(Based on Community Interaction – Conversation with Health Facility Management Committee Chairperson Mr Hari Lal Sarki (name changed) and community member Mr Ramlal Jaisi (name changed))
Maila is a remote but beautiful VDC located in Humla district. The musical rhythm of Karnali River flowing through the VDC and panoramic view of huge mountains surrounding the VDC adds beauty to this place. People here have a difficult life but they have been benefitted by services provided by PHASE Nepal.
Ramlal Jaisi (name changed), a local resident says- “Before PHASE was here, we had to reach Nepalgunj (3 days continuous walk then 1 hour by airplane, however airplane is not regular and often need to wait for some days) which was really difficult for us. Many people had to lose their life because of unavailability of basic primary health service in the village as well as poor economic condition. Many women here used to die because of complications during pregnancy and delivery. The condition of infant health was poor. Maternal and child mortality rate was very high. We weren’t even able to receive a tablet of analgesic medicine (paracetamol) when we had a headache.”
Ramlal recalls -“We did not have awareness on hygiene, sanitation and cleanliness. We had to face many epidemics. There is no any alternatives treatment. People had to accept deaths. I have seen many deaths because of diarrheal diseases. Most often people here used to believe in dhaami/jhankri treatment since they weren’t aware about visiting to health institutions for treatment. If someone suffered from any disease then s/he was more likely to lose his/her life rather than receiving treatment. But now the situation has improved as we are receiving good services. PHASE Nepal has brought us happiness and served as our god.”
He highlights - “Nowadays, the scenario has changed, PHASE Nepal has added precious beauty to our place. Most importantly, PHASE has provided us with a variety of medicines and capable health staff. PHASE staff remain regularly in the clinic and provide service throughout the year. PHASE has brought many positive changes here through awareness raising activities in the community. People's attitude regarding visiting health institution for treatment has increased. Most of the pregnant women visit health institution for checkup and send their children to attend school. It has been seen that people have started visiting health institution when they fall sick. People are well-aware about family planning and personal hygiene, which they teach to their children as well. It has been noticed that there is drastic change in hygiene and nutrition status of babies.”
Health Facility Management Committee Chairperson Mr. Hari Lal Sarki (name changed) says - “Since its inception in Maila village, PHASE Nepal is providing quality service in this place. We have learned lot of healthy behaviors through community health education, clinic health education and school health education session. Family planning awareness and service have very high positive impact in the community. Before PHASE, most of the people used to have more than half a dozen of children in their house but now pregnancy gap is maintained and birthing rate is controlled. Open defecation was common but now it is also controlled in the area. In average 50 to 60 patients are receiving health services daily from the clinic of Maila. Monthly meeting of FCHVs, mothers group and Health Facility Management Committee meetings have been systematized. Health Facility Management Committee, FCHV and Mothers Group are now capable themselves to organize meeting and making decisions. Also there have been changes among school students here. 10 to 12 women visit for delivery services on a monthly basis inthe PHASE supported clinic.”
Both Hari and Ramlal conclude that PHASE is still a very important service provider in the village as there is no regular service from the government. Not only from Maila but people from neighboring villages such as Madana, Srinagar, Kalika are also benefitted from PHASE’s service. We genuinely thank PHASE and its’ supporters for their generous contribution to quiet and isolated place like Maila.
Dear friends! This time, we would like to share with you some of the common traditional health beliefs and practices in Maila village.
Chetana Khadka is an18 year old school girl from ward number 9 of Maila village. She is studying in grade 10 in the local government school.
Chetana recalls- “it had been nearly 3 months since I had started being sick. I suffered from headaches, shivering, extreme fatigue when walking, anxiety as well as loss of appetite. At first, I did not do anything about it, thinking that it will be fine but slowly I was getting thin and my face also looked pale. My parents inquired about my wellbeing seeing the change in my appearance. I was afraid and explained about my illness to them.”
In rural Nepal, people often don’t do anything about their symptoms of ill health unless they become totally fatigued and can’t get out of bed. They hope if there is no severe pain then everything will be fine and recover by itself. Chetana also thought her health will recover by itself soon but instead it just got worse.
