Wednesday, August 21, 2013

Reflections on Achham: Growth and Opportunity.

GROW: a : to spring up and develop to maturity.  to have an increasing influence. to promote the development of. -Merriam Webster Dictionary.

Two months in Achham. Two months a world away from what we are used to in the United States, yet still, it is only two months. Two months is hardly enough time to understand, to appreciate, and to develop. Yet time flows differently in Achham and development, both personal and otherwise, comes sooner than one expects.

Growing up
Personal development is easy when one is starting from nothing. Before this summer, the world of international development and global health was very much a rhetorical one, given life only through articles and essays. In retrospect, despite nearly a year of campaigning and raising awareness through Globemed, my view of Bayalpata Hospital was significantly flawed before I actually got there. With all the rhetoric of ‘grassroots’ and ‘community-based’ I had thrown into my prepared elevator pitch, I was a bit unprepared to see a respectable looking complex with solar panels, tiled floors, that looked, well, a lot better than what I was expecting, honestly. My mental image was tied up in the form of the small community clinic that Nyaya started with, but the hospital has grown, expanded, developed. Nyaya has changed for the better, expanding and serving more people and as such it has, without us knowing, left behind many of the phrases we use to describe it.

Growing Out
Our rhetoric emphasizes that Nyaya is a grassroots organization. It’s a good word, one that really gets people excited. It invokes images of strong community backing and involvement, small, local roots, and a personal touch to healthcare delivery. Does that word still apply when if the small regional clinic has upgraded to one of two district-level hospitals that serve patients from hours away? Does it apply to the public-private partnership that is looking to dramatically increase the amount of government funding it receives, fighting through the bureaucracy to achieve it? Does that word describe an organization which has a U.S. team of researchers that receive tens of thousands of dollars in grants to do research that often seems to fly in the face of reason for the Nepal side? What does the word “grassroots” mean when the organization grows?  

Growing In
The point of a successful campaign is, in many ways, to paint the scenario in the best light. The danger of successful campaigning is that it becomes easy to believe your own elevator pitch. One forgets that organizations are not purely corrupt and inefficient or transparent and streamlined. Problems exist. Inefficiencies gum up the works. Communication lines are often tangled and tensions sometimes run high. That is the reality, not the campaign. And while it is important to frame the organization and the fundraising goal in a light that will promote action and involvement, it is essential that delusion does not become an accepted tradeoff. A realistic assessment of strengths and weaknesses is necessary for the chapter as a whole, not only to foster a better understanding of our partner, but to better think of ways to help strengthen the partnership.  

Growing Understanding
It is often difficult to describe the demographic Nyaya serves to others, whether while giving an elevator pitch, or while campaigning. “Rural Nepal” is hopelessly inadequate. “Under-served” is difficult to visualize. “Impoverished” gives a one-sided view of the situation. In reality, no summary for an elevator pitch can capture the full nuances of the Achhami populace. What’s a short way of saying “subsistence farmer / migrant worker / tea shop entrepreneurs / impoverished but not starving / hard working and generous / indolent and self-serving / caring parents / neglectful parents / victims/perpetrators of gender inequality / happily married / domestically abusive when drunk / bearing great burdens, physical and otherwise / mild hypochondriacs believing that no pills or tests means ineffective treatment” ? How do you summarize a caste system that segregates and discriminates, and how do you give an overview of a younger generation who couldn’t care less about caste? How can you express the changes occurring, from changing age-old traditions which harmed women to improving overall health through community investments, and how can you reconcile that with the cold reality that the more things change, the more things stay the same in the sense that at the end of the day, you still have to look out for number one. In a society where males are valued more, there are parents who love and pamper and cherish their daughters. In a community where most people perform migrant work or subsistence farming, there are some who dream of studying abroad and pursuing higher education. No matter how hard one tries, there is really no way of easily encompassing the population that Bayalpata Hospital serves, who are probably the most important detail when describing the hospital’s care.

Growing Pains
If a hospital runs out of medicine in rural Nepal, does it make a sound? Poisonous snakes are, unfortunately, all too common in Achham. The problem was exacerbated by a country-wide shortage of antivenom. So when, one night, a member of the Armed Police Force came to the hospital with a snake bite, what could be done? How must it have felt, knowing that if only there was this small vial of liquid, everything would be all right? What sort of terror and anticipation must have filled that officer’s heart when, in the middle of the night, he was told that there was a chance, a CHANCE, that the other of two district-level hospitals in Achham MIGHT have antivenom. That is the stuff of nightmares. Often, donations and campaigns are run for projects that are sexy, that are popular, that are easy ways to pluck peoples’ heartstrings and their wallets. But basic issues of supplies and logistics are sometimes more complex than a single hospital can handle, and sometimes the simplest things are the ones that need the most attention.  

Growing forward

Growth can be tough, and Nyaya fits all of the descriptions of growing. It has come to maturity, both scaling up in physical size and also in scope of services, going from a small clinic in Sanfe to being awarded “Best Hospital in Nepal”. More and more, Nyaya has increasing influence in both the region, and also the nation, through its work with the government. Through both Nyaya Health Nepal’s work with the government and also through Nyaya Health International’s work in implementation science, Nyaya works to promote its core values of transparency and efficiency in delivering healthcare to those that need it most. But growing can be difficult. Growing pains are normal. Nyaya faces challenges that it must overcome, from communication to employee retention. But growing also means new opportunities, for both Nyaya’s efforts in Nepal, and also for Globemed at Tufts to be as useful as we can for our partner. Whether or not we seize these opportunities and minimize the associated growing pains is up to us. 

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