The Foot Soldiers of Change: An Investigation of the Human Factors Operating in Maternal Health in Non-Western cultures through the Agency of Photography
Author McIlvenny, Kelly
Published 2016
Thesis Type Thesis (Professional Doctorate)
School Queensland College of Art
DOI https://doi.org/10.25904/1912/745
Copyright Statement The author owns the copyright in this thesis, unless stated otherwise.
Downloaded from http://hdl.handle.net/10072/367607
Griffith Research Online https://research-repository.griffith.edu.au
The Foot Soldiers of Change: An Investigation of the Human Factors Operating in Maternal Health in Non-Western cultures through the Agency of Photography
Kelly McIlvenny BDigitalMedia(Hons)
Queensland College of Art Griffith University
Submitted in fulfillment of the requirements of the degree of Doctor of Visual Arts
July 2015
ABSTRACT
This research investigates and engages with the layers of intervention involved in Nepali women seeking biomedical care during pregnancy and childbirth, through the agency of photography, interviews and participant observation. Documenting the layers of medical intervention in this manner allows for a cultural critique of how such immense social change, visible in the statistical analysis of maternal health indicators, is playing out on a micro level. This research engages with the women who have gained enough social capital to influence birthing practices both in biomedical intervention and social practice. This research is based on photographic documentation and participant observation conducted with women either in the process of birth or afterwards whose survival is due to the assistance they have received.
This exegesis outlines the contextual elements surrounding my photographic work, discussing the challenges and opportunities of cross-cultural visual documentation. Placing the research within the political and historical environment of Nepal, the paper outlines the narratives that Nepali women become entrapped in. The particular history of the state of Nepal’s maternal healthcare, and how women have played an integral role in its changing state will be discussed. Considering the visual portrayal of maternal health worldwide, both in photojournalistic photographic essays and more commercial outputs, there seems to be a growing voice for the plight of women during childbirth and pregnancy. This paper will shape where this visual research may sit within that expanding chorus of ideas and voices. It will discuss the employment of both traditional and new media documentary methodologies to create novel ways of engaging with the topic of maternal mortality; in particular, looking at ways of creating a visual representation of women in Nepal that neither glazes over their challenges nor ignores their abilities.
Statement of Originality
This work has not previously been submitted for a degree or diploma in any university. To the best of my knowledge and belief, the thesis contains no material previously published or written by another person except where due reference is made in the thesis itself.
Kelly McIlvenny Date 18 February 2016
Table of Contents Page List of Figures 1
Acknowledgements 4
Foreword 6
Introduction 8
Chapter 1: Background Investigation 10
Chapter 2: Visual Methodologies 17
Chapter 3: Fieldwork 33
Chapter 4: Creative Outcomes 77
Chapter 5: Conclusion 81
Reference List 83
Ethical Approval 88
List of Figures
Page
Figure 1 Kelly McIlvenny, Babita (left) and midwife Manju (right) holding 6 Babita’s two-month-old child, delivered safely at home under the care of Manju, February 2011. Figure 2 Kelly McIlvenny, Sadikshya Regmi and Surya Bhatta's wedding 14 day, February 2013. Figure 3 Google Maps, Map of Nepal, 2015. 34 Figure 4 Kelly McIlvenny, One Heart World-Wide's Foot Soldiers of 37 Change, 2012. Figure 5 Kelly McIlvenny, Welcome Labour Room: The Story of Maternal 38 Health in Nepal, Images from the exhibition of Welcome Labour Room: The Story of Maternal Health in Nepal at the Airport Gallery North in Sydney and the Gallery on the Lane, Gold Coast, 2012. Figure 6 The International Museum of Women, MAMA: Motherhood 39 Around the Globe. Welcome Labour Room was presented as a feature story in the MAMA exhibition curating stories on motherhood from around the globe, 2011. Figure 7 Kelly McIlvenny, View from the Baglung Highway, 2013. 43 Figure 8 Kelly McIlvenny, The Narayansthan Health Post, February 2011. 