A small gauntlet of community health volunteers gathered on the other side of the school’s stone gate to preside over our departure.  As we stepped before the group we bowed our heads and one by one they took their thumbs and pressed a pink tika into the skin between our eyebrows and up onto our foreheads.  The chalk pigment flaked down onto our noses and the fronts of our shirts.  After the tika was applied fine linen scarves were tied around our necks…

 

In the picture there are three girls, students at the school in front of which they are standing.  Most all of the school building is out of frame and the girls stand before a small section of mud brick wall.  The girl on the right has her head wrapped in a scarf.  It forms a fringed wool halo from the top of her head to her chin, and she is looking directly at the camera.  She is wearing a paisley dress over a baggy long sleeve shirt.  The collar and sleeves of the shirt are stretched from many consecutive days of wear.  The two girls to her right are younger and both cast a look of disdain or awe or both.  They look out beyond the camera, possibly at some adult trying to get them to smile. 

 

 

Two community health volunteers look out over the valley.

 

I was thinking about the four-hour walk back to the district capital, Dunai.  How long would it actually take us?  We had grossly underestimated the steep terrain on the way to Raha.  We were to leave Dunai the following day and there were still numerous supplies to be gathered and arrangements to be made for the next two weeks on the trail.  The team from Medic Mobile, Alex Harsha, Ranju Sharma, Pawan Acharya, and I, had been in Dolpa for five days.  Raha was the first Village Development Committee (VDC) we visited and getting there and back was in many ways a warm up for the type of traveling we would be doing in the coming weeks.

On the trail. Before we realized it was a 1000m climb to Raha.

Dolpa is a remote mid-western district of Nepal, accessed only by small plane, and once in the district all travel is done on foot.  Everyone walks.  It is not uncommon to walk for days between villages.  Lower Dolpa, where we were traveling, lies within the Himalayan Mountain range, and so the walking is done along rugged and winding trails and over mountain passes.  In Dolpa, Medic Mobile is partnering with the non-profit One Heart World Wide to implement a maternal and newborn health system that will use a SIM application to collect patient data, as well as provide community health volunteers with reminders to see pregnant women and their babies, and alerts to nearby health workers to facilitate support during delivery and emergencies.

The general plan for our trip was to visit three VDCs.  At each VDC we planned hold a focus group with female community health volunteers (FCHV) on the proposed plan to implement Medic Mobile’s tools.  We would also invite community leaders to a secondary meeting to hear their thoughts and concerns about the proposed project.  We were looking for more information.  Where were the problems going to be?  What improvements would this project make?  Was there any cell service?

 

Introducing the SIM application

 

The meetings in Raha were held in the classroom of a small school building.  Unlike the other classrooms in the school this room had a wood floor.  Extra chairs were brought in and arranged along the walls.  Pawan Acharya, a bright 25 year-old with a degree in public health, led the introduction of the project to the group of volunteers.

Pawan Acharya at work

It was evident from the first session that the list of impediments to the project was to be long: illiteracy, extreme geography and inexperience with mobile phones were just the beginning, not to mention unreliable cell service.  However, the conversations in Raha were lively.  The oldest FCHV, assuming her position of experience in the group, spoke vehemently about how difficult it is to get pregnant women to the district hospital in Dunai because they do not have any stretchers.  Gesturing with painted hands, she described how they often organize family members and neighbors to carry women the four hours to Dunai.  Another volunteer expressed the sobering sentiment that with a program like this the government would finally “see” their work.

So much of the health care in rural Nepal depends on these volunteers.  It is a fact that can not be detached from a sense of injustice.  While these volunteers have the capacity to form a strong and vital arm of the Nepali health care system, too often the position they have volunteered to fill is undercut by the government’s inability to provide regular training and access to simple resources like operational health posts, and stocks of medicines.

 

FCHV explaining the numerous difficulties to providing care in Raha.

 

FCHV trying out the Medic Mobile phone with a daughter's help.

 

At the second day’s joint meeting with community leaders the principal of the school sat holding his youngest daughter in his arms. Occasionally stretching and twisting in her father’s lap, she was asleep and her body paid no attention to the room.  The principal, engaged in the conversation, simply adjusted his grip according to the unconscious whims of the child.  Here was a room of concerned but ordinary people talking about a novel approach to implementing a health care system.  A rough circular diagram of arrows had been drawn on a black board depicting the chain of communication between a central server and the health workers with cell phones.  The principal’s daughter, still oblivious, napping, laid out on her back across the platform of her father’s knees, her legs and head falling victim to gravity.  Her sleeping presence seemed to qualify the room.  Her sudden groping into empty space and her father’s shirt sleeves somehow offered a simple reminder that after the meeting things would be just as they had been in Raha, at least for the immediate future.

Students at the local school.

For the past two days we had listened to the stories of the FCHVs and other members of the community.  During the breaks in our conversations we drank tea together, and ate firm early season peaches then tossed the pits into the dirt.  We hadn’t saved any lives, or passed out any clothes, or made any grand promises.  Rather we ate and slept in the village, walked through the hills that envelope the compact clusters of homes, and we listened.

After the last meeting a final round of tea was served.  I collected my camera gear and the other team members arranged their bags and filled water bottles for the trail.  It was nearly two o’clock in the afternoon and we were leaving later than we had planned.  We said our goodbyes to the principal and the village’s health worker, and then headed across the small dirt courtyard towards the stone gate of the school.

…As the scarf was tied around my neck I swallowed an involuntary gasp knowing that if it escaped tears would follow.  I looked up to see the face of the oldest FCHV.  Her hands were pressed together before her chest and she smiled back at me.  Pawan, once we were on the trail, suggested that the neon pink tika (which was not the traditional red) had probably been found in a last minute effort to piece together the small ceremony.   His thought barely registered in my mind.  I was lost thinking back to the ten-minute span of time that was our departure.  My thoughts once preoccupied with the days ahead were now struggling to absorb that humble and hurried ceremony.  I was in awe.  I looked out through the lenses of my sunglasses.  They were covered in tiny specks of pink.

 

 

 

Text and images by Lewis Feuer