Our last day in Nepal

The election is over, and in Kathmandu, the voter turnout was less than 10%. This was either because people were boycotting the elections or they were worried that if they did vote, there would be repercussions from the Maoists. The Economist called the elections “dodgy” and the BBC called them a “sham”. But it was the king’s hope that even if he did hand over the election administration to the military (from the Election Commission), and even if he refused to allow the presence of national and international observers at polling stations, that this municipal election would give his autocracy some sort of legitimacy...Half of the positions remained unfilled as there was no candidate, one-third of positions were uncontested, and 15% of candidates withdrew before the election because apparently, they never submitted their name in the first place. The monarchy offered a life insurance purse for all candidates and for any driver who violated the Maoist-called transportation strike. The purse amounted to $250 CDN or about one year of school fees for two small children...In the valley alone, the Maoists killed two candidates, and a taxi driver who worked during the strike. The king will pay their families a total of $750 CDN (or the equivalent of 0.00001% of the earnings from his cigarette company).

I am just wrapping up here in Boudhanath—outside of Kathmandu (and away from most of the excitement). The bandh, or strike, just meant that people like us didn’t do very much. Kids played soccer on the street and monks played cricket on the dry rice fields beyond our house. The monasteries still start banging on blocks, blowing on horns and chanting at 5am. Kai is ploughing through the Narnia series, and Aaryn is finalizing his 7, 8, and 9 times-tables.

Here is a summary of what has been done...the total amount of money donated and funds from the carpet raffle raised $3150 CDN. The money went to:

-Textbooks for nursing school libraries (newest editions of Myles Midwifery, Williams Obstetrics, Taber’s Cyclopedic Dictionary, and 7 copies of Textbook of Neonatal Resuscitation). Also 5 copies of the Nepali edition of Where There is No Doctor for some health posts that remain open during the war. This text is an excellent resource for practical maternal child healthcare (as well as providing valuable information on worms and scabies).
-medication for a school health camp
-medication for Thuman Village health camp
-newborn receiving blankets and heating pad, and resuscitation and intubation equipment for the delivery room at Western Regional Hospital in Pokara
-baby manikin for teaching resuscitation and intubation for one nursing college, and shared by many
-birthing centre equipment at the Stupa Community Hospital: room heater, wall thermometer, wall clock, another delivery set, sterilization equipment, resuscitation and intubation equipment, fetal heart doppler, and suction machine with vacuum delivery attachment. Yep, all that, Made in India and Korea is a wonderful thing...

This last batch of equipment for the birthing center allows it to provide twenty-four hour basic emergency obstetric care (BEmOC). In order to be a centre that provides BEmOC, according to the Word Heath Organization, the centre must be able to provide iv antibiotics, anti-hemorrhagic meds, and anti-convulsion meds, as well as do manual removal of the placenta, removal of retained placental fragments and assisted delivery—the last was the only thing lacking at this community hospital. Being able to perform an assisted delivery (such as vacuum or forceps)—is a necessary procedure when the delivery has to be done quickly near the end of the labour because there is fetal distress (detected with a fetal heart doppler), or any of the less common obstetric situations. The emergency room physicians will be trained in doing vacuum delivery so that there will be no delay waiting for the one obstetrician to arrive (I got virtually nowhere in my argument that the midwives should be the ones to be trained in vacuum—as it is a straightforward skill and a good use of already available resources...but was left with the impression, as is the case in Canada, that when it involves glossy new technology, it will remain the domain of the doctors until further notice).

Now, we’re packing up (with significantly lighter baggage coming home), visiting friends, receiving blessed protection cords and scarves...assuring everyone that we’re planning to return. The king has promised national elections for next year, the Maoists have promised to “clear things up” in the next two months, and although this lame civil war seems a bit crazy, Nepalis see it as a process towards something that is and will be uniquely Nepali...I believe there is no where else on earth where you can haggle with Hindus over the price of Buddhist religious ornaments, made from Tibetan fossils by Dalits (untouchables) hired at an Danish NGO...where riding with your 2 children on the back of a motorcycle is not illegal, provided you do not hit and kill a cow (12 years imprisonment plus damages to the owner of said cow)...where lost Gameboys are returned by shoeless Nepali boys...where doctors prescribe sun baths and mustard oil massages to newborn babies upon discharge from hospital...and where time is still taken to light 100 000 butter lamps around the Stupa on the night of the full moon (tonight).