She explains – “My parents discussed what they should do for my treatment. I had headaches but no other pain except feeling extreme tiredness and losing my appetite. According to my symptoms they tried to decide whether it is better to go to the health post or to call a traditional healer. Finally they decided to call the most popular dhaami (traditional healer) of the village saying that I was suffering from ‘deuta laagne’ (bad spirit). The dhaami saw me and also confirmed that this was the case. So he visited our house every week telling us that it was all because of the ‘bhoot-pret’ (bad/evil spirits) and he could treat it well. He performed ‘jhaar-fuk’ (spiritual chant) for about 3-4 weeks regularly. He burned me with a red hot iron spoon all over my body. I used to feel a little better for some days but again the same symptoms persisted.”
Many traditional healers burn patients with a hot spoon or splash boiled hot water on the body of ill people to make the bad spirit come out from the body. Chetana also got this treatment from the traditional healer. She usually felt better for some days (maybe because of the psychological impact of the traditional healer’s treatment).
She remembers – “My situation got really worse instead of getting better. My parents asked the dhaami why I wasn’t getting any better, the dhaami said that it could have been the ‘boksi’ (witch) which was affecting me and he could treat that too. He bit me in various parts of my body with his teeth and that was very painful and I had open wounds all over my body. He also bit my thumb on the right hand. But nothing improved. I still wasn’t getting any better.”
By this time Chetana had been ill for two months and wasn’t getting any better.
Chetana emphasizes – “My parents were unhappy with my sufferings. They again asked the ‘dhaami’ about my illness. The ‘dhaami’ then said that he had done everything he could. He suggested I might be suffering from a disease instead of evil spirits and this can only be treated in the hospital. My parents’ face turned pale because of the mistake they had made. We spent a lot of money for the dhaami’s offering and food as well. Now, I also realized it would have been better if I had gone to the health post.”
Chetana and her parents decided to go to health post. They felt quite upset that they had spent so much money and time already.
She says – “My parents and I decided to go to the health post (3 hours walk from my home) the very next day. There were a lot of patients waiting. After a few minutes, a sister called me inside and inquired about my problems. I introduced myself to her. She was a health worker supported by an organization called PHASE Nepal. After a short introduction, I felt quite comfortable with her and began to tell her all my problems. I also told her about the way that dhaami had treated me. She was astonished when she saw the wounds all over my body.”
Although Chetana and her parents had taken a long time to decide to go to the health post, ultimately it was the right decision. As with many patients, Chetana suffered additional pain and distress during the dhaami’s treatment, but she and her parents were merely following tradition.
Chetana recalls – “After listening to all my problems, the PHASE sister was upset that even being an educated girl, instead of making other people aware of these issues, I had possibly put my life in danger by resorting to such traditional practices. I told her that although I was educated, I couldn’t bring any change in people’s beliefs. If we try to change such practices, people will say that they have spent all their life believing in them and they are afraid to make the spirits angry by changing.”
It is not easy to convince the people who believe in traditional practices to change, or to bring change in the community’s social and traditional life. PHASE has organized two sessions of traditional healers’ training in each of its project areas and provided general information for traditional healers so they can refer sick patients to the health post as quickly as possible. They have also trained healers in basic treatment of diarrheal diseases and personal hygiene etc.
Chetana continues– “The sister examined me and she also did my blood test. She said that I had a very low amount of blood in my body - probably because of lack of nutritious foods and worms in addition to this - so I was suffering from dizziness, fatigue and other symptoms. She gave with the required medicines and advised me to have plenty of pulses, green leafy vegetables, fish, meat and eggs in my diet. She told me that it was not because of ‘bhoot-pret’ (evil spirits). She told me to have the medicine for 15 days and to visit her once again after 15 days. Immediately after a week, I started to feel much better! My appetite improved and I felt less dizziness as well. I again went to the health post after two weeks. Sister again tested my blood and said that there has been a lot of improvement. She again gave me medicines for the next 15 days and advised me to come back again.”
Chetana was now well. Although hers was not a very serious illness, mostly caused by the lack of nutritious foods in this remote and arid region of Nepal, she had suffered a lot of physical and mental distress.
