It's a Long, Long Road

The adage is as old as time - 'hit the road', 'get on the road', 'move on down the road' - there are a thousand variations on the theme, and no matter which one sings to you today, it's inevitable that some version of this theme will resurface for you tomorrow with yet another twist.  And so twisted the road as we made our way past the landslide over mountain, through valley, past river, shack, yak, goat and bull. 

We moved more swiftly at times than I was comfortable, but we were men on a mission.  Word had it that a bandh (national strike of transport services except airports) was in progress for the next day meaning if we did not complete our journey back to Napalgunj by tonight, there would be no travel by motorized vehicle the next day and we'd miss our flight back to Kathmandu (or K-du as I like to call it).

The road back was as beautiful as the road out, and along the way, we met a number of road warriors out to fulfill their own life's purpose.  Shepherds tended to their flocks, milkmen delivered their goods, the tupperware salesman made the rounds and the produce specialists loaded their goods for sale on their bikes.   Some transported their goods atop the old noggin and some - like this feisty little guy took the goat by the horns and muscled it from one point to another.  Every site was a feast - a reminder that it's a different life here.  It's a tough life no matter how you slice it, and the only way to make it through is to live unaware of how the other half lives.

It was the scenery that made our 15 hour journey back possible.  And since the visuals can speak more eloquently than any text, I will leave you with a series of photos that tell the story.  Enjoy!

This little guy could be the poster child for why we do this kind of work! His mom made the best meal I'd had since landing in Nepal - homemade noodles with local spices, tomato and garlic (sure beats dahl bat!)

 When you look up 'multi-tasking' in the Nepali dictionary, you are likely to find a picture of this woman.  She's got one child on the breast and she's playing Rock-A-Bye baby with another in the sack.

Bicycle produce salesmen load their vehicles for a days work.

We made it back in one day, but the strike necessitated that we take bicycle rickshaws back to the airport.

 The hotel we stayed at during our last night - Traveler's Village in Nepalgunj, is owned by an American woman who has now been in Nepal for 37 years.  She specializes in 'American comfort food' (and talking your ear off) - I had waffles for breakfast with homemade sausage.  (Don't ask what was in the sausage - I didn't want to know!)  Talk to you next from K-du!

Accept it and Move on

As I write this, a terrific thunderstorm is rolling over Kathmandu.  The sound and feel of it brings me back to the night the rains precipitated the landslide which sealed the road into the remote village of Manma.

Well, on the 3rd day after the 'slide, we could hear the sound of horns echoing through the valley - a sure sign that there was movement of vehicles.  Drivers blare their horns as they approach hairpin turns on roads barely wide enough for one.  The horns had stopped and now resumed, although without the passion or intensity that came with aggressive movement.

With a bit of confidence that we could pass through the blockage, we decided to make our move - so at roughly 6:30 in the morning we packed up and headed down the mountain.  It took 2 hours before we reached the obstructed area only to find that  movement was at a dead stop.  While the obstruction was largely cleared, the traffic on both sides was competing for right of passage.  Dozens of tractor-lorries and assorted vehicles jockied for position.  As each approached the focal point of the obstruction, the reason for the lack of movement became clear - rocks, combined with water, a naturally tight land formation and growing anxiety from the crowd that loomed eagerly along the rocks created the kind of drama that is legendary on Survivor.

Three hours later, our driver made it through and we began our journey back to the terai region.  After 5 hours we had not yet covered 1/10th of the distance we needed to cover by the end of the day in order to catch our flight the next morning back to K-du.  Our sense of urgency to get back in one day was exacerbated by the fact that there would be demonstrations in Nepalganj and throughout the Katmandu Valley that would prevent travel by vehicle.  These demonstrations will continue until Nepal passes it's long-awaited constitution.

The trip back, much like the trip out was riddled with difficult terrain including heavy dust, mud, river crossings and rock.  In the few paved areas it was even more terrifying as the driver felt a need to make up for lost time by accelerating along steep and narrow mountain roads.  At one point we rounded a bend to find a bus in the middle of the road and 20 or so of its passengers standing along the road looking into the crevice below.  A tractor lorry had gone over with two men on board.  Everyone knew they were dead.

Death in Nepal is a fact of life - if you don't die of dysentery, starvation, a road accident, obstructed labor or some not so exotic tropical disease, you are one of the lucky ones.  People have come to accept that if they get ill, death is the easy way out.  There is a fatalistic attitude among the Nepalis.  Your destiny is pre-determined, and there is little you can do to affect it.  I hope to learn more about this view as I get to know more about the Nepali people.

