Several of our ATP leaders have had exciting opportunities to spend this year abroad working on global health projects. Here’s a reflection on access to clean water written by Matt Fleming, who is spending his year in Nepal.
Nepal & Water: A Complex Stream
Nepal, according to the signs that greet you at Tribhuvan International Airport in Kathmandu, has the second (!) largest supply of natural water resources in the world. Then why is it so difficult to find water here in Nepal? I’ll attempt to expand on this theme using some personal anecdotes and data referenced below. Bear with me, this will be quite a bumpy and potentially emotional ride.
During my short time here in Achham I have learned that water is one of the most sought after resources for all people, all day, every single day. Currently the monsoons are going strong (including the loudest and brightest 3 hour absolute raining cats and dogs thunder and lightning storm I’ve ever seen) and will last for several more weeks. Even during this season, when water stores are theoretically high, the Director of Facilities here at the hospital mentions the water supply level and how long it will last at the weekly hospital update. This information is as important as the number of patients currently in house, systemic issues identified during the last week, and any new developments pertinent to patient care or operations of the hospital.
A Quick Tributary: Some Background on Nepal
This is a country in which the World Bank estimates that 25% of the population lives below the international poverty line (~$1.25/day). Two out of 3 people live in rural areas and mostly depend on agriculture for their livelihoods (ref: here). Additionally, the United Nation’s Human Development Index (a calculation that includes life expectancy at birth, mean years of schooling and expected years of schooling, and gross national income per capita) ranks Nepal 157th out of 187 ranked (ref: here). It’s estimated that 19.8 million Nepalese, in a country of around 30 million, don’t have access to proper sanitation. Official figures note that 80% of the population has access to clean water; however, when functionality of water sources is taken into account, it’s more like 53%. WaterAid, an organization working in Nepal to improve access to clean water and improved sanitation and hygiene, estimates that the budget for water and sanitation (currently 1 million USD) would need to be increased 14 times to accomplish the millennium development goal of 100% water access by 2017 (ref: here). After a decade long civil war between Maoist supporters and the government in Kathmandu that ended in 2006, the public sector was left without clear leadership. As a result of this, and many other political and social factors, public services have lacked strong advocates and financial backing by a fractious central leadership. Back to water. . .
On the jeep ride from Dhanghadi to Achham, driving past mud and tin topped houses nestled in the hilly terrain, I saw kids and adults washing from the pipes on the side of the main road, collecting water for cooking and drinking, and cleaning their clothes, all from the same source. From what the locals here have told me “the government” turns on public water supplies for a few hours in the morning everyday. Each morning, starting with the cry of the hens and the light of sunrise you can see locals- usually moms and children- walking up and down steep and slippery hillside trails carrying large pails. As an aside, these pails bear a strange resemblance to those I associate with carrying gasoline in the US. From what I understand, during the dry season that begins towards the end of winter, the “government” controls the on/off switch for these public water supplies. There is no announcement or warning of when or where there will be water shutoffs or shortages. For the people of rural Nepal when these water shortages occur there is no supermarket to purchase clean water at, no secret stores of water to fall back on, and no guarantee that tomorrow the faucet will turn on.
Economics: Scope and Tragedy
40% of Nepal’s GDP is attributed to agriculture and most of this is rain fed. As a result, agricultural production and many families’ livelihoods are subject to frequent devastation from droughts and floods. Estimates suggest that 17% of cultivated lands in Nepal have year round irrigation (Ref: here) while just under 50% have ‘some kind of irrigation.’ Clearly, water is an issue of national importance, affects rural communities disproportionately compared with urban ones, and plays a large role in the national economy, as demonstrated by the nation’s reliance on agriculture.
I will use the tragedy of the Kosi River flood of 2008 to help elucidate the complexity in the management and distribution of water in Nepal and India. Poor construction of river embankments and poor communication among different branches along the Kosi river lead to the devastating flood of 2008, ultimately affecting over 2.5 million people in southern Nepal and northern India. This disaster was exacerbated by the fact that when dam officials realized there was a leak in a stretch of the Nepal embankments and faxed a report downstream- apparently animals had been eating away at the banks causing the leaks- there was no one in the office to receive the fax (the appointed official for that station was on leave/vacation and no one had replaced him). Some news reports suggest that the central government of India was unaware of the flood for up to 5-7 days after it began. The breach in the embankment caused 95% of the water from the river to leave via what would eventually measure greater than a 3km wide breach (References: here, here, here). Millions lost there homes, land, medicines, and food stores, the Indian government declared a state of emergency and eventually enlisted the help of the Air Force to deliver supplies and rescue those in need.
