Wrapping up. Chapatis, tea and talk.

The staff meeting was to begin at 1:30. At 2pm people were beginning to gather. There seemed to be no agenda but we began. Everybody chatted and the agenda made itself apparent. Chapatis and spicey potatoes and cups of tea were brought in. People wandered in and out and at one point I thought I’d better give my prepared report on my visit. So I did. I wanted to avoid being rude and inappropriate, but the more I suggested the more they nudged me to be more direct. The staff received everything I said with such receptive kindness that it was humbling. Truly amazing how different behavior can be in another culture, and yet we really do understand and respect each other. There is something about the way things work here that is both frustrating and extremely refreshing at the same time. I will miss it. The slow pace is both pleasant and irritating by turns. Nothing happens and things surprise you and all of a sudden, it’s done. Birth can be like that too, can’t it?

I had my Dal Bhatt this evening, with the realization that I won’t be eating it many times more. I rode the bus on my 15 cent ride through the dirty streets knowing I would soon be breathing the marginally less polluted air of Texas. I walked through the throngs of pedestrians, narrowly missed by hooting motor bikers, knowing how much I would miss the street life, the noise and variety of Kathmandu in suburban Dallas.

Women are women, midwives are midwives, and birth is birth, but Nepali style it’s all a bit different, wonderfully so. Thank you Kathmandu. And lots of love.

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Things coming together…. progress?

The sun rose to another clear day and a clear view of the mountains the day after the elections. What would happen next? After breakfast, I got organized to head out to the birth center. Everything was…. normal. How interesting. No violence, no excitement, just life, busy streets and newspaper headlines that the elections were peaceful. Results were coming in. Record voter turnout. The maoists who led the stirkes had lost badly. But rather than responding violently to defeat, it seems they were licking their wounds and moving on. The marxist-leninists and the Nepali Congress are the 2 big winners with the vast  majority of votes. The maoists, with a smaller number, hold the balance of power. Other parties have mostly 5% or less. All of this seems such a mature democratic outcome and brings a dose of optimism and confidence in the future that I think is in the air.

With the birth room redecorated, the childbirth education in place and the brochure at the printers, my work here is coming to a close.The anti-shock garment project sent me in and out of offices, NGO and Government, and I did two hospital presentations on its use.The new graduate level program in midwifery will hopefully start next year, It will be the first in the country and a prerequisite for the Midwifery Society of Nepal to have membership in the International Confederation of Midwives which regulates the profession worldwide. An initial research project would raise the prestige of the program and of the profession. It may really happen that it will be an anti-shock garment project. Kiran is for it. Dr Regmi, a big cheese at the Ministry of Health is for it and will fund impementation if initial funding is found. Doesn’t that sound like concrete progress? It feels good.

Meanwhile there was a funny day last week when the world seemed to be converging on APS birth center.Volunteers and staff were hauling around dusty piles of medical equipment, sorting, chucking, organizing. That frenzied, excitable mood that happens with a big clean was all around. Some of the senior staff who come in occasionally, Rashmi, Asha, Amala, were all there. And so were the Duggars! What? Yes father Duggar and Jill Duggar from the reality TV show about the family with the 19 biological children along with TV crew, invaded the festive cleaning up atmosphere of the center. For my non-US readers, know that even if, like me, you are barely aware of television and popular culture, you cannot help hearing about the Duggars and their TV tribe in the US. Jill D is on her way to becoming a midwife and while visiting Nepal, she wanted to visit a birth center, Nepali midwives and make an episode about her aspirations. Rashmi was interviewed. Mothers, babies and midwives were filmed. A festive mood prevailed.

While this was going on, the normal day at the center was happening too. A couple came in, for what they thought was an intial prenatal appointment at 29 weeks pregnant. But no heart-beat, and measuring many weeks smaller than 29 weeks. Sadly her baby was not alive. The couple were hugged and supported. Follow-up care was arranged. They had a a quiet corner of the center as the camera crew charged around. Sometimes events coincide in strange ways. Meanings are unclear but the strangeness implies meaning of some kind. That is midwifery in Nepal and everywhere.

Here are some birth center pics and then some older tourist pictures

APS motherbaby, APS staff, and a Dugger!