She further adds – “Even though as someone with an education I should have realised, even I just followed traditional practices. It has been so long in our village that this was the only option people had when they were ill. Now that PHASE is here, we need to start changing our approach to ill health and move away from using dhaami/jhankris as the first line of health care. This may cause some conflict, but I believe that it is the right thing to do. I was certainly helped very much by the PHASE sister, and will use my experience to help others find the right way to treat their health problems in a timely way and to avoid harmful practices.”
Namaste Friends! Winter has nearly left us; however it is still very, very cold in most of the PHASE field posts around Humla and Gorkha regions. Despite winter, our staff have been working consistently for the last two months in the snowy regions. It is all possible because of your generous support.
Early pregnancy is one of the major causes in maternal deaths in rural areas of Nepal. Social factors such as culture, traditional practice and social status influence early age marriage in much of society, which leads to early marriage and then early pregnancy. To highlight this, let us share a story about teenage/early pregnancy in Maila village. Friends! Meet Rupshila Sarki of Maila village. Rupshila Sarki is a 17 years old girl married to Chandra Bahadur Sarki for the last two years.
Rupshila recalls – “When I was 15, my parents arranged my marriage to a 19 year old boy, Chandra Bahadur Sarki. We lived happily until a year passed but after this time, my in-laws started to look at me strangely. I did not care for a month or two about their weird behaviour but then they started to discuss pregnancy. I came to understand the reason why they looked at me strangely - They wanted me to have a baby soon!”
At first, Rupshila did not overly worry about her in-laws’ demand, thinking that every in-laws wants and deserves grandchildren. Chandra also did not listen to his parents. But Rupshila became stressed when she went to her parental home.
She says – “When I went to my parental home, both of my parents insisted that if I did not become pregnant within a month or two they will not allow me to visit my parental home again. They kept reminding me of the importance of having a baby. They also reminded if I do not become pregnant soon then society will cast doubt upon me; including my relatives.”
In this area, it is believed that if a married couple do not have baby within a year or two then it is because they did something wrong in a previous life. On the other hand, having a baby is seen as a symbol of prestige and status. Rupshila’s parents and in-laws did not want their family status to suffer.
Rupshila continues – “I was not able to think clearly. I did not want to become pregnant that soon. I used to sit in the community health education sessions run by PHASE staff in the village and came to know that early pregnancy is harmful to both me and the baby. But on the other hand, I could not bear the force from both my parents and my in-laws. I talked with my husband and decided go to the health post for counselling the very next day. I went to health post and met two PHASE sisters in the post. They took me inside the separate room when my turn came. I told them everything about my family problems.”
Rupshila had chosen the right place to go at the right time! PHASE staff gave her some advice about the risks and realities of early pregnancy and asked her to come again as soon as possible with her husband. When she was on the way to home she met some village women carrying fodder from the jungle. They asked her whereabouts and she explained, giving them the details. Rupshila found out from talking to her friends that there was also a rumour in the village that Chandra – Rupshila’s husband- has a problem with his reproductive system, which was preventing Rupshila from becoming pregnant.
Rupshila struggled to say – “When I heard about my husband’s problem from friends I felt like I was buried down in the earth; however after a while I also felt quite comfortable because there is no problem with me, it is all because of my husband. I planned to tell the facts to all my parents and in-laws and they will start to blame on my husband instead of me. I reached home and told my husband that PHASE sisters want to meet both of us together at the health post. I did not mention the rumours about his problem. The very next day, we went together to the health post. PHASE sisters took us inside the separate room and asked us about our education, family background and marriage date etc. They started to advise us about the risks of early pregnancy. They said best time to become pregnant is between 20 to 35 years of age. Whilst we are still young, the reproductive organs in our body are still developing, so it may cause vaginal bleeding and abdominal cramps which lead to miscarriage, placental abruption and placenta previa, premature birth and ectopic pregnancy as well. They also informed us that early pregnancy may lead to swelling and pregnancy induced hypertension. I felt scared and worried after hearing all their advice, and promised not to become pregnant before 20 years of age; my husband was also committed to do so. After a long counselling session, PHASE sisters advised us to bring our parents if they continued to insist on my becoming pregnant. I was happy but nervous on other hand. My parents and in-laws never stop insisting about us having a baby.”
