On monday, we began our tour of health centers in Nepal's mid-western region. Here we would get the opportunity to see rural Nepal and the challenges facing healthcare centers and the people that use them. I won't be able to adequately describe what an eye-opening experience this was, but I will do my best and I hope my nepalese teammates will give their perspective (and pictures) as well. It was a series of adventures beginning with a 1-hour flight to Nepalgunj, a small city in the valley region of Nepal. There we were met by our two drivers and their chromed out SUVs. Literally everything that could have a chrome accent was covered and we figured we would be rolling in style. The (older) adults piled into one car, and the rest of us jumped in the second with our bags piled in the bag seat. Our driver was dead silent (except when he was yelling at somebody on one of two cell phones in the car) and didn't look a day over 17. We quickly learned that driving outside of Kathmandu is even crazier than within. Sure, drivers seemed to pick the correct side of the road, but only after a harrowing horn-honking and brights-flashing chicken fight on a street that only fits one and a half cars. If you think that caused some anxiety, add 70 kilometers per hour into the mix and we had an uninterrupted stream of our lives playing before our eyes. It was a blast. Soon, we stopped for lunch in a town called Surkhet. Here is a picture of us (minus me) and Jona and Dr. Thapa, our gracious hosts from Jhpiego. We ate a traditional Dal (lentil soup) and rice dish, which was pretty good. Some of the flavors were definitely foreign to us, but we finished it off. Little did we know that this is what we would be eating for all but about 2 meals for the next week. Mmm mmm lentils! Thanks to everybody that worked so hard to cook for us!
After lunch, we continued our 6-hour drive into Dailekh district. But don't think that the drive was pleasant from there. No. It got even better as we Indiana Jones-ed our way up and down mountians (sorry, hills) on a sometimes-paved road that had seen its share of recent landslides. We also passed through a few security checkpoints at the entrance to a wildlife preserve area where armed gaurds had machine guns trained on us ("no pictures!") to make sure we wouldn't be taking home any tigers. Steep cliffs, hairpin turns, and oncoming mega-buses barreling (actually, careening would be an absolutely appropriate term) down the mountain with people clinging to the top were no match for our driver as he made sure to give a little toot of the horn before he whipped around a corner. I'll tell you what, I'm ordering up some Nepalese brakes for my car when I get home, because these guys are able to stop on a dime when they come face to face with another pair of headlights. Oh, and seatbelts? Please. Our seats weren't even bolted to the floor, so it wouldn't have done any good. No matter, Jan managed to sleep through almost the whole drive. We thought his neck was going to break and had a good laugh about it.
Along the drive we would see lots of people who live in the little villages dotting the mountainside. Consider yourselves lucky that we got these pictures because the car was definitely not steady. We would often see families dressed in traditional clothing and gathering plants from the hillside or men working to clear rubble from the landslides. The backdrop to all of this was surreal as we were high enough to be in the middle of a cloud. When the clouds would break, we would get a glimpse of the terraced mountains and could look over the edge of the road into valleys with winding rivers. It was absolutely beautiful.
Finally, we made it to Dailekh. Dailekh city is the center of Dailekh District, one of 75 in Nepal. The town consisted of one one-way road lined by homes and little shops selling everything from candies to water buckets. There is a lot of construction going on, so piles of chipped bricks would jut into the roadway away from homemade scaffolding. Almost nobody has a vehicle here so the streets are crowded with people walking between houses and shops, and cute uniformed children walking to or from school. We got plenty of stares as we flew through the street in our big cars, narrowly missing people, goats, and stray dogs. Jenny, Julia, Jan, and I decided to walk the town after putting our stuff in the hotel, and we couldn't have felt more out of place. We did our best to be friendly by saying "Namaste" to almost everyone, which was promptly followed by an acknowledging "namaste" and some giggles. We ran into some kind of cultural celebration where the village boys played homemade drums and a few donned masks and costumes as they danced their way up the street. One of the boys tried to get Jenny involved by handing her a colorful piece of cloth, but one of the women close to us quickly made the boy take it back. It took about 20 minutes to walk to the end of Dailekh and back, after which we ate dinner (Dal, of course) and settled into our rooms. Here is the view of Dailekh from one of the hotel balconies.