APS motherbaby, APS staff, and a Duggar!

Dinah and Jill (Dugger #4 outof 19)

Dinah and Jill (Duggar #4 outof 19)

APS board dinner

APS board dinner

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Annapurna just after dawn

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Annapurna dawn

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temple guard

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god eats other god alive

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Ganesh Himal

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New directions

Birth center chugging along. Feeling that my work there is finishing off projects: making sure the brochure is printed, getting new towel rails by the sinks (goal to encourage handwashing), discussing with Rashmi the placement of the new Ganesh statue. But my focus the last couple of weeks has been more outward and a bit outside my comfort zone: the anti-shock garment, hospitals, doctors, NGOs and Government administrators. Very different.

My first foray into the hospital world was a low key effort: Did a class for nursing students and faculty at at Tribhuvan University. It was a lot of fun. They were warm and enthusiastic. Here are some of the students having fun with practising labor support.

practicing labor support

practising labor support

Tea with faculty afterwards

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You may remember, that thanks to last minute donors I was able to bring a supercool neoprene and velcro device for stabilizing women who are in shock secondary to postpartum hemorrhage. Very enthusiastic about this simple thing that has been endorsed by the World Health Organization, has great outcomes in clinical trials but is virtually not used here in Nepal, where postpartum hemorrhage remains the number one cause of maternal mortality. So I put together a presentation on the device together with a bit of hands on training, and have been talking, telephoning, emailing, knocking on doors to spread the word. I have met some interesting people this way, and experienced lunch on the roof of the United Nations Fund for Population and a chauffered drive in a Government vehicle in which we drove through the middle of a preelection demonstration in Durbar Square. I did manage a presentation on the anti-shock garment at one of the hospitals, but whether I can really get a structure in place that will lead to training in use of the device, and incorporation into clinical practice is another matter.

Meanwhile, the elections took place yesterday and seem to have been largely peaceful with higher turnout than expected. The day was yet another holiday. This time the shut-down was total; a festive atmosphere of families wandering in the streets. Kiran, president of Midwifery Society of Nepal, invited me to lunch at her house where we talked for four hours…. all midwifery. went on the roof of her house to stare at the mountains through Russian communist era binoculars decorated with hammer and sickle. Ate dal bhat of course. Lots of tea of course.

A few pics.

election rally near the birth center

election rally near the birth center

from my window
from my window

baby massage on the street

baby massage on the street

The dentist's window

The dentist’s window

Below, false teeth. Above..... real ones!!!

Below, false teeth. Above….. real ones!!!

pahupathi. smokie rises from ghatts

pashupathi. smoke rises from ghatts

stoking the fire

stoking the fire

where the ghatts are for burning bodies

where the ghatts are for burning bodies

In every mini temple is....

In every mini temple is….

a "lingam" (phallic symbol)

a “lingam” (phallic symbol)

Politics, caste and the way it is.

A change of focus has brought some new perspectives. I had a week in the mountains. (To donors, please know that this was personal time and therefore personal money. Your donations are kept for midwifery work only) Awe-inspiring panoramas, infinite steps and some ambivalence. Trekking in Nepal is nothing like long distance walking in Europe or hiking in the wilderness in the United Stated. The endless steps connect the mountain villages to which there is no vehicular access at all. Everything is brought in on the backs of ponies or people (wearing flip-flops, which is an improvement over when my sister Sara went trekking 30 years ago and they were barefoot). Tourists are herded into “teahouses” which are village guestshouses of a basic sort. Despite the beauty of the mountain views, a certain sadness pervaded the trek. The early morning is the time of clear air and great views. Within a few hours the cloud/mist enshrouds everything and the mountains disappear. The moisture makes the melancholy mood, the damp is pervasive, and the poverty and tourists make a disturbing mix. The largest national group seen on the treks is the Chinese. They seem to surpass the Americans in loudness and enormous cameras.

