By Mary Anne Mercer

A nurse volunteering in Nepal struggles to adapt to an alien culture.

Someone was calling to me from just outside the tent. My wake-up call turned out to be Bhim Raj, the cook, who passed me a chipped white enamel mug of tea and a basin of warm wash water, accompanied by the flash of a bright, toothy grin. Bhim Raj was tall for a Nepali man, taller even than my five feet eight inches, and already I could sense another difference about him. He wasn’t timid around foreigners, the way that most of the porters were. He didn’t speak much English, but communicated with the few simple words he knew.

“MemSaab OK?” he asked. I realized with a faint (very faint) stab of guilt that I had probably slept later than I should have, given all the work ahead of me that day.

TIk chha,” I answered – I’m fine. I sipped the milky tea, very strong and very sweet, rushed through some basic ablutions, pulled my shoulder-length hair into a pony tail, dressed in the same outfit I had worn the day before (Omigod – my standards are already slipping, I thought), and readied myself for my first day at my new job in Nepal.

It felt momentous. After a scant month of language and culture training in the capital, Kathmandu, I was to begin as a volunteer for a health program in rural Gorkha district. What I thought to be a modest stipend of $225 would be deposited monthly into my bank account back home, although I was soon to find that even that amount was embarrassingly generous compared to the salary paid the local staff. Thinking back to other ‘first days’ at a new job, which were predictably unsettling, stressful, a confusing rush of information and impossibly complex-sounding tasks, it seemed likely this would be no exception.

My last full-time position in the States had been running a clinic in a community center in the North Beach-Chinatown neighborhood of San Francisco. Then I was a newly trained nurse practitioner, theoretically equipped to handle sick people with common illnesses and refer those whose problems were complicated enough to need a physician. The patients were a wonderful mix of all the ethnicities in that area – Chinese families from Hong Kong, older Italian immigrants, African Americans from a housing project nearby, and North Beach characters of all types. I loved the diversity, the friendliness, and the energy from the very first day.

I started that job with feelings of uncertainty, but that was nothing compared to what was facing me this day, this week, this month, probably even this entire year in the rural villages of Nepal. Now I was faced with what seemed an alien world, but in fact I was the alien. I had chosen to live with people who spoke a different language, were from a totally unfamiliar culture with customs I had never even dreamed of and whose incomes were, I estimated, about 1/200th of what we had in the US. I was soon to find that most of the village people had never ridden in a motorized vehicle, had never seen a movie or television, and lived essentially on what they could grow and make themselves. Awareness of the chasm between my life and theirs already filled me with an immense loneliness, a certainty that I could never bridge the gap between their lives and mine. I sighed, took two deep breaths, forced my face into a smile, and stepped into the sunny morning.

We were camped near the panchayat bhawan, or village meeting place, a small building with mud-pack walls and a thatched roof. Similarly-constructed houses were scattered in the village nearby, and already the sounds and smells of morning filled the clear, chill air: roosters crowing, dogs yapping in their endless small scuffles, multiple birdsongs that I didn’t recognize and children shouting, with the smoke of cooking fires emanating from every home.

“Namaste, MemSaab!” The customary greeting as I emerged from the tent came from several men and women milling about the camp. We gathered in the one-room structure for breakfast, a mountain of rice with lentils on the side and a slice of lemon to add some tang. The group included Corinne, a small, cheery American nurse with long blonde hair who was to be my partner in this health program, along with the immunization team of seven Nepali men and women that Corinne had been leading in their work around the district for several months before I arrived. We sat on straw mats on the floor in the semi-lit room, with only one window and an open door to let in rays of sunlight. The rest of the light came from a cooking fire burning in an opposite corner of the room, blazing cheerfully on the mud-pack floor and illuminating the smooth red-brown walls. There was a low murmur of conversation among the Nepali staff, little of which I understood.

As soon as we finished eating, Corinne began directing preparations for the day’s work. Breakfast was cleared away and all of the supplies and equipment that would be needed were laid out helter-skelter on the floor. The porters, I discovered, did more than just carry loads; they had a range of other responsibilities including packing up the immunization cards and gathering together other supplies that would be needed for the day.

