ASHOK KHOSLA:
I believe sustainable development means a development in which there's much greater equity - much greater emphasis on an economic development that basically meets the needs of the poorest...
NEELAM ADHIKARI:
You know, the solutions are not so much medical. Because medically we have the know-how. This is really, on a large scale, a socio-economic problem.
MOHAMED IQBAL:
As a doctor, I have a social commitment. I wanted to do something for the society. Here, I found the health is addressed totally - not as part of the problem...
Diktel, Eastern Nepal
INDRA MAYA:
What's the point of being angry? If we were in the right place, perhaps he would have lived. Even if he had been born and had died later, we would have thought it was his fate. From here to here they cut off tiny pieces and pulled him out with forceps.
COMMENTATOR (COMM):
15 years ago Indra Maya lost her first baby. For three days she had intense labour pain. There were no doctors available and the baby died inside her womb. It had to be surgically removed.
INDRA MAYA:
They must have gone to play. If they are not back soon they must have gone to play. The younger one must have gone to play with her friend. I wonder when she will be back.
COMM:
Even though Indra Maya has come to terms with the loss she still suffers from anxiety over her two other children.
But Indra Maya was lucky to survive. Nepal still has one of the highest maternal mortality rates in the world with as many as five out of every 200 women dying in childbirth. And the figures could well be higher. Studies show that 15% of all pregnant women throughout the world are likely to develop birth complications. Without emergency obstetric care, these women could die...
Only last year, an estimated 10,600 women would have needed emergency obstetric care in just four out of Nepal's 75 districts... only 452 of these women were seen by the hospitals. Nobody knows what happened to the other women.
Many may have suffered permanent injury and become socially ostracized... Probabilities are most of them did not even survive. In remote areas such as these, women are often not accounted for... They simply disappear.
After years of unfulfilled promises from the government, a new doctor has finally arrived at the District Hospital. Dr Gunraj Lohani has brought with him a new determination - to bring change to an ailing health system. For years, the lack of roads has kept most development and distribution of services away and the brain drain to the cities has led to an acute shortage of professionals, especially doctors and nurses. With the doctor's arrival, things look set to change.
It has just been two weeks since Dr Lohani trudged eight hours up the long misty trail that links the nearest airport to Diktel. Since his arrival, the number of outpatients has increased from 30 to over 100 patients per day. For the women in Khotang, Dr Lohani's arrival is particularly important... He is an MDGP, a medical doctor in general practice and is capable of dealing with emergency obstetric cases. But in the labour room, things are not going well for Rudra Kumari.
NURSE AND HUSBAND SUPPORTING RUDRA KUMARI:
Don't panic. Try and walk properly
Listen love, don't start pushing. It's not time yet.
The baby is not going to fall out right now!
COMM:
Rudra Kumari had complications in the delivery of her first baby. She and her husband, Jit Bahadur, decided to walk for a day from their village to the district headquarters to see Dr Lohani. Her cervix is scarred and if it does not dilate soon, Dr Lohani will have to perform an emergency operation. Dr Lohani explains the four delays that can lead to emergency deliveries.
DR GUNRAJ LOHANI:
The decision on when to take the pregnant woman to the hospital does not depend on her. The decision depends on the family, on the culture. In the villages, there is a culture of calling dhamis, the traditional healers and consulting local paramedics. They all treat in their own ways and the life of the patient will be decreasing. The countdown has begun.
Then, in the villages, there are probably no stretchers or any other equipment. You have to find people to carry the patient. Let's say it takes eight hours to get to the hospital. It might be raining and you don't know what might happen on the way those eight hours could easily turn into more.
Once she reaches the hospital, one cannot perform miracles. Blood has to be arranged. There is a question of instruments, doctors, whether or not staff and doctors are there. That takes time too. In total, a pregnant woman who needs help, suffers right from the beginning. There are a lot of women that we have not been able to save. Babies not surviving are something normal. It is very difficult to become a mother and we have seen many women's dreams remain dreams.
COMM:
It's hard to imagine how the election of one man in the United States, President George W Bush, could affect the lives of so many women like Rudra Kumari... In January 2001, President Bush re-imposed the global gag rule - also known as the Mexico City policy. This stops US aid going to any foreign non-governmental organisation that either supports or promotes abortions. Until recently, abortion was illegal in Nepal - and, as a result, as many as 2,200 women died every year through unsafe abortion.