Back in Thuman Village

Last year, we went up to Thuman Village to do a health assessment (see January 2005 below). This is the village of Pasang’s family. Pasang is finishing her heath assistant degree, and upon completion, she will be qualified to run a health post, or emergency room of a hospital. She was born in the village of Thuman, and two trekkers from Colorado took notice of her twelve years ago, when she was 7, and sponsored her through primary school, high school, and college. Based on the health assessment from last year, she organized a four day health camp for the villagers.

Health camps are popular concepts in Nepal—probably because there are few resources and everything is remote from nowhere. Basically, you make an educated guess of what supplies you need, you send word you’re coming, and then once you arrive, everyone emerges from far away pastures, fields, and from their homes. Using basic physical assessment tools and the history they give you, you educate them about their concern, you provide necessary medicine or bandages, or you refer them to the nearest health post or a hospital in Kathmandu if necessary.

We arrived after a seven hour trek up 1100m. Pasang’s grandmother held off everyone until the next morning. The kids and I, and Pasang’s extended family settled for the night on the floor of the one room home around the kitchen fire. The next morning, we awoke to the sound of Pasang’s mother building a

fire and making tea. I opened my eyes to find about ten people staring at me, waiting patiently for Pasang and me to get up. Under their gaze, I tried to dress modestly in my sleeping bag, and when they all started laughing, I decided to abandon the plan to change out of my long underwear or wear a bra. Even though the sun was just starting to come up, I had to wake the kids so they would not be walked on, since it appeared that more people were filing in. While they waited for us, Pasang’s mother served everyone tea or hot alcohol (yep, this is about 6am).

I was happy to see that worm treatment was well accepted by everyone but disappointed that we ran out of meds, and could have treated twice as many people. I have learned more about worms than I care to know. Roundworms are the popular ones here, and they take up residence in a person’s belly, consuming whatever the person eats. For example, a child in this village, age four, having never been treated for worms, has a swollen belly, thin arms and legs, and a voracious or poor appetite (varies on the kid). Treatment should take place in a village like this, routinely, every six months—until everyone has a proper latrine, and every house has better water facilities for hand washing. I won’t go into more details about worms—but if anyone wants more info on worm sightings, how worms enter and exit one's body etc. please send me a note, I’d be happy to share all this new information.

The next issue we addressed was lice and scabies. Since the available medicine in Nepal is banned in most other countries due to toxicity—we decided to educate each clinic visitor on lice and scabies, and only treat really bad cases. We didn’t want to carpet bomb the whole village, knowing that folks with mild cases are not going to be motivated to collect all the wood needed to boil all the water needed to wash the bedding and clothes, and all that regular bathing between treatments—it was just too much work for them, and they’d just reinfect themselves. One man came, and I recognized him from the monastery. He politely asked if he could have some scabies medicine. We asked to see his scabies, but he said it wasn’t for him, it was for the monastery floor—it had a mite problem. Err, no, sorry father...when he looked so concerned as to how he was going to deal with this mite problem, I buckled, okay, if after four days, there is leftover, we will give it to you...(I didn’t challenge him on what kind of Karma he was inviting by killing so many mites).

We brought a lot of soap this time. When someone showed up with a wound for dressing, we would send them away with a bar of soap, and tell them to come back after washing the wound. We introduced the concept of soaking the wound in hot salty water after washing. I think soaking, and the miracle of oral penicillin turned around a number of festering wounds, and people saw the rapid improvement—cementing the idea of wound cleaning as a basic first step when caring for any of the number of wounds caused from hatchet, knife, and falling. Also, we used ar-ah (clear homemade alcohol)—as an antiseptic. Some just thought this wasteful but conceded that it was readily available.

The rest of the complaints were blurred vision (they needed glasses), glaucoma, cataracts, eye infections, sinusitis, festering tooth infection, goitre (developed prior to iodination of salt now in widespread use), pneumonia, crazy hypertension, heartburn, amoebic dysentery, prolapsed cervix, vaginal infection, urinary tract infection, arthritis, and a handful of visitors that needed prompt referral—one painful abdominal mass (bowel hernia) and one possible epilepsy (both referred to Kathmandu), many possible tuberculosis cases (referred to health post in the town way down below), and head wound (referred to the regional hospital).

They listened attentively, returned if they forgot their instructions, returned for dressing changes, returned for repeat doses of antibiotics, and returned if they forgot to mention important information in their history (like the very old looking woman, who I failed to ask if she might be pregnant, returned to ask if she should take the antibiotics if she was pregnant—trying to not look upon her with pity, I asked her more questions, and we came up with a diagnosis of menopause—she looked very relieved).

