4 funerals and a wedding

And four births...this is the aptly named baby `Lucky'

Midwifery students in the equivalency program

Susan has her own baby, Peter Nanuq, on her back when she does the head-to-toe newborn exam on Teegan, age 1 hour.

These are the three rockstar midwifery students in Inukjuak. Between them, they've had 9 babies of their own. To be a trainee, they applied and were interviewed by staff at the health centre (I guess it formalizes it, since everyone knows everyone here). They are each at a different levels of their training, and carry varying responsibility for pregnant woman - all under the supervision of two Inuit midwives. Their training is all apprentice-based, and they keep a log book of cases, skills, and knowledge acquired. Once they've provided primary care for 40 women (throughout pregnancy, labour, birth and up to 6 weeks for the woman and baby) and have attended 100 deliveries - they 'defend' all their acquired skills before a panel of midwives...from there, they submit their application to the Ordre de sage-femmes de Quebec, the regulatory body of midwives in Quebec.

Working on caribou heart - learning how to infiltrate anesthetic into a wound...

And learning how to suture

Transport and referral from the north

Heading out the door at 430am - the start of 18 hours of daylight

Student Susan May, with her baby Peter 'Nanuq' - born at home with the midwives. (Peter is wearing his cool sealskin boots made by grandmother Eva).

One of two delivery rooms.

Transport equipment and supplies at the back door ready for medevac. There's a heater to the right that holds expired iv bags - used as hot water bottles to pack around the patient for the trip out.

But what about the 6 hour transport time on a good day and the inherent risk of giving birth. It seems that with good prenatal care, preventative measures, and referring at-risk women to deliver in PUV with a little extra technology available, or in Montreal with a lot of technology available, the outcomes are very good. And when something comes up quickly, you manage it and it resolves, or stabilize them and move them, or you stabilize them and then sit tight through the night until the skies clear.

The most recent data by Luo, up to 2000, found that there was no difference in perinatal mortality rates among infants born in the north, compared to aboriginal infants and non-aboriginal infants born in the south (Montreal). They did however find that infants born to Inuit mothers, when adjusted for infant's sex, parity, maternal age and education, and marital status, had 4x higher risk of postnatal infections and sudden infant death compared to non-aboriginal infants in the south. Limitations in the data did not permit the researchers to control for maternal smoking in pregnancy. And 99% of women here smoke in pregnancy, and presumably in the postpartum too - though in the last 10 years, there has been a very successful public health campaign to get people to smoke outside (yes, all year) if they have young children in the house.

What is somewhat hidden in this paper is that ~70% of all women in the north and aboriginal women in the south had <11 years of schooling, whereas ~10% of non-aboriginal women in the south had <11 years of schooling...and given that the Auditor General of Canada in 2004 estimated that if all things remain the same - this gap will take another 28 years to close...we likely won't see a change in these numbers for a generation, as maternal education is closely linked to both neonatal deaths (<28 days), and infant deaths (<1 year).

Meeting their great grand daughter, less than an hour after she was born

Inukjuak in Spring

I explain to the woman that since we don’t have a lot of information about her pregnancy so far, she should consider having an ultrasound so we can try to figure out when she is due. The ultrasound is in Puvunituq, an hour north of Inukjuak by plane - the regional government will pay for the flight there on one afternoon, the overnight at a transit house, the meals, and the flight back the next afternoon after the ultrasound at the PUV hospital. She seems hesitant - "but when should I go?"…I explain that the sooner the better since the scan is more accurate earlier in the pregnancy…she pauses and asks if it can wait until after goose hunting season. "When does goose hunting season end?" She smiles widely, as if to say "Oh girlfriend, what are you missing in life?"

And it’s true - I never knew about a place like Inukjuak existed in Canada. It’s a calm well-governed community, where families go away to camp/hunt/fish out on the tundra - where timeframes are governed by migration of wildlife. The cb radio is on all the time, and caribou migration is reported daily. Everyone speaks Inuktitut, most speak English, and some speak a bit of French. Familes are large and women start having babies young. A third of babies are adopted to extended family in a process that has only recently been tracked by any paperwork.

