Reflections from Nepal
By Paul Farmer
Photography by bec rollins
On a map of the world and to a doctor’s eye, Nepal is a rib-shaped slice of a country stretched laterally between two giants, hemmed in to the north by the Himalayas and to the south by India. It’s a place of stunning social complexity, in part because of developments over the past few decades during which Nepal has seen civil war and also a transition from a monarchy to a struggling democracy.
It’s also complex because this region, even the forbidding higher elevations, has been settled for so long and by so many different, if often related, groups. To cite anthropologist Dor Bahadur Bista, “Nepal is such a complex social conglomeration seeking perpetually to accommodate, if not synthesize, its diverse discrete parts.” In spite of close to three centuries of national identity, groups defined variously by class, caste, ethnicity, language, region and religion jostle for the kind of security that people everywhere want: access to health care and education and the chance to make a decent living without risking life and limb.
In much of the country, and among the poor, precisely such risks are faced every day. Bista, Nepal’s first anthropologist, had a keen eye for the forces stymieing his country’s development. He worried in 1989 about fatalism not among the rural poor but among an “ossified” elite. Much has changed since then. Great grievances piled up over generations led to a conflict shaped, it seems, less by ethnicity or caste (which assumed growing importance in the last two centuries or so) and more by the fact that so many struggled with the penury common in what remains in many ways a feudal society. The Maoist uprising that began in 1996 ended in peace accords and a fractious sort of calm: a lot of political parties, a commitment to constitutional democracy, and a war of words rather than weapons as the citizens of this beautiful country push for economic growth that will lift the majority out of crushing poverty. Although the rules of feudalism have been abolished, landless poverty keeps millions in profound dependence. Most of the Nepalis we’ve met—from Kathmandu-based political leaders to academic doctors to women’s groups in rural regions to patients and providers here in Achham—seem to agree that attacking poverty is the biggest problem at hand.
Some recent estimates peg the fraction of Nepalis who live on less than $2 a day as high as 80 percent.
First-time visitors to Nepal see little evidence of the conflict, but much of the conditions that generated it. Some recent estimates peg the fraction of Nepalis who live on less than $2 a day as high as 80 percent. These are the people Nyaya Health, our “praxis partner” (more on this term below) in far-western Nepal, was established to serve. As Partners In Health has done in ten countries outside of Asia, Nyaya has established a sister organization here and works in partnership with local groups and public-health authorities—local, district, central—to promote the right to health and to help break the cycle of poverty and disease encountered everywhere. Whether among the poor and marginalized in wealthy or developed countries or among the great majority in the world’s poorest countries, the concept of justice in action—of actually delivering on lofty concepts regarding the right to food security, safe schools, housing, water, and health care—remains as powerful and important now as ever. Perhaps more powerful: it’s impossible to argue, in the 21st century, that any of these challenges are somehow technically insuperable. They’re not, and we all know it. The challenge is in delivering on age-old promises that a rising tide will lift all boats.
Physicians are trained to expect an often grim universality from pathophysiology. A bad chest x-ray looks familiar in Boston or Rwanda; lungs and hearts sound the same across the globe; a fracture is a fracture is a fracture. Anthropologists are trained to focus on cultural particularities and there are, as noted, no shortage of them here in a society as complex as any I’ve seen. And then there is the terrain: the mountains of Achham—mere hills to the Nepalis—bring to mind Haiti or Rwanda. So did the ten-hour drive from Dhangadi to Bayalpata Hospital, home base for Nyaya Health.
It sits on top of a grass-covered hill and girdled by higher ones, many covered by stands of pine and bamboo. The monsoon season has just started, and already the river a couple of thousand feet below is audible when we step out of the wards or clinics. We’re also reminded of Lesotho, in part because of the sheer verticality of the place but also because of the hard facts of labor migration to a booming economy to the south. Nepal has an open border with India, and many of the patients we’ve seen have returned sick after working there. Labor migration also has its particularities and generalities, but whether men—and it’s mostly men who migrate—descend from the mountains of Lesotho deep into the mines of South Africa or from the hills of western Nepal to serve as night watchmen in India’s cities, such social disruption carries its share of penalties. Achham is probably the epicenter of the country’s AIDS epidemic, which invariably drives up rates of tuberculosis, too.
The mountains that ring the hilltop are tiny compared to the Himalayas, and form only a modest part of the barrier between the people of Achham and a shot at decent health care. Roads, where they exist, are treacherous. The district hospitals are by definition few and far between, poorly maintained and understaffed. The health centers and health posts in the villages and small towns are run by people doing heroic work but without the tools of the trade (whether preventives or diagnostics or therapeutics). There’s plenty of medicine for sale in the private sector, even in these villages and towns, but it’s easy to see, even on a first trip, that poor people are paying a lot for services of dubious value.