Another example of the intricate relationship Nepal has with water is India’s plan to build a hydroelectric dam within the borders of Nepal. This dam will provide power, irrigation, and flood control for India while displacing an estimated 75,000 Nepalis (homes, land, businesses, and culturally significant sights) (ref: here). As the horrible cholera outbreak in Haiti demonstrated, water sanitation and safe waste management solutions can affect global communities (NYT article on cholera epidemic in Haiti originating in Nepal here), not only those who live within the confines Nepal’s border. As evidenced by these stories above and the data previously cited, there have been massive public sector failures, poor leadership from governmental and non-governmental organizations (the UN in the case of the Haiti cholera outbreak), and great difficulty in supplying native Nepalese with sufficient water for their health and sustenance. As we’ll see below, the private sector also shoulders great responsibility in not improving water access to Nepalese citizens.
The Melamchi River Project: Improving Access for the Urban
In an effort to supply water to the over 2 million residents who live in the Kathmandu Valley, the central government started the Melamchi Project. The Melamchi Project (Melamchi Water Supply Project), when complete, will divert 170 million liters of water per day to the Kathmandu Valley. The project consists of a 27km long pipeline that will divert river water from the Melamchi river to a water treatment plant (part of the project) that will then supply the Kathmandu Valley. The project, started in 2000, was supposed to be completed in 2007, but in late 2012 the government terminated the contract of the Chinese contractor hired to build the pipeline and treatment plant. The project has been delayed twice now, first until 2013, and now until 2016. The government has initiated bidding for contractors and hopes to restart the project within a few years.
The KTM valley requires approximately 320 million liters of water per day. Currently, the Valley is supplied with 90 million liters per day during the dry season and 150 million liters during the rainy season. With the completion of the Melamchi River Project, Valley residents will have significantly improved access to almost sufficient supplies of water. Now, strong public sector and non-governmental advocates need to leverage their political clout to partner with a professional contracting company to deliver basic human rights to a population in need. Here’s to hoping construction begins again soon and the project is completed on time. Note: this will not improve water access in the Far Western Region, where Achham District is located.
Bringing it Back to Achham
Frequently when I go to use the restroom here at Bayalpata Hospital in Achham I encounter women and children filling their plastic pails with water. Often, they have a worried look in their face as if to say “please don’t tell anyone.” I have extraordinarily mixed feelings about Nepalese from communities near and far using the clean water resources of the hospital.
On the one hand, some may argue that folks like those mentioned above, who are not patients at the hospital and do not work with Nyaya Health, are taking away resources from patients whose treatment and health may depend on clean water. These folks are, one may say, using a resource and infrastructure that was not meant for their use. In a boardroom, a strategic planning meeting, or development conference it may be easy to use these arguments to explain why we should not let these Nepalese use the hospital’s water resources.
On the other hand, and allow me to be rhetorical for a moment, did anyone teach me (or likely you) to have access to clean water (many of you are likely familiar with a favorite global health idiom “don’t give a man a fish, teach him to fish”)? How about access to medical care, dental care, appropriate sanitation facilities, a reliable source of food, and so on?
I have never had to think about where I was going to get food and clean water from, where I was going to bathe or use the restroom, whether I could afford the prescription from my pediatrician or emergency department. In reflecting on these truths, and the fact that there are basic human rights that we (Westerners, Americans, NGO workers, healthcare professionals, compassionate people, ‘do gooders’, whomever) cannot teach populations to have access to. Perhaps the old global health adage “give a man a fish and you feed him for a day, teach a man to fish and he eats for life” needs a more modern adaptation to accurately assess the rights of individuals and the responsibilities shared by the intersection of the public, private, and non-government sectors.
In summary, what right do I have tell someone that they don’t have a right to access the clean water that comes from the hospital? How do I have any more authority than an average Nepali to determine who receives access to this resource? If anything, the people of Achham have more of a right to the hospital’s water supply than perhaps I do- they have lived here, and will continue to live here, for generations to come.
All I can muster when entering the restrooms in the hospital, which have faucets and running water most of the time, is a quiet “Namaste,” a small head node, and a quick smile.