The women who were to do most of the actual immunizations arranged the vaccines and syringes into the portable coolers. Sita was the youngest of the three vaccinators. Tall, she looked to be in her late 20s, with an intense expression that sometimes gave me the impression she was confused or angry. Sushila — slightly plump, pretty and smiling — had two small children of her own, left at home with other family members when she was working. Kaliwati was the oldest vaccinator, a young grandmother, who seemed to ‘mother’ the staff. Each of them had long black hair that was smoothed into a tidy knot at the base of their neck, and wore a light blue cotton saari with royal blue trim. Decisions were made about who would go where, what was missing, who forgot to restock their carry-bag, and where the thermometers had gone that were to be included in every cooler to make sure the vaccines didn’t bigriyo (spoil). I stood amid the commotion, smiling and trying to look engaged, not sure how much I should be involved and quite aware that my help wasn’t needed anyway.

Finally everything seemed ready and three teams set out for different villages. Today I would go out with one of the more experienced vaccinators, Sita, and a new porter, Tul Bahadur. My team was to cover the site closest to camp; I felt somewhat guiltily grateful that today’s work was relatively nearby. We would start with a trek out to the ‘ward’ or hamlet we were responsible for (“about half an hour” I was assured). Each ward had officials who would help us find the children to be immunized, and keep track of who showed up and who didn’t. If they didn’t come to us at a designated immunization site, we had to track them down in their homes.

The three of us headed down a well-used trail in the bright sunshine, accompanied by the trill of birds, the sweet smell of the morning’s cooking fires, and the gaze of curious villagers from the adjoining fields. The day was beginning to warm up already, but because this was only April and we were at an elevation of nearly 5000 feet, the temperatures would not reach the level I identified as ‘hot’ for another month or more. Soon we started gently downhill, and though I knew that every step downhill meant eventually one going back up, I enjoyed the sense that I was out for a pleasant stroll. The trail was mostly through a forested area and we spent much of the time in the shade. Even more enjoyable was finding that I was able to carry on some basic conversations in Nepali with Sita.

MemSab, tapaaiko periwaar ke ke hunchha?” Sita asked after a few minutes on the trail – who is in your family? I was to learn very quickly that family relationships are of paramount importance in Nepal. Nearly every conversation begins with an inquiry as to the health or well-being of family members.

Baau, Aama, char bahini, duita bhai” I responded – my parents, four younger sisters and two brothers.

Srimaan chaaina?” she asked – you don’t have a husband? Now we were getting into risky territory. In this very traditional society, how would they react to knowing that I was divorced? Did they even have divorce in this country?

Chaaina. Tiyo, tara ahile chaaina,” I responded – I had one but I don’t now. A brief conversation ensued about the marriage. Did he leave me? No, I left him. Did we have children? No. That seemed a satisfactory answer, and the conversation moved on to other topics.

Sita, “dear Sita” as I was to think of her before long, was not your ordinary Nepali woman. Later I learned her story, that she’d been offered in marriage at an early age, as nearly all young Nepali girls are in the rural areas, and Sita simply refused. She wanted something besides childbearing and drudgery, the life she saw for most women. That choice meant that she had to find a paying job, since she still lived with her parents and had to contribute to the household finances. She had not actually passed the tenth grade certification required for the job — although she had been able to convince Corrine that she had — but her intelligence was clear. More importantly, contrary to my initial impression Sita was outgoing, always joking, and she became our best vaccinator by far because she enjoyed being with people and talking to women about what they could do to keep their kids healthy. She patiently helped me limp through several topics of conversation in Nepali; Sita was clearly going to be the best language teacher I could hope for.

