The hardest thing about this job is not being able to do anything for the women I meet. As the representative of an organization that focuses on lobbying, capacity building, and networking between NGOs, I have nothing but abstract concepts and vague promises to make to women who have very real and immediate needs.

My interview with Padma Kumari was the last of fourteen interviews that I conducted with women across Nepal, and the stories seemed to only be getting more and more tragic. Perhaps it was not that the stories themselves were any more severe, but that I was suffering from the cumulative toll of so many interviews—so many interactions in which I could only take information (about their lives, their poverty, their symptoms, their pain) from women without being able to give anything in return.

I didn’t realize it, but Padma had been waiting at the clinic for over an hour. She sat on the edge of the clinic’s cement porch, simply waiting for the bideshi (foreigner) whom she had been told to see. She held her sleeping 18 month old son (half the size of another woman’s healthy eight month old boy) and her husband squatted in the nearby shade; all three waited.

The interview began, and Padma described her fifteen year story of prolapse. She had first experienced the condition six months after the birth of her first child, when she was only fourteen. Initially she travelled to a mission hospital in India, where she was able to receive a pessary ring to treat her early stage prolapse. She had the ring changed at the hospital twice, but after that she removed the ring herself. As the wife of a day laborer and an occasional day laborer herself, she could not afford the transportation or time costs of going to the hospital in India—the nearest facility that could provide prolapse services.

After removing her pessary ring herself, Padma spent the next thirteen or so years trying to ignore the symptoms. Heavy work was difficult and caused her severe back pain, but her husband told her he would not help. After the birth of her subsequent children Padma was back to work within ten days, because her husband refused to assist her with anything other than cooking.

Because of her prolapsed uterus, Padma also experienced sharp pain during sex. Her husband, however, did not believe that she was telling the truth. For thirteen years he ignored her pleas, and Padma was the victim of marital rape.

Fifteen days before the interview, Padma’s prolapse suddenly became worse. She began to suffer from fever and exhaustion, and she had so much discharge that her sari (wrapped several times around her waist) was visibly stained in the rear. She could not hide the signs of her condition, and as the neighbors began to talk about her health, she found that no one would hire her for day labor, making it harder for her to maintain a productive role in the household.

Padma says that she was only able to come to the clinic today because the local female community health volunteer (FCHV) convinced her husband to accompany her. She says that the FCHV—whom I had met the day before—was only able to successfully persuade her husband because she told him that a foreigner (me) would be there offering treatment. Otherwise her husband would not have taken a day off from earning wages in order to seek a treatment for his wife that he would probably not be able to afford.

So with the promise of a solution, Padma (carrying her year and a half old son) and her husband walked an hour from their village to the nearest health post, where I was conducting my interviews. This outing in the heat of the day clearly drained Padma. By the time I found her resting on the curb she was visibly exhausted, and her chest heaved with the effort of breathing. She looked up at me with dull eyes and searched my face for some promise of relief. All I could do was ask her to remember the first time she experienced symptoms

At the end of the interview, we called over Padma’s husband and explained to him the quickly deteriorating nature of his wife’s health. From her descriptions of the prolapse it sounded as if Padma was still in an early enough stage of prolapse that a pessary could reverse the damage, but we emphasized that if they didn’t do anything soon she would quickly be in a condition that required an expensive surgery. The husband protested that he had no money to spend on any kind of treatment, to which the FCHVs responded that if he didn’t make the investment now, before he knew it he would have a wife who was in so much pain she wouldn’t be able to do any work; then the family finances would truly suffer. He didn’t seem convinced by the concept of a preventive investment.

I was helpless to speak to the husband directly, but I thought that if he had been persuaded to come to the clinic because he thought a bideshi would help, perhaps he would consider my advice. So in between what were probably much more thoughtful and effective instructions from the FCHVs on how the husband should handle the situation, I interjected with inert tips like “let your wife rest” and “seek treatment now before she gets too sick.” He nodded unenthusiastically to the translated advice as Padma craned her neck to listen to the FCHVs.

I looked upon this scene of helplessness—helplessness on the part of the husband to provide treatment for his wife, helplessness on the part of the wife to make decisions about her own money or her own health, and helplessness on the part of the FCHVs to provide anything other than stern lectures—and I realized that I too, after ten weeks in Nepal, was still fairly helpless. I sat just feet away from a woman who suffered from domestic violence, poverty, malnutrition, and uterine prolapse, and all I could do was tell her to rest.

I try to remember that the work that AP and the UPA do on behalf of uterine prolapse in Nepal is on a much larger scale than this interview. Given the proper resources and institutional support, the Alliance will hopefully soon be able to lobby the government to implement wide-reaching policy changes, attract donors to fund surgery camps across the country, and coordinate national prevention and awareness efforts, thereby preventing and addressing the problem in a more effective and unified manner. But as Padma pulls her sari over her head and steps out on the road to walk back to her village, I can’t help but know that she has come all this way looking for someone who can help her feel better, and that all I have given her is a two hour round trip journey and another reason to expect that she will never be able to find an affordable treatment for her condition.

Chalidevi Regmi isn’t interested in having surgery to treat her prolapsed uterus. She has given up on the idea of an improved life, and she is ready to die.

At only 55 years old, Chalidevi has seen a lot in her life. She was married at the age of eleven and followed her husband, who was in search of work, to a variety of towns and villages across Nepal. She has given birth to five surviving children as well as two stillborn children. She has raised a family and run a household on her own, like most women from the area only taking a break from her daily routine of domestic and agricultural chores for eleven days after delivery.

Twenty four years ago, after the birth of her last child, Chalidevi developed the condition that is so common for women in this society. Unlike most women, however, Chalidevi had immediate access to health care, and was able to use a ring pessary to support her uterus and prevent further acceleration of the condition. She used the ring pessary for more than a decade until one day when she suffered a serious accident while grinding rice. The force of the accident cause Chalidevi’s uterus to advance further into what is likely fourth stage prolapse, at which point a ring pessary was no longer a viable or effective solution. She hasn’t sought treatment since.

Chalidevi’s story is like many of those narrated by poor women from rural Nepal, only Chalidevi—a decade older than many of the women interviewed—is like the tragic specter of what they may become. Most of the women I have interviewed are too poor to seek treatment or do not have access to relevant health care services. Like Chalidevi did after her accident, these women will eventually (if they haven’t already) reach a point at which they cannot sustain interest in seeking treatment. Rather they will, like Chalidevi, accept their condition as a burden they must bear as women in their society. And, with little other option, they will resign to living with uterine prolapse until they, too, are ready to die.

Birma Prayar’s dress is stained with grease and dirt. She is barefoot, and her hands—which she rubs nervously—are calloused. Her wrinkled face and frail body belie the fact that she is only 38 years old.

At first she is reluctant to talk about her medical problems, and she looks down at her feet or away to the fields when we ask her questions. Her husband is squatting just a few feet away in the doorway to their hut, monitoring the interview. When the female community health volunteers (FCHVs) tell Birma’s husband that he has to leave, he quietly gets up and walks away into the forest. Birma relaxes a little and begins to tell us about her life as a poor Dalit woman in this clay hut at the edge of the village.

Birma Prayar married when she fifteen years old. Like many of the women of rural Bardiya District, Birma married into a small nuclear family. Her husband’s parents had already passed away when she married him, and his older brother and brother’s wife lived in and maintained their own household. So like most women in these circumstances, Birma quickly became the sole person in the household to cook, clean, do the laundry, collect water, collect firewood, cut grass for the animals, graze the animals, and work the fields.