DR STEVEN SINDING, DIRECTOR-GENERAL, INTERNATIONAL PLANNED PARENTHOOD FEDERATION (IPPF):
What does safe motherhood mean? It means the ability to have children when you want them - to get proper prenatal and post-natal care; to be attended by a skilled attendant at delivery; to be tested for sexually transmitted infections and diseases, and to be treated for those infections and diseases when they occur.... All of those are the regular services of our reproductive health system - and those of many other non-governmental organisations... All of these are affected...
When the global gag rule is imposed, it doesn't just target abortion, it targets organisations - most of whose activities have nothing to do with abortion. But if they refuse to renounce counselling or referral on provision of abortions, they lose all their money. And that's the harsh reality at the field level - that safe motherhood is denied because of abortion politics in the United States.
COMM:
In 2001, Dr. Nirmal Bista, the head of the Family Planning Association of Nepal, travelled all the way to Washington DC to appeal to the US Senate. He wanted to tell them about the impact the global gag rule would have on the lives of women in Nepal.
DR NIRMAL BISTA, DIRECTOR, NEPAL FAMILY PLANNING ASSOCIATION:
The American, USAID money - when it phased out and the partnership was terminated, in the middle of 2001, we almost had to close three or four of our clinics and we had to downscale services in some of our service outlets. We had to enforce a lot of redundancies - almost 60 to 70 trained staff.
COMM:
Nepal's health system is heavily supported by foreign aid. But for Dr Lohani, the challenge is irresistible.
DR LOHANI:
Everyone asked the same thing, 'How long are you going to stay?' Apparently, doctors do not stay here for more than a week or ten days. I have told them 'I'm going to stay for two years!'
COMM:
The difficulties that lie ahead of him are immense... The hospital structure is basic, there is no blood bank and the equipment is minimal...
DR LOHANI:
My main aim is to give EmOC here, at least in this hospital. That would mean handling deliveries, removing placentas that has remained inside, stop any bleeding, give medicines to women who have fits or eclamptic fits... These are simple things. Besides we could also do instrumental delivery - vacuum or forceps delivery. An important part is blood transfusion because we might lose the mother due to excessive bleeding. If we can organize that, we can do caesarean sections and with it, we would be giving a complete package of emergency obstetric care.
JIT BAHADUR:
Situations are rough in my village. Those who can afford to take patients out do, but those who can't die and rot. These things happen in the village. We have a health post but there is no doctor. He has gone somewhere. I would say my village, Bacachul VDC of Khotang, is one of the remotest villages in Nepal.
COMM:
Jit Bahadur brought his wife to the district hospital - but most women in Nepal do not get this kind of support. Families are reluctant to bear the cost of treatment and drugs unless it is life threatening. Usually, by then, it is too late.
Kapilvastu, Central Nepal.
COMM:
In the central plains of Nepal, in the district of Kapilvastu, lives Pardeshani Chaudhary. Pardeshani was fifteen when she lost her first baby. That was last year. She was in her eighth month of her pregnancy. There was nobody in the house except her grandmother. All she can remember is extreme stomach pain. Her baby was still born. Now she is pregnant for the second time.
INTERVIEWER:
How long have you been pregnant?
PARDESHANI:
When was it grandma?
GRANDMA:
How do I know? Was it April or May? May, June, July, August... four months- four months then.
INTERVIEWER:
Do you know that you should not be pregnant at least a year after a delivery?
PARDESHANI:
No.
INTERVIEWER:
How come you don't know?
PARDESHANI:
I don't know!
INTERVIEWER:
Have you been to the doctor since you have been pregnant?
PARDESHANI:
No.
INTERVIEWER:
Why not?
PARDESHANI:
Haven't gone
INTERVIEWER:
Why not?
PARDESHANI:
Because, us, Tharus don't go.
INTERVIEWER:
So you stay in your house saying Tharus don't do this and that?
PARDESHANI:
What else to do?
INTERVIEWER:
Say that you want to go and go!
PARDESHANI:
They won't give me any money.
COMM:
Pardeshani's mother-in-law, Kukri, has nine children, all born at home, without any complications. Kukri does not understand why she has to take Pardeshani to the hospital.
KUKRI:
We will call the shamans at home. Call him for check-up. The midwife here will press the stomach and see how the baby is ... if it is dead or alive ... where the head and the feet are. The midwife will come and check...
INTERVIEWER:
What will you do if she insists on going to the hospital?
KUKRI:
What to do then? Take her. I will borrow money from somewhere. If she says she does not want to have the baby here and wants to go to the hospital, we will take her. She is our own child. If we disagree, she will get worried. Isn't that true? She might cry... Otherwise we Tharus never go.
