Posted by Bibhav Acharya
Chris, Mahendra, Bikram and I hiked up to Prabha to have conversations with folks who live there about their access to healthcare and about Nyaya’s clinic, which was opening soon. As we watched, listened and spoke, we learned a little more about suffering, health, nyaya (Nepali word for justice), and we reflected upon our role in Achham.
Prabha is a 30 minute hike from Sanfe Bagar, the site of Nyaya‘s clinic. One of the more developed settlements in Achham, Prabha has very closely placed communities of Kunwars (high caste Chettris) and Dalits (the “untouchables”: the lowest caste).
As we were walking up, we noted that several women and girls were working in the fields, collecting grass for cattle and wood for their homes. Males were conspicuously absent. Mahendra and Bikram (Bikram was born in Prabha and completed his schooling there before heading off to Kathmandu for further studies) said that most men are working either abroad or in other districts. Those who stay back do little in the fields and almost all manual and physical work is undertaken by women and girls. They told us that we would find a lot of men once we reached the village.
Several women and girls were working in the fields, collecting grass for cattle and wood for their homes. Males were conspicuously absent.
Because we got there on a Saturday, the government-operated health-post was closed. We were told that the health-post, like most in rural Nepal, is almost always unstaffed and not providing any services. Our first stop in Prabha was Madi where all residents were Kunwars. We talked with about 15 men, mostly in their 30s and 40s, who were sitting around and chatting after lunch. Everyone had heard about our clinic and was telling us how glad they were that a doctor was finally arriving in Sanfe. We asked them about healthcare in general in Prabha and were told that most people usually try traditional healers first and then go to a local private “medic”, a term for someone who may or may not have received formal health training and operates a pharmacy to provide allopathic health services at a steep price. I asked the medic in Prabha about his training. He has completed 3rd grade. He practices medicine based on working for 14 years for another medic, who is trained as an Auxiliary Health Worker and runs the most popular and profitable medical practice in Achham.
In Madi, we spoke with about 15 men, mostly in their 30s and 40s, who were sitting around and chatting after lunch.
The medic who runs this private practice and pharmacy in Prabha has completed 3rd grade.
One of the health programs operated by the Nepali Government recruits thousands of Female Community Health Volunteers (FCHVs) who live in the communities they serve. Nyaya is planning on engaging them as Community Health Workers (CHWs) and supplementing their training, enabling the FCHVs to provide primary care to their communities and make referrals for high-risk cases to Nyaya’s clinic. Although everyone at Nyaya believes we should provide a salary for the CHWs, the government rules make it impossible to hire these incredible health workers. It is very unfortunate that these women, who understand their community very well and have earned the trust and respect of their community members, are expected to work for free while other health workers (including doctors), who are absent from their job postings, are paid very well. Many folks we spoke with said that these paid health workers received medications for free from the government. However, instead of providing them for free to the villagers, they operate their own private practice and charge their patients, often requiring the latter to sell their personal belongings and take out large loans to pay for health services that should have been free or heavily subsidized by the government. Obviously, it was not possible for us to establish validity of this claim regarding every health center and every health worker. However, the formal surveys that Nyaya conducted and our conversations with people in Achham have captured many instances of staff absenteeism in government-operated health centers. This has led to a strong perception in the community that educated members, especially those working in health and development, are receiving benefits from the government or other donors and are making profits for themselves in the name of the poor.
Everyone we spoke with knew about FCHVs and said they are doing a good job in the little tasks they are assigned (administering vaccines and vitamin A capsules twice a year, making referrals, promoting health and in some cases, performing childbirth). Unless they are engaged by other organizations and the government in special projects, they are free almost all year. When asked if they did anything on the side, we were told that FCHVs do their health-related work in addition to all their housework so they have little incentive to do anything else since they are not paid. An older person commented that it was stupid to weigh kids and tell the parents that the kids need to eat more nutritious food because the parents are doing their best and there is nothing else they can do. Honest statements like these should haunt health organizations. Health workers should go beyond the tendency to treat these real-life issues as problems that can be solved by “increasing awareness”. It is obviously critical to convince parents that feeding nutritious food to the child is extremely important. But this only takes you half of the way. There is not much the parents can do if they are not able to produce or afford nutritious food.