By the age of sixteen Birma had given birth to the first of four children, three of whom would survive. She worked in the fields up until the hour she gave birth, and only rested from her heavy chores for nine to ten days after the delivery. Birma’s husband was present for the delivery but did not assist her in anyway, and left the young Birma to go through her first childbirth alone. Even while Birma was recovering from delivery, her husband did not help with any of the chores. He even refused to cook for her, so Birma was forced to make her own simple meals of rice and lentils. Sometimes she was too tired or in too much pain to cook, so she just didn’t eat.

A few years later, this pattern was repeated for Birma’s second birth. This time, after returning to work again after only a week’s rest, Birma’s uterus prolapsed. For twenty years since Birma has lived with the pain and inconvenience of what is likely second degree uterine prolapse. She says that sometimes her lower abdomen and back hurt so much that she feels like she is having labor pains, but she cannot afford pain killers and she cannot afford to stop working, so she continues to work from five in the morning to eight at night every day.

In addition to the usual women’s duties of cooking, cleaning, and working in the fields and the jungle, Birma also does wage labor in town. For about 80 rupees ($1.20USD) a day, Birma harvests rice, pounds rice, carries heavy loads of grass or water, or does anything else that her employers demand of her. Sometimes if Birma does not find wage labor for the day, she cannot afford to eat.

Birma is very much alone in her hut among the fields at the edge of the village. Her two daughters have married into families of their own; one daughter lives just a few hours away but is poor herself, and has neither the money nor the time to visit. Birma’s youngest son is studying in Kathmandu on a scholarship, but he has not been back to visit his family since he first left many years ago. Birma only has her husband, who often beats her when he is drunk.

Birma first came to know about uterine prolapse five years ago, when a local community health volunteer was going door-to-door, calling women for an upcoming uterine prolapse screening and treatment camp. The volunteer spoke to Birma and discovered that she was among many women in the community suffering from the condition, but when she asked Birma’s husband if Birma could attend the camp he said no. Birma has to this day not told her husband about her health problem, so he saw no reason why she should attend the camp.

Although Birma’s descriptions of her symptoms suggest that she has an early stage of prolapse that would not require an expensive surgery, treatment is still out of Birma’s budget. Second stage prolapse cases such as Birma’s can be treated with the application of a pessary ring that is inserted to hold the uterus in place and prevent it from falling. The nearest facility capable of providing such rings, however, is in another village; the cost of travelling to that hospital and purchasing a pessary is roughly equivalent to four days of Birma’s wage earnings. On top of that, pessaries must be changed every three to six months, and many poor patients like Birma are forced to abandon treatment because they cannot afford the constant travelling costs required to maintain the pessary.

Until pessary rings are made available at all health posts and sub-health posts, women like Birma will continue to live with prolapsed uteruses and will eventually progress from early stages to advanced stages. And although providing such services and training staff in thousands of health posts across Nepal to deal with pessary rings is a daunting task, it is probably the easier of the solutions that are necessary to address cases like Birma. Because until women like Birma live in a society where violence against women is not accepted, where husbands share chores with wives, and where women do not have to endanger their health just to feed themselves, the problem of uterine prolapse is not going anywhere.

My interviews with Yam Kumari Budha and Dilsara Chand happened almost accidentally. After meeting a group of thirty or so female community health volunteers (FCHVs) at a health post in rural Bardiya District, I had been sent hobbling down the road with the local FCHV coordinator in search of interviews. Shantidevi, the coordinator, was taking me to meet a nineteen year old girl who had recently developed uterine prolapse, six years after giving birth to her first child. After dragging my broken foot down the dusty road for ten minutes, however, we had to turn around. The young woman had gone off to the jungle to graze her water buffalo, and her neighbors didn’t expect her back for a few hours.

Dilsara Chand and Yam Kumari Budha were among thirty or so female community health volunteers (FCHVs) gathered in rural Bardiya District, Western Nepal, for a training on an upcoming measles campaign.

As we walked back to the health post to regroup and come up with a new interview plan, we were joined by a few of the FCHVs whom I had met earlier. Shantidevi, turned to me as she pointed to one of the FCHVs who walked with us: “She has this problem also. You can interview her.”

We were ushered back to the health post, where a dozen or so FCHVs—all dressed in their uniform blue saris with red sari blouses—crammed into the injection room to watch my interview with Yam Kumari Budha. Yam Kumari narrated what has become an almost predictable story: she gave birth to her first child as a teenager, never had a birth attendant present for the birth of any of her children, was forced back to work by her mother-in-law eleven days after the birth of her last child, prolapsed shortly thereafter, and has since lived with back pain and difficulty walking for twelve years.

Yam Kumari has told her fellow FCHVs and her husband about her condition, and while her husband is encouraging her to seek treatment, she says she is too shy to do so. As I listened to Yam Kumari try to answer my questions about why she was too shy to report to a doctor about her condition, another FCHV tapped me on the shoulder. She pointed to yet another FCHV, standing quietly in the corner: “She has this problem too.”

Before I knew it I was being told another story of a local woman forced to return to work within two weeks of each child delivery and now suffering from uterine prolapse. Dilsara Chand doesn’t know how long she has had this condition, but she remembers the day that she realized the problem she had was uterine prolapse. Like Yam Kumari, Dilsara Chand is an FCHV, and among her primary duties she is responsible for motivating local women to take advantage of local government health services. Five years ago Dilsara was accompanying one such patient to a general health camp that was being held in the area. As she listened to the doctor assess the patient’s symptoms and declare a case of uterine prolapse, Dilsara realized that she had many of the same problems. After the camp Dilsara went home to conduct a self-diagnosis, after which she confirmed that she too had uterine prolapse.

Although they both wear the uniforms of FCHVs, Yam Kumari and Dilsara are hardly model examples of health seeking behavior. Yam Kumari regularly stuffs a wad of cloth into her vaginal canal before doing heavy work so that her uterus will not fall, as it frequently does when she exerts herself. This is despite the fact that Yam Kumari knows that such self-administered treatments can lead to severe infections and accelerate stage progression of uterine prolapse.

Dilsara, as an FCHV, is supposed to be an agent of behavior change and a promoter of an open culture of health and health seeking behavior. But until the day of the interview, encouraged by Yam Kumari’s openness in front of the other FCHVs, Dilsara had never told a soul about her condition. Neither she nor Yam Kumari could explain to me why they were so shy to seek treatment for this condition, which they know is common and curable. And when I asked them how they were supposed to encourage other women to talk about health problems if they themselves couldn’t talk about their own issues, they just laughed shyly and turned away.

In their blue saris, with their government health bags hung from their shoulders, Yam Kumari and Dilsara are, above all, a testament to the great battle that lies ahead. Until women are confident enough to talk about their reproductive health and seek medical care for their problems, uterine prolapse will continue to plague communities at the high rate that it does in Baridya District. And while Yam Kumari and Dilsara have both promised me, in the presence of other FCHVs, that they will go to the district hospital to get pessary rings (which can prevent further progression of and even treat early stages of prolapse), it is evident that we are still in a stage in which behavior change is an individual and slow process.

I met Mansala BK in the post-op ward of the Kohalpur Medical College, outside of Nepalgunj. She was one of three women curled up on consecutive beds, in an otherwise barren ward. The room was in the far wing of a dusty and quiet floor of the hospital and the ward was unattended.

Nine days ago Mansala underwent a successful hysterectomy to treat an advanced stage of uterine prolapse, from which she had been suffering for two years. It took Mansala three days to reach the hospital—one day in a bus and two days of walking. Although she suffers from back pain, heavy bleeding, and difficulty walking (because her uterus protrudes from her body), Mansala had no choice but to make the journey. She was identified and sponsored for the surgery by an NGO in her home district of Jazarkot in the Far West. But qualified teams of gynecologists, surgeons, and anesthetists at reputable hospitals are not available in the Far West, so NGOs have opted to send women like Mansala to Nepalgunj, where the hospital accepts patients from NGOs on a voucher system.

