To Bajura in Nepal's Far West with PHASE, March 2015
By Sarah and Anthony Watson
(Althought Sarah and Ant didn't visit the exact region this project fund they visited an area very close)
The 15th July is a matching day on Global Giving from 2pm UK time donations will be matched!!
We are back at home after another trip with PHASE – enjoying, slightly guiltily, the pleasures of sitting on chairs, sleeping in soft beds, washing in private, hot water from a tap, and (as we as we love Nepali food) eating things other than rice and dhal. All this acts as a reminder of how privileged we are in our Western lifestyle, and also how privileged we were to live alongside PHASE health workers and other villagers, and to experience first-hand what such a different culture has to offer.
There are so many positives, probably the biggest of all being the friendliness of the people and the way they interact as a community in the remote mountain villages. They have a wonderfully self-supporting community structure. From the moment we set foot in the village of Wai, in Far West Bajura, we were made welcome.
We were greeted by village elders and their families, with flowers, garlands and red paint on our foreheads. Then we all sat round on a big tarpaulin and introduced ourselves (the locals as well as visitors). Sunita had come with us from the PHASE office in Kathmandu to travel round several health posts, and she acted as translator. The welcome continued throughout our stay in Wai. If Anthony, who was working on an irrigation project, happened to be on his own at our 'home', the neighbours, the lovely Mr and Mrs Ginn, would see he was well supplied with food and tea!
The community projects far exceeded that which would be found in many parts of this country. The community grows mainly barley, and were conscious that the irrigation arrangements were insufficient. The committee had approached PHASE, asking for advice on lifting water 200m up from the river. This was Anthony's project – to do a feasibility study – and was the reason we ended up in Wai.
Having had to cancel our planned trip last November at the last minute for family reasons, we were hoping the journey would go smoothly this time. Not so. At Manchester airport we were informed that a Turkish airliner had crash landed at Kathmandu that morning, closing the airport. Instead of going via Abu Dhabi, we were sent to Heathrow, and then to Kuala Lumpar – where we spent the next five days! Not quite what we had planned.
The following day we were back to the airport, where we waited for the (much smaller) plane to turn up. This took just nine passengers; the 35 minute flight flew quite low through the mountain ranges, giving us more wonderful views as we flew north to Kolti.
We were met on the runway by the lovely Yogesh, the senior nurse at the health post there. After a drink and a rest, we were taken on a walk through the olive grove. This area was used for a research project by a German company, aimed at finding the best type of olive tree to grow in the region. There are many wild olives, but these only yield 1-2% of oil, whereas cultivated trees can yield 15%.
The following day we walked the three hours to Wai, along with Sunita and Yam, PHASE employed agricultural assistants. The journey was mainly along the river, naturally with ups and downs, along a rocky track like many we had walked upon two years earlier. Mules were carrying loads in both directions. Were it not for the airstrip, this would be a seriously remote part of Nepal. The fact that there are daily (if conditions allow) flights from Nepalganj gives less of a sense of remoteness than the upper Gorkha valley, which we had visited on our previous trip with PHASE. For those going on to health posts in Humla, however, there is a real feeling of being seriously remote, as that can involve up to five more days of walking.
After our wonderful reception in Wai, we were given a drink and rest (it was a Saturday, the only day off in Nepal) before being taken up through the village to the health post. I was impressed by the building – a far better facility than I saw in Philim two years ago, which has recently been replaced. There was a good-sized consulting room, treatment room, ante natal room, storeroom and public meeting room, albeit with no power. This seems such a shame, since solar panels these days offer a relatively simple solution. But the building is owned and maintained by the government, not by PHASE, so one just has to wait...
Unlike many health posts, at Wai there were a number of government health workers (GHWs) before PHASE became involved seven months ago. The motivation and organisation of the GHWs sadly leaves a lot to be desired however, and the villagers were not happy. It has proved a big challenge for the two PHASE ANMs (auxiliary health workers), Chitra and Suprina, who, through their presence, aim by example to improve the standard of practice. They are doing a great job, and standards have improved a great deal over this period. Unfortunately, they still face daily challenges, especially finding their drug stocks in disarray, and having been able to make little progress with the PHASE philosophy of allowing all patients to have consultations in private.
