Women: Appreciate Yourself Day!

We have a day in Kathmandu before we leave for home.  We decide to start the day at Swayambhunath, the monkey temple, which gave us wonderful views of the city after we climbed its 365 steps.  It was a trip down memory lane for me, since Sandi, Maggie and I visited this temple together back in 2001, when Maggie was a little girl of 7 and we were living in Singapore.

  Left, the monkey temples main resident, right, the stupa at the top of the steps

Kathmandu (just a small part of it), seen from the monkey temple

Buddhists believe that prayers inscribed on wheels spin off into the universe when the wheels are turned.

As we entered Kathmandu Derbar square we started to see throngs of women, of all ages, dressed in red, on line to purchase offerings and dancing in groups in the square. Today turns out to be "the festival of the women."  The hallmark of this festival is that women come together and dance in groups.  The dance is unique - while the women dance together, the dance is individual, not coordinated.  As I think you'll see in the video, the women seem to be appreciating themselves on their special day.  This culture puts a big burden on women, so having at least one day to celebrate themselves seems like a good idea to me!

After being in throngs of women for 40 minutes or so with loud music and quite a bit of shoving, I needed to, well, have my head examined...watch the video:

Then we did some shopping.  Since we three guys were on our own to shop (and we couldn't really consult any of the women around - they were busy) we may have made some questionable purchases.

I was tempted...

Good-byes, or total tikka

Monday was our last full day in Achham at Bayalpata hospital.  It was a week of goodbyes, first to our hospital director, Dr Cam Bopp, who left for Liberia to set up a hospital in the Ebola zone, and now us.
The acting hospital director, Dr Sampurna, informed the staff that there would be a program in the afternoon.  We gathered together after a really hectic day trying to complete last minute tasks in the operating theater and the inpatient ward, and were surprised to find Dr Sampurna in a speech making mood.  He very kindly and movingly spoke of our time in Achham, how we had become friends, and how helpful the work we had done was.  Jess Kribbs from the US, who leads finance and HR functions, thanked us for making her life easier, and integrating into the operations of the hospital.  Dr. Deependra, surgical head, thought the staff should take a lesson from the fact that we didn't have a boss here to look over our shoulder, but got good work done anyway (hint!).  We impressed on the group how very talented and capable they are, and that carrying on the improvements and recommendations we've made is now in their hands.

The final good-bye ceremony was the application of tikka to the foreheads of each of the three of us, by about 40 members of the staff.  By the end of it our faces and much of our clothes were covered!

We ended the day with chicken momos (Nepali steamed dumplings), some chalk drawing and a bit of football (Nepali style).

Tuesday morning we said goodbye to our home and friends of three months.  Thula, 13 years old, pictured below, got a lot of hand me down used clothing and gear from the three Merck fellows.  While I feel like a part of me remains in Achham, and I already miss the place, I am SO looking forward to coming home!  We passed through Dhangadhi and are in Kathmandu, leaving for home or next destination at the end of the week.

 Dr Sampurna applies tikka to my forehead during the going away program

Thula (right)

Thoughts on Leaving Achham - Gratitude, Limits, Love

We have one week to go in Achham, after which we make our way back the way we came, to Dhangadhi, Kathmandu, and thence to USA and the Netherlands.

Feelings are mixed on my part, and I think that of my teammates as well.  We're really looking forward to seeing and talking to our wives and many other loved ones, having a real mattress and a flush toilet and dining without flies.  But we'll miss the hospital, the doctors, nurses and administrators, and those of the patients and community members with whom we've managed to communicate and form a bond.  We feel we've been privileged and blessed to have an opportunity to make an impact here.  The truth of that came home a few evenings ago in the Emergency Department when a 14 year old girl with a collapsed lung needed a piece of equipment that was right where it was needed, which was an improvement, but nobody knew it was there. We solved the problem so the girl's care wasn't impeded, but we learned, again, that we still have work to do.

