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 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?”

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.