Wai is a beautiful village, reminding one almost of a Mediterranean mountainside. The accommodation for PHASE workers lies at the edge of this, and as the hillside has a concave shape, there are wonderful views from here across the rest of the hillside village. The early mornings in March are cold, but when the sun hits the village at 8.30 am, steam rises with a vengeance from all the rooftops – one could almost imagine the village was on fire. People come out to warm themselves in the sun, the chattering starts, and the village comes to life.
One morning, there was a funeral procession. I had seen the lady in question the day before. She was maybe in her fifties (impossible to tell with Nepalis – they are usually a lot younger than they look), had been vomiting for five days and was very dehydrated. The ANMs and GHWs worked together in the clinic to put up a drip and gave her fluids. I learnt later (my lack of Nepali is a big problem, as most volunteers find) that she had been ill with renal failure for some time, and had had many admissions to hospital. The family were reluctant to take her there yet again. None the less, I had not expected her to die so soon, and was quite shocked when Chitra mentioned at the end of the day that she had died. Nepalis, I think, all have a much more philosophical approach to death than we have. Transport is such a major barrier, that they are much more likely to die in their own home.
The death was announced the next morning by a procession of men weaving their way through the barley fields below the village, carrying a long banner. Shortly afterwards there was a long procession of about 30 men, with the body being carried at shoulder height midway in the procession. The women are not expected to follow the procession, but watched from the rooftops crying and wailing loudly.
The days would start, as in all village households, with household chores followed by a meal of dhal bhat taken in the kitchen (on the floor, naturally). The working day begins around 10 am, and goes on, usually without a break of any sort, till around 5 pm. Arriving home, there would be tea and a 'snack', such as noodles. Hopefully there would then be time for me to have a teaching session with the girls, before they had to prepare the next meal of dhal bhat, eaten at about 8 pm. This worked best on two occasions when the 'chaps' cooked the food, giving us time for teaching! Dharma was best at this. He is the PHASE social mobility worker and is involved with everything from money saving meetings for village women, to agricultural and hygiene projects.
It was a different experience living with men! My previous experience, on Philim, had involved only the female ANMs. All ANMs and other female PHASE staff I have met are quiet, gentle committed, hardworking and sensitive, though fun and humorous with it. The men – in this instance – were also committed (definitely) and (fairly) hard working, but certainly not quiet! It all led to quite a lively household.
Anthony slept in the boys’ room; I was next door with the girls. I was allowed the bed; they had the floor. There was much intermingling (entirely 'proper') between the two rooms, with little consideration given by the boys to privacy. We noted that this was very different in Kolti, where the characters were different, and men knocked and waited before entering the girls' room!
Sometimes we would play games, before or after the evening meal. They all loved these, especially rummikub!
My days were usually spent at the health post, commenting where possible on Chitra's and Suprina's (and sometimes the GHWs) consultations. The patients we saw were usually not so different from British general practice; small children with coughs and colds, adults with coughs, skin conditions, joint and back pains, and significantly more gastritis than we would normally see.
Quite a few 'extras' turned up when word got round that an English doctor was there! We saw a profoundly deaf six year old boy, very bright but without speech. His parents were motivated to help, but had taken him to a hospital and been told that nothing could be done till he was 10 – quite incorrect! With help from Gerda, we were able to advise reputable (and probably much cheaper) hospitals.
On other days we did 'home visits' to other small villages, up to two hours walk away. I loved these days! It's wonderful to be able to trek these remote mountain paths, with stunning views.
When we arrived at the villages we would be made very welcome. Chitra or Suprina would settle themselves with a small group outside, and wait for the group to become bigger, which did not take long at all! They would then talk to them, usually about childbirth, preparations, afterwards and complications, with the help of a laminated picture sheet. I was particularly impressed by one man, busy spinning wool with a small hand held device (popular round here) who asked a lot of questions. I asked what he was saying and was told he was mainly asking about how to recognise danger signs.