We've made recommendations on the management of the hospital - who does what, how it gets done, how communication at various levels can be improved.  Several of these have been implemented, with good results, to our delight.  We reorganized the way medicines are procured, stored and distributed, how inventory is tracked and managed.  We've instituted a standard formulary so everyone knows what is supposed to be in stock, and uses the same name to refer to each item.  We designed and installed storage units for the places where medicine is dispensed, and trained personnel on keeping stock.  We've installed and configured a stock management software system and trained the staff.

We've helped the hospital to get the ball rolling on the purchase of a new generator so power will be less of an issue in the future, and we've laid out a strategy so the hospital can ensure quality of its medicines while simplifying and streamlining the procurement process.

Yet every day we realize we could do more.  There are the young men in the stock room, Min, Purna, and Dinesh (from left), who we could train just a bit more.  There's the Procurement Officer, a position we recommended and which was filled three weeks ago by a young man named Nabin (right), who I'd love to have another few weeks to coach.  There are refinements to processes and improvements to procedures we'd love to implement, but these things will have to be left to others.

As a good friend periodically reminds me, Mother Theresa once said "We cannot do great things.  We can only do small things with great love."  While I am called to do my part with diligence, it is God who gives sight to the blind, makes the lame to walk...

So I'm back to the theme of a previous post - limits.  My time here is limited; my talents, foresight, and plans are limited, so my contribution will be limited.  I am coming to peace with that again in a new context.  One aspect of this reflection has been the realization that my limits have changed; they've been explored, scouted, and in some cases pushed back a bit.  I know with greater clarity what I am good at, and what I'm less good at.  I have a better sense of where to contribute, where to put my gifts to use in the service of global health. Somehow, I have these insights more readily when I'm well out of my comfort zone, as I think is true for many of us.

The last reflection I'll share is that the Bible teaches that love is a verb.  It's not just a feeling.  Caring for the basic needs of our fellow men is an act of love which the people at Possible do every day.  It was a privilege to join them in their work.

Hike to the Buddha Tree

Yesterday was our second-to-last Sunday in Achham.

Ever since we got here, I have been admiring a huge tree at the summit of the hill across the valley from where we are staying.  It's massive, appears to be perfectly round, and is positioned at the very crest of the hill.  It seemed to be calling me.  I learned from my friend Umanga that these trees are called "Buddha," "Bodhi," or "Pipal" trees, and have been planted for thousands of years for people to sit under.  They are remarkably cool and are thought to have antihistamine properties.  This type of tree is sacred to Buddhists as it is said that it was under such a tree that Buddha achieved, or received, enlightenment.

Nardi pointing at the Buddha tree on the far slope

Yesterday Nardi and I set out to walk up to the Buddha tree, which we learned is in the village of Nawathana. What a great adventure we had!  We set out at 11:30 AM and walked down the hill to the river that feeds the Buddha Gangi for the first part of our trip.

Once in the valley, we had to walk across rice paddies.  Nardi took a little spill and his camera wound up in the rice paddy, but we're hoping the pictures can be salvaged and the camera is covered by insurance.  We had to cross the stream, which was running much higher than our last hike in this direction a few weeks back.  During the crossing, Nardi lost a shoe (which was recovered by a little boy who was bathing downstream) and a sock (which wasn't).  So my intrepid hiking partner walked the rest of the hike in a wet shoe and one sock.  What a trooper!

 Nardi in the river that ate his sock.  The boy to his left retrieved his shoe.

The shoe rescue made the river warrior band quite proud.

As we gained height on the opposite slope, the way became steeper, the sun stronger, and the hospital gradually came into view.  What a wonderful perspective we had on our little community!  We passed two homes with enough English to confirm that we were on the right track, although the path at times was so steep we weren't sure we were going the right way.

After several rest stops and more climbing than we had counted on, we made it to the Buddha tree. The views were astounding!  We saw our home for the past three months, Bayalpata hospital, from a completely new perspective, we shared great conversation, and we had a great workout.  The hike to the summit took about 4 hours, and we hiked back down to Sanfe Bagar in about 2 hours.

