Deliverance

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Scenes from the national Maternity Hospital, Kathmandu.

Yesterday all the blood rushed to my head and I thought I was going to pass out. I had to go stick my head out the window and wait for the feeling my face was swelling up to go away. Then for a while I had to fight back tears. "This is not your moment Robin. This is this nice Nepali lady's moment. Do NOT cry." Then when it was all over I just stood there smiling like I was on drugs, peering at the shriven creature whose messy twisting entry into the world I had just audienced. I'm going to be a doctor? Right.

The only childbirth I had ever seen before yesterday was of large farm animals, precisely one lamb and one foal, and the lamb was in kindergarden. Somehow in humans it's different, even though on a nuts and bolts level it's quite the same. There is pushing and resting and wetness and blood and lots of sweating and eyerolling. But that makes it sound beastly, when really, at least to me, in one of my fellow humans it was almost elegant.

I've never been at a delivery in the States, so I didn't have any fast expectations for what would go on at Maternity Hospital, but from my limited experience around American medicine the following I have deduced is different enough to be worth nothing. First, women admitted in early labor all hang out in big hall called the antenatal room, a really tense place with great communal squirming and blanket-clutching, and lots of yelling by nurses and doctors, but mostly silence from the pregnant women themselves. They wait there until things are more or less a go, and then they get wheeled to a bright room full of cabins like office cubicles, open on the side facing the middle, staffed by young nurses wearing baby blue, unless there is some complication like a breach, and then they go to a darker scarier more metallic and wide open room staffed by doctors. To enter either "delivery theater" you have to take off your shoes and put on a pair of communal plastic sandals like a chain-smoking house-coat wearing grandma in Ocean City would wear. The nurses all wield knives and needles and scissors with open-toes, and I even saw a few birthing attendants walking around in bare feet, no lie, among the blood and other liquids on the floor. No one seems to think this is a hygiene issue - no one even made me wash my hands when I came into the delivery room in my street clothes.

Husbands do not stay with their wives during any of it. The women all had a female friend or relative attending them who stayed for the whole thing, but the men wait outside in a cloud of cigarette smoke, sucking on death while their wives are pushing on life. The woman whose delivery I watched start to finish had to have an episiotomy, a really terrible procedure involving a knife, some local anesthetic, lots of blood, and pretty great risk of messing up something important, whose purpose is to open things a bit when the baby is too big. (look it up.) On top of that she had her first child, a boy (a really big deal here), got sewn back up and cleaned up, and hung out with her baby for at least 20 minutes before her husband finally came in to see her. He didn't kiss her or the baby. But he did bring a glass of milk and some cheese crackers. I hoped that that was some kind of specific request - honey all I'm gonna want is to see your face and some cheezits, ok? - but I don't speak Nepali and the wife never stopped smiling so I have no idea how her post-partum snack went over. I do know that during her labor she would look up from time to time and make eye contact with me, the random white stranger who was staring at her crotch for the most important moment of her life. I was usually horrified by half of what what I was seeing or teary eyed or woozy, but if she looked at me I'd smile really huge and nod super encouragingly as if everything were going SO great, and make prayer hands and nod some more - and she always smiled back. I would have kicked me out immediately, so I was really impressed.

I think delivery is handled really well at Maternity Hospital. Of course there is no privacy whatsoever, and there are weird hygiene issues like the bare feet thing, and the fact that they reuse rubber gloves, washing them and hanging them to dry, and then there's the nurse in charge of weighing the new babies who grabs them by the feet and flings them down pretty roughly on a metal scale, a total law suit in the US, but those quirks aside it's a very professionally run show. I guess some part of me expected to leave shaken, pitying the women of Nepal who give birth in squalid conditions (a lot of them do, this is the nicest place you can go) or terrified of ever having a baby myself. But weirdly I felt relieved. It's tough and gross and as gory as I could have imagined, but they make it through ok, and I think I probably could too.