44 Figure 9 Kelly McIlvenny, The suspension bridge over the Kali Gandaki 44 River that connects Narayansthan to Baglung when the steep dirt road becomes impossible to travel on due to weather or damage. Figure 10 Kelly McIlvenny, Standing in front of the Narayansthan health 44 post, you can look across the valley to Baglung Bazaar. Later in this research, the geographical challenges become more apparent as the field research penetrates deeper into the district. Figure 11 Kelly McIlvenny, Tilkumari Kolpata, 58, has been volunteering as 45 a Female Community Health Worker in Narayansthan for over 15 years, February 2011. Figure 12 Kelly McIlvenny, Bina Kumari B.K., 31, has been volunteering in 47 Narayansthan S. Namunagow for seven years, February 2011. Figure 13 Kelly McIlvenny, Janaki K.C. proudly shows me the sole operating 51 theatre in the district, fortunately for the mothers of this district the operating theatre is located just meters away from the delivery room in case of an emergency, July 2011. Figure 14 Google Maps, Map of Baglung District, 2015. 53 Figure 15 Kelly McIlvenny, The Female Community Health Workers of the 53–54 villages of Resha, Lekhani, and Batakachur during a week long course, training them in newborn care and emergency resuscitation techniques, 2013. Figure 16 Kelly McIlvenny, Maya Devi Gautam (top left), 31, has been 55 working as an FCHV for eleven years in Resha, Bainthan. Dhanmaya Shrish (top right) has been serving as a Female Community Health Volunteer for 17 years in the village of Lekhani. She is the mother of three healthy daughters, and here tells the story of her second child who would not live to see their
1 first day. Luxmi Kunwar (bottom left), 21, has been serving as a FCHV for one year in Resha – 8, Anchusmuni. Bhumi Devi Hiure (bottom right), 38, has been working as an FCHV for eleven years in Lekhani, 1 January 2013. Figure 17 Kelly McIlvenny, Skilled Birth Attendant, Devi Korki, 30, checks 56 on 36 weeks pregnant Sita Khadka, 20, who recently became a female community health worker. January 2013. Figure 18 Kelly McIlvenny, when I first met Taulkmaripun, the silence was 57 almost intrusive, as she lay almost motionless while the nursing staff and students surrounded her to check her drips, 2011. Figure 19 Kelly McIlvenny, Janaki K.C., a staff nurse at the Baglung District 58 Hospital, checks the newborn girl’s skin and damaged hands. She explains the blue around the mouth and limbs is not normal, indicating the new life is not obtaining enough oxygen, 2011 Figure 20 Kelly McIlvenny, The mother’s sister gathers up layers of fabric 59 for the nursing students to wrap the newborn girl in preparation for taking her to Pokhara, where she can receive further treatment, 2011. Figure 21 Kelly McIlvenny, Heema Shiris, the Skilled Birth Attendant for 61 Pandav Khani, November 2014. Figure 22 Kelly McIlvenny, Pictured above, the top photo shows the village 64 nestled into the side of a 4,000-metre peak taken from the road leading into town. In the second image you can see the health post, the white building on the right hand side located near the bottom of the village in the densely populated centre of town, November 2014. Figure 23 Kelly McIlvenny, Rupa and Dammar Shrees pictured above 24 66 days after the birth of their baby boy. Heema Shiris checking on both mother and child. Likewise Rupa Pun, 19 pictured below with her 14-month-old daughter, Qurina Pun, faced a similar fate with Heema negotiating unborn Qurina’s legs first from in her mother’s birth canal, November 2014. Figure 24 Kelly McIlvenny, Chandika Sapkota, Skilled Birth Attendant of 67 Hatiya, November 2014. Figure 25 Kelly McIlvenny, Chandika Sapkota, Skilled Birth Attendant of 68 Hatiya, completing her daily duties at home, November 2014. Figure 26 Kelly McIlvenny, Chandika Sapkota, Skilled Birth Attendant of 68 Hatiya enjoying a quiet moment at the Hatiya health post. November 2014. Figure 27 Kelly McIlvenny, Kalpana Sapkota Acharya, Gwalichaur’s Skilled 69 Birth Attendant, feels the skull of 28 day old Ritesh Kharel, Gita Kharel, 19, child. November 2014. Figure 28 Kelly McIlvenny, (From left to right) Bishnu Pariyar, 30, with 70 eight-month-old Skikha, Kopila G.C., 22, with two-and-a-half- year-old Jibika, Shanta Ghimire, 24, with one-year-old Shiru, and Bashanti Acharya, 29, with five-month-old Shanti, November 2014. Figure 29 Kelly McIlvenny, Kamala Karki, Baglung District Hospital, 72 February 2014. Figure 30 Kelly McIlvenny, Kamala Karki is taken into the operating room 73
2 undergo a caesarean section at the Baglung District Hospital, February 2014. Figure 31 Kelly McIlvenny, Kamala Karki’s husband Dipak holds their 74 newborn child for the first time while his wife is still in surgery at the Baglung District Hospital, February 2014. Figure 32 Kelly McIlvenny, Kamala Karki rests with her two-day-old 75 wrapped in layers of blankets to protect them from the winter chill inside the post-operation room. February 2014. Figure 33 Kelly McIlvenny, Jalmaya Sunar, 17, and her husband travelled 76 one and a half days from their home in Bongadoban, in order for Jalmaya to have a caesarean due to an arrested labour. February 2014.