Next we went to Podheri Khola, a dalit community, where we did not meet a lot of adult males since they are either in India, working in the fields or dead. We spoke with several children, 2 adolescent males and a mother in her late 20s and some other families. We could not find a single person who had heard about Nyaya’s clinic. The gap in communication was striking, especially given that one can not even tell where Madi ends and Podheri Khola begins. In the picture below on the right side, note the two houses with dark roofing materials. Those houses are part of Madi while the remaining houses are part of Podheri Khola. There is virtually no way to distinguish the two communities from outside yet the access to information and services is disproportionate since the upper castes do not interact with the dalits.
Note the two houses on the right with dark roofing materials. Those houses are part of Madi (where upper caste Chettris live) while the remaining houses are part of Podheri Khola (where dalits, people from the lowest caste, live). There is virtually no way to distinguish the two communities from outside yet the access to information and several services is disproportionate since the upper castes do not interact with the dalits.
When I asked all the children shown in the picture how many of them did NOT have parents working in India, only 3 raised their hands. Two were brothers whose father was working in someone else’s field in Achham (he does all the work, owner takes half of the harvest, leaving him with enough to feed his family for about 3-4 months per year). The third child’s father is dead.
We walked down to Sunarwada (community of goldsmiths, also dalits) where we met a 69 year old male who had not heard about the clinic. His nephew, who is a teacher, had also not heard of it. When asked about childbirths, we were told (again) that they happen in their homes unless there is a complication. Maternal health has suffered mainly because of this practice with 1 in every 125 childbirths leading to the death of the mother in Achham. I was reminded of a documentary screening I had attended on Achham in which a male “health worker” brags about conducting abortions. He explains the procedure which involves inserting either a sharpened bamboo or a hot iron rod into the vagina and poking the uterus and the fetus until it starts to bleed. Once the bleeding begins, you leave the instrument in for several hours until there is an abortion. The documentary was about a woman who had undergone this procedure and was left in that state for 16 days, after which she had died. She had been raped by an armyman during the Maoist war (although the director left this part out of the documentary so that the focus would be on the issue of treatment of women and not the politics of the Maoists and the Nepali Army). The person describing the procedure then goes on to mention that he has induced abortion on his wife using this method. When asked about the health risks and the possibility of his wife dying, he cheerfully replies: “Oh if she dies, I will just get a new one.”
One family showed us the Chaupadi Goth (literally “menstruation cattle-shed”) where women are sent to stay alone when they are menstruating, delivering a child or recovering after a delivery. As shown in the picture it is often an unclean space that is not higher than 4.5 feet. A recent childbirth in that family had taken place in the health-post. It was pleasantly surprising because 99.5% of childbirths in Achham take place outside a health center, often in Chaupadi or a corner of the house. They knew about the delivery allowance that the Nepali Government provides for deliveries carried out in a health center. They have been promised the stipend and are still waiting for it. It has been 7 months and they have no hope that they will receive the stipend. “These government institutions do not get anything done,” they said.
One family showed us the Chaupadi Goth (literally “menstruation cattle-shed”) where women are sent to stay alone when they are menstruating, delivering a child or recovering after a delivery.
