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.