For Mansala, the history of her prolapse starts at the age of 15, when she married and moved into her husband’s home. At the time, Mansala’s mother-in-law was already deceased and her husband did not live with any other family members. Barely pubescent, Mansala became the sole person in charge of running and feeding a household.

For the last thirty-five years, Mansala has maintained a regular routine: awake at 4 am to cook, clean the house, feed the animals, and do the laundry until about 1 pm, when she finishes her housework and heads to the jungle and the fields to spend the rest of the day grazing the animals and hauling heavy loads of grass, wood, and water. For five days a month, when Mansala has her period, her routine varies slightly. This is because in the region where Mansala is from, cultural beliefs maintain that women are ritually impure at the time of menstruation. Women who are menstruating must therefore be secluded and isolated from contact with food and other humans, lest they anger or offend the gods.

The small huts where women from these communities go during their monthly periods are called chaupadi. They can vary greatly in size and condition. The worst of the chaupadis are not even tall enough for a person to stand, and barely big enough for a few to sleep close together. Often they are constructed of simple twigs and mud, and sometimes they double as animal sheds. In these cases women are made to eat and sleep in the company of their family’s livestock.

In many of these communities, menstruating women are seen as the source of curses, so they are confined to the shed on permanent quarantine until their periods are finished. They cannot cook, so they can only eat what their family serves them: often left-over rice, or perhaps a few roti.

The physical and social isolation that women experience in the chaupadi is not only psychologically traumatic, but can also be fatal. It is not uncommon for women to fall ill from snake bites while staying in the chaupadi. Recently, a 14 year old girl died of diarrhea while she was confined to a chaupadi; nobody would help her or take her for medical care, because they were afraid that if they touched a menstruating girl they too would become ritually impure.

Mansala’s situation was not as severe. She says that because she had no mother-in-law (and mothers-in-law are quite frequently the enforcers of traditional practices and violence against their daughters-in-law), her husband was lenient. Her chaupadi was attached to the house, and large enough to hold a bed that her husband built for her. She says that if she had had a mother-in-law, she would have had to sleep on the ground.

With the benefits of not having a mother-in-law, however, also came the hardships. Traditionally a menstruating woman must stay in the chaupadi all day and all night, so that she doesn’t risk spreading her impure status throughout the community. Mansala, however, did not even have what might be construed as the “luxury” of rest during her period. Because there were no other women in the household and her husband refused to make up for any of the chores other than cooking, Mansala was forced to work in the fields and the jungle during the days of her period and return to the chaupadi at night.

Mansala, like most women in her village, also gave birth in a chaupadi. Notions of female impurity correspond to menstruation and birth, so that women are thought to be polluted at the time of child delivery and for ten days after. Birth attendants are not available in her village and men do not attend to births (nor can they enter the chaupadi), so Mansala gave birth alone in her chaupadi. For ten days she remained alone in the room, where no one was allowed to visit or touch her or her newborn child. Her husband cooked for her, but Mansala was otherwise left to do her own washing, bathing, and childcare.

Despite the difficulties that Mansala faced in her home and in the chaupadi, she says that things were not so bad. Her husband may not have helped clean, work the fields, take care of their child, or go to the jungle, but at least he was able to cook for her when she was in the chaupadi. Now her husband is dead and her daughter is married and in another village.

After only ten days of recovery Mansala will make the journey back to Jazarkot; she expects that it will take her four days to walk through the hills to her home instead of three, because of the difficulty of walking after surgery. Mansala wipes tears from her eyes with the edge of her sari as she explains how her husband was supposed to accompany her for the surgery. Although she is now cured of the pain that she suffered from a prolapsed uterus, she has not been relieved of the hard work and isolation that she suffered for years at home and in the chaupadi. Now, as a poor widow in the remote Far West of Nepal, she will face an even greater burden of self-sufficiency and loneliness.

We’ve been talking about this trip to Nepalgunj for weeks now. This would be my last chance to go the field before I left the country, and this would be the only chance that either Nicole or I would have to visit the west—Nepal’s frontier where development indicators are lower and cultural practices are more conservative. This was going to be the trip during which I would get the crucial information that we had been after for months—insight into the cultural and familial practices that both facilitate and aggravate the condition of uterine prolapse. This was to be the culmination of all the work that Nicole and I did this summer.

Advocacy Project and Nicole and I projected so much hope into this trip, I almost have to wonder if we forgot that I was in Nepal—a country where it is nearly futile to invest so much hope and expectation into events that are never entirely in your hands.

It started with a hairline fracture in my right foot, which not only delayed my original departure date but also made it fairly difficult to move about once I arrived. Thankfully through a contact at GTZ (the German aid agency) I was able to hitch a ride to a rural area outside of Nepalgunj. Once I was there, however, the list of potential women with uterine prolapse whom I could interview was limited to a half mile radius—the greatest distance that I could hobble down dirt roads within a reasonable time.

A translator who didn’t speak English and a schedule dictated by the comings and goings of the GTZ vehicle (fixed to someone else’s agenda) also wreaked havoc on my plans for detailed and in-depth interviews. I’ve found, however, that when you’re working for a new and un-funded NGO like the UPA you have to take whatever resources you can get. Without the help of GTZ and with no other contacts available through the UPA, I would have been limited to interviewing women in the nearby medical college, where I found only two older women from far away districts recovering from hysterectomies. So I made do with what I could get and got by with Hindi-medium translation and fixed windows of time in the field.

A Nepali friend once told me that there is no point in planning anything in Nepal, because there are so many variables that are bound to get in the way of your plans. While this trip has probably once again proven his point, it was in no way a failure. In just two days in Bardiya District and one morning in the hospital I was able to interview a handful of women with uterine prolapse. Their stories illustrate the great range of women’s experiences with this condition, but they also highlight the underlying theme: that this is problem that affects women who are already marginalized and without resources and leaves them in a state of further social and medical vulnerability.

After adjusting my original expectations (as I have learned to do here), I might even call this trip a success. From a personal perspective, anyway, it was an incredibly valuable way to end my time in Nepal with the UPA. Field visits are what kept me going in Nepal and provided me with the interactions and outcomes to make my work with the UPA real and grounded. This trip was no exception, and I met, as usual, a number of incredibly warm and accommodating women. On my last day in the field, I sat on a woven cot on a shaded porch during the heat of the day and chatted with many of these women: one auxiliary nurse midwife (ANM), one female community health volunteer (FCHV), the woman who cooked our dal-bhat, the wife of the local doctor, and a few other unidentified women who had managed to find a place on the porch and just listen in on our conversations out of curiosity. They made fun of my broken foot and my runny nose, and assailed me with the usual questions: Why aren’t you married yet? Why do you wear slippers (flip-flops) outside? Why don’t children in your country live with their parents when they are older? Is it true that women in America can just get rid of their husbands if they don’t like them?

Female community health volunteers (FCHVs) gather in Bardiya District for a training on an upcoming measles campaign. The women are also trained to identify uterine prolapse, though no local facilities for treatment are available.

