I sit overlooking a village in Nepal’s western foothills. My feet are blistered from the journey here but the air soothes my lungs after months in Kathmandu’s chemical fog. Above the dark mountains in front of me looms a jagged white line: the Himalayas.
I am here to follow one woman from this remote village to a hospital in Nepal’s third largest city. The woman, Mandari, suffers from uterine prolapse, a condition in which a woman’s falls out of her vagina. She is traveling to the city to get surgery. The International Rescue Committee (IRC), an international humanitarian organization, is enabling Mandari and 20 other women like her to take this trip, which otherwise they could not have afforded, much less imagined.
According to some estimates, uterine prolapse afflicts nearly one in three women in rural Nepal. Its causes – poor nutrition, multiple and closely spaced childbirths and years of carrying heavy loads – are facts of life in this country of subsistence farmers. Women spend their days fetching water and firewood and gathering grass for their animals, often walking hours with loads that weigh up to three fourths of their body weight. To help ease the demands, they have children- on average five per married couple. When the rains are bad or the soil is not right, they eat less.
The onset of uterine prolapse is gradual. If caught early, Kegel exercises or the insertion of a vaginal ring can help. But left untreated, the uterus can drop entirely outside of the body. When this happens, only surgery, a hysterectomy, can fix it. According to a recent study by the United Nations Population Fund (UNFPA), 200,000 women in Nepal are in immediate need of this surgery. Until recently, no one in rural Nepal had access to such treatment.
Pre-occupied with fighting the Maoist insurgents during Nepal’s 10-year civil war, Nepal’s monarchy neglected the country’s already ailing health services. Since the Maoists came to power in a surprising and decisive election in 2008, they have done little to improve the nation’s health system.
Jajarkot District in mid western Nepal, where I currently sit, is one of the least served of the country’s 75 districts. Until recently, most government clinics in the district were without drugs, staff, and in some cases, walls. Not surprisingly, life expectancy in Jajarkot is 50 years, a decade less than the national average.
Last summer, IRC started a project to improve healthcare access in Jajarkot, training health workers, delivering medicine, fixing broken walls and improving water and sanitation facilities in 10 rural clinics. The team also runs reproductive clinics, educating and diagnosing sufferers of uterine prolapse. This week, they are helping women with the most advanced cases travel to the city for surgery.
Mandari is one of these women. It is the day before we are to depart and I have arranged to meet her on a sunny hilltop. Across the valley, houses cling improbably to the sides of cliffs. Smoke rises from one rooftop. My ears, accustomed to Kathmandu’s incessant honks, tinny Hindi music, and the ka-put of ancient engines, are not used to the silence. The bah of a lamb from down below startles me.
Mandari climbs the hill alone to meet me. We bow our heads and recite the universal greeting “Namaste,” meaning hello, goodbye and, literally, “I bow to you.”
My thin, 5’ 8’’ frame feels huge next to her. Her cheekbones are high, sharp. Her head reaches my shoulders and her snug shirt reveals delicate, pigeon-like bones. If a gust of wind should come up, she might topple, plummet down the cliff in front of us. A stop-sign-red swath of cloth wraps around her tiny legs down to her ankles.
We sit on a patch of dry grass. Mandari plucks a piece of wheat and hangs it out of her narrow, thin-lipped mouth, chewing slowly. Heavy copper hoops hang from her ears, pulling on holes stretched the width of a pencil eraser. Her eyes squint across the terraced valley, fixed nowhere in particular but in the direction of the hill that separates The Known from The Unknown.
Mandari tells me her fears. Rajan, a thick, clean-shaven public health worker on IRC’s health team, translates for me.
“Cars,” she tells me. “I’m afraid of cars.” She sticks out her tongue and makes a rasped “blahhh” noise. Vomiting. A neighbor told her that cars make you vomit. She’s also worried about leaving her buffalo behind. “She’s feisty,” Mandari tells me. “She doesn’t let anyone but me milk her.”
She leans to the side and spits, then continues chewing on the wheat.
She makes the “blah” noise again, sticks her tongue out. This time she clasps her bony hands around her neck.
“She’s afraid she’ll die from the surgery,” Rajan tells me.
I ask her to tell me about her life.
Mandari thinks she is 35 years old. An orphan at four, she grew up with seven siblings in a one-room mud house. Since she learned to walk, she was busy fetching water, cooking chapatti, and carrying grass for the animals.
She got married at 17 and gave birth to six children – five survived. Her oldest child, a daughter, is now 10.