COMM:
But Pardeshani is nervous this time. She would like to convince Kukri to let her go to the hospital. Pardeshani and Kukri are a part of a women's group in the village. With the support of the women, Kukri agrees to let Pardeshani visit the hospital. The nearest hospital, Bahadurgunj is around two hours bus ride away for Pardeshani. The hospital is one of the oldest in the country and had become totally dilapidated.
The government did not find the building worth repairing, and the community then decided to try and rebuild the hospital themselves. Eighty-year-old Raj Bahadur Shaha became the backbone of the project.
RAJ BAHADUR SHAHA:
We do not have any money. We are collecting money from here and there, asking for donations going from house to house, selling trees, bricks and the wood from the old building etc. etc. I am already old. Perhaps I will die in two to five years. But I believe that the present generation will complete the work.
COMM:
The community managed to build the out patient department. But they have to look for money for the inpatient building. Hiring hospital staff, doctors and finding equipment is a problem that the community will have to face.
By the time Pardeshani gives birth, the hospital hopefully will be fully equipped. Twenty-one year old Prabhavati Mauri is having serious eclamptic fits, a result of hypertension - a danger sign for pregnant women. Bahdurgunj hospital is not equipped to handle her problems. Prabhavati is referred to Butwal hospital three hours away. The hospital had the necessary equipment, and both Prabhavvati and her baby daughter survived.
DR STEVEN SINDING, DIRECTOR-GENERAL, INTERNATIONAL PLANNED PARENTHOOD FEDERATION (IPPF):
I've worked in this field for over 30 years now, and for 20 years I was working in the population programme of USAID, the US government's programme.
I was very proud through that period to be part of an assistance system that got services to women in the most remote rural areas of the entire world. I worked in Kenya, I worked in Pakistan, I worked in the Philippines. I spent hours and hours in the most remote rural areas seeing how American assistance was often delivered through NGOs like Planned Parenthood - was making services available to poor women...
Often, these were the only services that were available. Education wasn't there; nutrition services weren't there; food was scarce and difficult to come by. But they had access to decent reproductive health services.
And for me, it's just terribly painful to see that the decision of an American president - with the stroke of a pen - can result in so many millions of people being immediately and directly affected at the grass-roots level - in villages, and in small towns, all around the world.
That's how important international development assistance is. When it's well administered, it really makes a tremendous difference in people's lives. And when it's denied, it makes just as much of a difference - in a very cruel way.
I believe sustainable development means a development in which there's much greater equity - much greater emphasis on an economic development that basically meets the needs of the poorest...
NEELAM ADHIKARI:
You know, the solutions are not so much medical. Because medically we have the know-how. This is really, on a large scale, a socio-economic problem.
MOHAMED IQBAL:
As a doctor, I have a social commitment. I wanted to do something for the society. Here, I found the health is addressed totally - not as part of the problem...
Diktel, Eastern Nepal
INDRA MAYA:
What's the point of being angry? If we were in the right place, perhaps he would have lived. Even if he had been born and had died later, we would have thought it was his fate. From here to here they cut off tiny pieces and pulled him out with forceps.
COMMENTATOR (COMM):
15 years ago Indra Maya lost her first baby. For three days she had intense labour pain. There were no doctors available and the baby died inside her womb. It had to be surgically removed.
INDRA MAYA:
They must have gone to play. If they are not back soon they must have gone to play. The younger one must have gone to play with her friend. I wonder when she will be back.
COMM:
Even though Indra Maya has come to terms with the loss she still suffers from anxiety over her two other children.
But Indra Maya was lucky to survive. Nepal still has one of the highest maternal mortality rates in the world with as many as five out of every 200 women dying in childbirth. And the figures could well be higher. Studies show that 15% of all pregnant women throughout the world are likely to develop birth complications. Without emergency obstetric care, these women could die...
Only last year, an estimated 10,600 women would have needed emergency obstetric care in just four out of Nepal's 75 districts... only 452 of these women were seen by the hospitals. Nobody knows what happened to the other women.
Many may have suffered permanent injury and become socially ostracized... Probabilities are most of them did not even survive. In remote areas such as these, women are often not accounted for... They simply disappear.
After years of unfulfilled promises from the government, a new doctor has finally arrived at the District Hospital. Dr Gunraj Lohani has brought with him a new determination - to bring change to an ailing health system. For years, the lack of roads has kept most development and distribution of services away and the brain drain to the cities has led to an acute shortage of professionals, especially doctors and nurses. With the doctor's arrival, things look set to change.