The women laughed at my answers (because I’m too young; because they’re comfortable; because adults take care of themselves; yes) and continued to fan themselves and me with hand-sewn bamboo and fabric fans until eventually the GTZ vehicle arrived. They escorted me to the car, gave their respect to the GTZ officials (who support the local health post), and waved goodbye. For all the help that they had given me (identifying women with UP, dragging me through town, making me tea and translating between Nepali and Hindi),they asked only that I make sure that the stories I had taken would be heard and turned into action of some kind. I had already had to explain to them that the organization I worked for was not a service providing agency—that I was not doing the groundwork for a uterine prolapse screening or surgery camp, which is the only hope that such women (without money to pay for surgeries and without local facilities to provide the services) would ever have for treatment. I had to explain that instead I was taking information that would hopefully be translated into effective advocacy and awareness campaigns at some point in the future.

It is a stretch for women who live with uterine prolapse as a fact of daily life to imagine the long-term benefits of story-telling and lobbying campaigns, but they accepted my promises. Now I can only hope that someday these stories and the voices of other women (sufferers and activists) will reach someone somewhere, and that the women of Bardiya District will eventually have access to treatment for a painful and demoralizing condition that they will otherwise have to live with for the rest of their lives.

“Your husband is supposed to be looked upon as God,” Bimala Ghimire says, explaining the way she was raised in a strict hierarchy of gender roles in her upper-caste Brahmin community.

“I used to think that way,” she adds. “Because I didn’t know any better. But now I look at my husband as an equal. And he also sees me as an equal.”

Bimala Ghimire has an unusual story of transition from what she describes as a “typical” Brahmin subservient housewife to an engaged and empowered female leader. Like many Brahmin women from her generation, Bimala was married immediately after she reached puberty so that she could fulfill her responsibilities as a good Brahmin wife and mother. When she was just 13 years old she left her natal home and moved in with her husband’s family. There she found that she occupied one of the lowest places in the household hierarchy: an outsider and a new addition to the family, she had to earn her respect from the family through work and obedience. Her mother-in-law was particularly adamant that Bimala earn her worth, and kept the teenage girl busy with endless tasks in the fields and the house.

“I never even had time to comb my hair. The only free time I had I made for myself. Every day when I went to the fields to do work I would sneak my books with me and study in the field, squatting below the rows of corn so that nobody could see me.”

Bimala continued to live under such conditions—suffering verbal abuse from her mother-in-law and physical abuse from her husband—for the first twenty years of her marriage. By the time Bimala had given birth to her four children she had come to accept her life as a second class citizen in her own home.

In the early years of her marriage, Bimala was confined to the fields and the home. Now her mobility has improved and she works freely as a community mobilizer and activist while still maintaining her authority at home and in the kitchen.

It wasn’t until Bimala’s husband was sent to London for work that a formative change took place in her life. “[My husband] went to London and he observed the culture there. He saw how women were like equals to men. He came home and he asked me to come out of hiding in the home—to go by own name and do something for myself.”

Bimala gives complete credit for her transformation to her husband. Upon his return from London, it was he who encouraged Bimala to run for the position of ward chair person of the VDC. With no experience outside of the home and an education that ended when she was 13, Bimala was at first hesitant to run for such an important position. Without her husband’s support Bimala says she would have never succeeded in that first bid for office and become the first woman in public political life in her district.

Not surprisingly, Bimala’s experiences in politics opened her eyes to a range of possibilities and issues, and encouraged her to become an activist on behalf of other women. “At first people said that I was a bad woman—that I was ruining my family and my home.” Instead of letting this discourage her, Bimala only took this criticism as further motivation. She served five years as the ward chair person, and then another ten years as the chairperson of the district women’s organization, promoting income generation, capacity development, leadership and micro-finance programs.

Inspired by her involvement in working for the upliftment of women, Bimala started her own organization a few years later. At first the group was simply a women’s co-operative, promoting income-generation activities and a savings and loan program. Ultimately this group became the Social Organizaiton for Women’s Development (SOWD), a community-based organization that advocated on behalf of abused women and victims of domestic violence. Now the organization has expanded to include awareness activities targeted at women to improve health, empowerment, and leadership.

It is in this capacity that I met Bimala, whose NGO is one of the many partner organizations of the Uterine Prolapse Alliance. Though the organization is small and un-funded, last year they had four local women sponsored for hysterectomies to correct advanced stages of uterine prolapse. Through these and other efforts realized through SOWD and in her political positions, Bimala has become a trusted source of health information in her community. Women who have suffered from uterine prolapse for decades without telling a soul have started to approach Bimala to seek solutions for their problems. Bimala insists that this is because she has encouraged a culture of openness about this condition—an openness that she has achieved by vocalizing her own experiences with prolapse.

Three years ago Bimala underwent a hysterectomy to remove her own prolapsed uterus. For two years she had suffered from heavy bleeding and abdominal pain, though she had dismissed the symptoms and assumed they were a sign of her approach to menopause. Ultimately the bleeding and the pain became so severe that Bimala, at the encouragement of her husband, went to a doctor for a check-up. He immediately recognized the case as one of uterine prolapse, and she was shortly thereafter taken to a private hospital for treatment.

Bimala had heard of uterine prolapse before her diagnosis, but was unaware of its severity and prevalence. When she returned from the hospital she discovered that her own mother-in-law had been suffering from the condition for almost forty years and had never sought treatment for the condition. When they took her to the same doctor for treatment he said that she was too old to undergo surgery and that she would have to continue to live with the condition until her death. It was then that Bimala began incorporating uterine prolapse awareness programs into her work with SOWD. Now Bimala is a local advocate for uterine prolapse and other reproductive health issues, encouraging women to be open and proactive about their own health.

A few days ago I spent the morning in Bimala’s house, which also doubles as her office. There she commanded the kitchen (where she served me the best Nepali meal I have eaten yet) with the same authority and confidence that she commanded a group of twenty or so community volunteers. In preparation for the upcoming women’s festival, Teej, the women wore red saris and sang and danced.

In preparation for Teej, Bimala (pictured at left) hosted a gathering for her twenty volunteers. The women sang and danced to songs that they had composed about women's rights and domestic violence.

As Bimala twirled her hands and shuffled to the tune of a song written by her volunteers about domestic violence, her husband did chores outside, obviously accustomed to the loud and festive gatherings of women that now take place regularly in his home. It is hard to imagine that Bimala’s life was ever so different than it is now—that once her husband may have scolded her for neglecting her duties and that she would have hung her head and gone off to work in the fields obediently. Now Bimala is an example of so many of the things we work for: for men to understand the value and potential of women, for women to seek educational and professional opportunities beyond their home, for communities to be open and proactive about health, and for community-based development to be a process that can be initiated and led by women. As the Uterine Prolapse Alliance prepares for a national campaign to educate communities about uterine prolapse and build the capcity of small NGOs to identify and address this health problem, Bimala and her organization (SOWD) act as exapmles of the kind of change that will hopefully one day take place at the national level.

At first glance it seemed an unlikely location for a community information session. An hour by motorcycle from Butwal and then another ten minutes from the main highway over a bumpy dirt road, the building was of a simple wood construction. The bottom level was open on two sides: two water buffaloes rested in the back among stacks of hay; a goat was tied to one of the front beams.

A basic set of wooden steps led to the top floor, which was a simple loft enclosed by three walls and a slanting roof. A man was busy laying out mats on the floorboards. He disappeared and came back a few minutes later bearing a TV and a tangle of electric cords. In the loft above the cattle shed he set up the TV and the DVD player (carefully preserved in its original box) to prepare for the upcoming information session.

Downstairs a group of young girls sat around a table fanning themselves from the hundred degree plus heat. They were the social mobilizers sent by the Opportunity Development Council (ODC), a local NGO that was sponsoring the session. Nandu and I took our seats with the girls and took turns fanning each other as we waited for people to arrive.