So what do people look forward to?  A night out? A movie? A local sporting event? Not exactly.
A treat to the Nepalis - especially to the peasants in the countryside might be to add something to their monotonous diet.  A typical (and when I say typical, I mean 3x/day) meal for a Nepali peasant is dahl baht - lentils and rice.  If fortunate enough to have access to a local butcher - or shepherd who has sacrificed one of his flock for a couple thousand Rupees (~$25US), s/he may be able to add some goat, pig or chicken to his/her dahl baht.  In this photo, a man has slaughtered a goat and is now harvesting its remaining delicacies - the head and feet - for sale.  The final photo shows two men - on the side of a village road preparing a pig for sale after removing its head.  

While at first shocking, slaughtering animals in a public setting is part of the culture of living in an uncivilized place.  So too is living without the luxury of running water, power, Internet, trash pick-up, a sewage system, extensive dinner menu or access to healthcare.  Vehicles that lose their footing and tumble off mountain roads are just another part of that very same same culture - you can read about such accidents in the local papers every day.  There is little that one can do without a fully accountable government and without people who are willing to take a stand and challenge the status quo. Is it the fatalistic attitude of the people or is it something more? Until they know how to affect change there appears to be little to do but Accept it and Move on.  

Waiting it Out

The morning we learned of a landslide that had closed the road, it hardly registered with me.  I mean, could some dirt and a few boulders across an already dirt and boulder road really be that big of a deal?  So, I did what any other western-thinking person would do - put it out of my head because, clearly that was someone else's job and surely 'those people' would get on it lickety split so that by the time we needed to go anywhere, of course the road would be cleared.  We were planning to say 3 days in Kalikot district to provide capacity development for local governance councils, healthcare leaders and district health personnel.  We would be much too busy to concern ourselves with the landslide.

The meeting facility where the training workshop took place was donated some time ago by DFID (Dept for International Development) - a British organization that has generously contributed on numerous levels to develop Nepal's infrastructure.  The generosity of DFID to the Kalikot district alone is acknowledged on a large poster in the center of the village just outside the meeting facility.  In addition to DFID's generosity, USAID has contributed significantly to the supply chain and logistics for the drug supply.  And GIZ, a German donor organization has also made significant contributions to the health system infrastructure in Nepal.  A key component of my work in Nepal will be to evaluate the procurement practices, distribution and logistics of the drug and medical products that feed every institution from sub-health post to district stores to tertiary care center throughout the country and to identify gaps and opportunities for improvement from working with the private sector suppliers to the people who forecast the needs within the villages, districts and regions.  My findings will be used as evidence to support recommendations for policy change and to work with my government counterparts and the donor organizations to implement these recommendations.

On my 2nd day in Kalikot, I arranged to meet the district storekeeper at "the dungeon" and to go with him to the hospital to begin my work.  To get there involved a 40 minute downhill trek.  In this picture, you can see the blue roof of the hospital from the hillside where we began our hike.  By the time we got to the facility, I was in a pool of sweat.  The sun was beating down and the trek was as rigorous as any hike I'd taken in the mountains of North America.  While there was a road, we took the short route that took us through yards, down paths, over rock, ledge, etc. Not only do these people do this EVERY DAY- many do the trek in flip-flops at breakneck speed.  And some make the trek while carrying loved ones on their backs in a basket! (This may be the origination of the term, "basket case", but the real genesis of the term eludes me.)


So we reach the facility and our first stop is the hospital pharmacy. Local practices demonstrate non-adherence to procedures for logging what has been dispensed, estimating demand or managing supply.  The rest of the tour was no more encouraging causing me to succumb to the reality that there is much to do in terms of developing and reinforcing systems that will lead to improvements in operations at the district level.  With 75 districts and the rigorous terrain that defines Nepal,  an approach must be designed that can be replicated without relying exclusively on on-site educational initiatives.  

As it turns out, politics plays a heavy hand in personnel appointments despite the civil service exams as an initial step for assessing talent for positions in the healthcare sector.  When appointed by a government official, individuals often believe they are protected and consequently do not feel obligated to report to work or extend themselves to meet even basic job requirements.