Kai, Aaryn and I confessed immediately upon arriving that we were not partial to Tibetan tea. I truly believe that no one outside of the confines of the Tibetan heritage circle could every develop a taste for salty yak-butter tea. It was a deal I made with the kids, that I would not make them drink it with a smile this time. Word got out, and I was only ever offered slightly sweetened black tea during the afternoon rounds of home visits. We ate tsampa, a barley polenta, or rice, steamed greens with chillies, and cauliflower in a curried ox meat broth twice a day. Then we’d have snacks of popcorn, roasted soy beans, flat Tibetan bread, and boiled wild potatoes or eggs. On the day we were leaving, people dropped by with gifts of rice (about 40lbs), beans, potatoes, eggs, walnuts, and dried corn on the cob for popping. It was very generous of them since food production—ploughing, planting, harvesting, pounding, pummelling, and grinding—are all done without the help of ox or machine.

After hiking down to the town with road access, we slept overnight at the Lhasa Hotel. The Maoist flag flies in this town, and we were reminded that Nepal has a “political situation”. We called people in Kathmandu to ensure that the roads were open. We brought with us one boy with possible epilepsy, his brother for company, and their uncle as chaperone. The two boys had never been beyond this town, had never been in a vehicle, and were only reluctantly wearing shoes. We happily corrupted them with momos (Tibetan steamed dumplings), French fries, orange Fanta, crackers, honey on toast, a bed with a mattress, soap and solar heated water that came out of a shower. We left early the next morning, with enough Gravol to allow them to enjoy the sights of their own country from a different viewpoint. They tried to stay awake for the seven hour trip to Kathmandu—and I tried to imagine what they were thinking as we drove into the valley, seeing Kathmandu for the first time.

Finished in Pokara

For our last week in Pokara, we wrapped up everything we had planned and promised to do. Howard did a short placement at the TB Regional Centre and found the teaching staff to be enthusiastic. They pulled every manner of chest x-ray to show him advanced stages of TB. At Manipal Hospital, following an unusual case (for him), they found numerous other CAT scans to show him where the tapeworm cysts lodge themselves in the brain—the only symptom being headache then sudden blindness or loss of consciousness. His last days were spent at the Leprosy Hospital, which is a United Mission Hospital, a well-funded charity providing free care.

We quickly organized our own little trek and covered a whopping 2230m in one and half days (this number me

ant nothing to me before—it means that we walked up to the tip-top of the CN Tower four times–with Howard Song as our porter). We passed mercifully content buffalos, ponies carrying supplies up and apples from Mustang down, and consistently excellent food and lodging from the Gurung folks, one of the ethnic minority of Nepal. They too shared our disbelief that the health posts were unstocked and unstaffed—the excuse that there is a war on has run a little thin with everyone. But when you are introduced to a four year old child (who looks barely two) who has infant paralysis in both legs from preventable polio—you have to believe that someone should be held responsible.

I finished teaching at the government hospital. The dynamic and energetic medical superintendent is also one of the three obstetricians. She decided that every staff person who comes in contact with a newborn should be trained in neonatal resuscitation. So emergency staff, NICU staff, and maternity staff all took turns acting out scenarios involving a newborn who is not breathing. The question of keeping the newborn warm kept coming up as there is nothing more than two 40 watt bulbs perched above a table to warm a baby.

Generally, women who have just delivered want nothing to do with their newborn baby. I’ve come to understand that everyone in the family has a job; promptly after delivery, the job of just being with the newborn is not the mother’s but the father’s or mother-in-law’s (I’ll admit that I thought the same thing after my second was born). So the idea of keeping a newborn warm against his mother is odd. But, the problem that kept coming up was that the little creatures would cool down so fast when delivered wet into the world, and usually with no proper blankets, but rather yanking the woman’s shawl from under her, or from around her head, and wrapping the baby in that. On one occasion, it was so busy, that a few babies just kept getting wrapped in their mother’s manky shawls, a piece of tape with their mother’s name identifying them stuck to the shawl, and then just plunked into a basinette, hoping they’d stay warm together. Passing by, with yet another newborn slung over my arm, I noted one baby looked blue. Not the dusky grey-blue of not breathing well, but this real blue—like my kids get when they swim in the ocean off the coast of Nova Scotia. While his mother was still being taken care of, I took the baby out to the waiting room, and started yelling his mother’s name. A woman of 100 years came up to me. I told her that this was the son of this woman—who was she? She said she was the grandmother. Hoping she had no reason to lie about such a thing, I asked her to follow me to the roof. She climbed through a window that led to the adjoining roof from the waiting room. Pease sit, I told her. This baby cold is. This baby blue is. Blue cold good no is, I shook my head. Pink warm good is. Understand? She wobbled her head, cracked open her shirt, took the baby, and placed his naked body against hers. She then took her shawl and wrapped it around her, settling into the sun to do her job. I came back 15 minute later, and he was starting to pink up. And not that grandmothers will ever be replaced, but from the carpet raffle funds, the delivery room now has 60 infant receiving blankets and a very large heating pad to warm the blankets. So the new baby can be dried off with a pre-warmed blanket, before being wrapped in his mother’s shawl or grandmother’s arms.