Mandari’s day starts at four in the morning. She lights a fire with wood collected the day before from a three-hour jungle hike, milks the buffalo, makes tea and chapatti. By eight, she is off to collect firewood and grass for the next day, returning at four. By eight in the evening, she’s cooked dinner, cleaned up and ready for bed, exhausted.
Last July her routine changed. Something started coming out of her vagina. She didn’t know what it was. It became painful to milk her buffalo, walk and lift heavy loads. She could no longer make love to her husband.
Only her husband knew about her problem. She could not tell anyone, since her family, friends and other villagers regard a weakness of a person’s sexual organs as inauspicious. She kept silent until the pain became unbearable.
In October, she sought help. She attended a Reproductive Health Clinic that the IRC organized in her village. Kashi, the young health worker, examined her. Kashi explained that the bulge is her uterus, the sac that carried her five children.
If left unattended, Kashi explained, it will become more painful. In time, as the sensitive tissues that belong inside her body are exposed, ulcerations will develop. They will fester and become infected. Eventually, the condition could kill her.
The only way to fix it, Kashi said, is through surgery.
“You’re lucky,” Kashi told her. “The IRC will pay for you to get the surgery.”
But Mandari did not feel lucky. She was afraid to leave home and afraid of the surgery. But the pain was so bad. Her husband insisted she go. “Who will take care of our children if you die?” He said. So she signed up.
She pauses. She tells me she must go. She must make dinner and then prepare for tomorrow. I ask if she’d like to listen to her recorded voice first. As she listens, flies buzz around her face and people walk by, talking. She is still, silent. It is the first time she’s listened to her voice ever. As I fall asleep that night, I wonder what Mandari is thinking. I cannot imagine.
The next morning over tea, my colleague Rajan explains the journey ahead. Today we will climb over the mountain that separates Mandari’s village from the rest of the world. By nightfall, ten or twelve hours later, we will reach Kholepuzne, the closest town with a road. Tomorrow morning we will take a bus the 20 other women to the hospital in Nepalgunj, a large city to the south. If we’re lucky, the bus trip will take six hours. If protestors block the roads, the bus breaks down, or the road is broken, it may take longer.
After breakfast, Rajan and I meet Mandari on the top of a small hill outside of town. She is with her husband and her 1-year old son.
I feel prepared for the journey. I am wearing quality hiking boots. I have two liters of water and several packets of coconut biscuits in my bag. But I worry about Mandari and her family. She is wearing thin canvas shoes and the same red wrap skirt she wore yesterday. Her husband is wearing plastic sandals, the kind you’d see on a sale rack at Wal-Mart. Strapped to her back is Mandari’s son, who is the size of a sack of potatoes.
The trail heads immediately up. I stop to take off my windbreaker and fleece. I say I will catch up, but I don’t. How are Mandari’s canvas shoes faster than my hiking boots I think. When I finally catch them my breathing is heavy. I wipe the sweat off my forehead and notice that Mandari’s is dry.
View from the trailLater in the day, we come across the first, and only, settlement – twenty mud huts spread across a steep hillside. We have tea at a wooden stall and Mandari unwraps a canvas sack. It’s full of roti, chutney and leaves stuffed with rice pudding, which she offers everyone. Leaving my coconut biscuits in the bag, I taste the roti. It is fresh, whole wheat, thick as the sole of my boot. The chutney spices taste like they were ground that morning.
ukalo, or steep.
The sun lowers. Men carrying sacks of rice hurry past in order to reach home by dark. By evening, we round a corner and see, instead of more trees and mountains, a cluster of mud homes 800 meters away. Hallelujah. Mandari, who hasn’t spoken in hours, brightens and says something to Rajan in Nepali. “She says she wants to go back to her village!” Rajan explains. Everyone laughs at the joke.
We enter town on the main road, a dirt track the width of a bus. A few dozen shops line the street. Old men sit behind wooden tables, sipping milky tea from glass cups. Next to them, white sacs of rice and potatoes wait to be hauled away.
We pass a truck and Mandari slows down. She peers in its windows, examining a vehicle for the first time in her life. “Thulo chaa, hoina?” I ask, not knowing what to say. (It’s big, isn’t it?) She nods, keeping her eyes on the truck. A distant smile forms on her face, an expression I see again as she encounters other firsts – a stereo blasting Hindi music, fake leather jackets, powdered milk.
The next morning we join the other twenty women who have come for surgery. Waiting for the bus, they sit on cloth sacks that hold the belongings they’ve carried from their villages. Deep rivets line the faces of the older ones, eyes and chin sagging. Two gold-colored rings decorate their noses and heavy beaded necklaces hang from their thin necks. They wear brilliant wrap skirts and flat canvas shoes.