Rupshila was happy but nervous. She was scared about the reaction from her parents and in-laws. On the way to home, she discussed with her husband and decided to take both their parents to the health post to clarify the reasons why she does not want to have a baby sooner.
“At first, my parents did not agree to come to the health post since they live in 4 hours walk away. Also, they were upset with us because of taking advice from health staff. They were upset and said that we ruined their social status by going to health post to stop pregnancy. They also said- they were only 19 when they had their first baby, and have had 6 children without any problem. They also said this is a natural gift; we have to accept it as soon as possible without delay.” Rupshila further adds – “I ignored their reproach and said calmly that PHASE sisters are good and they will give us the way to become pregnant in healthier way as soon as possible. After refusing for a while, they agreed to go the health post thinking that they will become grandparents soon. We six including parents and in-laws went to the health post after a week. PHASE sisters were in their usual duty. After half an hour, they called us inside. We all entered into the separate room. PHASE sisters greeted all of us and started the conversation from wellbeing and usual daily lifestyles. After a while they repeated the same counselling again with my parents and in-laws. They queried that if anything happens to me who will be responsible? If I am not in perfect health then how can I give birth to a healthy baby? They incorporated several examples of risk and dangers in early pregnancy and convinced our parents that it would be safer to have a baby after three years. After the counselling both parents were happy and promised not to force me until three years. We thanked sisters for their help and support. We returned happily to our home.”
PHASE staff organizes community health education session, door-to-door home visits, clinic health education session and school health education session every three days in a week. Rupshila attended the events and kept in mind that early pregnancy is dangerous. This helped her to avoid the possibility of early pregnancy.
Thank you very much for your generous support!!!
Please help us continue our work in Maila so that women and children can get the health service they need.
Friends! Our field staff have already reached their respective work stations after the long holidays of Dashain and Tihar festival. Between the festivals they got several trainings- Dental Training, Obstetric Training and some of them also received Women Empowerment Training in Kathmandu.
This time we would like to share the story of a malnourished child in Maila village: Kamala Jaisi is an 18 year old married women living in Maila village.
Kamala explains, “I often take part in mother’s group meetings organized by PHASE health workers in my village. I have learnt a lot of things about antenatal care during health education sessions. Health staff also taught us about danger signs during pregnancy.”
Some months after her marriage, Kamala got pregnant. She knew about antenatal services provided by PHASE health staff in the health post. She went for her regular antenatal care in the health post and the health workers gave her iron tablets and Albendazole to prevent anemia and worms.
Kamala remembers, “I went to the health post for antenatal check ups regularly. The PHASE sister said that everything is normal and good. In the 8th month, one day in the afternoon I felt a pain inside my tummy. At first I did not pay attention to the pain but it started to increase slowly and I could not bear it. I hurried to the health post. There I met the PHASE sister and immediately asked her about my pain. She checked me and said that it is labour pain, do not worry about pain it will increase a little more till you give birth. I was shocked to know this because it was just 8th month. I asked the PHASE sister about my date. She explained that sometimes this may happen and it is called premature delivery. After an hour or two, I gave birth to a baby.”
Kamala gave birth to a baby boy in the 8th month of pregnancy. It was her first baby and because it was premature it was underweight i.e. only 2100 gram. PHASE staff taught her about the care of a premature baby and reassured her that everything will be fine.
Kamala says, “The PHASE sister said I have to breastfeed 8 times in a day, but unfortunately I could not do that because my breast was small and it did not produce enough milk. I went to the health post again and explained my problem. They taught me a different technique but it did not work again. They also advised me to feed boiled cow milk after mixing certain portion of water and sugar in it, as maybe my baby was too small and was not able to nurse well. I tried to feed cow's milk but my mother-in-law refused to do so. It is believed that feeding cow's milk makes the spirits angry which may harm the baby. Also, I was busy with regular household chores and could not take care of the baby too much except trying breastfeeding time to time.”
Kamala was very busy tending the fields and her normal household chores. She could not take care of her baby intensively. Her baby could not grow well and got thinner.