A few years ago, the medical students who founded Nyaya opened a health center in a warehouse in a small town in Achham, and brought in the district’s first biomedically trained doctor. Three years ago, the Ministry of Health sent them up the hill to re-open the abandoned public hospital, and now Bayalpata has three doctors, not counting the part-time volunteers—including Ruma Rajbhandari, Duncan Maru, Jason Andrews, and Ryan and Dan Schwarz—who are in training at the Brigham and Women’s and Massachusetts General hospitals. There’s the dynamo from Michigan, Dr. Payel Gupta, and two Nepalis, Dr. Bibhusan Basnet and—to the delight of the locals, a native son. Dr. Roshan Bista, recently graduated from Nepal’s finest medical school, is now the first Achhami doctor to serve a district that, only a few years ago, counted a quarter of a million souls but not a single physician. The doctors complement a dedicated staff of health assistants, nurses, paramedical employees, and administrators. A small but vigorous community-health team links Bayalpata to scores of community health workers.
Their work isn’t easy. It’s hot in Bayalpata: well over 100 degrees and humid enough to make us wish for rain. It feels and looks like Haiti in late summer. Inside the clinics and wards, the heat is all too familiar, as are the mortal dramas. Women with third-trimester catastrophes. Abscesses from injuries. Rheumatic heart disease. Enteric fever. Parasitic infestations from round worms to kala azar. Childhood malnutrition and its companion diarrheal disease. All manner of waterborne ailments (less than two weeks ago, almost 100 soldiers showed up one day with food poisoning, probably from Salmonella). Tuberculosis and AIDS (Achham probably has Nepal’s highest rates of these two chronic infections, long associated with poverty, gender disparities, and labor migration, all of which are also associated with conflict).
There are non-communicable chronic diseases, too: congestive heart failure, renal insufficiency, mental illness. It’s a well-known catalogue but with a few local twists. Dr. Payel referred to Nepal as “the ortho capital of the world without the orthopedists,” in part because of road accidents but in part because the terrain is so forbidding that people are injured while carrying produce to market—or by simply falling out of their own hillside plots. Kids work these plots too. Yesterday alone, the team provided services to three children with fractures. En route here from Kathmandu, after a one-and-a-half hour flight and in the course of a ten-hour ride, some stopped to say a prayer for the twelve people who’d just perished when their crowded bus went over a cliff—a depressingly common occurrence that makes headlines each week.
The good news is that every one of these problems can be prevented or palliated or cured by the basics of modern medicine and public health. By the basics I mean clean water and safer roads, of course, but also a fairly modest array of vaccines and diagnostics and treatments well within the reach of the sorts of partnerships that Nyaya and Nepal’s public health authorities are trying to forge. In an era in which we talk glibly of “value for money” or “return on investment” or “cost-effective interventions,” it would be hard to argue that the work at hand in Achham and in other regions of rural Nepal doesn’t offer a terrific bargain—to push the metaphor crassly—for those wishing to make a difference in a world riven by inequality and its attendant suffering. The team laboring here on the hilltop is anything but fatalistic. One of the great joys of this trip for me was leading clinical rounds, seeing scores of patients, and conducting sessions to discuss the hardest and most complex cases, from multidrug-resistant tuberculosis to an explosive and mysterious outbreak of food poisoning.
If you do this work long enough—and I still work with people I met in Haiti or at Harvard in 1983—life starts to be defined by this tension between the general and the specific, the universal and the particular, and is always linked to the mortal dramas mentioned above. These dramas can be hidden away, and often are, but they exist whether we acknowledge them or not. For those seeking to leave behind medieval conditions—and only those who have left it behind ever romanticize such poverty—there is no hiding from the afflictions or accidents that take so many lives so early. Acknowledging this injustice is not enough; linking knowledge to reparative action is what we’re all called to do, together; it’s the heart of the matter for partners in health, lower case, as it is for the many groups seeking to promote global health equity.
It’s for these reasons that a group of us from PIH (I traveled with bec rollins, who took these photos and hundreds more, and Emily Bahnsen, who with me spans PIH and Harvard Medical School and the Brigham and Women’s Hospital) and Nyaya-PIH supporters Bruce Payne and Jeff Kaplan (also on the board of Nyaya) felt grateful to be part of an effort with much to celebrate but much left to do. The cause of global health equity will not be advanced by culling only the low-hanging fruit, though that is work enough. Beyond reducing fractures, beyond providing prenatal care and family planning, beyond vaccination and first aid, beyond primary care is a Pandora’s box of complex ailments. How can we promote global health equity without the tools of the trade? The fitting way to mark the third anniversary of the reopening of Bayalpata’s rebirth is to add essential instruments to the toolkit. We did this by cutting the ribbon on a new operating room and a laboratory.
On that day, or shortly thereafter, we saw three patients who served as stern reminders of why we have to reach higher. One was a man who slit his own throat after he was told, in India where he was working, that his abdominal swelling, weight loss, and edema were due to cancer. His wound was stitched up but his underlying pathology is yet to be diagnosed; he might well have tuberculous peritonitis, which is eminently treatable. Another young woman, seven months into her fifth pregnancy, presented with fever and joint pain. She received antibiotics, but miscarried before she could be transferred to a hospital able to provide advanced obstetric care; there is no NICU in all of the Far West of Nepal.