Finding and retaining physicians is another challenge.  Trained healthcare workers quickly become frustrated with facilities that have old, outdated and non-working equipment.  And as if that is not enough, the remote areas where they are asked to practice are difficult to access, offer little in terms of intellectual stimulation and do not allow them to routinely practice the skills that they were trained to do. It was discouraging to see the condition of the hospital - beds without bed sheets, an O.R. that had not been used in nearly 2 years.  Lack of supplies. A birthing room with the tell-tale signs of a birth that took place days before.  A clinical laboratory which relies on reagents and microscopes rather than state-of-the-art diagnostic tools.  Reporting systems and communications infrastructure that lag behind advances that the civilized western world witnessed nearly a century ago.

I left the hospital and district stores compound feeling a burden of responsibility to the people of this village yet not quite knowing where to begin.  Upon returning to the workshop that was in process, I cast a hopeful eye toward the bottom of the valley realizing I had not heard or seen a single vehicle moving up the hill all day.  Indeed, the road was still obstructed. 

Getting there.

As you probably know, by mere virtue of the fact that the Himalayan Mountains dominate the northern border of Nepal- this is a country with a diverse and rugged landscape.  The lower plains of Nepal along the Indian boarder are referred to as the "Terai"- it ranges from flat to rolling hills and it's climate is hot, humid and at times quite wet.  As you head north toward the Chinese border, the topography becomes increasingly rugged - from the "Lower Hills" to the "High Hills" to the "Mountain" areas.  And while man has conquered Mountains by skiing down them, boring thru them and climbing up them, the mountains and hills of Nepal are anything but tame.

Despite all this 'hoopla' about tough geography, remote villages, lack of this or that, blah, blah, blah... a team of eight of us (plus drivers) was setting off in three vehicles to a remote area of the country that would take us from the terai through the hills to the edge of the Himalayas with the intention of answering a host of questions that would inform our approach to improving access, managing cost and enhancing the quality of healthcare in the remote areas of this mysterious, yet captivating country.

In this rigorous landscape, the word 'remote' takes on new meaning.  It means you get your water from the rain, the river or the melting snow-capped mountains.  It means you get your electricity from power that is generated from harnessed water that rushes through channels in the mountains or from solar panels atop your south-facing, mud-hut roof.  It means that when kids head off to school it's a 4 hour trek before school and another 4 hours after.  'Remote' also means that if you want to ... make that NEED to see a doctor, you can walk up to 3 days (yes, DAYS) to get to a health post and then pray that the doctor showed up that day - if there is a doctor posted there at all.  It means you can't call in advance to make an appointment; you can't select your provider; you can't expect that medicine will be there when you need it and you'd better have friends or relatives with strong backs (who love you a LOT) in case you need someone to haul you up or down a mountain to a health post to see if you can find someone who might be in a position to tend to your needs.  [Never mind have the tools necessary to address them.]

Imagine for a moment there is only one road that leads to your village - it is subject to heavy rains, erosion, landslides and the stress that tractors, busses and other vehicles put on it.  Noone in your village owns a car - noone!  The road to your village is like the coronary arteries that feed the muscle that pumps life through your body and if it should suddenly close - just like your heart can arrest, this paroxysmal collapse of life-sustaining nutrients can end life as you know it as it threatened to for me and my team when we visited the remote village of Manma in Kalikot District - located in the upper hills of mid-western Nepal in early May of 2011.  The horror is still fresh in my mind and will remain there for years to come.

Our driver overlooks Kalikot district upon arrival.

It was Sunday night, we had just completed a 12 hour drive deep into what must be one of the most remote locations on the planet.  The views en route, while treacherous, were spectacular and awe-inspiring.  The last 30 or so kilometers of our trip took nearly 2 hours (on the Autobahn, 30 km would take roughly 12 minutes) - through water, over rocks, in mud requiring periodic stops to 'road repair', assess risk and slowly migrate toward our destination.  There were times we held our breath, held silent vigil and negotiated with our ultimate judge for one more kilometer.

 Just as we arrived, the rains began (although it's pre-monsoon season, when the rains hit, they hit hard).  They began slowly at first and increased in intensity as we listened to the thunderous drumming on the corrugated metal roof of what I began to refer to as the 'dungeon hotel'.  The "White Guest House" in Kalikot is no rural resort, no upgraded safari bungalow and no place for someone of your caliber to spend a single day of your blessed life.  It was...well, let me just say it was an experience I shall never forget and lest any one of us should ever complain that the thread-count in our bed sheets does not exceed 500, a visit to the White Guest House might be just the right prescription to ensure that such trivialities no longer register as we consider what really matters in life.  I'll be the first to admit that this experience was long overdue for me.