We were in Baluwa village, just down the road from Nandu's home village. When I met Nandu several weeks ago in Butwal I had been working with her roommate, Deepa, on a community radio feature about uterine prolapse. Nandu, who had once been a community volunteer with Deepa in an international NGO, took interest in the issue and decided that she wanted to host an information session about uterine prolapse in her own community. After setting a time for the session and identifying an NGO that Nandu could work with (ODC), I had finally made it back to Butwal. Following a rushed morning of preparations (scratching out lists of symptoms and prevention methods on sheets of white butcher paper) we arrived in Baluwa on the back of motorcycles and waited for Nandu's audience to arrive.

Despite the incredible mid-day heat, a steady stream of women from the village began to appear. We filed into the loft, where a fan had been added to the rudimentary electrical set up, but which nonetheless felt more like a sauna than an appropriate place for an hour long educational session.

Ultimately seventy five adults squeezed into the loft, with half as many children who had come along for lack of anything better to do on a scorching Saturday in the rural terai. Obligatory introductions were given by one of the young women from the NGO, and Nandu was allowed to begin her information session.

Using posters provided by the UPA, Nandu explains the risk factors for uterine prolapse to a room full of neighbors and community members.

"Pateghar ke ho?"

"What is a uterus?"

It was a tough opening question for a young woman like Nandu to pose to a room full of her neighbors and elders, and to no great surprise she was met with silence and downward stares. Although her voice betrayed a slight nervousness, she repeated the question. Someone raised their hand to explain that a uterus is for holding a baby, and from there the session proceeded with more comfort.

Nandu went through her home-made posters about the definition of a uterus, the definition of uterine prolapse, its symptoms, and the way it is caused. Although the men in the room had self-segregated to the very back of the room and represented a mere quarter of the participants, even they seemed to be interested as Nandu fearlessly detailed a condition that is so frequently treated with silence and taboos.

The session represented an exciting collaboration of grassroots, community level, and national actors. Nandu--a concerned citizen wanting her community to be educated about a major health problem--had spawned the idea for the session and had pursued her connections with local NGOs to identify a partner for the session. The NGO had provided the space for the session and had done some community outreach in the days before the session to guarantee a sufficient turnout. The Uterine Prolapse Alliance, attuned to the session through my connection with Nandu, had provided educational materials: posters describing the risk factors for uterine prolapse and the relationship between gender discrimination and women's poor health, as well as a video docudrama about uterine prolapse.

The audience follows the story of Mirchi's womb with keen interest, in the process learning about the gender discrimination and the root causes of uterine prolapse.

After Nandu explained the posters that had been provided by the UPA we popped in the video, roughly translated as "Mirchi's womb has fallen: What to do?" The half hour video piece was one of the most effective educational materials I have ever seen in practice. Although the audience became fairly squeamish and even giggly when images of real prolapsed uteruses flashed across the scene, they continued to follow the progression of Mirchiís personal and medical story with keen interest. By the end of the video they had seen Mirchi give birth, suffer a prolapsed uterus from heavy work in the postpartum period, sustain verbal abuse from her mother-in-law, progress from early stage prolapse to advanced stage, experience difficulty walking and doing household work, and ultimately become involved in a community health program that encouraged her and her husband to learn about her condition, share domestic chores, and save money for Mirchi's ultimate surgery. The drama of the video and the medium seemed perfectly suited to the audience, which followed the lifelike story with a dedicated interest that they may not have shown to a factual presentation given by an individual speaker.

The session would have ended there, but they granted my request to ask some questions while we still had an audience. First I asked how many people in the room knew someone--a friend, neighbor, sister--who had uterine prolapse. One woman volunteered that she had heard of a woman several villages away who had a similar sounding problem, and a few other women piped into to concur that they had heard about this woman as well. I told them the reason that I was asking was because in some areas of Nepal up to 50% of women have prolapse, and I was curious about whether this was the case in this community. They all adamantly shook their heads "no" and said that this was not the case in their community.

I suspect that their insistence reflects a lack of knowledge about the issue and a persistent inclination to keep such personal health matters under wraps. After some discussion amongst the women in Tharu (a local language that I don't understand), I found out that two more women had revealed that they also suffer from prolapse. One woman, clearly not yet fully empowered to admit the severity of her condition, told us that she only has prolapse when she is sick--an explanation that is not very likely and is probably just an expression of her desire to not admit to having this serious health problem.

Women and children read the educational materials provided at the end of the information session. The woman pictured at center admitted that she suffers from uterine prolapse and agreed to go to the doctor for a check-up.

I then asked the women how we can prevent uterine prolapse, which prompted a few responses and some general discussion about the importance of going to a doctor and not doing heavy work while pregnant. All of these answers were fine and good, but I was worried about the long term effectiveness of the information session if only women were learning about how to prevent and recognize the severity of uterine prolapse. The few men who had attended the session to begin with had left when I started asking questions, and only two were remaining. When I expressed my desire for the women to share this information with their husbands and brothers so that men too could be educated about the issue, the director of ODC called upon the two remaining men in the room and asked them to stand up. He then forced them to expound upon ways to prevent uterine prolapse, resulting in one older man's soliloquy on the importance of chore-sharing between men and women and the necessity of allowing women to rest when they are pregnant and in the postpartum period. It was encouraging to see an elder male figure assert the importance of gender equality and women's health in this context, even if it is only a small step toward male involvement in the issue.

Though the community information session was short and we have no way to evaluate the effects of a one-time session, the surface indicators are encouraging. When we passed out the remaining posters and pamphlets at the end of the session they were snatched up and read curiously by women, men and children alike. And although I suspect that more than two women in the room were suffering from some stage of prolapse, the fact that we encouraged those two to speak up about their condition suggests that it is possible to create an environment in which prolapse can be talked about, prevented, and treated without shame.

Most importantly the session offered importance evidence for the kind of umbrella role that the UPA can play. As a coalition of NGOs working on uterine prolapse policy and programming, one of the UPAís primary roles is to act as an authoritative and overarching body on uterine prolapse in Nepal. Further, one of the objectives that we have drafted for the UPA campaign is to enable the UPA to act as a capacity-building organization for smaller NGOs in the area of uterine prolapse in Nepal. Seeing ODC's interaction with the UPA proved that this is indeed a crucial role for the UPA to fill. By providing educational materials (posters and video) the UPA was able to equip Nandu and ODC with the tools that they need to reach a very localized audience. As a sub-component of that same campaign goal we have proposed that the UPA needs funds to develop an Educational Package (of posters, pamphlets, videos, flip charts, training manuals, etc.) so that they can continue to provide a more thorough and consistent set of materials for NGOs like ODC across Nepal, thereby empowering local institutions to conduct grassroots level awareness campaigns.

It can be challenging to work on the issue of uterine prolapse in Nepal knowing that there are at least 600,000 women across the country who suffer from the condition, and that as of yet the UPA still does not have the funds to make the voices of these women heard and help treat and prevent further suffering. But these visits are what make our strategy sessions and our endless goal-defining efforts more tangible. They allow me to know that several months from now--at a time when I will not even be in Nepal to see the end result of our work--a document will be produced which will clearly state the objectives of the UPA, which will allow the UPA to receive institutional and financial support, which will enable an environment in which government and non-government bodies across Nepal can begin to work in a collaborative and complementary manner for the eradication and prevention of uterine prolapse, which will allow women like the women of Nandu's village to speak out about their condition and seek an end to their discomfort and shame. It is a long process that we have sketched before us. But we must have faith in its possibility if we are to imagine a day when the women of Baluwa and the women of Nepal will see uterine prolapse as a condition that can be prevented and treated, rather than as a woman's burden that must be silently suffered.