She recalls, “My baby was getting too thin – he even could not cry loudly. My husband said that I had given birth to a curse and a sin of a previous life in the form of our baby, which will leave us soon and we will have only suffering and painful memory with us. He kept ignoring him and even refused to hold the baby, trying to avoid even looking at him"
In this community, there is still a belief that when someone has an abnormal or disabled baby in the house it is because of a curse or a sin from a previous life. Most people do not try to treat their abnormal or disabled babies because of this superstitious belief among the society.
“One day, the PHASE health worker came to my house during her regular routine of door-to-door health education sessions. The PHASE sister smiled when she saw me and asked me about my wellbeing and baby’s health etc. I could not speak in front of her. I just showed my baby. Tears dropped from my eyes. She exclaimed with fear and anger seeing my thin baby.” Kamala recalls, “the PHASE sister yelled at me because of not taking my baby to the health post even after this situation. She was also angry because of not feeding cow's milk according to her advice. I explained PHASE sister the reasons of not being able to feed cow's milk and visit health post.”
Kamala’s husband and mother-in-law refused when she wanted to go to the health post for advice. People in this area believe that it is not good to take babies and small children out of the house because a bad spirit may catch them.
“After my short explanation, the PHASE sister called my mother-in-law and husband outside the house. She requested us to sit together on the floor mat. She started to explain about baby health, baby feeding technique slowly and clearly. She clarified to my husband and mother-in-law that my baby is suffering from malnutrition.” Kamala adds, “Sister requested me to bring a small half bowl of boiled cow's milk. After that she demonstrated to mix water and sugar in it and taught us to feed the baby. She clearly explained that no bad spirit will harm my baby if I feed cow's milk. She advised me to feed cow's milk every two hours. She also reminded me to bring the baby to the health post after two weeks.”
Now, Kamala’s husband and mother-in-law were also convinced and they allowed her to feed cow's milk. Kamala fed her baby with cow's milk according to the advice of the health staff. Her baby easily swallowed the milk. After a week she started to notice changes in her baby. She got excited and kept feeding her baby happily.
“My husband and mother-in-law also helped me making milk for baby. I kept feeding the baby in two hour intervals. After two weeks, my baby’s face became lovely, his skin also started to look soft and healthy. I went to health post with baby. This time, my mother-in-law and husband both were happy and they allowed me to take baby to the health post.” Kamala says, “When I reached the health post, sister was very happy when she saw my baby getting better! She weighed my baby. She said it is improving and advised me to continue feeding cow's milk. After 3 months I started to feed ready-made formula bought in the market. PHASE sister also advised me about vaccinations and the correct time for weaning. I kept going to health post every month. Now my baby is 8 months and 9 Kg – the right weight.”
Malnutrition among young children is a common problem in Maila because of the factors described above: Young mothers often have very little time to care for their babies, and mothers in law often still follow unhelpful ancient traditions. Prejudice about what is and isn't good for small children, and worries about the bad luck attached to ill and disabled babies contribute to the effects that poverty and lack of alternative feeding sources can have. As Kamala's story illustrates, these factors are not insurmountable: because PHASE staff are trusted and known in the community, they can often persuade families to depart from tradition and follow their advice.
Kamala did not forget to thank health staff for their continuous help and support.
Sakuntala Jaisi is a 22 year old young mother from Madana, a village approximately 6 hours walk from Maila health post. She had her first baby, a little girl, a few months ago, ably assisted during the birth by the PHASE health workers.
Here, we are not focussing on her delivery, but on the events leading up to and during her early pregnancy, which demonstrate the wide range of problems our health workers deal with:
“I come from a poor and remote village, my parents are farmers and my father sometimes goes to Simikot (district headquarter of Humla) to work for a local trekking company, to increase our income. I went to school for 3 years but then dropped out to help my mother with all the chores, looking after the younger children and the animals and working in the house and on the fields. When I was 19 years, my parents arranged a marriage for me with a young man from Madana village, and I moved in with my parents in law. Life was OK with my new family, except that I missed my mother and sisters. But after about a year of married life, my mother in law began to question me every month because I had still not fallen pregnant.