3 Acknowledgements
In dedication to all of the women who participated in this research: This would not be possible without you.
In memory of Margret and James McIlvenny For the man who introduced me to the intimacy and power of the photograph, and the woman who unconditionally supported us.
To all who opened their homes and lives to the project, you have my deepest gratitude for your kind hospitality. With sincerest gratitude, I would like to thank the staff of One Heart World-Wide for opening the doors to this research. In particular, I thank Arlene Samen, whose openness and encouragement allowed for such a partnership to begin and continue. To Sunita, Surya, Anji, Manju, Laxmi, Suraj and the rest of the One Heart support staff, I thank you for your time, company, translation and laughter on my trips. I look forward to working with your team for years to come. My gratitude and appreciation to my supervisors Dr. Donal Fitzpatrick and Dr. Laini Burton for their unwavering support and encouragement over the past three years. In particular, thank you Donal for many hours of discussion and posing the hard questions that needed to be answered. I am grateful to all my mentors past and present, in particular Jack Picone for beginning this journey with me as my supervisor in Honours. Your generous guidance and insightful mentorship has shaped my practice, and helped me take new directions in my life. My deepest appreciation goes to my family, friends and partner who unconditionally supported my endeavours, including my German Shepherd who has acted as both sounding board and therapist.
On a personal level, it has been rewarding to be a part of the One Heart World-Wide family. The work is deeply indebted to the field trainers who acted as translators, companions, logistics managers, and invaluable collaborators. Without them, this work would not have been able to create such a diverse and sustained inquiry. In particular, I would like to thank Sunita and Suraj for their enthusiasm, insight and partnership. Mostly, I thank them for their trust and latitude in providing the freedom
4 to work undirected, but also the support to create ethical and sensitive practices. The ability to return to the sites of previous trips and watch the changes taking hold is something I hold dear, while exploring the areas where these programs are only just beginning to make an impact is important to understanding what challenges continue to impact on women during childbirth and pregnancy in Nepal.
5 Foreword: The Beginning
Figure 1: Kelly McIlvenny, Babita (left) and midwife Manju (right) holding Babita’s two-month-old child, delivered safely at home under the care of Manju, February 2011.
My feeling is it’s not what you’re going to get. More like what are you going to give? What are you going to learn? There’s so much to learn out there with a camera. It gives us power for educating ourselves and for educating others. We have to be patient, try to learn as much as we can until there comes a point where we have something to share with other people. And that doesn’t come for a long time.
—Donna Ferrato (Light 2000)
For me, the camera has always been a tool to record the things I dare not forget. The precious moments that make up my existence, and my shared existence with my fellow travellers on this road we call a life. This particular journey began where roads stop, and you must take to foot to continue—at least at the time of year when the lack of rain turns the roads to dust, hindering the most able jeep. In the small examining
6 room of the Paiyanpatta village health post, two women would alter my understanding of the immeasurable value that small changes and shared knowledge make on the individual. As seventeen-year-old Babita sat, happily bouncing her two-month-old baby on her lap, her midwife Mauju explained to me that she had given the young mother pre-natal vitamins and iron tablets, and that together they had prepared a birth plan. Babita had given birth at home with a clean birth-kit under the watchful eye of Mauju, knowing that if there had been a complication, they had a plan to get her to Baglung hospital, a two hour hike down the mountain-side. These simple medical interventions—vitamins, a clean birth-kit, and a trained and prepared midwife—were unheard of in these mountains even a few years ago. Sitting watching the two stunning women enveloped in the colours of the Himalayas, cooing at the waking child, against the vibrant blue of the health post walls, I could not help but think that they had something valuable to teach me. Indeed, there was something to learn here: the nuances of social, economic, and cultural change and the profound effect they can have on women. This moment with these two women would lead me on a series of trips, deep into the ideas and places that are affected by the women working towards change. The following is the rest of the journey, one in search of knowledge and understanding through the lens.