We came back to Kathmandu to see Howard off on his flight back to Canada. Then, a few hours later, in one of those surreal moments that only Nepal can afford—we sat in a friend’s living room watching Nicole Kidman become a Stepford wife...then we heard a very distinctive bomb blast, gunfire, then silence. This was followed by nearby shops closing their metal grate doors...then more silence. We continued to watch the movie and then came a phone call from one of the medical directors, letting us know that the municipal office across from the Stupa Community Hospital was bombed, but the hospital was fine. The next morning, you’d swear you dreamed it. Nothing had changed. There is now a curfew but no one ever went out past 8pm anyways. The King has called an election for February 8th, and none of the major political parties are planning to attend. The former Minister of Information and now head of one of the larger political parties, is asking citizens to boycott the election. The current appointed Minister of Information is quoted as saying that human loss is normal in an election (and he’s trying to get people out to vote?).

So we’re planning to head out of town, to the village of Thuman, which has a fine view of Langtang mountain range—for a health camp.

The End of the Ceasefire

Hajur? I didn’t understand what the man said. He repeated himself and I had to stop a nursing student to translate for me. He asked how his wife is feeling, ma’am...He’s using the low form ma’am. She meant that when he referred to his wife, he had used the form of address for animals. Above the low form isthe address for children and usually husbands to wives, then an honorific form for colleagues and wives to husbands, then there is a highest form of address for royalty and priests. Err, your wife is fine, congratulations, here is your daughter (Iused the utra-polite word for wife). I handed him a baby bundled in his wife’s dirty patuka (cloth belt) and shawl—they hadn’t brought a baby blanket. His 2 year old first daughter bounced on his lap next to the new baby. The father looked grateful, every member of his family was doing well.


This is at the government regional hospital. For the 119 beds, there are 3 obstetrician-gynecologists and 12 nurses. There are another 20 nurses who volunteer. In one day, with the help of 30 students, the staff and volunteers will do 25 deliveries,180 prenatal visits, 2 to 10 abortions, and attend to other major and minor obstetric or gynecologic outpatients. One’s first impression is chaos but there is an order that is not readily apparent. I didn’t realize that the government healthcare is largely propped up by volunteers. Once nurses, auxiliary nurse midwives, heath assistants, and community medical assistants have completed their training, they volunteer. Sometimes as long as two years, they hope to find a job in the private sector or go abroad. Half of all Nepali nurses and doctors leave the country. So with international calls to increase the number of healthcare workers, it is actually, for Nepal at least, an issue of lack of paid healthcare positions...there are plenty of midwives and nurses at least, simply without jobs.

The hospital income (user fees) covers maintenance and staff salaries—government hospital salaries are less then half of what the private sector offers. Any government money would (theoretically) cover new equipment and an addition to the physical building. When a Nepali comes in for care, they buy their supplies—and essentially cover the cost 70-90% of their care. And with a miserable lack of political will, there is no continued investment in healthcare and no long term plan to do so. It’s a little depressing...

Some of you may have heard in the news that the Maoists have ended their 4 month ceasefire. To announce this, they let off a few bombs around the country—with no fatalities. It is always hard to get an accurate picture of things, as journalists are, according to Journalists Without Boarders, the most heavily censored in the world—but the taxi drivers reliably offer a wealth of local coverage, and things have been relatively quiet here in Pokara. The most danger we’ve been in was being charged on a trail by the usually passive buffalo. When I was passing her house, she put her head down and ran at me. I thought, oh dear, this is going to hurt...she pulled up short, with her horns pointing at my stomach. I steadied my wobbly legs and yelled at her to go away. The very old man of the house shouted something at her, and she ambled towards him. -–Oh Father! I called out,what did I do wrong? (more like, what wrong I do?)...Oh Little Sister, that one’s crazy but she gives good milk! We started down the trail, looking back often. Kai and Aaryn’s friend informed me that when I’m speaking to a buffalo, I can use the low form of address—not the honorific form (I had basically said in a quivering voice—Oh Madame buffalo, please go away—-maybe the old man thought I was crazy...)