It has just been two weeks since Dr Lohani trudged eight hours up the long misty trail that links the nearest airport to Diktel. Since his arrival, the number of outpatients has increased from 30 to over 100 patients per day. For the women in Khotang, Dr Lohani's arrival is particularly important... He is an MDGP, a medical doctor in general practice and is capable of dealing with emergency obstetric cases. But in the labour room, things are not going well for Rudra Kumari.
NURSE AND HUSBAND SUPPORTING RUDRA KUMARI:
Don't panic. Try and walk properly
Listen love, don't start pushing. It's not time yet.
The baby is not going to fall out right now!
COMM:
Rudra Kumari had complications in the delivery of her first baby. She and her husband, Jit Bahadur, decided to walk for a day from their village to the district headquarters to see Dr Lohani. Her cervix is scarred and if it does not dilate soon, Dr Lohani will have to perform an emergency operation. Dr Lohani explains the four delays that can lead to emergency deliveries.
DR GUNRAJ LOHANI:
The decision on when to take the pregnant woman to the hospital does not depend on her. The decision depends on the family, on the culture. In the villages, there is a culture of calling dhamis, the traditional healers and consulting local paramedics. They all treat in their own ways and the life of the patient will be decreasing. The countdown has begun.
Then, in the villages, there are probably no stretchers or any other equipment. You have to find people to carry the patient. Let's say it takes eight hours to get to the hospital. It might be raining and you don't know what might happen on the way those eight hours could easily turn into more.
Once she reaches the hospital, one cannot perform miracles. Blood has to be arranged. There is a question of instruments, doctors, whether or not staff and doctors are there. That takes time too. In total, a pregnant woman who needs help, suffers right from the beginning. There are a lot of women that we have not been able to save. Babies not surviving are something normal. It is very difficult to become a mother and we have seen many women's dreams remain dreams.
COMM:
It's hard to imagine how the election of one man in the United States, President George W Bush, could affect the lives of so many women like Rudra Kumari... In January 2001, President Bush re-imposed the global gag rule - also known as the Mexico City policy. This stops US aid going to any foreign non-governmental organisation that either supports or promotes abortions. Until recently, abortion was illegal in Nepal - and, as a result, as many as 2,200 women died every year through unsafe abortion.
DR STEVEN SINDING, DIRECTOR-GENERAL, INTERNATIONAL PLANNED PARENTHOOD FEDERATION (IPPF):
What does safe motherhood mean? It means the ability to have children when you want them - to get proper prenatal and post-natal care; to be attended by a skilled attendant at delivery; to be tested for sexually transmitted infections and diseases, and to be treated for those infections and diseases when they occur.... All of those are the regular services of our reproductive health system - and those of many other non-governmental organisations... All of these are affected...
When the global gag rule is imposed, it doesn't just target abortion, it targets organisations - most of whose activities have nothing to do with abortion. But if they refuse to renounce counselling or referral on provision of abortions, they lose all their money. And that's the harsh reality at the field level - that safe motherhood is denied because of abortion politics in the United States.
COMM:
In 2001, Dr. Nirmal Bista, the head of the Family Planning Association of Nepal, travelled all the way to Washington DC to appeal to the US Senate. He wanted to tell them about the impact the global gag rule would have on the lives of women in Nepal.
DR NIRMAL BISTA, DIRECTOR, NEPAL FAMILY PLANNING ASSOCIATION:
The American, USAID money - when it phased out and the partnership was terminated, in the middle of 2001, we almost had to close three or four of our clinics and we had to downscale services in some of our service outlets. We had to enforce a lot of redundancies - almost 60 to 70 trained staff.
COMM:
Nepal's health system is heavily supported by foreign aid. But for Dr Lohani, the challenge is irresistible.
DR LOHANI:
Everyone asked the same thing, 'How long are you going to stay?' Apparently, doctors do not stay here for more than a week or ten days. I have told them 'I'm going to stay for two years!'
COMM:
The difficulties that lie ahead of him are immense... The hospital structure is basic, there is no blood bank and the equipment is minimal...
DR LOHANI:
My main aim is to give EmOC here, at least in this hospital. That would mean handling deliveries, removing placentas that has remained inside, stop any bleeding, give medicines to women who have fits or eclamptic fits... These are simple things. Besides we could also do instrumental delivery - vacuum or forceps delivery. An important part is blood transfusion because we might lose the mother due to excessive bleeding. If we can organize that, we can do caesarean sections and with it, we would be giving a complete package of emergency obstetric care.
JIT BAHADUR:
Situations are rough in my village. Those who can afford to take patients out do, but those who can't die and rot. These things happen in the village. We have a health post but there is no doctor. He has gone somewhere. I would say my village, Bacachul VDC of Khotang, is one of the remotest villages in Nepal.