We arrived at our destination, consisting only of a few scattered houses on either side of the trail, after substantially more than the predicted half hour. We set up our equipment under a tall tree that had a curved stone wall ringing its base – giving the odd impression that it was the tree’s rock foundation. Called a chautara, the site was a well-recognized meeting place for the village. Before long local women appeared, with one or several small children either on their backs or holding their hands. Tul doubled as recorder, Sita gave the health education messages and we both gave the injections. The women seemed shy, afraid to look at me directly, but they smiled back when I smiled at them and their babies. I noticed two women conversing with Sita and then giggling at something she said.

“Sita – what did they ask you?” I queried, wanting to be in on the joke.

“Oh, MemSaab – these rural people! They asked if you were a man or a woman, because you don’t dress like them.”

I was shocked — and felt slightly foolish and humiliated, my femininity questioned. I had already realized how different physically I was to the Nepali village women – light skinned, brown haired, blue eyed, and at least six inches taller than most. This comment made me realize how different I looked to them in other ways – very unlike what they had identified as “woman” every day of their lives. I hadn’t noticed that my below-the-knee skirt was similar to the garment that many of the older men wore, and I didn’t wear the traditional gold earrings of women in that district. The Nepali women all dressed alike, with long cotton skirts that were essentially a large overlapping tube held in place by a thick cummerbund. They all wore long-sleeved cotton blouses with mandarin collars and ties that that crossed in front – a style no doubt evolved to simplify breastfeeding. Some had turbans wrapped around their heads. Many wore elaborate nose rings, of tooled gold that hung down over their upper lips. I found out later that for most villagers Western women had a kind of gender-free status, allowing us to do things that only men typically did, such as travel unaccompanied or meet with village elders. What did these women think of their lives, and mine? I must look like a gangly freak to them, I sighed. Just one more thing to get used to.

But it was not only appearance and gender roles that set us apart; the poverty of the villages was also sadly apparent. Many of the women wore skirts so tattered, faded and dirty that I could hardly recognize the color underneath. They spoke very little, with an air of resignation about whatever was to happen. The day was dusty and hot, and for the first time I noticed the swarms of flies that seemed to follow me wherever I went, landing on my ankles and on the faces of the children around me. Skinny yellow dogs wandered about, looking desperate for the smallest morsel of food. Most of the children, though they looked beautiful to me as all children do, wore ragged, dirty clothes with many unwiped noses among them. They were oddly quiet, at least until the dreaded needle came their way, and then they screamed in panic and clung to their mothers.

Everything that day was a wonder to me – I couldn’t take it all in, and at times found I was shocked to see myself in this startlingly new environment. This was Asia. This was me, living in Asia, working in Asia. I would occasionally flash back to movies I had seen about Americans living in foreign places, and wonder how I would appear on the big screen. Not exactly glamorous, with my dust-smeared clothing and so many flies buzzing around my legs that I had to continually do a little shuffle to keep them from biting.

When we had vaccinated all the children we could find, that easy downhill trek turned into the part I dreaded, going back uphill. But we had finished early, and the return to camp was a more or less leisurely two hours. By the time we approached the camp I was once again anticipating some of that quiet time that I have always seemed to need – space to go inside my head, to let the “me” inside have a rest. Ah, the tent, there it was. Bliss.

Not quite. As we came closer I saw a small group of men talking excitedly to Bhim Raj as they watched our approach.

“MemSaab, baby sick,” he said in English and then launched into some detail in Nepali, explaining that I needed to go to a neighboring house because a small child was ill and perhaps I could help. I missed a few finer points of the explanation, no doubt, but what needed no translation was the anxiety and sense of helplessness of the men – who it seemed were family members of the sick child. One was the child’s father, a very thin older-looking man who had heard that there werebideshis (foreigners) in the village and they no doubt were doctors and had medicine (the usual assumption). I started to object, aware that I had no clinical training in pediatrics nor in tropical diseases, and I hadn’t the slightest idea of what medicines we had that might be helpful even if I could figure out a diagnosis.

But it was a short-lived objection. I’d soon learn that when there was no one around who knew more medicine than I, there was little choice but to do what I could and hope for the best. I scrambled through the bag with the medicines we kept in our tent, shoved a few bottles and a stethoscope into my daypack, and set out with Sita and the men to the baby’s house.

