept my mouth shut, letting the peddlers descend on Chris instead.

We stopped briefly for lunch, where I had a buffalo sandwich (buffalo are not considered sacred like cows here), and noted that it tasted just like beef, just a little tougher.

Our next visit was Pashupati, the holiest Hindu site in Nepal. Unfortunately, this meant it was so holy it prevented leather shoes, wallets, and belts (and their hapless non-Hindu owners) from entering. Nevertheless, Bikram wanted to show us the small village that had sprung up around it, and proceeded to buy a bunch of bananas. We quickly found out the reason, as he gave each of us one, bit one himself, then threw the rest into the street. A crowd of monkeys descended onto the pile, squeaking and scrambling for the fruity morsels. I hate to put it this way, but they were definitely among the most charming of the area’s attractions. The rest of the temple was blocked from our entrance, though we were allowed to photograph whatever we could see from outside. We hiked around the gate, though, and caught a glimpse of a gigantic golden bull in the midst of dozens of statues.

There was a funny smell in the air, so I asked Bikram what kind of incense they burned here.

“People.” He replied.

Apparently, the river that runs through the temple is considered holy like the Ganges, and many Nepalis are cremated here.

“Oh.”

Shifting gears in religion, we then took a local bus to the opposite end of Kathmandu to visit Swoyambu, Nepal’s most holy Buddhist site. The Buddhists were more accommodating, and after a rainy 15-minute hike, we made it to the monastery and stupa at the top of the hill. The temple, exploding with tiny statues, was incredible, and offered a stunning view of the entire capital city. We spent a bit of time meditating with the monks and listening to recordings of Nepali chants. To Chris’ amusement, Swoyambu was also overrun by monkeys. No bananas for them, though.

Note: In my haste to get this blog up, I forgot to enable commenting by non-google people. I've since unlocked it so anyone can comment, so feel free. I'll answer. (And thanks to Jordan and Ryan. Much love).

July 23, 2007 – Back to Work

We finally finished the somewhat murky process of taxes today with ace tax student Manoj. I admit we were a little befuddled by the circuitry of the system, but Manoj handled the work like a champ and promised us that all our tax woes would be complete by Thursday morning.

Later today, we also met with Dr. Bishnu Kattel, our prospective medical director and clinic doctor. Our insights:

- He’s articulate and intelligent. He was well-aware of the agreements prior to the meeting and got to the point about his thoughts right away.

- He’s very friendly. The meeting was really comfortable, and he actually apologized at one point for being too colloquial with us (which we didn’t mind at all). He said that since Bibhav and Bijay are colleagues and friends (he also personally knows many of the local doctors at Doti, Nepalgunj) he felt at ease with us all. Personally, I’m happy about this, since he’ll be my travel partner for a week.

- He seems dedicated. He’s gone through all the documents already and seemed set on signing. His application had some interesting personal insights about some of his experiences in resource-poor settings.

- He’s ready to travel to Achham. Since he recently returned to Nepal from the US, he’ll be taking the next 3-4 days to travel to Gorkha to visit his family, but wants to leave for Sanfe ASAP after that. Once there, we’ll meet with Sangita (our prospective ANM) and other staff, so we can start planning now.

Once Bibhav gets into town, we’ll meet and finalize everything. Our overall opinion of him was quite favorable and it seems the feeling is mutual.

July 19, 2007 – Chow Chow

Though we were planning a trip to the Social Welfare Council and having Bikram show us the holy Hindu temple of Pashupati, but endeavors fell through. Nevertheless, we still managed to pass by some notable landmarks such as the (outside of the) Royal Palace and the Queen’s Lake. We ducked into a small bookstore where Chris bought “Forget Kathmandu” and I picked up a long-overdue copy of “The End of Poverty.”

Since not much happened today, here’s a little update on Nepali food. Though most people are Hindu, meat is not difficult to find (called “masu”) and I’m at a guest house, which means they’re used to barbaric foreigners ordering chicken and pork and... buffalo? In addition, Nepal’s location between India and China means that it’s easy to get food of either region. Curry is a daily staple, and chow mein, fried rice, and chop suey are everywhere. I found Korean cup ramen at the local grocery store, but didn’t end up getting it. Apparently, you can even get Chinese food in Achham as well— according to Chris, there’s a vendor who just sits there and fries up tons of noodles every day. The domestic Nepali ramen (chow chow/ wai wai) market has boomed recently, and actually advertises it as a health food— the company Mayo enriches theirs with Vitamin A and has the slogan “One a Day.” Other than the fact that the whole thing is still just a brick of flour and sodium, I guess they’re not that far off…

My favorite Nepali dish (which is actually Tibetian) is a soup noodle dish called “thukpa.” It features thick noodles in broth and vegetables, and though a little heavy sometimes, is really good. In addition, a popular dish called momo is quite familiar to me since it looks and tastes very much like East Asian dumplings (Chinese dim sum/ Korean mandu/ Japanese gyoza).

