I don't even know where to begin it has been such a whirlwind. Electricity, like phone service and internet is spotty so I will only be able to post occasionally.
I arrived Monday night and by the time I got to the hotel I had been traveling over 34 hours and was completely wiped out. I settled in, fell asleep, and was awoken early by Kiran from the Midwifery Society of Nepal (MIDSON) saying they wanted me to go out to the districts that day. We were to drop off supplies and 2 nurses who would be acting as midwives in an area almost completely devastated by the earthquakes. The 8 hour round trip ended up being 10 hours 1 way and by the time we got to the birthing center it was too late to travel any further so we spent the night at the clinic there. Here is a photo of the two nurses (they are called nurse-midwives here because that is what their role will be) sitting in the back with Rosini who will mentoring them, and Laxmi who is spearheading all the outreach work for MIDSON. What you don't see is how small the truck is and how crowded we are, and how full the back is with much needed supplies. It was quite a hot and bumpy journey, but the views of the countryside were stunning.
It would be an understatement to say that destruction I witnessed first hand is not overwhelming. Just next door to my hotel another guest house is gone - it was totally destroyed. I do not have a photo yet of that but will post one later. It is humbling to see the buildings looking safe and strong next to piles of rubble. Below are a few scenes of the countless I saw.
Our first stop was to drop off supplies donated by Unicef for the Ministry of Health in the Bhatkapur district not far from Kathmandu. The sights and smell along the way were reminiscent of my trip here 14 years before and it felt comforting. We then continued to Chautara Municipality to drop off water filters in the Sindhupalchok district. This district was the most affected with 80-90% of homes being destroyed and over 1000s of deaths and people missing. In Chautara the hospital itself had collapsed and was now being replaced temporarily by a tent hospital run by the Norwegian Red Cross. It was an interesting lesson for me to see the politics of it all - even in times of crisis the back and forth of discussing the plans (to drop of requested water filters), delivering them, going back for signatures to the Minister of Health, more meeting and discussions with administrators. What could have been accomplished in 10 minutes took more than 2 1/2 hours.
Next we stopped along the way to assess health clinics and birth centers there. So far the more rural birth centers see approximately 1 woman/week for births. Given how remote some of these places are it seemed an impressive number. Below are the 2 midwives who serve the clinic, as well as a lovely woman who graciously made us tea.
We finally made it to Melamchi where again the hospital was destroyed, but fortunately a clinic building was intact. The Japanese Red Cross set up a hospital facility there and the birthing center is in the clinic building. This is a very populated area and the midwives are seeing an average of woman birth/day.
I want to backtrack and explain the midwifery situation in Nepal, as much as I understand it. Currently MIDSON is working hard to create an education program specifically to train midwives but so far there is not a specific program. There have been some programs aimed at helping them, including a twinning program with the Royal College of Midwives out of the UK (https://www.rcm.org.uk/global-midwifery-twinning-project). However, most births occur in hospitals with nurses or at community health centers with workers there. In the very rural areas especially in the Western regions most births occur at home (Midwife Pilgrim posted a documentary via Al Jazeera on our FB page). Fortunately the Western region was not as affected by the earthquakes. After the earthquake UNICEF supplied a grant to train nurses very quickly to function as midwives and work in the most affected districts - the two young nurses we were transporting had only a few days of training and witnessed a handful of births. They were rightfully nervous, but it was felt that they were "better than nothing," which sadly is true. I spent several hours discussing scenarios with them to help their confidence level and to reassure them they will do their best and that they will be fine. They will have Rosini with them some to mentor and assist as needed. But of course I worry about them and the women in these areas. The closest hospital was 1 1/2 hours away and most women from the villages could not afford the ambulance fee ($25 US) if their is an emergency.
After a not so restful night of sleep, we headed back to Kathmandu, but first we were to check out several other health centers with birth centers along the way. These assessments were being made to check on the damage to the facilities as well as to assess the level of care being provided and hopefully determine a plan to help improve the services.
I have often complained about the roads in Vermont, especially during mud season. I remember years ago talking about the roads to the more touristy areas of Nepal and how dangerous they were (often one lane with sheer cliffs on one side). If any of you have read my blog about my time in Uganda you will know how bad the roads are there. None of this compares to the incredibly steep, cliff sided back roads of Nepal during monsoon season. These are not the road the buses travel with tourists and make our class 4 roads back home seem like paved highways. I mention this because our first stop in the morning was to be high up in a village that would normally take 30 minutes in good conditions. 2 1/2 hours later after several times being stuck and more than once having to back up due to other vehicles attempting the same route, we gave up. I wonder for these women what options there are if there is a complication.
We then made it to Bhotechaur, having gone up one mountain, down again, across the valley and up the other mountain. The roads there were better, but not without its challenges. We literally had to navigate in a river to reach the road at one point (we had crossed many small rivers but this was a first for me). Along the way we saw a long line of people waiting for supplies which were being handed out by one of the relief organizations. The photo does not begin to show the hundreds of people patiently waiting.
I could see the Bhotechaur health center from the other side of the valley. High up in the mountains, it was stunning in the sunlight. However, once we arrived the damage was too great for it to be utilized anymore. They did have a makeshift structure that they were using for deliveries, and another building next to the health center which had been offices was being used as a clinic. The health care workers were very new there - one only arriving 3 days before and the "midwife" only having been there 20 days. They too averaged 1 birth/week. The midwife had no training at all in maternity care.
Another stop, another facility. This one outside of Kathmandu and was not damaged. They were very excited to know that a doppler was available for their use. These midwives have specific training and years of experience, which was reassuring.
What have I not mentioned? The beautiful smiles of the Nepali women as we drove by or stopped briefly. Their warm welcome and "Namaste." The clear resilience of the people here to rebuild their communities.
But there was also the woman who I did not photograph. The only woman who did not make eye contact. She sat outside one of the health centers with her two young children and it surprised me when she did not meet my gaze. Until I saw her face and the new bruises covering her eye and cheeks. My heart broke for her and I could do nothing to ease her pain.
While I am sure we all think about the devastation of the earthquakes, there is much more to this community. The health care infrastructure is not adequate to serve its people, and the remoteness makes it almost impossible. In speaking with the medical director at Melamchi he told me there were 39,000 villages, many of them not even on a map, and only 15,000 physicians. There are very few trained midwives. The maternal mortality rate of 280/100,000 or lifetime risk of maternal death of 1:190 (compared the US, which is not the best in the world of 28/100,000 and 1:>1800) is far too high and the earthquakes made a difficult situation even worse. Gender violence is high and the violence toward the woman I mentioned above is probably all too common. But maybe the earthquakes will offer some hope - more awareness is being made and funds have been given to try to improve the situation. Hopefully it will be longterm and sustainable.
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