It wasn’t exactly nearby. Sweet Jesus, I muttered to myself. Will I ever believe these people’s estimates of time and distance? After an hour of up and down hill on a small trail, passing a few scattered houses, it was obvious when we reached our destination. A small crowd was gathered around a large house just off the trail, and as we drew closer I could see a child about two years old on a straw mat on the porch.

Sita whispered, “They are of the Kami caste, MemSaab, so they wait for us outside.”

Although I had been only a few short weeks in Nepal, I already understood that the Kami were one of the untouchable Hindu castes, and people of the higher castes did not enter their homes. They were taking precautions, making sure that the child was outside their “polluted” house in case help arrived in the form of a higher-caste Hindu. The thought of such discrimination revolted me, and I later wondered if the discrimination against lower castes in Nepal was so different, even if less subtle, from that endured by African Americans in my own country. But for the moment that concern was overshadowed by the task ahead.

I moved up to the porch, and the neighboring crowd moved aside. The little boy was very pale, eyes rolled back, breathing in rapid, shallow grunts, and clearly unconscious. One thing a nurse learns in working with children, more clearly than all the detailed symptoms or procedures or medicines she memorizes, is what a sick child looks like. This was a very sick child. I realized that this baby could likely not be saved even if we had an ambulance waiting to whisk him away to a pediatric emergency room, lights and sirens announcing the importance of his life, his parents’ panic, the neighborhood’s care and concern.

And alas, there was only me. I picked up his grubby little-boy hands, felt his swollen abdomen and pinched his skin to look for signs of dehydration, and completed a cursory exam. In my halting Nepali I asked the boy’s father about how and when the illness had started and posed the other usual questions—when was he last awake to eat and drink, had they given him any medicines so far. But nothing in what I saw or heard fit with a specific diagnosis – no diarrhea, no cough, no rash, just a fever and eventually – this.

I realized then that in all my years as a nurse, I had never faced this situation: someone was dying, I was the only one who could help, and I was helpless to do anything at all. Waves of something like panic rose in my chest. I struggled to maintain a calm demeanor, aware of many eyes on me. I covered the baby’s bare body with a wrinkled cloth that was lying beside him, took at deep breath, and said gravely to the father, “He is very, very sick.”

“Will he die?” was his response.

Before I could answer, I heard Sita say softly, “MemSaab, the mother.” A group of women had been inside the house, and I looked up to see a small woman, in her late 30s I guessed, worked her way towards me. She was weeping, wiping her eyes with her sleeve, with a look of anguish on her face that combined despair and anger – despair because she didn’t have to be told that her child was dying, anger because, as it turned out, this was the second child she had lost.

She began a litany of what she had suffered, and even as I wasn’t sure I understood the details, I was clear on the sense of it. She wailed that she could not go through this again, she just could not. She had seven children still alive, and that was enough. Was there not something she could do to not have any more? “Pariwar niyojan” was a national slogan – plan your family. Could I help her do that? If I couldn’t save her baby couldn’t I help her with that one thing so she would not have more children, just to see them die?

But family planning was mostly just a slogan in that district, and I had nothing to offer. I took the mother’s hand, struggling in vain to find the words in Nepali for ‘I am so sorry,’ hoping that she could see that I understood her pain. My throat seemed to be swelling nearly shut in an effort to hold back my own tears. She continued to cry, more softly now, and went to sit by her baby son.

I had a sudden glimpse of the scene that was unfolding: the dying patient, the anxious family, the nurse. The question asked by the boy’s father seemed to hang in the air, unanswered. And then another picture came to me, when as an emergency room nurse I had encountered a man whose wife had been brought in after a tragic and, as it turned out, fatal accident. He was frantic, wild-eyed, screaming for someone who could help. I had abruptly shifted my care-giving priorities at that moment from the woman to the man, from the dead to the living, and spent the next hour trying to help him face the new and awful reality of his wife’s death. Remembering that time, a feeling of strength returned, confidence that I could do what was needed. I was the healer, but as in any setting, the healer could not always save the patient.