This sounds like a romantic image of the nobel savage but what I mean is that it is nothing like I was expecting. I arrived in northern Quebec at the beginning of May to work in the maternity wing at the Inukjuak Health Centre. The maternity is run by two Inuit midwives, apprentice-trained and registered with the College of Midwives of Quebec. There are also three students doing their apprenticeship. This is a major success story since other areas of Canada have attempted to have local registered midwives, and the training never got off the ground. The midwives scope of practice is broader than in the south - they cover all the reproductive and newborn healthcare and can consult with one of the two family physicians on staff.

Inukjuak is a village of 1500 people. If you look at the Hudson Bay east coast, at 58˚North, it looks like a side view of a pregnant woman and Inukjuak is at her xyphoid. The health centre has a busy out-patient ward, occasional dental and psychiatric services, social services, and the maternity wing.

The health centre serves the immediate community and outlying communities, which have a nursing station. The healthcare staff are mostly Quebecois, and the frontline staff and translators are Inuk. There are ‘first responders’ on staff to call for transport to the airport, and emergencies can be medivac’d to Puvunituq or Montreal if needed - you plan for 6 hours transport time if the skies are clear (no blizzard, no fog), and the winds are calm (I have never been in a windier place in my life).

But apparently Inukjuak was called 'the Bosnia' by locum physicians willing to come for a week or two in the mid-90s...and this is what I was expecting.

I don’t really know what all the problems were but there were more suicides, gun accidents, people lost on the tundra, and alcoholism than there is now. Inukjuak is the village that used to be called Port Harrison. In the 1950s, the federal government relocated families to the high Arctic of Resolute Bay and Grise Fiord, to act as 'permanent residents' in order to claim territorial sovereignty in the Arctic…families were split up, and some have returned to Inukjuak after 30 years. The community received a government apology last year and the story was depicted in the NFB film, Martha of the North.

Lisa with her first grandson, baby Charlie, number 424 born at the maternity

The other issue, a similar story as the rest of the far north, in which women were sent to Moose Factory or Montreal a month prior to delivery. And the profound experience of birth was taken out of communities. This sounds a wee bit dramatic, but the opening of the Inukjuak maternity corresponds with the improved social conditions of the community, 13 years and 428 births later, Inukjuak is considered a success story of Inuit self-government and the professionlization of the traditionally trained midwife.

Dalacia with 3 week old baby Ethan in her amati

This is an apt quote from PUV midwife Nellie Tooliguk, in the SOGC guidelines on returning birth to the north. "Just imagine this: You are having a baby. A group of people with PhDs have decided that Denmark’s perinatal statistics are better than Canada’s.

They decide it will improve the medical outcome for you and your baby if you are flown to Denmark three weeks before your expected delivery date. You will remain there, without your family, until your baby is born. You arrive alone in this place where you have never been. You can’t adjust to their strange food, so you eat very little for your last weeks of pregnancy. Everything is in a different language. Sometimes an interpreter is available.

Your family calls after two weeks to say that your children have been taken to another relative’s. The house you know is already over-crowded. The children cry on the phone to you, and you know you can’t pay for this phone bill when you return home.

If you refuse this new plan, which has no evaluation of impact, you are considered selfish, undereducated and

willing to put your family’s health at risk! When you

ask if this money could be used to simply improve the

health care at home you are told studies need to be

done first to see if it is possible. This is just a small

piece of what injustice we have been put through by

health care policies and policy makers."

Espoir d'enfant Orphanage

Here's a July photo update from the facebook of Espoir d'enfant. Money raised from the Silent Auction at The Coburg on May 14th 2010 has gone to fix the bricks and mortar of the building. All the rest of the donations - Flip flops, art supplies, and toothbrushes and toothpaste arrived with us and was immediately put to use.

Asny Altinor released from prison

This really isn't in the vein of maternal health but rather, in over-arching framework of human rights. An NGO called Clean Water for Haiti, run by Canadians, had one of their employees arrested for arson. The evidence was weak, and the man was held in prison for 10 months. His case was heard finally and was thrown out, for more info on the story...see Sue's article...(update - sorry this link is broken I can't find the original article)

Heading home

many photos by Carl-Henry Jean-Baptist

I'm heading home now after a very short visit. Most people warn you that Haiti gets under your skin. I think it's because you immediately feel at home because of the people, and probably because there is no end to the addictive emotional whomp...