7 Introduction
The reality of maternal health worldwide is grim: over 800 women die every day from preventable complications during pregnancy and childbirth (World Health Organization 2012, 1). Despite experiencing a harrowing civil conflict from 1996 to 2006, Nepal has achieved the remarkable by lowering its maternal mortality ratio by almost 75% in the past two decades (Khanal et al. 2012, 1). Research has only recently recognised the large role that female community health workers have played in this achievement. My research seeks to visually document these women as agents in a process of social and cultural transformation, by recording the stories that engage with this successful social change. This visual research documents the human factors operating in maternal health in Nepal. As a documentary-photography research project, it aims to contribute new and extend existing knowledge of the issues and tribulations facing women in impoverished and isolated regions of Nepal during childbirth and pregnancy. A result of the invitation of the International Non- Government Agency (INGO), One Heart World-Wide, this research has reached out to women in the remote western regions of Nepal through the process of visualisation. By making these agents visible, it is anticipated that this research will contribute to a critical understanding of both the causes and effects of poverty on expectant and new mothers and the innovative programs that are changing these women’s realities.
This exegesis outlines the contextual elements surrounding this photographic work, discussing the challenges and opportunities of cross-cultural visual documentation. Placing the research within the political and historical environment of Nepal, the paper outlines the narratives that Nepali women become entrapped in. The particular history of the state of Nepal’s maternal healthcare, and how women have played an integral role in its evolution will be discussed. Considering the visual portrayal of maternal health worldwide—both in photojournalistic photographic essays as well as more commercial outputs—there seems to be a growing voice for the plight of women during childbirth and pregnancy. This paper will shape where my visual research may sit within this expanding chorus of ideas and voices. It will discuss the employment of both traditional and new media documentary methodologies to create novel ways of engaging with the topic of maternal mortality; in particular, looking at ways of creating a visual representation of women in Nepal that neither glazes over their
8 challenges nor ignores their abilities. This new research will expand on the work created for my Honours degree (2011, 1st class), which culminated in the multimedia project and exhibition Welcome Labour Room. It is framed around the following research question: What are the roles played by women, as agents of medical intervention, in producing Nepal’s successful reduction in maternal deaths over the past twenty years, and how is this result attained within the constraints of the physical, cultural and social environments of Nepal? Before proceeding, I will provide a brief chapter outline.
Chapter 1 will briefly introduce the history of Nepal, outlining some of the country’s social problems, particularly maternal mortality and how the rate has improved in recent years despite challenging circumstances.
Chapter 2 will discuss the visual methodologies that this doctoral work has employed and benefitted from. It explores the guidance and examples of mentors and teachers, key lessons I have learnt from the breadth of photographic art practice and history and the visual canon that this research stems from.
Chapter 3 will outline the fieldwork conducted during this research and feature and discuss the resulting photographic documentation. It will contextualise this work within the literature and the social aims it hopes to achieve.
Chapter 4 will review the creative outcomes of this research project.
9
Chapter 1: Background Investigation
1.1 Nepal’s Historical, Political and Social Landscape
Nepal has been often presented as a single vision; one of idyllic villages, with mountains for those who dare climb them. Those who pay particular attention to the news may have had this singular vision disrupted in 2001, when the Himalayan kingdom’s King Birendra Bir Bikram Shah was killed in a massacre at the Narayanhiti palace. Following his death, the country plunged into chaos, and thousands of lives were lost to a violent Maoist insurgency. Manjushree Thapa explains in the novel Forget Kathmandu: An Elegy for Democracy (2005),
In this period it wasn’t easy for Nepalis to trace what was going wrong, because so much was…Yet if we in Nepal were unable to understand our present, so too was the rest of the world—or those segments of the rest of the world that were paying us any attention. The last anyone knew, this was a pre-political idyll, a Himalayan Shangri-La good for trekking and mountaineering and budget mysticism. Suddenly, the news out of here jarred: Maoists? In this day and age? In a Hindu Kingdom full of simple hill folk? (Thapa 2005, 1–2)
Despite Nepal’s geographically significant position between the two Asian giants of China and India, it remains largely outside of mainstream media. However, it recently again received international attention for a freak blizzard that hit the Thorong La pass on the popular Annapurna Circuit trekking route, killing forty people by burying them under at least thirty-five feet of snow (Barry and Bhandari 2014).1 The economic politics of tourism in a developing country, where trekking agents work for roughly ten dollars a day and are ill-prepared to meet developed nations’ expectations of safety, remained in the media for a few days, with little being discussed on Nepal’s political history.