Bayalpata hospital from the Buddha tree - the hospital is in the clearing on the opposite slope

 The Buddha tree

Panorama from under the Buddha tree

2nd Merck Blog: RTC Fellows at Work and Play in Nepal

Here, dear readers, is my 2nd Merck blog:

In my last blog I promised that I’d use this post to explain what we’re doing here at Bayalpata hospital in Achham, Nepal, in a bit more detail.  I’m also going to share another fun part of our Richard T Clark Fellowship experience with you – our four day trek in the Annapurna Conservation Area.

The first draft of our work plan for Possible Health was refined in a series of meetings with the CEO and one of the founders of the NGO before we left for Nepal.  There are two main work streams: improvement of the internal and the external supply chain.  Internal supply chain improvement includes clean up and organization of the hospital’s stores, and implementation of a software system, business processes, and Standard Operating Procedures to track inventory of pharmaceuticals and supplies.  External supply chain involves the development of a comprehensive strategy for sourcing of medicines and medical items with the goals of ensuring quality, lowering cost, and improving service.  While all three of us worked in both areas as needed, we decided it would be helpful to have a leader for each workstream.  I’m leading the external supply chain strategy development and implementation. 

We hit the ground running on the way into Nepal.  During our first week in country, we benchmarked external supply chain best practices at several large hospital systems, and met with government and private suppliers in Kathmandu and Dhangadhi, the closest big city to Achham.  Armed with a better understanding of the Nepali pharmaceutical business and regulatory context, we came up with an improvement strategy for the hospital.  In a nutshell, the new strategy involves consolidating procurement to a few larger, trusted generic pharmaceutical manufacturers and arranging to negotiate terms directly with the manufacturer.  Last week, we met with the sales divisions of each of four large Nepali manufacturers, as well as an importer for Indian and other international manufacturers.  We also visited and inspected three Nepali pharmaceutical factories.  The purpose of the site visits was both to assess fitness of the manufacturer to become a long term supply partner for the hospital and to provide improvement suggestions to the factory staff.  We were pleasantly surprised at the state of equipment and procedures at the manufacturers’ sites and at their willingness to be a partner in executing the hospital’s strategy.  We’re now awaiting quotations.

The three of us have also had the opportunity to assist Possible Health in a way that was not in our original work plan.  Our experience with team and project management, as well as the business acumen we’ve developed at Merck, has enabled us to be effective management consultants to the NGO’s senior leaders.  We’ve made recommendations related to roles and responsibilities, division of labor, and work flows and talent management which have been accepted and quickly implemented, to our delight. 

After working for six weeks on all of the above with only two days off, we needed a break!  On our one week leave, two of us (Bryan and me) went to Pokhara while Nardi visited with his wife in Kathmandu.  While in Pokhara, Bryan and I embarked on a four day trek in the Annapurna Conservation Area.  We were truly blessed to have clear morning views of the snow-capped Himalayas, an unusual sight during the monsoon season.  Four days of vigorous hiking, including an elevation gain of more than 6,000 ft, was also a great workout!  Here are some pictures that give you a flavor of our wonderful four day trek:

                          

Bryan (left) and Philip (right) and two friends we made on the way up Poon Hill at 4:30 AM for a sunrise hike.

Annapurna South (left) and Himchuli (right) from Ulleri on Day 2 of our trek

Appreciate Your Man Day

Today we celebrated Janmashtami in Nepal.  On this holiday, it's customary to cook a nice meal for the men in your life - your brothers in particular.  I like this idea very much.  And, it's a day off - bonus!

It's also the birthday of the Hindus' Lord Krishna, so temple visits are in order.  As it turns out, there is a well regarded temple down the hill and across the river (a 30 minute jeep ride) from Bayalpata hospital.  We expected crowds of pilgrims.  So at 6:30 AM we gathered to...wait for everyone to assemble...and then leave at 7:15 or so to drive to the temple.  It turned out that there were no crowds, and it was a beautiful morning -- a lovely time to snap a few photos.  Hinduism and Buddhism have mixed together (synchretized to you theologians, although grammarians might not like my usage) to a great extent over the centuries in Nepal, so if you look carefully you'll see signs of both religions in the photos.