Despite the wide array of foods, the traditional meal that all Nepalis eat is called “dhaalbhat.” Dhaal is a soup of varying thickness made with lentils and grains, and bhat is long grain white rice. Add a side of vegetable curry and chutney, and there you have it. Bon apetit.

July 17, 2007 – Reflections on UNICEF

We were all over town today, finalizing an agreement with MSMT (a non-profit drug procurement organization) and meeting with the director of the NCASC to discuss PMTCT training for our medical staff. In fact, Dr. Chand agreed to promote the Nyaya clinic to a full AIDS treatment center, complete with ARV (anti-retroviral) supplies and training, granted we could get approval from the District Health Officer.

In the process of running to DHL to discuss a long-term pharmaceutical delivery service, we made a quick trek through the twisted backstreets of Kathmandu. We actually got lost, but Chris asked for directions in Nepali and got us back on track within 15 minutes, right before I’d begin to panic. What a champ.

Anyways, to square off the day, we went to the UN House, where we spoke with a Maternal Health Consultant. Ms. Karmacharya was absolutely amazing and gave us some really inspiring news about the work UNICEF is already doing in Achham. For our clinic, she let us know that we could apply to get our doctor and ANMs (Assistant Nurse Midwives) training as SBAs (Skilled Birthing Attendants). In addition, we would be getting a powerful local support staff. One of UNICEF’s latest initiatives is to train all Female Community Health Volunteers (FCHVs) in Achham district to help promote proper maternal health, assist in home births, and provide support for mother and newborn child. To that end, she showed us a pictorial manual to be published in August and distributed in the region. The booklet, though mostly composed of large diagrams and simple words, was quite comprehensive in concepts, ranging from signs of complication to explaining financial incentives for rural mothers to have in-clinic deliveries.

Having observed the UN here in Nepal for the past few days, I can now say I’m a firm supporter. The organization is doing so much work for the people who need it the most. They preserve the peace (they’re mediating the post-civil war negotiations between the Maoists and monarchists), provide health services to the weakest populations (women and children), and project the message to residents that the First World cares. Despite the fact that the UN’s efficiency is debateable, they also stand as a symbol of order and stability in these tumultuous times.

I also understand why it’s so important for the privileged to do global service. As representatives of the international community, we’re in a unique position to meet with figures in power and can do so much more for the disadvantaged countryman— just because of our background. I’ll consider it both a blessing and a responsibility.

July 16, 2007 – Earning My Keep

This morning, I woke up to loud shouting of Nepali over a megaphone. When I poked my head out the window, I saw a government vehicle rolling down the street, loudspeakers blaring. A man was throwing pamphlets out the window. A closer look at a sign on the front of the car read “HERPES”. My grasp of the language is terrible, so it may have been something other than an STD campaign, but it remains an intriguing possibility of a pretty frank method of public health education.

Anyways, today was my first day of official duties, and Chris has been amazing in helping me get used to the work. First, we visited Patan Hospital (one of the best state-run hospitals) to request special Peds/Obs training for our MBBS doctor. We next dropped by the National Center for AIDS and STD Control and spoke with the Deputy Director there. Dr. Pant (who did his MPH at Johns Hopkins) seemed quite optimistic about providing our clinic with both documentation and supplies to help us set up a Prevention of Mother to Child HIV Transmission (PTMCT) program, something both exciting and encouraging.

As part of the “detective work” involved in securing medical resources, Chris and I went to Teku in search of the elusive Dr. Upreti, Chief of Immunization and Health Services in the Dept. of Health Services in Nepal. We had originally believed that he worked for the Ministry of Health, but that search proved fruitless, as the main office informed us he wasn’t under their direct organization. Since UNICEF is one of major provider of vaccines, we then attempted to locate him there, but that was a false lead as well. Finally, after wandering about the government buildings in town, we found his signature on a form in the Child Health Division. A quick meeting with him then provided us with more good news: all the vaccines for the major diseases are already present at the district hospital; we just need to talk to the local District Health Officer to procure them. Mission success!

