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...)
I taught a few classes of newborn resuscitation at the government school. This school has no resources, and there are triple the number of students per class than at the private schools. The school uniform is the dated sari (try bustling around a Nepali hospital and staying clean in a white sari...) Students are bachelor level—so they have volunteered or worked for at least two years after finishing their certificate level nursing—these students gave me a snap shot into practices in maternity care outside regional centres. One thing I find confusing is my perception of this healthcare dichotomy going on between the acceptance of fate and heroic measures—or any measures for that matter. Howard noticed this as well, working in IUC at the private hospital. Here, the doctors do not talk to the family about not performing CPR on a very sick patient if their heart stops (a do-not-resuscitate order), They go ahead and attempt to resuscitate everyone (heroic measures). On the other hand, there is the pervasive Ke garne? which means ‘What to do?’ accompanied by a shrug and inaction (acceptance of fate or perhaps waiting for orders from higher up). But maybe there is no conflict, maybe the gods’ plan involves heroic measures or inaction on the part of the heath care provider...this is your healthcare provider, this is your fate... Howard’s patient told the staff doctor that he had a dream, and God told him to leave the hospital. The staff doctors said, that’s fine, but until God gives me a dream telling me to discharge you, you’ll need to stay...Then again, not treating a patient because they don’t have the money for further treatment requires inaction on the part of the healthcare provider—healthcare is not provided for free. One student asked, ‘Ma’am, how long do you help the baby?’ I said, ‘After 15 minute of no heart beat, you can stop the resuscitation, the baby has expired. Why? How long do you continue?’ ‘Hours and hours ma’am...’ I’m no closer to an understanding.
In true basketcase form, the Royal Nepali Army receives quiet military aid from the People’s Republic of China (whose present political philosophy is a rendition of Mao’s writings)—and the Maoists, who also claim roots in Mao’s political philosophy, receive money from communists in Northern India and a ‘tax’ they levy on aid projects set up by international non-governmental organizations doing work in their controlled areas.Last week, there was a one-day nationwide strike called by the alliance of political parties due to a military massacre outside of Kathmandu. At a village fair, one soldier became angry with the local boys after they hassled him for bothering the local girls. The soldier returned to the fair later in the evening, and sprayed the crowd with bullets, killing 11 and wounding 19. He was then shot. The leaders of the political parties have questioned whether he acted with or without orders...who killed him...and how could one man acting alone shoot into a crowd from a number of different angles...Since then, there have been demonstrations protesting the shoddy investigation into indiscriminate acts by the military—indiscriminate military acts are usually a little less obvious...