For breakfast we treated ourselves to...roti and dal, which regular readers of this blog will recognize as our typical breakfast.  But the roti were deep fried, piping hot, and yummy.  And there was a "sweet" that went along with it that was fabulous.  Somehow the diet of lentils, rice and roti make me (and many westerners) violently crave sugar.  For the first time, it makes intuitive sense to me that people have historically been willing to fight for sugar.  For me, Coca-Cola is a trip to the moon.

Photos of Baidyanath Temple

Below, the Buddha Gange River running high with monsoon rain and Himalayan snow melt, as seen from the Baidyanath Temple.  This is the same river that we see and hear from Bayalpata Hospital

Best Monsoon Trek Ever! - Part 4 (Last Part)

After climbing and descending Poon Hill, which started at 4:30 AM, we had breakfast and then began our trek east to Ghandruk.  All told, we spent more than nine hours on the trail that day, walking across the tops of hills with the Annapurnas to our north and the gorge we had traversed to our south.  The terrain was amazing and varied: tropical grassy hilltop, mangrove forest, wet riverside jungle.  We encountered a few water buffalo, several horse and donkey companies (goods are mostly transported by donkey up there) and a few leeches ("leechies" as our guide called them, as though they were cute little butterflies).  Bryan seems to have the chemistry that attracts both mosquitos and leechies - which I was very grateful for.  Leechie score: Bryan (2), Philip (0).

The walk across the mountainside was probably the most challenging of the trip.  Rockfall and rain made the going very slippery and the footing uncertain.  Adding our fatigue from the length of the journey made the risk of slips and falls uncomfortably high.  So we were grateful on many levels to arrive safely in Ghandruk about dinner time on the third day.  From there we were once again in the shadow of Annapurna South and Himchuli, but closer than we were at Ulleri, and with a much better view of Macchapuchre, the Fishtail mountain that is holy to Nepalis.

Once again the dawn in Ghandruk brought enough clearing to make the beautiful snow capped peaks visible.  We were treated to traditional Buddhist chanting (a recording) from a house down the valley as the sun rose and lit the holy mountain on its eastern faces.

from left, Annapurna South, Himchuli and Machhapuchre (Fishtail)

Our walk down the gorge to our starting point in Nayapul on our last day was just, well, gorgeous.  We crossed raging streams and beautiful rice paddies, ate some local bananas, and relished the memories of our glorious four days in the Annapurnas.

Birthday in Achham

Today I'll take a break from the "Best Monsoon Trek Ever!" series to say "thank you!" to all of you who participated in the birthday card deluge I received for my birthday yesterday.  The expressions of love and support, arranged by my wonderful wife and kindly delivered via the New York office of Possible, got to me early in the week so I could open them on my birthday.  They were fabulous, they made me laugh, they reminded me of home and did me a lot of good.

I began the day as we do six days a week here - with morning meeting of the hospital staff.  This day I handed out sweets - a great custom, I think, that Nepalis observe when they celebrate birthdays (or maybe they just have unsuspecting expats observe it...hmmm).  In either case I got a lot of Nepali birthday greetings, and we took a picture of the whole staff.

I worked in the Emergency Department where I am helping to organize medicines and supplies and rework the re-stocking process to ensure meds are where they're supposed to be when they're needed.
During the afternoon I spent some time on my favorite hill overlooking the river.  Along came Aloo, who snapped a selfie:

He didn't like my hat:

In the evening I went to Sanfe Bagar - down the hill from the hospital at the Buddha Gange River, and had dinner and beer with my team and a few friends from the hospital.  There was a good deal of singing on the ride home!