COMM:
Jit Bahadur brought his wife to the district hospital - but most women in Nepal do not get this kind of support. Families are reluctant to bear the cost of treatment and drugs unless it is life threatening. Usually, by then, it is too late.
Kapilvastu, Central Nepal.
COMM:
In the central plains of Nepal, in the district of Kapilvastu, lives Pardeshani Chaudhary. Pardeshani was fifteen when she lost her first baby. That was last year. She was in her eighth month of her pregnancy. There was nobody in the house except her grandmother. All she can remember is extreme stomach pain. Her baby was still born. Now she is pregnant for the second time.
INTERVIEWER:
How long have you been pregnant?
PARDESHANI:
When was it grandma?
GRANDMA:
How do I know? Was it April or May? May, June, July, August... four months- four months then.
INTERVIEWER:
Do you know that you should not be pregnant at least a year after a delivery?
PARDESHANI:
No.
INTERVIEWER:
How come you don't know?
PARDESHANI:
I don't know!
INTERVIEWER:
Have you been to the doctor since you have been pregnant?
PARDESHANI:
No.
INTERVIEWER:
Why not?
PARDESHANI:
Haven't gone
INTERVIEWER:
Why not?
PARDESHANI:
Because, us, Tharus don't go.
INTERVIEWER:
So you stay in your house saying Tharus don't do this and that?
PARDESHANI:
What else to do?
INTERVIEWER:
Say that you want to go and go!
PARDESHANI:
They won't give me any money.
COMM:
Pardeshani's mother-in-law, Kukri, has nine children, all born at home, without any complications. Kukri does not understand why she has to take Pardeshani to the hospital.
KUKRI:
We will call the shamans at home. Call him for check-up. The midwife here will press the stomach and see how the baby is ... if it is dead or alive ... where the head and the feet are. The midwife will come and check...
INTERVIEWER:
What will you do if she insists on going to the hospital?
KUKRI:
What to do then? Take her. I will borrow money from somewhere. If she says she does not want to have the baby here and wants to go to the hospital, we will take her. She is our own child. If we disagree, she will get worried. Isn't that true? She might cry... Otherwise we Tharus never go.
COMM:
But Pardeshani is nervous this time. She would like to convince Kukri to let her go to the hospital. Pardeshani and Kukri are a part of a women's group in the village. With the support of the women, Kukri agrees to let Pardeshani visit the hospital. The nearest hospital, Bahadurgunj is around two hours bus ride away for Pardeshani. The hospital is one of the oldest in the country and had become totally dilapidated.
The government did not find the building worth repairing, and the community then decided to try and rebuild the hospital themselves. Eighty-year-old Raj Bahadur Shaha became the backbone of the project.
RAJ BAHADUR SHAHA:
We do not have any money. We are collecting money from here and there, asking for donations going from house to house, selling trees, bricks and the wood from the old building etc. etc. I am already old. Perhaps I will die in two to five years. But I believe that the present generation will complete the work.
COMM:
The community managed to build the out patient department. But they have to look for money for the inpatient building. Hiring hospital staff, doctors and finding equipment is a problem that the community will have to face.
By the time Pardeshani gives birth, the hospital hopefully will be fully equipped. Twenty-one year old Prabhavati Mauri is having serious eclamptic fits, a result of hypertension - a danger sign for pregnant women. Bahdurgunj hospital is not equipped to handle her problems. Prabhavati is referred to Butwal hospital three hours away. The hospital had the necessary equipment, and both Prabhavvati and her baby daughter survived.
DR STEVEN SINDING, DIRECTOR-GENERAL, INTERNATIONAL PLANNED PARENTHOOD FEDERATION (IPPF):
I've worked in this field for over 30 years now, and for 20 years I was working in the population programme of USAID, the US government's programme.
I was very proud through that period to be part of an assistance system that got services to women in the most remote rural areas of the entire world. I worked in Kenya, I worked in Pakistan, I worked in the Philippines. I spent hours and hours in the most remote rural areas seeing how American assistance was often delivered through NGOs like Planned Parenthood - was making services available to poor women...
Often, these were the only services that were available. Education wasn't there; nutrition services weren't there; food was scarce and difficult to come by. But they had access to decent reproductive health services.
And for me, it's just terribly painful to see that the decision of an American president - with the stroke of a pen - can result in so many millions of people being immediately and directly affected at the grass-roots level - in villages, and in small towns, all around the world.
That's how important international development assistance is. When it's well administered, it really makes a tremendous difference in people's lives. And when it's denied, it makes just as much of a difference - in a very cruel way.