Stairway within the 'Dungeon Hotel'

We fell asleep to the sound of thunder and awoke to the news that a landslide had closed the road and might not be opened for days - or weeks.  We were literally trapped.  The only way out was to head north, deep into the Himalayan Mountains toward China where the roads are less traveled and expectedly worse than what we had already experienced.  Unimaginable at best. Downright isolating at worst.  The thought of becoming a long-term resident of Manma village was a thought I preferred not to entertain, but there I was considering the unimaginable.

But we had just arrived and fully expected that this would be open before the day was out because that's exactly what would have happened had this occurred in the civilized world that some of us can call 'home'.  Unfortunately, but not surprisingly, the road did not open that day, or the next...or the day after that. Ugh.

(To be continued.)

Monkey Business

 It seems everyone has a gig these days, doesn't it? I mean truly - the guy at the local pharmacy wants you to buy a certain aspirin because he got that one for free from his buddy who made a deal with a Chinese company that was trying to unload it because it was about to expire.  The beggar at the stupa puts her baby in your face while cooing, "Papa, papa, buca" - the baby's got to eat, papa - as if I was the father (and I'm pretty sure I'm not) and I were responsible for feeding it!  And the driver of the 3-wheel bus who insists he can take more passengers even though you just saw a tire blow off a similar craft two blocks down the street that had half the number of people stuffed inside.  Or the shopkeeper in Thamel who wants to sell you a backpack for 8,000NPR until you tell her you want the Nepali price because you work and live here and then get the same thing for 4,000NPR....We call this monkey business. And there's no shortage of it here in Nepal.

Now I don't mean to suggest that the people aren't welcoming, warm, kind and generous... they're just trying to make a living and in this area of the world the living is tough.  Can you blame them?  Doing laundry is an all day affair - and how many of us do it with a smile on our face even though we have the water, the power and the technology to do it with the push of a button?
 This week we learned that there's some monkey business of a different kind taking place within the healthcare sector.  Medical products - specifically vaccines and syringes have shown up with forged paperwork to falsify ownership suggesting that the supplier obtained the goods from an unreliable source.  A truckload of condoms arrived - from an organization who shall remain nameless lest any of us question how our tax dollars are being spent - 5 mm larger than is appropriate for the Nepali population indicating that something is awry in the procurement of these items.  [Who'd have thought that such personal anatomic data actually exists allowing for objective comparison of men around the globe?] And tens of thousands of contraceptive products ranging from the single-use type to the long term implantable are arriving in quantities so great that if used according to package instructions without waste could bring the growth of the population of Nepal to a screeching halt faster than a stupa monkey could snatch a banana from your hip pocket.

Fortunately for me, I have some terrific colleagues - native Nepalis who can teach me the ropes like Suresh who studied and received his PhD in Public Health in Canada.  He and his lovely wife Asa invited me to their home last weekend where we went trekking in the hills around their home - despite the morning's monsoon, the weather cleared up as they predicted in time for a great hike following a great traditional Nepali lunch which included dahl bhat - lentils and rice (among a smorgasbord of other assorted local delicacies).

From the top of the hill, we met a number of young buddha women who, at the young age of 20-something have made a commitment to live solitary lives in a buddhist monastery in this rather remote place.  And if you are contemplating this type of lifestyle for a change of pace, you may want to review some of the basic rules that you would need to adhere to while preparing yourself.  Of course the list is by no means comprehensive as there were other more descriptive postings on the compound that support the themes seen here.  And, yes, in case you thought I misspoke, these are women - shaving the head is another part of the preparation for life as a buddhist.

 Yes, it's all around us - from the stupas to the merchants to the washroom, at the taxi stand and even ... or should I say and most certainly at the ministry.  It's monkey business and as benign as it may sound, it can be rather painful if you find yourself on the wrong end of the deal.

By the end of May, Nepal will find itself at a crossroads - the government that is in power has been promising the people a new constitution for 2 years now with a deadline of May 28th.  It's hard to know exactly what will happen if the Maoists who came to power after a civil war cannot present a new constitution by month end, but from here, you can feel the pressure that they are under.  Key government and ministry positions that have been unfilled for months were filled just the other night - 12 or more of them! Fortunately a new Minister of Health is among them.  It's too soon to know what this means for the ministry, the constitution or the stability of Nepal, but I can assure you that you will be among the first in the western world to know if this will be the precursor to real change - or just monkey business as usual.  All the best from Kathmandu.