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.

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.

July 22, 2007 – The Family is Wonderful. Mother Nature is not

The Acharyas have been so accommodating in opening up their home to us, and I’ve learned much about Nepali culture and family life from them. Bibhav’s parents are very religious (they’re members of Hare Krishna) so I’ve had a crash course in Hinduism. I can say that I’m now quite proficient at eating with my hands, and had the chance tonight to eat (okay, okay, so I didn’t eat it. I kinda licked it) what is called “Pepper that can set a hundred men’s mouths on fire.” Let’s just say I smelled it and my nose started hurting.

Bibhav’s parents’ religion prevented them from talking to us this morning (they’re in ritual prayer from 3:30AM-7AM), so Mr. and Mrs. Acharya “saw us off” last night. Bibhav walked us to the bus station at 6, though, and we parted until he arrives in Kathmandu to fly back to the States. I’m sure I’ll be seeing a lot of him back at Yale, though, which is awesome since he’s such a cool guy.

Mercilessly, the Himalayas remained hidden from view by huge clouds again. If anything, it was cloudier today than any of the other days we were in Pokhara. Thanks a lot, Nature.

July 21, 2007 – More Tourism and Bloodsuckers, Part II

One of the things I was most excited about seeing in Pokhara was the Himalayas (which you can see if it’s clear enough). Unfortunately, it drizzled yesterday, obscuring our view. Today, it rained buckets, so no dice again. We spent the morning watching Blood Diamond. It cleared up by 2PM though, so we rented a boat and paddled around Phewa Tal, a gorgeous lake north of the city. If you haven’t gone rowing, you should seriously consider it— it’s one of the most relaxing things you could possibly do. We then landed on the opposite shore and hiked up for 30 minutes to the World Peace Stupa, a huge pagoda with Buddhas from five nations (China, Thailand, Japan, India, and Nepal). Unfortunately, it was undergoing construction, but the sweaty uphill hike was still great exercise. The view of the city from up there was gorgeous as well.

A special highlight of the hike was the fact that we were occasionally solicited by leeches. Yep, leeches. At first, Chris got bitten. He thought it was awesome and took photos. Five bites later, he didn’t think the same. I luckily only got bitten once, and I pulled the sucker (heh, pun not intended) off pretty quickly after he latched on, but fought off three other buggers before they had the chance to sink their jaws in. By the time we got back down, Chris was bleeding a lot from his feet since leeches have an infamous blood anti-coagulant (which researchers are trying to use for stroke and heart attack medication). Nevertheless, paddling on the river was unbelievably nice, and though I crashed our boat into the shore at least three times, we got back to the operator’s shack in one piece.

We took a leisurely walk along the lakeside, and boy, is Pokhara touristy! There were dozens of hotels with signs in over ten different languages (the Korean hotel/restaurant claimed to serve dolsut bibimbap, which I haven’t had in over a year) and the number of gift shops is just staggering. This doesn’t change how peaceful the city is, and I’ll be sad to leave.

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 18, 2007 – On Bloodsuckers

A note needs to be made for Anopheles mosquitoes. These are not your home-grown Culexes. I now see why malaria is so prevalent in the tropics. Anopheleses don’t buzz or hover around you before they strike. They hide on the walls, then silently beeline for your vulnerable areas. In a world of buzzing blood purloiners, they’re the F-22 Stealth Fighters. Needless to say, they’ve made short work of my legs and arms— a few have even bitten my hand! How they do it, I don’t know. Insect repellant has failed me (succeeding only in irritating my skin) and swatting has proven fruitless. Anyone have any suggestions?

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.