Working with the Uterine Prolapse Alliance (UPA) has been, in some respects, an exercise in faith. Although the Alliance was formed over a year ago, they are still in the process of figuring out just who they are and what they want to do. As a coalition of over thirty NGOs of all sizes, the UPA struggles with competing agendas and perspectives, from different priorities (should they focus on curative efforts or prevention programs?) to different approaches (should they engage a services-based public health framework or one based on gender issues and equality?).

These kinds of problems are almost inherent in the concept of a coalition, but with the Alliance they are aggravated by the fact that, as of yet, the UPA remains for its members a voluntary association. The UPA has no funds for promotional activities, let alone for an office, a staff, or regular meetings. Without dedicated funds or staff people in the Alliance, it is a challenge to provide significant incentive for all thirty member NGOs to participate in an alliance that is still too new to carry any weight of its own.

To promote the decision-making ability and forward motion of the UPA, the Alliance has formed a task force composed of eight individuals representing various member NGOs from the Alliance. But because the members of the task force also have full time jobs with organizations such as the Safe Motherhood Network Foundation, the Rural Health and Development Program, and the Women's Reproductive Rights Program, they have little time to devote solely to the UPA. As a result the Alliance is also afflicted by an inability to get everyone in one place at one time and proceed with policies and actions.

In the five weeks that I've spent in Nepal I have only met with the task force once (other meetings have been attempted but canceled or were attended by only one or two members). It was a startling introduction to the UPA--a meeting charged with the passions and convictions of eight women who are determined to see the eradication of uterine prolapse in Nepal. Voices were raised, proposals were put forth and immediately torn down by other members, and frustrations over lack of resources and commitment were expressed. Throughout the meeting I had to turn to Nicole (who has worked with the UPA for almost a year now) for explanations of terms, histories, relationships, and internal politics; by the end I still wasn't sure what was going on, and I left feeling overwhelmed by the institutional complexities of the Alliance.

Though the UPA suffers from the inertia of an un-funded coalition, I have since my first meeting with the task force still found it possible to cultivate faith in the ultimate vision promoted by the Alliance. This is in large part because of Samita Pradhan, the secretariat of the UPA, the chairperson of the Women's Reproductive Rights Program (WRRP), and my primary contact with the UPA. Although she is soft-spoken and often deferential to the more demanding voices of other task force members, Samita manages to keep the UPA moving forward with her persistent dedication to the issue and her willingness to take on the work of the whole task force herself when it seems like otherwise the task force will not be able to move forward. Her organization (WRRP, under the Center for Agro-Ecology and Development) is one of the most active of the Alliance, and her insistence on a multi-sectoral and collaborative approach to the problem on a national level is a major driving force for the continued existence of the Alliance.

Led by Samita, the task force as a whole is little-by-little striving to validate the idea that a coalition of NGOs in Nepal can promote a unified and more effective solution to uterine prolapse in the country. To this end, one of the primary tasks that Nicole and I (as AP Peace Fellows) have been set to this summer is the drafting of the objectives for the UPA and its international campaign (in partnership with AP). Given the competing perspectives and impossible schedules of the task force members, it is no surprise that this process has been somewhat trying. But the differing backgrounds and agendas of the members also keep the UPA balanced and well-rounded. When we need to know numbers related to surgeries and infrastructural capacities, for example, we can turn to Dr. Binjwala, a public health specialist with the Safe Motherhood Network Foundation. When we try to imagine the best way for facilitating nation-wide community-based educational programs, we can consult Samita, who has been working on such programs with WRRP for over ten years. The combined expertise and passions of the members are at once what hold back the UPA in the short-term and what make the future of the UPA seem strong and productive.

For an intern like me, only in Nepal for ten weeks, it can be difficult to appreciate the forward motion of the UPA and the ultimate fruits of our labor. Our progress has been incremental and the outcomes have been theoretical, rather than applied. Instead of running surgery camps and lobbying government ministries, we have been talking about how to craft program policies and advocacy strategies. The work is without question essential, as the UPA must reach a consensus and a firm set of objectives before it will receive funds or be able to move forward as a coalition. In addition, the experience has been a valuable lesson for me in the patience and imagination that are required in crafting a social justice campaign.

To counterbalance the administrative and theoretical work that I have been doing with the UPA on its campaign objectives, I have also been fortunate enough to conduct some field visits. The primary goal of these visits is to gather and then disseminate information about how women experience uterine prolapse in Nepal; through written profiles (see previous blogs) and photos, we hope to put a human face on the condition and gain a better understanding of what kinds of policies and programs are necessary to both treat and prevent it.

This weekend in the terai my field visit proved more valuable than usual, as it served as an unintended affirmation of the value of the UPA and the kind of work that it plans to do. For almost a week now I have been working with Nicole and members of the task force to define the future value and activities of the UPA, hoping that we can create an alliance and a campaign that will build the capacity of Nepali government and non-government institutions to address the issue of uterine prolapse. Yesterday, in the loft of a cowshed in rural Ramnagar VDC, I was given a glimpse into this possible future. Far away from the politics and whiteboards of Kathmandu offices, I saw the UPA for what it could be: a national body that can empower grassroots-level actors to eradicate uterine prolapse by providing resources and a unified approach to the issue. Read my next blog for a description of this experience and how it has renewed my faith and conviction in the powerful possibility of the UPA.

For twenty years Barabati suffered from uterine prolapse without telling even her husband about her pain and symptoms. “If I told anyone, they would neglect me and treat me badly. They would say that I am a bad woman.”

Like many women, Barabati was working in the fields when she first knew that something was wrong. By her best guess she was around thirty years old at the time; just two years earlier she had given birth to her one and only child. It was April, the peak of the harvesting season, and Barabati had been cutting and tying bundles of grass. As she bent over to pick up a heavy load she felt a sudden pain in her lower abdomen. Barabati had never heard of uterine prolapse, but she immediately knew that something wasn’t right.

Despite the pain that she endured as a result of her prolapsed uterus, Barabati told no one about her symptoms. Like too many women, Barabati was afraid that if she told even her husband about her personal health problems, she would be stigmatized—maybe even blamed for bringing the condition upon herself. “If I told anyone, they would neglect me and treat me badly. They would say that I am a bad woman.”

For twenty years she bore her condition stoically, continuing to labor in the fields of the terai (plains) region of Nepal. Her silence only ended when, twenty years after her first pains, a community volunteer arrived at Barabati’s door and began to talk to her about uterine prolapse. At first Barabati denied having ever heard of this condition. Knowing the high prevalence of uterine prolapse in poor agricultural communities such as Barabati’s, the community volunteer persisted. Eventually Barabati admitted to her condition, and is now among a small group of women from her community who have shared their experiences with the community volunteer.

“Now that I have more information,” she says hopefully, “maybe I can seek treatment.”

Her optimism, however, is short lived. This is because the minimum price of a hysterectomy to treat uterine prolapse is 15,000 rupees , or approximately $223 USD. Average income in Nepal is equivalent to approximately $200 USD, and Barabati--as a poor farmer--is well below that average. Free surgery is sometimes offered through sporadic government surgery camps or NGO efforts, but no such projects have been undertaken or are planned for the area where Barabati lives.

When Barabati finds out how much the corrective surgery will cost , a look of resignation passes over her sun-darkened face. “I do not have that much money,” she says simply.

And just like that, Barabati rejoins the ranks of poor women in Nepal who must submit to a lifetime of discomfort and pain.

Chandmati Pasi is, if nothing else, candid. She answers inquiries about her life with a measure of directness that is unusual in her community. Ask her how many children she has borne, and without even the suggestion of emotion she will tell you of the four children that have survived and the three that have died—one at birth, one within eight days, and another within five months. Prompted about her medical condition, Chandmati will just as matter of factly tell you about the day she felt her uterus prolapse.