Our conversations are superficial at first, limited by my pidgin Nepali and, I imagine, an unspoken cultural norm that prevents open conversation about their condition. How long did it take you to get here? How many children do you have? Have you ever been outside of your village? I ask. Most women have walked for days. Most have about half dozen kids. None have traveled this far from home in their lives.
As we wait for the bus, I talk with an older couple sitting apart from the group. The woman’s earring holes are dime-sized, weighted down by thick, gold hoop earrings. The man’s hair is storm-cloud gray. He talks. She bites her nails. “19 years,” he says. “She’s had the problem for 19 years.” The woman looks at the ground. For the first 18 years, they had no idea what was wrong. “We thought she was a mutant,” he says. Then last fall they attended a Reproductive Health clinic run by IRC, the first of its kind in their village. They learned about the condition, and about this chance to have surgery.
“And what is it like to be surrounded by other women who have the same condition?” I ask. The husband begins, but the woman interrupts him. It is her first time speaking.
“Before this trip I thought I was the only one in the world who had this problem. Now I see I’m not alone.”
I ask her how she feels about the surgery. Her calloused fingers fiddle with the bead necklace that hangs from her neck. Her eyes moisten.
“I feel nostalgia. I feel afraid I might die.”
I tell her what IRC’s health workers have already told her - that the surgery is safe, that few people have ever died from it. She nods and smiles faintly.
Over the next few days, I hear this same fear repeated. Often the women clutch their necks when they tell me, just as Mandari had days ago. I ask why they’ve come if they think they’ll die. The answer is always the same: “If I don’t have the surgery, I will die anyway.”
The bus trip takes two days. Mostly we wait – for the bus to come, for the bus to leave, for the bus to get petrol, and on and on. I am impatient, wanting to move. But the women seem relaxed – they smile, talk, and sleep. Hours of sitting on a comfortable bus beats days of walking through the hills of Nepal.
I overhear one conversation. A younger woman points to a bike outside the window. “What is that?” she asks. “A cycle,” the old woman next to her says. She explains that it’s meant for one person but two or three people can fit, too.
But the bike is forgotten behind as the young woman sees a more awesome sight ahead – a multistory brick complex bigger than any building she has seen before: the hospital.
Inside, the hospital is a maze of long, white hallways. It smells of curry and urine and Lysol. Men in white jackets bustle by, clipboards in hand.
We go to the pre-operation ward. White beds line a room the size of a basketball court. Nurses in starched white robes assign a bed and a number to each woman. Against the bed sheets, the women’s pink wrap skirts, turquoise scarves and the colored tassels that dangle from their braids stand in stark contrast.
Hospital's "official" height chart.
Over the coming days, the women are checked and re-checked by doctors in white uniforms. They have x-rays taken and their blood is tested. They ogle over Mandari’s son, tickling his mouse-sized feet and commenting on his chubby cheeks. They doze in the sun and braid each other’s long, black hair. Mostly they wait.
The second night, I hear a chorus of giggles as I approach the ward. I enter to see an older woman dancing in the middle of the room. Her arms wave, her arthritic body spins in stiff jolts. The women in her corner clap and cheer. The old woman turns to Mandari who is in the bed next to her. She holds a sack of air in her hands and points to Mandari’s crotch. Dancing, she shows the sac hanging and wobbling between Mandari’s legs. Mandari laughs, the first time she’s laughed since leaving home. The old woman makes a cutting action with her hands and grunts. The room erupts in laughter.
The tension built up from years, decades of suffering in silence, feels released.
The afternoon before Mandari’s operation, I talk with her on a concrete bench outside the x-ray room. I ask her if she’s afraid. I say I’ve noticed she seems relaxed, happy even. She clasps my hand and looks me in the eye.
“Not afraid at all,” she says. Her smile is easy. “I was never afraid. I feel strong and ready,” she says.
The benefits of this trip are clear – the lump that has plagued these women will be removed. They’ll be able to walk without pain, bend over to milk their buffalos without feeling ill and make love to their husbands again. But something bigger happened during the journey - the women are talking, sharing stories and laughing. They are coming out of what must have been a terrible, isolating condition. They are not alone.
On the eve of the operation, I come to wish the women good luck. Most are asleep, but I see Mandari grinning broadly. She clasps my hand and points to her nose. Both rings are gone. She whispers that the doctors made her take it off. She looks naked, anonymous without them. She asks me to touch her nose. We giggle.
“Malaii kushi laghyo,” she says to me over and over. I am happy.