Last night, our final one in Achham, stretched into the morning. We spent a lot of our time evaluating a woman who looked twenty years my senior but said, as did her son, that she was 45. She had been coughing up bright red blood, lots of it, due to tuberculosis. She also had diabetes and weighed less than 90 pounds. She was first diagnosed and treated for TB in Bayalpata, but never really responded to the therapy. She wept throughout much of our evaluation, since she and her son were worn down by trying to negotiate, without planes or hotels or proper accompaniment, a steep path that led her, astoundingly enough, all the way to Kathmandu. It would be, I told the team, a blessed miracle and a surprise if she did not have multidrug-resistant tuberculosis. Duncan took her sputum to a reference lab in Kathmandu today. There are surely thousands of patients similarly afflicted in Western Nepal, but because Michael Rich and other members of the PIH TB team have worked with the Nepali TB Program, I think I have a pretty good notion of how many patients are receiving treatment: five, with a sixth slated to start hortly. It will be cold comfort to this woman and her family if we have deep knowledge of the disease and how to treat it but cannot manage to turn expertise into action. This has long been the challenge of global health equity: the delivery challenge.
Twenty-five years ago, we made a pledge not to avert our gaze from these complex problems, which is why we’ve since been part of teams that have directly treated tens of thousands of patients with MDRTB. It’s why we are involved in the daily care of more than 15,000 people with AIDS. It’s why we will soon open, in partnership with the Rwandan Ministry of Health and Harvard-affiliated hospitals, what is likely rural Africa’s first cancer center. It’s why we’ve launched programs to train a new generation of physicians and nurses who wish, as do so many of the staff at Bayalpata Hospital, to address the pain endured by those who face both poverty and disease—especially those diseases that serve as a rebuke to hope and optimism.
To take on the noxious synergy of poverty and disease is tedious and hard and full of pitfalls and disappointments. But many people here have fought hard, and made sacrifices, in order to insist on something as simple as a hospital in this region of Achham district. I met one elderly man on the day of the inauguration and again in a town not far away, where we attended a meeting of a community-based organization established to improve care for people living with HIV disease.
We ran into Mr. Kadayat as we were leaving the village and stopped to say hello. He was happy about the improvements in the hospital in part because he spent three and a half years in prison for his role in a 1976 demonstration that turned violent. The story I heard from my co-workers was that people in the region were agitating for a hospital; security forces opened fire on the demonstrators and six people were killed. Six more people, including Kadayat, went to jail, and part of his sentence was served in Kathmandu. “I was taken there by helicopter,” he added. The airport here was later bombed, and is just now being rebuilt. On the positive side of the ledger, some of those who served time for the Bayalpata Hospital were on hand to see it reborn and growing. Speaking as a teacher of doctors, I’m proud to have been present to see some of our Brigham residents involved in reparative justice.
The hospital’s third birthday happened in the middle of PIH’s 25th. Over the past quarter century, I’ve been asked a thousand times a variant of the following question: “This work to provide health care as a right is a good thing, but is it sustainable? Can it ever be brought to scale?” And I’ve said a thousand times, especially to my own students, that it’s possible to tell whether these questions are asked to start the conversation or to end it.
For those seeking to start conversations about sustainability and scale, or about the right to health care, we have learned a great deal over the past decades. To sustain such efforts requires that a new generation of activists be engaged in global health equity. It requires investments in training on both sides of the great divide between rich and poor. To bring such efforts to scale requires that we engage the public sector, since only governments can confer rights to citizens and others within their borders. PIH cannot possibly bring services to all those who need them even in the ten countries where we work, to say nothing of the destitute sick elsewhere. But we believe those lives are just as valuable as the lives of those we meet directly. We’ve known this for 25 years, and that’s why we started, along with groups like Nyaya Health and Tiyatien Health in Liberia and Village Health Works in Burundi and Project Muso in Mali, the “praxis network.” In fact, the Sanskrit-based word nyaya means “justice in action”—it’s perhaps a shorter and more elegant term for global health delivery.
As we mark our 25th year, it’s our hope that the praxis network will grow. For some, any suggestion of filial descent—that somehow an older organization helped to beget offspring—rankles. But as Partners In Health celebrates its anniversary, let’s recall that Zanmi Lasante, our Haitian affiliate, is even older. It’s not about “branding” or “niches” or who came first but rather about building a movement for health and social justice. It’s about making rights real, tangible. It’s our hope that the Nepali and American friends who launched Nyaya Health just a few years ago feel as proud of this connection—this partnership—as we do.
Two nights ago, on the hilltop where cell phones were unknown a few years ago and where now signal works some times and not others, my phone rang. It was Jim Kim, who was halfway through his first day as the president of the World Bank. The Bank’s motto, emblazoned over the metal detectors in the lobby, reads “working for a world free of poverty.” Easy to say, hard to do. But for those who reject cynicism, including those we’ve been lucky to work with from Haiti to Siberia, from the Navajo Nation to Rwanda, and from Roxbury to Achham, the dream of global health equity takes root and grows wherever we turn cherished social goals into pragmatic efforts to meet them.
July 3-4, 2012