Behind the Gates of NGO Oz

In the world of international health, all the NGOs, INGOs, volunteers, do-gooders, community groups, and even the government offices of the developing countries themselves - the ones charged with effecting all that meaningful change - are supplicants at the altar of their king and queen, the UN and the WHO, the highest of development royalty. If Bill Gates wanted to give townhall in Banepa, Nepal, $1 billion for universal teeth whitening he would have to get the OK from their court. So when you work for an INGO (international non-government organization) your plan for anti-retroviral donation or cataract surgery or (in my case) cervical cancer screening is little more than a good story for show-and-tell back at home, until you are granted that one important meeting with the great Oz (mythical, not Mehmet), behind the terror-blast-proof gates and through the maze of white-UN-emblazoned SUVs, eyes gleaming with your "escorted visitor" ID. It's totally weird and possibly wrong, but, it is.

So, after all the work put in - a month of meetings with Nepal's reproductive health elite, the 20-page report I just finished drafting, the terrifying bus rides on mountain roads to obscure cancer hospitals in rain forests, and becoming the country expert in a topic I knew zero about when I landed here on June 1 - I am totally un-ironically proud of this picture. Jhpiego has lots of friends in high places, so it's not like it was so hard to get this meeting, but for my project my presence here means go, rather than wallow. Maybe. Hopefully.

A bit about what I've been doing here... Jhpiego is an INGO started by Johns Hopkins that works on women's health and reproductive health projects all over the world, with funding from big donors like Gates and USAID. (www.jhpiego.org.) One of their biggest projects is CECAP, a cervical cancer prevention program that's gone over well so far in a lot of places, including Malawi, Ghana, Thailand, Indonesia, and the Philippines. Cervical cancer is the number one cancer-killer in the world for women (breast is more common, cervical is more deadly) and it mostly affects the developing world. In the US and the UK few women get cervical cancer because we screen for it all the time - if you don't show up for your pap smear in England the government literally calls your mom. In the developing world though, there tend to be more pressing problems, resources are scarce, and getting women to live through childbirth is enough of a challenge - forget prevention, and things like cancer, which you have to be healthy enough to live long enough to get. Except cervical cancer, which kills women in the prime of their lives - usually somewhere in their 40s - because it's caused by an STD called the human papilloma virus (HPV), which 80% of people in the US have and more and more in the developing world have now too. Think warts, but think cervical cancer as well. So, cervical cancer is not your average cancer. It shows up early, it takes a huge socioeconomic toll on communities and families, and oddly enough, it's preventable.

If you screen for cervical cancer using a pap smear or something called Visual Inspection with Acetic Acid -- translation, "looking with vinegar" -- you can catch the transformation of normal cells into cancer cells, and scrape, freeze, burn, or cut them off. It's actually really easy, and in the west we do it all the time. But in places like Nepal, women never see an OBGYN, ever, unless they are having a huge problem, like their uterus has been falling out for the past 15 years because they had a difficult childbirth, and even then, they might not go to a doctor. There is no "culture of prevention," to say it in NGO-speak. Women have it hard here, they do all the farm work and manual labor, and go right back to it the day after having the baby. Seventy-seven percent of the time they can't read. Most of the time their lives are ruled by the mother-in-law they came by through their arranged marriage and the first time they get to choose what they would like to have for dinner is the day she dies. So, they're not running to the doctor every time they have a problem. And even if they wanted to, outside of the Kathmandu Valley there wouldn't really be a doctor to see, at least not without taking 2 days off of farm-work for travel time.

All that said, Nepal isn't a total backwater when it comes to health care. It's way further along than a lot of places in Africa for instance. It has chemo and radiation therapy for cancer, a major cancer hospital, and a functional government hospital in every one of its 72 districts, which are like states. And Nepal is right next to India, which is pretty sophisticated when it comes to medicine; it's not exactly cut off from the modern world. So Nepal is a reasonable place to introduce cervical cancer prevention, or at least more reasonable than Malawi, if less reasonable than Thailand. Which is where I, fledgling med student and former radio lackey come in.