I had not told her – or anyone – that my womb was dropping down and causing me quite a bit of discomfort when walking, and I was worried that this might be the reason that I wasn’t falling pregnant. I tried to keep this from my husband as well, and always pushed my womb in with my hand before we had marital relationships.”
Sakuntala is one of many women in Nepal who suffer from uterine prolapsed. In most countries, this is a problem mostly seen in older women who have had many children, but for reasons still not quite clear (probably related to malnutrition and hard labour), in Nepal even young women can be affected. Uterine prolapsed is not a life threatening condition but can cause discomfort, bleeding and discharge and often women feel very embarrassed about it.
“After about 2 years of marriage, the pressure to have a baby was getting bigger and bigger and I was getting very worried that my mother in law would ask my husband to take another wife, even though he really loved me and told me he was not worried about me not having children. I had heard that in Maila health post a new organisation, PHASE, had started working and that the health workers there were very good and had helped many people. I decided to go there in spite of my embarrassment about my condition. When there was a group of other people from the village planning to go to Maila for treatment, I joined them, but I was worried that I might have to tell about my problem in front of them, so I thought up an alternative story of headaches and back pain in case I couldn’t speak to the health worker alone.”
Sakuntala needn’t have worried: In all PHASE health projects, great emphasis is placed on patient confidentiality, and the health workers always make sure they see individual patients in a separate room.
Sakuntala described what happened next:
“I was really shy about the story, but when I told them about not having had a child in two years marriage, and the kind sister asked me about other problems, such as my periods or problems with my womb dropping, I told her everything. The sister then examined me – I had to cover my face for embarrassment – and placed a soft ring inside me that kept my womb up. Even on the way home to Madana I felt the relief of the treatment.”
PHASE health workers are all trained in the fitting of rubber ring pessaries, which is the best treatment for young women who still want to have children. Older women might opt to have an operation, but this is not always easily available.
Amazingly (we don’t really have a scientific explanation for this), Sakuntala fell pregnant within 2 months! Her troubles were not over, however:
“One day, about 2 ½ months after I had first missed my period, I noticed that I was having trouble passing urine. It didn’t hurt, but only a few drops seemed to be coming out every time I went, even though I really felt as if my bladder was full. This got worse very quickly and by the next day I was unable to pass any urine and I was in great pain with a swollen abdomen. I told my husband – “there is something very wrong, we must go to the health post in Maila as soon as we can”. – It was a big struggle to get all the way to Maila, I was in so much pain, and the path that usually takes 6 hours to walk took us 9 hours instead. I felt near to fainting many times and just collapsed on the floor outside the clinic when we finally got there. The nurses quickly asked what had happened and realised that something must be blocking my urine from passing out of the bladder. They passed a small tube into my bladder, and although that hurt a little, the relief when the urine came out was great. They advised me and my husband to stay overnight, to make sure that I could pass urine on my own.”
Unfortunately, by the next morning, Sakuntala’s bladder was full again – the growing womb was just exactly the size to fill the whole pelvis and press on the urethra, the small urine vessel from the bladder, and block it. The nurses used a catheter again, but then the question was what to do next? Sakuntala couldn’t stay in Maila, she had work back home, and she couldn’t come back every day to have a catheter – ideally, this needed to be done at least twice a day.
Although the PHASE health workers hadn’t seen such a case before, and hadn’t been told what to do, they came up with the right solution: They taught Sakuntala’s husband how to catheterise her – including how to wash his hands and sterilise the catheter!
Sakuntala takes up the story:
“The nurses very carefully taught my husband how to use the small tube and how to keep it clean so my bladder wouldn’t get infected. I was still quite embarrassed about it all, but it was better than the pain when I couldn’t empty my bladder at all! Luckily, I found after about a week at home that I was suddenly able to pass urine freely again and so we didn’t have to use this treatment very often!”
Once the womb becomes bigger it will push itself out of the pelvis into the abdomen and will then not press on the urethra anymore. If Sakuntala hadn’t had treatment in time, she might well have died of kidney failure in early pregnancy. The presence of the PHASE health workers probably saved both her and her unborn baby’s life, through a very simple intervention which even her husband could do, once he had been taught!
Please help us continue our work in Maila so that women and children can get the health care they need when emergencies like this arise.
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