To end a long day of trekking, we went to check out a big mall in a central plaza—and almost forgot we were in Nepal. The complex looks like a shopping center in the US (complete with glass elevators and AC) albeit a bit smaller. Puma and Nike sneakers cram storefront windows, while Beckham soccer jerseys and Armani slacks hang by the rackful. Young people with Ray Bans and iPods shuffled past in the consumer paradise we Americans know so well. Sometimes you realize what a small world it is.

July 15, 2007 – How to be Nepali, How to be Fat

I crashed inadvertently at 8PM last night, so I woke up at 5AM this morning. After spending some time staring out the window at the early-risers on the streets below, I embarked upon my first adventure— the hotel bathroom.

The toilet here doesn’t really… flush. It basically trickles water for a few minutes until you give up. I also decided to take my first shower upon entering the country. There’s a small problem. Most places only know one setting of shower: cold. Nevertheless, I managed to shiver my way through it and get clean.

Once I hit the streets, the first thing that struck me was the huge diversity of complexion in the Nepalese population. At one end of the spectrum, the people are very dark and South-Indo-looking. At the other end, individuals have highly East-Asian features. While I was standing in the visa application line, a Nepalese man approached me. “You look Nepali, but have an American visa,” he noted. He had seen the navy-blue booklet poking out of my pocket. When I explained that I was Korean, he asked, “Oh, so one of your grandparents is Korean?”

Apparently, I pass as Nepalese, which has its benefits and downsides. For one, I blend in well so nobody finds me out of the ordinary. On the other hand, unless I introduce myself as American, people will launch into Nepali when I approach them. Nevertheless, most folks here speak bits of English and some people are quite fluent.

Chris got a call from one of the kids he met in Sanfe earlier this month. Bikram, the cousin of a political figure in the town the hospital is in, met us at the guest house that afternoon. The nineteen-year-old sociology student spoke very good English, even picking up on bits of slang Chris and I tossed around. I was delighted to exchange pieces of cultural knowledge with him, as he proved an enthusiastic and friendly conversationalist.

At one point in the conversation, though, Bikram suddenly turned to us and said “how can I be like you and Andrew, Chris?”
Chris, with his dry humor, leaned back and answered with a grin, “it’s not easy.”

When prompted further about what exactly he meant, Bikram replied, “How can I be fat like you?”

(Note: Regardless of our personal opinions on our physiques, we’re definitely not fat).

After our initial laughter, he explained in detail: “I’m too skinny. My parents worry so much, because I keep losing weight too.”

I made some lame first world references to TV dinners and driving instead of walking, but there was no getting away from the truth of the matter— the American way of life is vastly different from an Achhami’s.

July 14, 2007 – Stranger in a Strange Land

True to the country’s reputation, the first thing that appeared on my initial descent into Nepal was a huge mountain poking its peaks through the clouds. As we broke the puffy cover, they were soon followed by rolling hills, dense forests, and pastures so green my eyes hurt. Before touchdown, Kathmandu, the capital city, exploded in a cluster of houses, factories, and phone towers.

When I finally made my way out of Tribhuvan International, I met Chris, my coworker. As he noted in his e-mail, he was easy to find— the only white person at the gate. He grimly noted upon our meeting that the taxi driver union was on strike again today. As such, we were forced to settle for a renegade cabbie who would only give us the 20-minute trip to our guest house… for 1500 Rupees. That’s about $23 US Dollars. I was getting better rates in NYC :/

The taxi ride afforded me an intriguing look at Nepal’s capital, though, and it really cemented in the realization that it’s developing. Women wash clothes by hand in ditches by the side of the road while Toyota SUVs thunder past. Momo-vendors cook dumplings off open coals under massive billboards advertising Motorola mobile phones. The streets are exploding with microbuses, motorcycles, and rickshaws, but there are almost no traffic lights. Dogs, goats, and cows freely roam the streets. “It’s two years in prison for killing a cow,” said Chris, punctuating my thoughts. That’s right. We’re in a Hindu country now.

Despite the glaring inequities of this heavily urban center, there’s a certain charm about the city. Everything is a mix of old and new (technology, buildings, culture, and people), and it works. As my guidebook notes, Kathmandu is a sensory overload of strange sights, sounds, and smells; but a fascinating place to be.