My job here has been to write up a "cervical cancer prevention situational analysis.” This basically means figuring out what they're doing here about cervical cancer now (nothing) and assessing what the obstacles would be to getting a prevention program started in the future (lots). Doing this for the most part has meant lots of tea, because to figure anything out here you have to have lots of in-person visits. People are not big on talking on the phone, even to answer simple questions. Forget email. It's the polar opposite of the PR world orbiting Oprah that I used to inhabit. Publicists agents publishers and magazine editors never actually want to see your face, ever. Here they want to see it, maybe touch it even, and definitely feed it tea, at their place, not yours.

Which all has been great, because I've been sent round to the big offices of Family Health International and the Family Planning Association of Nepal and the Safe Motherhood Network, met with cancer research groups, women's health advocates, former prime minister’s wives, expat Indian doctors, eager government officials, and lifetime developing-world experts, seen remote medical schools and scuzzy ERs and medical records written in pencil on damp log books, and most important for me personally felt like I was actually doing something useful, instead of studying for multiple choice tests.

Today I presented the basics from the report I wrote to the head of reproductive health for the WHO, who “sits,” physically and metaphorically, at the UN offices, hence the picture. On Thursday I have to present it to her again, along with the government people and all of the “stakeholders” – more NGO-speak – meaning people who will play a part in any future prevention effort. After that they are supposedly going to write national guidelines, and someday, with money from the government and people like Bill Gates, implement them. During all of which I will be on a plane – to India, Thailand, Cambodia, Laos, and finally home to New York. No ruby slippers, just a terrible seat in coach and hours of half-sleep half-had under an eye mask.

We’ll have to see of course and it will definitely take a while, but hopefully having been behind the magic curtain for tea wasn’t just the end of a month-long dream. At least I have a picture to prove I was there.

Directed Chaos

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In Cormac McCarthy's "The Road" a cohort of townmen open the earth in remote country to find a bolus of writhing snakes -- they set kerosene and flames to them, just to watch the mute burning of evil, or its effigy, or its physicality outside of themselves, recognized by its own same slithering energy within. (Most men in history have done the same thing at some point, whether it was the bombing of Dresden or the smashing of a roach on the kitchen floor.)

Feeding the fish at this "holy pond" at Bhaktupur, a town out in the Kath Valley, reminded me of that scene. The human fascination with watching the surfacing fish - an occasional orange coy but mostly brackish brown slick shiny muscular and snakelike - as they suck at rice krispies thrown through their roof and bully each other for position, is somehow as I imagine those snakes in the fictional ground. You throw the rice puffs over and over just to watch them reemerge heaping and thrashing and knocking each other off - a scene going on in every one of our cells, and in euro cup soccer matches, in public swimming pools throughout America in summer, in the crowd at rock concerts, and in every Kathmandu traffic jam. The rising and receding, maybe not of pure evil but of directed chaos. People sit at the edge of the pond and lose themselves in it for hours.

silk worms and cubists

My friend Raju took me to the school where he teaches tapestry weaving. He is now master where for 11 years he lived as a student, spinning silk for 2years as a 9 and 10 year old when he was too little to do anything else. He took me on the full tour: silk worms in their cocoons, bamboo looms, half-knotted sheets of hemp and scratchy cotton for saris curtains towels and shawls, scales for weighing powdered dyes, the school-wide obsession with Picasso's cubist period, the buddha his student is weaving that is too lovely to be for sale, 9 foot tall metal looms that take 3 months to set up in their intricacy. To him these machines are fingertip-tech like google platforms and facebook applications, instruments of art, yoga for the hands, and the place he is possibly happiest in the world.