We then spoke with a female whose husband is in India. She did not know about the clinic; when told, she asked us if it was for HIV. She said she has been tested for HIV several times. The global boom in HIV funding has trickled down to this corner of the world. Indeed, fueled by migration (about 80% households have at least one male member migrating to India for work), Achham and the neighboring district of Doti shoulder the highest rates of new cases of HIV in Nepal. HIV awareness programs and HIV testing have become quite common in Achham. If you do require treatment, however, the nearest HIV clinic is 12 hours away and costs about a month’s wage of an average Achhami, making treatment impossible for virtually everyone, a fact highlighted in a short documentary that Nyaya prepared. Nyaya plans to provide HIV care as a part of primary care soon. There are no official data for the percent of Achhamis with HIV but the District Health Officer of the neighboring Doti district had told me earlier that there were entire villages from where over 500 people would come for testing and about 40-50% were testing positive. Meanwhile the government and several organizations push for more awareness and tell the people that having a single sex partner and staying away from injecting drugs will prevent you from getting HIV. Almost all cases of HIV in Achham, Doti and other districts in rural Nepal have been attributed to migrant workers who spend several years in India, become infected and pass it to their wives and children who are faithful and abstain from injecting drugs.
We walked up to the home of a 16 year old woman and her 18 year old husband with a month-old daughter. They had not heard of Nyaya’s clinic. They had heard of the delivery allowance in the government health center but did not bother to deliver in the health-post. He said that the money never comes through. She also did not take the TT vaccine although they had heard about it. When we asked why they delivered the child at home, we were told it was “like a tradition. This is how things have been done and are done here.” Needless to say, the husband was doing all the talking.
We walked back to Madi. On the way back, we saw more women working in the fields. We passed by a small store where several men were chatting and playing cards. We got back to Madi and the men we had spoken with earlier were huddled in a store as well and playing cards.
On the way back to Madi, we saw more women working in the fields. In Madi, the men we had spoken with earlier were huddled in a store and playing cards.
A patient was brought in for check up at the private medic. 5 men had carried him for about 4 hours from Budhakot to Prabha. I spoke with the men who had carried him over. When asked about visiting traditional healers, they said it is like a tradition and it is the first thing they do. Only if that does not work they bring the patient to the medic. This is preferred because it is cheaper and closer, they said. When asked about childbirth, they said men do not stay around when women are in labor. Usually women do it on their own or may get some help from relatives. They usually do not have trained birth attendants around. Only if there is a complication, they are rushed to the medic. Sometimes it takes hours and even days and women die on the way. But the general philosophy appeared to be that unless there is a complication, childbirth is conducted at home. The man they brought in had a fever and was feeling weak for a week and they first took him to the traditional healer. His situation did not improve but he was still able to do some work so he continued. Then slowly he became very weak and unable to work or even walk so they brought him over. They said that if he feels better by tomorrow, he will be back working in the fields.
It is dangerous to make sweeping statements about a people after spending a day, a month, a year or maybe even several years with them. We are trained to be sensitive and to contextualize everything that may appear shocking at first. “Cultural relativism” comes to the rescue when outsiders may plan to break the social constructs that allow suffering of women, children, dalits and the poor. I think, however, that it is more dangerous to be a passive witness when you see women being treated worse than animals. Those social constructs need to be broken down, not by outsiders who may think their value system is superior to that of the target population but by the ones who are suffering. Improving health and improving lives are huge challenges. Finding the money and time to operate health systems like a clinic is an important first step but there is a long way to go. Spending time there and watching things from an “outsider’s” perspective (despite being a Nepali, I am aware that I am often perceived as an outsider since I am not from Achham and I very much felt like one as well), I now feel more strongly that our work should be about genuinely empowering those who are suffering the most. Seeing X number of patients in the clinic will not mean much if we are not able to help the most marginalized populations take back control over their lives. Nyaya plans to stay in Achham for as long as necessary but we will come and go while the people there will have to continue with their lives. There is not a lot that free antibiotics can do if women are expected to work 17 hour days, become pregnant every other year, given less food within the household and never have a strong and organized voice in changing the status quo. We should address health, of course, but we should address nyaya (justice) as well. The goal is to reach the most marginalized and provide them with support and resources to make real choices that are not hindered by oppressive practices and policies that are making people sick, exploiting them and killing them every day.