And I love the little reminders to check your semi-automatic machine gun at the door...

Returning to their homes

Steps are being taken by various NGOs to assist families in moving from the camp to something more permanent. Housing has been classified as red (needs to come down), yellow (repairable), and green (safe to move back in). Families can be categorized into three groups: never had decent housing in the first place, has a house somewhere but are too afraid to move back into it, and those who have a green house but who receive greater benefit in the camp (security, food, healthcare, NGO work) than at their home. There is also the question of how to determine land ownership, removal of rubble, finding empty spaces to settle people in the mean time...'transitional housing' is a tent and this is considered the step up from a tarp. Transitional housing is the housing plan for the next two years.

Needless to say, the camp experienced outburst of domestic violence. Today, I was working with Andy, the team physician for the New York Rangers. A woman arrived with her head wrapped in a towel and she was covered in blood from the top of her head down to her knees. It's Sunday, and we're seeing emergencies only (it's noon and we've already had one 2 year old with severe burns from falling into a pot of boiling beans, one 11 year old with a head injury who fell two floor from a roof onto a pile of rubble, a semi-drunk 21 year man passing kidney stones, a woman in labour who has an eclamptic seizure with a blood pressure of 190/120, and a 9 month old baby with some sort of diffused pneumonia cooking a fever of 41C).

Hubert, a very kind 24 year old translator, explains to Andy that this woman was hit in the head with an iron rod. She's in shock and leans against the guy who helped her walk up to the tent hospital. We unravel the cloth around her head, pick through her hair, and cut some of it off to find the superficial slices on her scalp. Hubert gently coaxes her to tell him what happened. "She said her husband did this, they fought when he wouldn't give her money to buy food for their children." Andy starts to suture her head, and I get out the Domestic Violence Checklist from the hospital protocol binder. I start taking notes, and explain to them that we'll need to call the UN Police. Then this oddly surreal moment unfolds in which Sean Penn arrives with his Glock pistol in the back of his pants, and asks me to ask her for directions to their tent - as of last Thursday, his crew has now been put in charge of security in the camp. I efficiently cross out "Call UN Police" on the checklist and replace it with "Call Sean Penn - head of camp security".

Sean (an American actor) and Bulldog (a Haitian ex-supermarket security guard) leave. Hubert tells me that she won't tell him what she did to deserve this because in his opinion, Haitian men don't hit women. "Hubert," I sigh like an old, tired feminist, "Zanmi, she did nothing to deserve this...don't go there, you'll lose." Andy backs me up. "It's never ok," he confirms.

Later on, we're sending the 9 month old baby by jeep to St. Damien's Hospital, with Bulldog riding shotgun. Whenever the jeep gets slowed down in traffic, 6'6" Bulldog jumps out and starts banging on the hoods of cars to clear a path for the jeep. He got the eclamptic women to hospital through the worst church traffic. Hubert arrives at my side as I wave the jeep off. "Okay, I just have to tell you, she stabbed her husband first - she just told me." I don't know what to say..."See? It was self-defence." "Perhaps, but it's still messed up, don't you agree - why isn't there enough money for food?" He pauses, and then says slowly "I know this probably isn't the right answer, but maybe she spent it on her hair extensions that you just cut off?"

Petionville Hospital at the Golf Course

This is baby number 116 to be born in the 12 bed tent hospital since they started counting January 27 2010...and 110 of them have been girls. This is a natural experiment in demonstrating excess male fetal loss that was published in BMC Public Health in May. These authors used 9/11 to show that it was not a decrease in conception of male fetuses, but an increase in miscarriage of male fetuses, since they looked at deliveries of infants who were conceived before 9/11. One hypothesis is that male fetuses are more sensitive to the mother's increase in corticosteroids released in response to extreme stress.

Baby Julie's proud father is holding his second daughter in a blanket donated with funds from Canadian friends. A short time later, baby Ann, number 117 arrived (err, the temperature inside the tent is 46C...Rachel from Montana and I didn't just shower, we always look that glowing).

Haitian Pharmacy

This is a Haitian pharmacy. It's blister packs of meds arranged by colour.