A visit to one village coincided with a vaccination clinic done by a government health worker (who I had met already in Wai). Suprina was able to take advantage of this by talking to many mothers with advice on childcare, family planning and doing surveys on the under fives, which are done routinely wherever possible, as part of a study looking at malnutrition levels.
Perinatal and maternal mortality has always been high in the area. A major focus of PHASE is to tackle this. The aim is that every birth should have an ANM in attendance. They will always go to a home delivery, however far they may have to walk – provided somebody tells them.
These days, most people, even in these areas, have mobile phones charged by solar power. This feels extraordinary, considering how few other possessions they have, but it does make calling for help a great deal easier. Otherwise a husband or relative will go for help. During my time in Phillim two years ago, I was lucky enough to go to a home delivery at 3 am. Thankfully it went smoothly!
If they choose, they can go to a 'birthing centre' (government provided). But this may be several hours walk away, and is likely to be a very basic facility, certainly lacking anywhere to stay before the birth, or for a relative to stay.
Anthony, meanwhile, would go off at 7 am with Dharma, Yam and other local men, armed with a long length of hosepipe, two walking poles and a GPS. They used these to measure water flow and fall along that stretch of river.
One day, as they were about to pass the school along the riverbank, they were stopped by the army. The important school leaving certificate exams were taking place, and nobody was allowed past, in case they might be smuggling in the answers. Finally a teacher was found to accompany them!
The feasibility study concluded that there would not be enough energy for a hydro powered pump; but there were other solutions, and at the village meeting shortly before we left, the villagers appeared pleased with Anthony's suggestions! At any rate, they had a free hydro engineering opinion...
Members of the water level team measuring the Karnali River
The staff were involved in a number of training meetings with assorted groups of local people in our week there. I sat in the cold in the mothers money saving group at 7:30 one morning, observed a village sanitation group meeting (much emphasis given to hand washing), and spent one day mainly with GHWs while Chitra and Suprina were busy with an all-day training session.
The agricultural boys were also busy, and one day held an 'animal camp' and inoculated over a thousand animals. There is no doubt that PHASE are having a gentle but very positive impact in this area. They are very much respected by the community (unlike, sadly, the GHWs), who turn to them for advice on various things, and are clearly delighted with the support they receive.
In Nepal's far west, it is still common, indeed normal, practice for women to be excluded from the home and from kitchens, both for five days when they are menstruating and for 28 days after childbirth, when they are also likely to be bleeding. During this time they will normally stay in the animal shed under the house.
We witnessed this first hand on our trek to RaRa Lake at the end of our official time with PHASE. We stayed in a household, and I was surprised to find that the husband, a teacher, had cooked our meal. He explained that his wife was menstruating and “in our culture, people do not go in the kitchen when they are sick”. I was pleased at least to note that he took her some leftovers!
It is not that uncommon for deaths to occur, from hypothermia or even from snake bites. In one village alone, four babies died of cold in the last year. This no longer happens in most other parts of Nepal. PHASE is keen to eradicate the practice, but there is no easy solution. It is a much ingrained practice, and it seems to be the older women, rather than men, who are determined to perpetuate it.
After a final night at Wai, we were sent off in celebratory style by a gathering of neighbours, and walked the three hours (in midday heat) to Kolti. The next morning the plane appeared bright and early. The Kolti accommodation is right by the airstrip, so it is but a short hop to get on the plane. After a few hours of waiting in Nepalgunj, we were then off back to Kathmandu. Another wonderful experience – thank you PHASE!
Humla is one of most rural district of Karnali zone and Maila is one of the rural VDC of Humla district, which is also border of two districts Mugu and Bajura. Its 4 days walk from headquarter of Humla, as no means of transportation exists except walking.
This is case about diarrhoea. It was late night, when we were studying in our stay place. Some people came to call us from village as one lady had labor pain and we quickly moved on for attending it, it was about to rise sun when we succeeded making delivery. After successful delivery, while we were returning back to our resident, we met some other people on the way who were searching us.
Upon asking what happened they said "I have brought one patient suffering from diarrhea, and her condition is very worst let's go fast".