"22" in Kathmandu

Ok, so maybe not exactly 22... but close! I couldn't have asked for a better birthday celebration even though I was on the other side of the world from everyone I love. I somehow collected the loveliest of motley crews in Kath, an Everest climber, an Egyptian musician named Emad who shared my birthday (born in 61 not 81), Masha my Russian salsa-dancer-jewelry-designer friend, DJ Tantrik or Kichaa or Boom depending on who you ask, Bishnu my nepali friend from the Pokhara adventure, Alex the world-traveling expat from NYC, Bob for whom the 60s never died maaaannnn, and Raju artist of woven tapestries and great friend courtesy of my much-missed former roommate Wanda (who called from Canada!) Then of course there were some idealistic NGO workers like me, and numerous expats and professional travelers, not to mention Sudesh the owner of New Orleans who so kindly turned over his restaurant to my party and played the guitar to the tune of "22 in Kathmandu" and doled out enough red wine to keep everyone out very very late by Kath standards.

Alex wrote my horoscope, Bishnu remembered that my favorite Hindu goddess is Saraswati (goddess of poetry, song, wisdom and education) and found me a beautiful statue to take home, Raju wove me one of his famous tapestries, and I'm shipping the 5 latest unreleased DJ Tantrik CDs to NYC for security reasons - get ready.

Better than the presents though and all the Gorka beer and the best apple pie in Asia for dessert, better even than the e-cards from my mom and all the happy birthday messages on facebook that kept me from feeling too lost in the world, is seeing that somehow in 24 days in this place I had reached my tentacles out wide enough to find this awesome assortment of characters that had me laughing and drumming and singing until far past the hour when my birthday was technically over. Gita at my office brought in a chocolate ice-cream cake yesterday to celebrate at work. "I didn't want you to feel lonely so far from home on your birthday," was what she said when she got it out of the fridge. I can probably think of birthdays when I did feel lonely, even if I had no real reason to, or if only because I wasn't actually present enough to enjoy whatever the celebration was because I was lost in my head somewhere dreaming of something else and missing out on everything that was right in front of me. But this was definitely not one of them, and I don't think I'll ever have one like that again. If I do, I'll just have to remember turning 22 in Kathmandu, and unfold my tentacles once again.

"I know you think it's unethical, but..."

Pic: the OBGYN exam table at the Medical College Hospital, Bharatpur, Nepal. The doctor I interviewed about cervical cancer screening practices there told me that because the women are so uneducated and illiterate (77%), if they have any kind of pre-cancerous lesion he goes ahead and gives them a total hysterectomy. Even though I didn't comment one way or another, he kept saying, "I know you probably think that's unethical. But if we don't just take it out, she'll never follow-up with treatment and she'll get really bad cancer, and we'll have to deal with it later. So if she has had her children we just remove everything." Even though there are easy, cheap treatments for pre-cancerous lesions of every grade. Usually doctors don't call themselves on their own unethical medical practices.

The last place you'd want to go in an emergency... the ER

You never want to have to go to the ER for any reason, ever. If you have been you know that you'll wait forever, the guy who wants your insurance info is as sympathetic to your problem as the bouncer at Bungalow 8, the doctor charged with dealing with you looks like he hasn't slept in 3 days and couldn't care less that your heart is palpitating/hand is broken/brain is oozing out of your nose/or whatever he has seen a thousand times before, and you totally inherently trust the place to save your life no matter what.

Now imagine that you wouldn't trust the place if your life depended on it, but unfortunately, it does. The ER at the Tribuhvan University Teaching Hospital (TUTH), one of the top hospitals in Kathmandu, is in the pics above. The third pic is of the entry-hall/waiting-room area, which was swimming in dirt, kind of under renovation, and still being used. The last is a view into the ER itself, where they wouldn't let me in even though I kept saying "I'm a doctor!" Can't imagine why in my sundress with camera in hand they didn't buy it.

The first pic is the orthopedic surgeon's office, total swarming chaos. The second is from from another hospital, the Medical College at Bharatpur, of the menu advertising OBGYN services. I mean if it's free...