In the women's clinic today, a woman arrived visibly pregnant and asked for a check up. She looked a little pale. I asked her a few questions and learned that she was 6 months pregnant and had spent the night in writhing pain. She had taken cytotec purchased for $2 from a pharmacy such as this. Abortion is illegal in Haiti - but cytotec, like in Latin America, is a medical means for early abortion available to anyone. It is sold in readily available homebirth kits for the prevention of postpartum hemorrhage. If it only partially works for abortion, a woman can come into hospital reporting complications from a miscarriage and receive a D&C.

This woman wanted an abortion after learning she was pregnant a month ago. She thought she was pregnant earlier but a foreign health worker told her that it was normal to not have your period after the stress of the earthquake, but the worker didn't provide her with a pregnancy test. She lives in a tent with her three children, and her husband is dead under the rubble.

So, during the check up, I listened with the doppler, and for the first time in my career, I said "sorry madame, but your baby is still alive." She just laid on the cot with her hands over her eyes. I blathered on about options, don't do anything drastic, referrals....Then, gradually, she got up and arranged herself, thanked me with a tired smile, then left.

The Beach

We headed out of Port-au-Prince to ejoy a swim on Saturday with our host Nickel and Soneide, Carl and kids...under a hut on the edge of the concrete pier, young folks hung out together and played competeing music with the next hut. Guys in boats would sell cocout to drink and spear fisherman surfaced with a catch of 4 crab and various fish to sell. Out beyond the edge where the kids play, there was always a dozen couple, spearated by a few metres, grinding and sexing (apparently you put the condom on before you enter the water) where they could get relative privacy compared to their home (?)...our hosts shrugged like 'what the big deal'and Sue and I agreed that we were raised by our mother afterall and why were we so pruddish? So for the NGOs that are focussing their HIV prevention efforts in the camps, they should really do a turn at "the beach".

Golf Camp

This is the Petionville Golf Course before the earthquake on the left, and after the earthquake on the right.

I'm staying in the neighbourhood of Delmas 40B, which is one block from the largest camp in Port-au-Prince Camp Golf where right after the earthquake, people just started setting up shelters on the private golf course. 60 000 people have settled in, set up shops in front of their tent or in their tent.

Most interesting are the beauty shops since they are run by young women, and they provide the not-necessary-for-life hair cuts/extensions/wash and set as well as manicures and pedicures. Many set up right after the earthquake and are struggling with a 3x higher price in supplies and a clientele that has little money. And in the four hours it takes to do extensions, they share a lot of info on birth control, safe sex and sexually transmitted diseases. June's salon now has a box of "Huge" condoms (really, that's what they're called) to hand out to customers, courtesy of an American NGO of course...

Camp Dadadou

Sue’s friend Carl lives in Camp Dadadou, one of the comparatively smaller camps in Port-au-Prince. After the earthquake, people living in the middle-class neighbourhood Delmas 3 moved across the street to the soccer stadium and set up tents…10 000 people. The houses remain under the rubble, along with the deed to their properties and their loved-ones who have passed. Relatively speaking, it is one of the nicer camps since it is surrounded by a high stone wall and barbed wire providing memory of a previous Haitian era when Haiti was represented in the World Cup in 1978. There is a volleyball and basketball court, and folks have started businesses, like cell phone charging stations, Skype phones service to Canada and US, and shops stocked with the Cheetos, beer, cigarettes, rice and beans.