After hearing that we rushed towards health post, there was a 51 years old woman named Padma Shahi (name changed), residence of 4 number ward of Maila VDC, she was suffering from severe diarrhea and she was in a critical condition. Although we referred her as there was no other near referral centre for her better treatment and it would be too late if sent to Nepalgunj as it was long distance. So, with no option we took oral consent as there was not enough time to take written consent and started further treatment. On treatment procedure, we were unable to hear her blood pressure and it was very hard to count her pulse rate. Now depending and praying for god we opened vein form both side and started IV fluid. After 5-6 bottle of fluid now we had been able to count her pulse rate. When we met her, her diarrhea and vomiting had stopped because her whole body was dehydrated. After the bottles of fluid again the diarrhea and vomiting started. Patient’s symptoms showed that might be she suffering from Cholera. Then after we started antibiotics and more IV fluid too in One day we gave her altogether 22 bottles of normal saline. Gradually, we could notice improvement inpatient condition. Accordingly we kept her in our health post and sent her home back after three days continuous treatment.
Before arrival of PHASE Nepal in Maila VDC last year in rainy season 23 people untimely died due to diarrhea as they could not receive treatment. After successful treatment of this 51 years lady in whole VDC provision was set to come to Health post to seek treatment for Diarrhoea from whole VDC, otherwise they would call for PHASE Nepal staff in case of emergencies.
Humla is one of the most remote districts of Nepal, situated in the mountainous mid-west. Maila village is located 3-4 days walk from Simikot, headquarter of Humla. Here, people still die due to restricted access even to basic medicines like oral rehydration solution or Paracetamol. Difficult topography, illiteracy and lack of transportation facility have made the lives of people here very difficult and vulnerable.
This is the story of Raj a 25 year old married woman who lives in Maila, Kattelgaun-3 with her in-laws, husband and her two daughters. She was 8 months pregnant when she started having a noticeable headache from morning. She and her husband had been to Nepalgunj recently to identify if they will be having a son or daughter and as they wished, it was a son. Their happiness had no limit then.
That morning she was a little tensed because of the headache she was having but tried to ignore it as she used to have headaches during her last two pregnancies as well. So she hoped that as before, it will go away soon.
'I remember being advised by sisters of health post about danger signs of pregnancy when I had gone for ANC checkups. But thinking that my headache was a minor problem, I didn’t do anything. After some hours I started feeling unwell. There was no one in my house and I was panicking.' Raj recalls.
When her brother-in-law returned home, he found her unconscious and shaking. Her family members thinking that it was because of labor pain, called a dhaami(traditional healer) for ritual treatment. It was only after a school teacherheard about it and scolded them that she was taken to the health post on a stretcher. Her condition was critical when she reached the health facility.
She had very high blood pressure which was getting worse. Junila, PHASE Nepal's ANM in Maila, diagnosed her with eclampsia which is highly dangerous for both mother and baby. She needed immediate treatment for that condition. Fortunately our staff was a trained SBA so she recognized the condition and knew that the correct management of this complication was immediate treatment with a high dose injection of Magnesium Sulphate. She also knew it was a bit risky in a remote area like Maila as a Magnesium Sulphate overdose can lead to respiratory arrest, but since it was the only option available, she went ahead. She also had the antidote, Calcium Gluconate, in case the patient's breathing became too weak.
After treatment Raj had no more seizures and some minutes later she started having labor pain and then delivered a baby boy. The baby didn’t cry immediately after delivery so it required resuscitation. She was still unconscious and did not regain consciousness until the next day. Raj tells us, ' When I opened my eyes the next day, I felt like I was blessed with a new life. I had my baby beside me! I realized that my small mistake had nearly cost me my life. If I had followed the sister's advice then I and my baby wouldn’t have had to face such a dangerous situation, and if Sister hadn’t treated me I would not be here today. All my gratitude and wishes goes to PHASE Nepal.'
(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.”
Project Reports on GlobalGiving are posted directly to globalgiving.org by Project Leaders as they are completed, generally every 3-4 months. To protect the integrity of these documents, GlobalGiving does not alter them; therefore you may find some language or formatting issues.
If you donate to this project or have donated to this project, you will get an e-mail when this project posts a report. You can also subscribe for reports via e-mail without donating or by subscribing to this project's RSS feed.