We stayed a bit longer. I spoke to the father again, wanting the family to understand our concern and sympathy, but that we had no magic to keep the child alive.

I knew that the poverty that the little boy’s family endured was very close to the worst in the world. But the cause of his mother’s pain was not just lacking the means to buy food, clothes, the essentials of life – as important as they were. It was having no power over what she could and could not do. She was among the most powerless individuals I could imagine: low in status as a Nepali woman, a member of the lowest possible caste, in one of the poorest countries of the world. She had no control over her life, her choice to reproduce, her ability to keep her children well. In contrast, I was there in Nepal purely because I wanted a change, an adventure. I felt my own privilege shining out from me like an unwanted aura, and it embarrassed me. She was deprivation, pain and poverty; I was privilege, wealth, excess. What on earth was I doing here, with my Girl Scout desire to “help people?”

As Sita and I slowly made our way back up the trail to camp, I struggled to understand what sense I could make of this little boy’s death, of his mother’s anguish. Part of me wanted to shut it out of my mind, but I knew that these recent moments would be burned into my memory. What could I do with this awareness of the misery that I had just witnessed? Would I see this again and again, and finally be unaffected by it? Was simple acceptance the best path, the only one, or was there another way?

It was clear that this scene did not fit the common story line about the fatalism of the simple rural people: because so many village children die, they “get used to it.” This mother wasn’t used to it, her family and neighbors didn’t accept it as inevitable, and I couldn’t either. As much as I thought I knew of the world, I had just come face to face as never before with its essential unfairness. No mother should have to see her child die, I thought. Yes, these things happened, but I had never seen a death that was so unnecessary, so devastatingly unjust. The baby’s problem was likely something that a simple antibiotic at an earlier stage would have cured.

We were told the next day at breakfast that the little boy had died during the night. As it happened, I was never again called to see a dying child, though I knew children continued to die from causes that could have been prevented. But there was usually no one for the family to call in those last desperate hours.

Over the many months I often pondered the questions that had slapped me so abruptly in the face that first day of work in Nepal, and many others as well. Why did the village people work so hard, and still have so few material goods to show for it? Why were most of the children so giggly and happy, even though malnutrition seemed rampant and death rates high? How could the families I sometimes ate with be so warmly generous, always providing the best they could despite their shocking poverty?

As time went on I saw more and more similarities of this culture with my own rural upbringing. I saw the older women worship faithfully every morning at their Hindu shrines – so much like my own mother, who prayed devotedly to a Catholic God. Over time I saw how, for both Sita and me, having meaningful lives meant living outside the norms that mandated a stable life of husband and children. Over time my affection for the Nepali staff I worked with grew to the point that I thought of them as family, some of them close family.

When I left Nepal, I still had far more questions than answers to the mysteries I had encountered. But I had learned what I needed to know to go on with a sense of my place in the world: the globe is a vast, unknowable orb of people and their stories, and as much as our lives differ the stories are universal. There is pain and suffering, there is beauty and injustice, and there are surprises. In place of my simplistic desire to “help people” I learned that it was more important for me just to be with them – to understand their lives as fully as I could, to respond as I would to anyone in need. Most importantly I learned that I was not an alien; I was one of them.



Mary Anne Mercer began life in rural Montana and recently returned to her Montana roots, where she is rehabilitating a small ranch near Red Lodge. She holds a doctoral degree in public health and is on the faculty of the University of Washington in Seattle, where she teaches global health. She has worked or studied in 15 developing countries, lived in rural Nepal and Thailand, and currently supports maternal and newborn care projects in East Timor for a nonprofit organization, Health Alliance International. In addition to academic publications, Mary Anne co-edited a book on the health effects of globalization, “Sickness and Wealth: the Corporate Assault on Global Health” and blogs for the Huffington Post. During the school year she also sings and studies writing in Seattle.