I met several Tibetan Nepalis and received a bit of an education on thier lack of rights. They are denied refugee status due to pressure from China and even those who have been here 60 years or were born here have no rights in Nepal: no official right to work or vote, no passport or travel documents. They exist by working around the system which in this country is kind of what everybody is doing anyway, but…. no way to live. Poor Nepal squeezed between India and China seems totally stuck.  And talking politics, there is an election for the Constitutional Assembly here on the 19th. Some of the Maoists, who fought and won a civil war are against the election (they might lose) and are planning strikes. It seems that the strikes are not a popular idea so they may not come off. I hope they don’t… Had it a bit with holidays! However there is concern that if they lose the election they may not relinquish power and,  well,  it could get complicated. The recent political history here is dramatic in the extreme. For the bizarre story of the massacre of  almost the entire royal family in 2001 by one of the princes, follow this link.

http://blogs.hindustantimes.com/kurakani-in-kathmandu/2011/06/01/ten-years-on-mystery-behind-nepal-royal-massacre-still-lingers/

And this is about the election from the New York times….yes a fascinating mess: 120 parties, ballots to be collected from high up in the Himalayas, fun will be had

http://www.nytimes.com/2013/11/07/world/asia/in-fractured-nepal-plans-for-national-elections-provide-a-series-of-subplots.html?pagewanted=1

Today I met with Kersten at United Nations Population Fund(UNFPA). She is a Swedish midwife, whose mission is to strengthen the midwifery profession in order to improve maternal child health outcomes. I was looking for her help in promoting the use of the anti-shock garment. About that she was encouraging and gave me more contacts, but about midwifery in Nepal she is a bit pessimistic. The bureaucratic and political barriers are great. Karma and caste maintain the status quo.

Here are a few pics. Yes, beautiful.

Pokhara lake sunset

Pokhara lake sunset

Traditional house and terrace

Traditional house and terrace

A few of the endless steps

A few of the endless steps

looking cold!

looking cold!

hooray

hooray

flowers through the waterfall

flowers through the waterfall

more traditional village buildings

more traditional village buildings

marijuana widely grown. Legal on Shiva's birthday only!

marijuana widely grown. Legal on Shiva’s birthday only!

stunning, huh?

stunning, huh?

i love terraces

i love terraces

pack pony

pack pony

gentians for mum

gentians for mum

witchy haystack thing

witchy haystack thing

That’s the way it is in Nepal

I drew back the curtains one morning last week, and the air was clear. The mountains rose behind the houses. And there behind them… were the real mountains, the snow-capped Himalayas right outside my window. They had been hidden every other day by smoggy haze. Hooray, a clear sharp view of snowy peaks puts the smile on any morning face.

So through the city to the birth center. All is well. Things are happening despite glacial slowness. Why use one person to do something when 3 will do? Decide to go to buy the flooring for the birth room at last but wait there is a phone call then someone comes round with an important piece of paper to sign which involves much thinking and rereading and then of course there is another cup of tea and finally off on the errand we go. That’s the way it is. The task of getting the brochure printed is mammoth. Misunderstandiings about who is doing what and how it should be done… days pass. Leisurely dysfunction.

The story of Ratna sadly exemplifies the way it is in Nepal. She is a nurse with a few months’ midwifery training like most of the staff at the center. She wants to study more and finish her Bachelors in Nursing. Last week she told me that her grades weren’t good enough and she was on the waiting list. I commiserated. Today Rashmi told me the full story. Most applicants are wait-listed she said. Those that are accepted from the list are those who pay. Ratna can’t pay. Rashmi tried to use her influence, without paying, a little string-pulling but to no avail. No pay no place.

On a more hopeful note, I think I have found someone who will “champion” the non-pneumatic anti-shock garment in Nepal. It will need a champion to push its use, spread the word, inform, instruct, and cajole. Asa works part time at APS as well as full time at the big public hospital. She told me that she became a midwife because of her mother. Her mother died at the age of 33 of a postpartum hemorrhage. We weren’t talking about the anti-shock garment when she told me about her mother. We have not talked much. I am not sure why she told me about her mother. It was emotional and hard to talk about. Strange that she told me. Then I told her about the anti-shock garment. The anti-shock garment impressed her. She knows it will saves mothers’ lives.

And I want to tell all you deviners out there, Nepal is a place where it is apparently impossible to lose things because someone will find it for you. From my little flashlight which I left in a crowded restaurant and was returned to me 3 days later, to my camera which I lost at the Boudenath stupa and was returned to me by a delightful Nepali child. And a bag of precious goodies I had bought were carefully rescued for me by a guard at the Golden Temple in Patan.