However, being small means it has been overlooked by the larger NGOs in infrastructure management. They haven’t had drinking water for two months and they have 126 toilets for 10 000 residents. They have 24 orphans who are housed by a tent provided by USAID but are fed by the residents of the camp. A mobile clinic is run by Partners in Health and a Haitian nurse provides emergency care and delivery attendance 24/7. This nurse has attended 126 deliveries in the tents, 3 of which were transported for cesarean. There were no maternal deaths and 5 neonatal deaths.
The camp has security that residents provide. Though fighting between residents is managed as any mob would, without the back up if police and ambulance to disperse the crowd. Last night, while Sue and I were at Dadadou, having a beer and visiting with Carl’s family, a fight broke out between two teenage girls. Everything stopped – the volleyball game, the basketball game, bathing children, cooking on the coal pit – everyone rushed to see two girls lunge at each other with batons and back away and taunt one another. They were cheered on by the crowd. Entering into the circle of the fight, came a young man who raised a thick baton – it happened quickly, one of the girls stumbled and collapse unconscious. The crowd didn’t disperse but some men were able to carry her to the clinic which is surrounded by barb wire. She was laid on a camp cot in the clearing of the clinic and observed by the mob from the edge of the barb wire. Carl led me through the wire. The girl continued seizing for the next two hours while there were these Lord of the Flies moments of cheering and calls of justice served. A middle age woman appeared and said she was a friend of the girl’s mother, she asked if the girl could be taken to a tent for a rest? Would she wake up? I pointed to the girl’s seizing right hand, stiff legs and jaw, non-response to pain, and fixed pupils – her brain is bruised, she needs to go to the hospital. My limited experience in resource-poor countries (or who come from resource-poor countries and are receiving care in Canada) is when you tell someone they are sick or injured – the default pathway is death, and it only once you explain that there is treatment do they consider life a possibility. Whereas in Canada – our default is life, and we’re shocked to learn that medicine can’t rescue everyone from death. When I said she had to go to the hospital, the mob at the barb wire, and those who had managed entry and were now surrounding us in the clearing, said she’s as good as dead. It didn’t help that the girl when collapse on the cot, stiffened and start seizing again…in Haiti, voodoo beliefs are stronger than rational belief. And no explanation of brain bruising and bleeding vessels would dissuade the mob from pointing out that she was changing into a cat or a dog, and she was about to leave. Finally, our friend Nickel appeared with his jeep and we loaded her into the back, her head resting on the lap of the woman accompanying her to the hospital. We arrived at the National hospital, and knowing that she wouldn’t be assessed until the morning, we left them. The next day, we were told she was discharged, having progressed from seizing and unconscious to a headache…

Port-au-Prince Haiti

Tomorrow morning, I'm heading to Haiti to volunteer in a hospital. My sister is heading back after covering the earthquake to follow up on stories (and start the celebrations of her fiftieth birthday)...stay tuned...

Mehendi wrapping up

What a great job everyone. Mahendi is wrapping up its work in Thuman village. Nepal has enjoyed peace, albeit tenuous. Governement money flows into previously held Maoist territory such as Thuman. Mahendi's work of rehabilitating the health clinic, helping the village folks access money and support from the government, completing the training of the auxillary nurse midwives, and organizing and training a village emergency response team is complete. The work of technical assistance is now starting with the help of ICT for Health...check out the website...www.mahendi.org (edit - this site is no longer active, please visit www.annmontgomery.ca)

Also, check out the video of the work at the health clinic...http://www.youtube.com/watch?v=UHJjrY7BEjU

New Org

Welcome everyone;

maternal-health.org has moved in with MAHENDI.org (edit - this link is no longer active, please go to www.annmontgomery.ca)

MAHENDI works on issues in maternal health in Nepal in three areas: training skilled birth attendants such as midwives, implementing health management systems to provide 24 hour quality care coverage, and expanding maternal healthcare into the social business area for financial viability and sustainability.

3rd Annual Tibetan Carpet Raffle

It's back, the 3rd Annual Tibetan Carpet Raffle. Buy a ticket and get a chance to win a 4'x6' handmade, child-labour-free, wool carpet. Tickets are $20 or 3 for $50--chances on winning are about 1 in 50 (errr, they're about 1 in 13 at the moment). If you buy a ticket, you will get a chance to go on a virtual shopping trip with me in Kathmandu--and I'll bring the carpet back for you. Second prize is a pashmina shawl in the exact colour of your choice (you just give me a paint chip and they'll make it to match)...Draw is to be held at a benefit party on November 17th, 2007.
If you'd like a ticket or more info, please contact me ann@maternal-health.org.

Also, check out our new website at www.maternal-health.org (edit - these are no longer active - please go to www.annmontgomery.ca). We have partnered with the Himalayan Outreach Foundation and are now able to provide tax receipts for donations for the women's health projects we're organizing. They have applied for an operating grant and we will hear whether it has been awarded in December. The monies will allow us to launch clinic camps in the Kaski region, near Pokara, to train health workers and screen women for long-term health disabilities related to poor care in pregnancy and birth.

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.