Chandmati Pasi, a poor farmer from Rupandehi District, Southern Nepal, has suffered from uterine prolapse for eighteen years. She has accepted her condition and does not expect that she will ever be able to afford the surgery to correct it.

Chandmati was out collecting wood just fifteen days after the birth of her last child when it happened. It was a rainy day and the roads were slick with mud, causing Chandmati to slip. As she fell she experienced a sudden pain and the sensation of something dropping in her lower abdomen. Despite the pain, Chandmati had more work to do. With the same sort of un-questioning attitude with which she tells this story, Chandmati stood back up, adjusted the load of wood that was balanced on her head, and returned to her village to continue her day’s work.

Eighteen years have passed since Chandmati first felt her uterus fall. For eighteen years she has suffered through pain, fever, difficulty walking and an inability to control her bladder. Sometimes she has to stay squatting in a field for up to an hour and a half before she can overcome the pain that it takes to urinate. Eating and drinking also cause her severe pain, so she has reduced her food and water intake, despite warnings from the local community health worker that she is cutting short her own life.

For Chandmati, treatment for uterine prolapse is not a realistic financial possibility. Unwilling to tell her husband about her condition at first, Chandmati turned to her mother-in-law, who helped her collect some money from friends and relatives for medical attention. Chandmati took this money to the local health post, where she was prescribed medicine that would cure a related infection, but would not treat her prolapse. She took the medicine for one week, with no improvement.

Years passed and Chandmati’s condition only worsened. At one point Chandmati consulted a local village doctor, who told her that her condition could be cured with six injections. Chandmati saved 100 rupees for the first injection, but after that was unable to pay for the remaining five. Chandmati has simply accepted the improbability of treatment and continued on with her life, cutting grass in the fields, collecting wood from the forest, and raising her surviving children.

Eighteen years after her first fall, Chandmati is undoubtedly now experiencing an advanced stage of prolapse that can only be treated by hysterectomy. For this surgery, Chandmati would have to travel to the nearest major town and then pay at least 5,000 rupees to have the surgery performed. Chandmati says she cannot even afford to make the journey. “How can I pay for treatment?” she asks. “If someone can pay for my treatment, then I will go for surgery. Otherwise, I cannot,” she says, in her characteristically blunt manner. “I am a farmer. I have a family to take care of.”

In the style of most Nepali friendships, my friendships with Deepa and Nandu were almost immediate. I met Deepa through my work with Radio Jagaran in Butwal, and after only a few short hours of working together she invited me to have lunch at her house—a small room that she rents on the top floor of a co-worker’s home. Deepa’s roommate is Nandika (affectionately known as “Nandu”), and the two girls share everything, from the bed they sleep in to the cooking duties.

Deepa and Nandu, partners in crime, even share the same umbrella.

Over several days in Butwal I managed to find myself in their room quite frequently. Twice they attempted to teach me to cook (which means I sat in the doorway of their closet-sized kitchen and listened as Nandu reeled off lists of spices) and one afternoon I napped as they read through books and pamphlets about uterine prolapse. But mostly we just talked. Over many cups of chia (sometimes tea with lemon, sometimes with pepper) and in several languages (Nandu and I could only communicate in Hindi, while Deepa and I could only communicate English, and Nandu and Deepa usually recapped to each other in Nepali) we covered a great variety of topics, from the way that women in the US dress to the songs that Nepali women sing during festivals.

Deepa and I enjoying the dal-bat that Nandu has prepared for us.

Through these discussions (conducted informally as we all lay sprawled across various mats in the room), I was introduced to the complex overlap of caste, class and values in today’s Nepal. Together the girls present an interesting perspective on the negotiation of culture and identity in a rapidly changing society.
Deepa comes from the Dalit (untouchable) caste, and although she can tell you stories about neighbors in her village who won’t allow her into their kitchens (for fear that her very presence as a Dalit will pollute the space), her confidence and outgoing manner betray no internalized consequences of discrimination. She speaks excellent English and seems to be quite aware and accepting of the differences between western culture and Nepali culture. She has a collection of skinny jeans that would impress any fashion-conscious young western woman and only once in my week in Butwal did I catch her in a traditional salwaar-kamiz; even then she changed out of it before lunch. Deepa figures—although she says we can never be sure about these things—that she will have a love marriage, instead of a traditionally arranged one. She speaks about such matters openly and with little of the giggling and naiveté that usually accompanies similar conversations in Nepal.

Nandu—more frequently found in a salwaar-kamiz—is from the Janajati caste. When explaining to me what that meant, she told me that it meant she was one step above Dalit caste. She insisted that she would never have a love marriage, as this would lead her to be expelled from her family and her community. Her family, she gave as an example, would never allow her to marry a Dalit, though she lives with Deepa (a Dalit) and eats the food that Deepa cooks (which by the orthodox interpretation of the caste hierarchy would not be prohibited). Although Nandu comes from a higher caste than Deepa, her village was poorer and her education less comprehensive (thus explaining her very minimal English). At the age of 23 she expects that she will soon be married off to a Janajati boy of her parents choosing.

Nandu does most of the cooking in the house that she shares with Deepa (though she insists that Deepa often makes dinner), and it is not hard to imagine that in a few years she will be making some Nepali man very happy with her homecooked meals and regular rounds of chia. She is currently undergoing teacher training, though she makes no specific mention of plans to work after marriage. Deepa, on the other hand, intends to build a career in community radio. The way she sees it she will put in a few years of service with Radio Jagaran in order to give herself the opportunity to work her way up the ranks. Jagaran Media Center (the parent company of Radio Jagaran) will soon be opening two new stations in farther regions of Nepal, and she imagines that she will be offered a promotion and the chance to work in the new stations. Several years down the road she sees herself working for Jagaran Media Center in the Kathmandu office.

Together Deepa and Nandu present a fascinating image of young women, friendship, and tradition in modern Nepal—but it is one that begs many questions.

I don’t expect that I will leave Nepal after ten weeks with any sound answers to these questions, given the variety of communities, regions, and beliefs in this country and the rate at which change is taking place. I only hope that many years from now I will be able to sit with Deepa and Nandu over another cup of chia and learn how their lives have unfolded in this interplay of values of identities.

Just a month or two after giving birth to her first child at the age of 19, Sabitri Kohar became pregnant with a second child. She describes the second delivery as being much like the first one: both were relatively uncomplicated labors played out on the packed dirt floor of her thatch house. At the end of both deliveries, the mid-wife attending her birth pushed and prodded Sabitri’s stomach in an effort to release the placenta. When describing her first two deliveries, Sabitra almost forgets to mention one crucial difference in her experiences. “That second time, I had not eaten for eight days before I gave birth. We had no food in the home, so I did not eat.”

Although Sabitri does not consider her second birth to be remarkable in any particular way, her body undoubtedly suffered from extensive stress during her second labor. Undernourished and still in the recovery stage from her first delivery, her reproductive system would have struggled to manage the second labor. The cumulative effects of the mid-wife’s prodding after both deliveries also likely damaged the already sensitive and stressed muscles in her pelvic region. A year after Sabitri gave birth to her second child, the consequences of her dangerous delivery caught up with her.

Bending over to pick up a load of grass in the fields, Sabitri felt a sudden and sharp pain in her back and lower abdomen. That same day she noticed that something was protruding from her vaginal canal, but she told no one about it and did not think to go to the doctor’s. A month later, Sabita returned to her birth home and mentioned her persistent symptoms to an elder female relative, who told her that she was probably experiencing pateghar khasne samasya (“fallen womb problem”). Too shy to share the details of her personal health with anyone else, Sabitri kept her problem to herself for the next fourteen years. Even Sabitri’s husband has been ignorant of her condition for fourteen years, during which time she gave birth to two more children and suffered silently through the pain and discomfort of a prolapsed uterus.