And some pictures:

Beautiful Boudenath where I lost my camera

Beautiful Boudenath where I lost my camera

more Boudenath

more Boudenath

prayer wheels at Boudenath

prayer wheels at Boudenath

she found my camera!

she found my camera!

Happy at the Golden Temple. Have'nt lost my bag yet

Happy at the Golden Temple. Have’nt lost my bag yet

the fabulous Golden Temple

the fabulous Golden Temple

on a wall at the Golden Temple

on a wall at the Golden Temple

Sumitra learnt to apply the anti-shock garment

Sumitra learnt to apply the anti-shock garment

Ratna and Amala measure the floor of the birth room for the new lino

Ratna and Amala measure the floor of the birth room for the new lino

delightfully round faced baby

delightfully round faced baby

The birth center makes angelic babies

The birth center makes angelic babies

Three hours old

Three hours old

Dashain fatigue…. and reenergizing

The festival of Dashain lasts 15 days! The build-up was fun. There was the buzz of shoppers, travellers, preparation. Then there was the height of the festival: ritual, puja, tika, food. And then… it went on. Many shops still closed. Not much getting done. Personally, I had a case of Dashain fatigue. I wondered if the Nepalis felt the same. I had the feeling that some of them did.

I continued working at the birth center through the holiday. It was quiet but a bit of action here and there. Babies get born whatever is happening and the clinic is always open. But today the festival is over and despite being saturday which is the Nepali weekend, I had a much-anticipated meeting with Kiran at the Midwifery Society of Nepal and feel energized in new directions. We had a wonderful two hours together. She described her struggles for acceptance for the profession of midwifery and the resistance of both physicians and nurses (a sad and old story). She is working towards an in-hospital birth center (more like a midwifery led unit in the UK) which can serve as a model midwifery care site and as a clinical setting for midwifery students. We planned my continuing education topics. I will do a series of weekly hour-long sessions to the society through November. The first will be (surprise surprise) childbirth education and adapting teaching models to Nepal. The second will be on the topic of the anti-shock garment. Hooray! The third will be on birth centers and there may be a fourth on finding and using evidence for midwifery care practices. So lots of prep for me for those workshops lies ahead. Of course I continue to work with Rashmi and the midwives at APS Birth Center.

So now a few pitures. First shoving the sacrificial goats into a variety of vehicles!

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You can put a goat on a motorbike

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Or in the back of a car

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Or in the front of a car

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car puja

I was invited to Devi the tailor-carpenter for family celebrations

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Puja for devi’s carpentry tools

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Puja for Devi’s tailor tools

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tika for Devi’s wife

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tika for Devi’s mother

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tika for Devi’s guest

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HAPPY DASHAIN!

Outside “helpers”. Thoughts from a wandering Jew.

Tiptoeing through a minefield

Tiptoeing through a minefield

We are a wandering species. Wandering and shared culture is mutually strengthening. One of my personal goals on this trip is to be tipped off-balance by new experiences, different people and places, and to gain personally from this. As I wrote in one of my earliest posts (“Intercultural Understanding July 29th” https://wiwok.wordpress.com/2013/07/  ) “I believe that help is a minefiled”. My whiteness and my American experience give my words and my ideas power that I do not intend. I am treated with a deference that is both natural hospitality and a discomfitting honor that belies a very mixed intercultural history.

Bringing ideas and teaching imply a negative assessment of midwives and APS Birth Center. A negative assessment does not mean criticism. There is no blame given. But I know it is felt. And that feeling weakens the confidence of those struggling here under very difficult circumstances. It disempowers them and makes them more dependent. So, what if I didn’t try to do what I am doing? What if all the do-gooders walked out of Nepal and left them to their own devices? Maybe they would be better off and midwifery, mothers and babies would figure out quite happily how to care for themselves. Such abstract questions are meaningless and absurd, however, in a globalised and interdependent world. The strength of technological systems deriving from corporate power are such that the marginalised, the midwives and normal birth would lose. So I continue to tiptoe around the minefield.

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