We slept (pretty) well and were excited to begin working in the morning. We visited Dailekh district hospital to speak with the District Health Officer, the guy who is in charge of healthcare for Dailekh district. They wowed us with a presentation about the successful prenatal calcium pilot run by Jhpiego in the district. They have been able to significantly reduce the prevalence of pre-eclampsia/eclampsia and maternal deaths, along with increasing the number of antenatal care visits by mothers. We learned that with a solid distribution model and a strong training program, devices and medications can have a large impact. After the meetings, we had a tour of the main hospital, which had very little light, only a few beds, and limited staff. Keep in mind that this is the place people come if they can't get help at the smaller, more poorly equipped health posts and clinics in the surrounding areas. But they do the best they can. They had an x-ray machine, an ECG, and a dedicated space for antenatal care visits. At the antenatal clinic, we met an auxiliary nurse midwife (ANM) who explained how she cares for the pregnant women who come to visit her. She meticulously keeps a record book of every patient and counsels the women on how to take care of themselves and their baby during pregnancy. After the counseling, she allowed us to observe as she used a pinard horn to check the baby's heart rate. The pinard horn is the standard of care in low resource for measuring the fetal heart rate (FHR). It is typically made of aluminum, plastic, or wood (all of the pinards we have seen are aluminum), and consists of a long cone shape which is placed on the mother's abdomen, and a smaller cone on the other end which is rested against the ear of the health provider. An experienced provider like this ANM can quickly find and measure the FHR in a quiet antenatal care setting with a pinard, but the task becomes much more difficult in a busy labor ward and during active labor. Notice the condition of the pinard in the picture below. Often this is the best tool they have to determine the health of an unborn baby. The next picture is of another pinard we saw at a birthing center just outside of Dailekh. We were told that this pinard is over 40 years old.
After the hospital, we trekked down to a "sub health post" below the village. This was a two-room naturally-lit building next to a school, and is basically the front line of health care. Not much can be done at this building and anybody needing more help is fortunate enough to have the district hospital closeby. On our walk down, we were passed by a group of men carrying a woman up to the hospital on a homemade stretcher. They had some rough terrain to navigate before they made it there.
The next few pictures are all related to the trip to the sub health post. Here is team Nepal looking awesome as usual (please ignore the sweat; it was hot and we were hiking).
Dr. Kusum Thapa is constantly reminding us to think about how difficult it would be for a pregnant woman, possibly in labor, to get to an adequate hospital to deliver her baby and have the best chance of survival. We can only imagine. While we (note that in this case, I am talking about my own experience, having a daughter) are at home worried whether traffic will be very bad in the 10 minutes to a ginormous hospital with a relaxing jacuzzi tub and all of the newest technology in a nicely decorated and private labor suite (and unlimited crackers, ice, and juice, as well as free diapers, televisions, a plethora of highly trained medical staff, and a nursury), these women are required to choose between risking a home birth (with an unskilled birth attendant if she is lucky) and a day trek across mountains to the nearest hospital or birthing center. Wow. But in a good-hearted attempt to imagine, Jan donned his backpack in the front and made his way down the mountainside.
We might have been able to drive down to the sub health post, but the roads had been washed out by the recent rains. Transportation is difficult anyway, but monsoon season makes it worse.
At the sub health post, we met with some FCHVs (that's Female Community Health Volunteers) who are nominated out of the mother's group to receive a little bit of training in labor and delivery, as well as inform women and pregnant mothers about the importance of antenatal care and appropriate family planning. They wear a pretty blue sari as their uniform. They were kind enough to talk about some of the skills they had learned for neonatal resuscitation, and we have to say we were impressed. They pulled out their Baby Anne infant simulation doll supplied by our friends at Laerdal, although I think this one is a couple model years back!
They explained the tools they carry around in their bag, and then they explained how to do Kangaroo Mother Care (skin to skin contact to keep a baby warm) following birth using Jenny as a model mother. Great work, Jenny! We couldn't help but smile at the cute little girls who were peering through the window as we had our meeting. It was tough to get them to smile, but I succeeded with one of them as you can see in the last picture!
We left Dailek on wednesday with a new perspective about the challenges we will face in developing appropriate technologies to help people living in places like this. It is a big task, but we are motivated to help as many people as we can. Thanks for teaching us so much, Dailekh!