Best Monsoon Trek Ever! - Part 3

We arrived at Ghorepani in the early afternoon of our second day, checked into our room at our tea house, and gladly had lunch and a break from climbing.  Just after we arrived it started to rain heavily, and a steady stream of trekkers arrived from Spain, Germany and Korea.  After a single night I had gotten "used to" being the only guests at the tea house, but this experience would prove to be even better than our first night in Ulleri.

The most meaningful experience for me was meeting and talking to Noah, a 20-something student from Korea, who picked up on my use of the word "calling" during our opening (rather standard) conversation about what we were doing in Nepal.  He immediately guessed that I was a Christian, and told me that he and his friend Jun Ho were also Christians.  He then told me his story, in which he expressed his sadness at not being able to continue his studies at UC Berkeley.  He was struggling with a decision about what to do next, looking for direction from God, and needing some counsel.  Let me pause to express how amazing this is.  Here we were, two travelers from opposite sides of the planet, sharing a literal and metaphorical path for a short while in an improbable location.   Not a coincidence in my view, not a chance meeting!  We talked for a while, prayed together, and said good night as the rain continued to fall and we hoped for a clearing before our sunrise hike to the top of Poon Hill.  Before bed I wrote out Psalm 40 and left it in Noah's shoe - Maggie had written out this Psalm for me when I left for Nepal.  It says in part:

God is our refuge and strength

An ever present help in trouble

Therefore we will not fear

though the earth fail, and the mountains fall into the heart of the sea...

The rain fell heavily throughout the night, and at 4:00 I awoke to find it still falling.  I prayed, of course, for a clearing, thinking that if God could cause mountains to smoke with his touch, surely a breath could push away a few clouds.  At about 4:15 the rain began to slacken and I heard two of my new-found Spanish friends waking up.  I said to myself, if I don't get up and go up the hill, I won't see the miracle.  So I woke up our guide (who preferred to go back to sleep) and Bryan (who came along) and the four of us went up Poon Hill.  We ascended the hill in the dark in 45 minutes with head lamps and rain gear - but we didn't need the rain gear.  The clouds receded as the sun rose and we had the most fabulous views of the Annapurna range for the entire trip. 

Psalm 40:

...There is a river whose streams make glad the city of God

the place where the most High dwells

God is within her, she will not fail

He will help her at the break of day...

I was thrilled to see Noah and Jun Ho come up the path a little while later and join us at the top.  Noah and I talked more on the way down.  What a fabulous blessing it was to experience the incredible beauty of Nepal's Annapurnas, and to share it with friends!   The physical and the spiritual journeys coinciding and complementing each other for a few beautiful hours - what an incredible and unforgettable experience.

 Noah, Philip and Jun Ho

 Annapurna I (8,091 m), left; Annapurna South (7,219 m) right

View from Poon Hill with Dhalagiri I in the background

 Dhalagiri I from a break in the jungle on the way to Ghandruk later on day 3

 One of many waterfalls on the way to Ghandruk

The Ghorepani crowd (minus Noah and Jun Ho)

Best Monsoon Trek Ever! - Part 2

We awoke on day 2 in Ulleri to a wonderful, miraculous clearing of the monsoon rain clouds in front of the nearby Himalayas visible through the gorge, and, as the sun rose, the clouds behind the mountains cleared out as well to give a truly glorious view of the snow capped Annapurna South and Himchuli.

 View of Annapurna South (left) and Himchuli from our tea house on the morning of the second day  

View south down the valley toward the way we came, also from our tea house

We had ascended 3,110 ft on day 1 from Nayapul to Ulleri.  Our trek this second day would take us to Ghorepani, an ascent of another 2,750 ft. Here's a map of our trek.

Our trek route: Nayapul-Ghorepani-Poon Hill - Ghandruk - Nayapul.  Elevation in meters

We walked up to Ghorepani over the course of 5 hours or so, and Bryan had his first of two leech encounters.  That's the down side of trekking in monsoon season.  One of the upsides is that the waterfalls are amazing!