we are up for very serious and long-term stuff, as you said when we met in Boston. Parag, I and two other colleagues had had very serious discussions about how to spread the word around here, get more people interested in contributing to this wonderful initiative and also be part of it.

Lau hai ta

regards

Jyoti raj sharma

As often happens when I read anything you or Nyaya publishes, I am very impressed. Your sensitivity to caste and gender, insider and outsider status, and issues of power stand out from my normal reading of Fulbright and Peace Corps “development” materials. You understand that while you might be able to bring ideas, money, organization, and energy, you cannot “bring change”. Most of the change has to happen at the local level – change in attitudes, change in habits, eventually changes for justice. Clearly your model is working – the ideas, money, organization and energy are flowing into Achaam. You have the government on board for some things, and grants and personnel for others. And local change is happening – people are coming! Reading your post one could feel the scale of need is so huge, and the injustice so deeply rooted, that it is impossible to choose a place to start. You did – a place to start and a place to stand. I continue to wish you well – and to share the message.

Your point about cultural relativism is well- taken. We can’t sit idle when there is so much oppression and brutality around us. As you so eloquently write, “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.”

Yes, honest statements like these should haunt not only health organizations, but also every individual, and every sector of society and government.

Thank you for sharing your passionate work.

Thanks for sharing your thoughts and observations. Many of your comments about discrimination against women and the issue of healthcare delivery in societies where “jhaar-fook” is synonymous with medical treatment remind me of some shocking cases I have myself encountered during visits to rural areas of Tanahun. As you pointed out, one of the biggest challenges faced by any organization trying to deilver healthcare to rural areas is accessibility of service. While some villagers may choose to go to traditional healers simply because they trust them more than real doctors, others go to them because the former are much more accessible. I wonder if it’d be worthwhile to look into the possibility of a decentralized healthcare delivery system in rural areas, where representatives (similar to the CHWs trained by Nyaya) don’t just wait at a clinic for patients to come to them from distant villages, but instead visit those remote villages on a periodic basis. You could have, say, 5 paid CHWs well-trained in the basics of primary care and each one of them visits a remote village away from where the main clinic is set up once a week or month depending on health problems in that particular village. Better yet, this could be combined with an on-call service where one of your trained medical personnel can go to remote villages if they receive a message that someone in a remote village needs serious medical attention. If such a service is offered, I’d think villagers who were initially deterred by the inaccessibility of central health posts, will now be more likely to seek real medical help. I’ve heard news about telephone service in the most remote villages of Nepal lately- such a facility would make the decentralized system even more efficient because the message of medical emergency wouldn’t have to wait very long to be delivered. I know all of this is easier said than done, and you have probably seen or know of many constraints that make such an arrangement less possible or less efficient than it looks here on my computer screen…

It is indeed a real challenge to get people in rural areas to go to modern medicine and not “jhaar-fook” for their medical needs even when accessibility is not an issue. Many people I met in villages in Tanahun went to traditional healers first just because they trusted those “jhankris” more. They would do/eat anything the “jhankris” prescribed, but the idea of taking something that came packaged in caplets and brown bottles at the suggestion of some newbie who touts the miracles of modern medicine seemed ludicrous to them. I wonder if people in Acchaam who go to traditional healers for similar reasons could be given the real medical help they need if the traditional healer him/herself prescribed real medicine instead of some “jhaar” or “booti” or some kind of animal sacrifice. Do you think Nyaya could work with traditional healers- train them in modern medicine and even pay them if necessary and ask them refer patients to a real doctor for more serious health problems- to combine their faith healing with modern medicine so that skeptic villagers still get the real medical help they need?

Finally, it’s rather unfortunate that women in rural areas have to shoulder a large fraction of the physical labor needed to make a living for their families. I wonder if educating the younger generation (from school-going boys to newly weds) on the kinds of health risks borne by women throughout their life and especially during childbirth, and on the respect they really deserve could make at least some difference in the long run. If today’s sons learn that they should not treat their future wives the way their fathers have treated their mothers, the picture you’ve posted above of men playing cards while women work in the fields could become antiquated in the not-so-distant future.

Once again, thank you for sharing. it’s great to hear that you are making efforts to help the cause that you feel so passionately about.

- Brikha

Your post attests to the fact that health issues and thus the challenge of improving the health status of a community is not one dimensional ; especially when issues are compounded by social practices such as this one that ostracizes the most vulnerable.

I agree that one of the biggest worries is how to go about empowering these people. How do you gain their trust and convince them that even though you are an outsider, you have their interests at heart and want to work with them to improve their lives?

Thus, I was particularly intrigued by the Female Community Health Volunteers (FCHV’s). Why has the gov’t made it impossible to pay them? What exactly is the regulation? Maybe there’s another way to give incentives to these women, to gain their support and also to raise their value and respect level in the community. Maybe you could help make their job easier, either through giving them access to better transportation (I’m not sure what that would entail) or to things they can distribute (food, anything of value) or give them payment in the form of food/necessities for their own family.

I think it’s great that Nyaya will be working with these women and supplementing their training so that they can do more in the community. It seems like there’s so little healthcare available that any additional services these women can offer would be a great improvement. And educating these women and allowing them to be spokespeople for Nyaya is probably one of the best concrete examples of empowerment that I can think of.