It wasn’t until a community health volunteer arrived at Sabitri’s door and began to talk to her about pateghar khasne samasya that Sabitri shared the details of her experience with anyone else. Since then she has gathered the courage to tell her husband, who agrees that she should seek treatment. Sitting in a circle of other women who are suffering from uterine prolapse, Sabitri says she is happy that she has met the community volunteer and finally told her husband. After fourteen years of not being able to talk to anyone about her condition, she now knows that she has support and there is hope yet for her suffering.

Described as flat, dusty, crowded and hot in the Lonely Planet, the town of Butwal provides much in the way of pleasant surprises. Although Butwal is part of Nepal’s terai (plains) region, it is in fact surrounded in three directions by low hills, and the plains on which it sits are heavily wooded and green. It is hot, but certainly bearable, and the wide streets and small-town feel easily distinguish it from the crowded atmosphere of Kathmandu.

In Butwal I have met up with Heather Gilberds, another AP Peace Fellow who is working here with Radio Jagaran, a community radio station targeting the dalit (untouchable caste) community and their issues. In just one afternoon I have already been impressed by the exceptionally kind and welcoming dispositions of the Radio Jagaran staff. Harmin—a tall, skinny man with a bright smile—devoted most of his afternoon to making sure both Heather and I were adjusting well to Butwal (she has been here only a week). He gave me a tour of the radio station, introducing me to everyone from the guard on the ground floor to the young and enthusiastic news announcers preparing for the live news reading. From the roof he pointed out all the good hiking routes from town and showed me the transmitter room, where the radio transmitter connects to the satellite tower and reaches out to a 50 km listening area, presided over a by a somewhat haphazard shrine to Vishnu propped against the wall in a corner of the dusty room.

A small parade of curious young radio folk came in to greet me, the most enthusiastic of whom was Dinesh. Small, skinny, and overwhelmingly polite, Dinesh burst into the room where Heather and I sat in a shower of grins and “Namaste”s. He seated himself next to me on the couch and folded his hands shyly into his knees. “I have been waiting for you to arrive. Heather, she told me you were coming and I have been asking ‘When is your friend arrive?’” His genuineness positively overflows from his small frame.

Dinesh tells me that he announces the international news and works for the human rights radio program at Radio Jagaran. In the latter capacity, he explores the nuances and manifestations of local caste discrimination, including the difference between treatment of dalits in the terai areas and the treatment of dalits in the nearby hills. Asked to elaborate on those differences, Dinesh suddenly becomes serious. “Here in the terai there is so so so so much of discrimination,” he says, straining his muscles with emphasis.

“Actually I myself am a terai dalit.” Dinesh tells us his own story of discrimination—the time he and his younger brother, boarders in youth hostel, were kicked out of their room when their landlord discovered that they were dalit. It was a monsoon day with heavy rain, and Dinesh came home to find that their room had been emptied and all of their belongings had been thrown in a heap in the rain. Their landlord told them never to set foot on his property again, and none of the other boarders came to help or defend him. “This time I was so much crying,” he says, as suggestions of those same tears start to form in his eyes afresh.

I try to suggest that Dinesh is lucky that he has the opportunity to now work with Radio Jagaran—to make a difference on an issue that is so important to him and to reach out to the community (dalit and non-dalit) to educate them about the persistent ills of discrimination. But it comes out all wrong. “I am not lucky,” he says, with glassy eyes. So I try again. “You should be proud, then, that you are working so hard for social change.” In quiet agreement he drops his head.

When Dinesh raises his eyes again they are dry and he is smiling; he quickly changes the subject, carrying on with the small talk we had initiated before. Eventually he stands up to excuse himself to prepare for the news hour. In a shower of waves and more smiles, he retreats. As he leaves he walks backward, bending forward slightly and making himself smaller in a gesture of humility. I cannot help but note that Dinesh is the only one I have seen who has done this, and that his exit is in the fashion of India’s harijan (untouchable caste) community. Centuries ago—in a tradition that is still carried out in some particularly stubborn contemporary communities—harijans were taught to walk backwards with a broom in hand, so that they might constantly erase their footsteps in the dirt and thereby eliminate all evidence of their spiritually polluted existence. Whether it is some remnant of this tradition that has made its way to Nepal and informed Dinesh’s behavior, I cannot be sure. But his politeness and his eagerness to please cannot be separated from his experiences as a young dalit in the terai. I have to wonder whether Dinesh is an example of the case that caste discrimination is pervasive and often internalized, changing even something as subtle as way that a progressive and energetic young man like Dinesh retreats from a room.

Other visitors come to say hello, and after some time I am finally introduced to Deepa, who runs the women’s show at Radio Jagaran and who is hopefully to be my partner over the next week. Over tea with the station manager, Deepa is given permission to work with me to produce a short radio feature about uterine prolapse. She is incredibly agreeable and consents to all of my requests for her time in the field, translation skills, contacts, and a spot on her radio show. Though it will be a challenge to seek out women who are willing to talk about their experiences of uterine prolapse openly (and for a radio audience), it is clear that I have fallen in with an appropriately energetic and willing crowd for the task. I am hopeful about the possibilities for the next week.

After two days of grey and intermittent rain in the valley, today was bright and clear. The sun was strong—a reminder of its proximity—and the clouds looked to be thick as cotton and electrically white. From the roof of the Safe Motherhood Network Foundation office I had 360 degree views of Himalayan ridges and a new appreciation for the color and activity of Kathmandu. Days like this (after days of monsoon) seem to offer a new sense of possibility and beginnings. So it was an appropriate day for me to start my fellowship and begin the work with the Uterine Prolapse Alliance (UPA) that I have been building toward for so long.

The UPA is an alliance of various NGOs in Nepal working toward the reduction of uterine prolapse in the country. Uterine prolapse (UP) is a condition that women suffer when the muscles holding their uterus in place become weak and begin to deteriorate, causing the uterus to fall out of place. UP, also known as “fallen womb,” is caused by a combination of a variety of factors in a country like Nepal: heavy labor performed by women up until and right after birth (which causes excessive stress to their pelvic muscles), malnutrition, lack of quality of obstetric care, and stigma that prevents the condition from being talked about, prevented, and stopped in early stages. UP is thought to be highly prevalent and under-reported in Nepal, and the UPA was formed last year to guarantee that this issue no longer goes unnoticed or ignored by the government of Nepal.

As a 2008 Peace Fellow for the Advocacy Project, I have been sent here to Kathmandu to work with the UPA as they begin to formulate a national and international campaign to call attention to UP. From meetings today with representatives from three of the member NGOs of the alliance, it seems that my primary tasks will include helping the UPA launch a website and assisting them in the collection and production of information for campaign purposes. Currently I am compiling information from each of the approximately 40 partner organizations in the alliance so that I may write their profiles for the website. Also in the works are plans to collaborate with another AP Peace Fellow (Heather Gilberds, based in Butwal) on a community radio piece about UP and to travel the country gathering oral histories and producing photo essays about women’s experiences of the condition.

Having survived a sort of initiation today (a slideshow of uncensored photos showing women who suffered from UP undergoing surgery), I know that this work will be both emotionally challenging and incredibly valuable. I hope that those of you who are interested in women’s rights, reproductive health, rural development, and Nepal in general find in this blog an opportunity to follow the beginning of what promises to be a very important national and international campaign.