1 Please note, this exegesis was written before the devastating earthquake that killed over 8,000 people and destroyed over 500,000 homes on 25 April 2015. While not covered in this research, I returned to Nepal in June 2015 to document how the devastating effects of the earthquake would affect Nepali women and their ability to seek care during pregnancy and childbirth (“Death Toll from Second Nepal Quake Rises as Relief Efforts Spread Thin” 2015).
10
Nepal, as a state, has only existed in its current geographic form since the Gorkha Kingdom, based eighty miles west of the Kathmandu Valley, took control of the Himalayan foothills and a strip of North Indian plain in the eighteenth century. From 1846 to 1951, the Shah dynasty remained on the throne, with effective political power in the hands of the Rana Family. In the 1950s, the Hindu Kingdom removed its policy of seclusion and, with the backing of the monarchy and newly independent India, experiments with parliamentary democracy continued through the decade (Whelpton 2005, 2). In 1960, the royal palace banned party politics, centralising power once again until the mass protests of 1990. In 1980, student protests forced the King to hold a referendum where the panchayat system (partyless framework) won over a multiparty system amid suspicions of electoral rigging. In 1991, elections were held and the National Congress party won. In 1994, internal strife within the party led to mid-term polls, and the Communist Party of Nepal emerged as the single largest party. In 1995, National Congress leader Sher Bahadur Deuba became prime minister with the support of the Rastriya Prajatantra Party (a pro-monarchy outfit). In 1996, the Communist Party of Nepal launched a ‘People’s War’ (Jha 2014). The instability continued, with Nepal unable to see a Prime Minister last a year. Journalist Thomas Laird described the atmosphere in 2001 when Crown Prince Dipendra massacred King Birendra and his immediate family as follows:
After ten governments in ten years, the corruption of the elected politicians surpassed anything of the past, at least in the minds of the people. With few reliable internal news sources and no investigative journalism, suspected corruption—like the back-room deal that led to elections in 1991—remains the subject of shadowy rumors. Ghosts guiding reality. By 2001 the corruption and blatant inefficiency had so tarnished democracy that the king and queen had never been so popular.
King Birendra was shot at a moment when Nepal teetered between left and right. As a Maoist revolt seized more than 20 percent of the countryside, people in Kathmandu wondered aloud if the army, kept in the barracks by squabbling political factions, was conspiring with the palace for the return of absolute monarchy. In the months before the massacre two questions hovered in the air. Who controls the army? Why hasn't it been deployed against the Maoists? (Laird 2001)
11 The Maoists’ People’s War would rage on for another five years, ending on 21 November 2006 when a peace pact was struck between warring forces. As one source notes:
The promise of a new Nepal has collided with the entrenched power structures and the decadent political cultural of old Nepal. Instability has remained the norm, with a government changing every nine months. A multi-class, multiparty alliance enabled Nepal to defeat the monarchy and restore democracy. (Jha 2014)
The insurgency left 16,000 dead; today, the Maoists face the political battle to remain relevant to those who feel they have not lived up to their revolutionary politics (Pattisson 2013).
These revolutionary politics, which sought to demolish the feudal system, continue to play out as the high-caste Hindu Brahmans and Chetris of Indian descent (Aryans) continue to control the government, economy, and own much of the best farmland, while lower-caste Hindus are marginalised. The mountaineers and hill tribes of Tibeto-Burmese descent (including Sherpas), who have animist or Buddhist beliefs, still resent the arrival of the Hindus centuries ago for imposing their culture and religion upon them (Symmes 2001). Meanwhile, tensions over overpopulation, deforestation and corruption have left many economically and socially displaced.
The decade-long civil war persuaded many skilled and un-skilled labourers to seek work in the Gulf states, India, Malaysia, etc. Nepali men have long chosen to work overseas, including the infamous Gurkha warriors who fought in the British Army during the Anglo-Nepalese War in 1816, through both world wars to today. Remittances now make up 28.8% of Nepal’s gross domestic product, according to the World Bank (Balch 2014). This conscription and migration has led to large recruitments of child labourers, with factory owners taking advantage of parents sending their children into the urban areas so not to be conscripted by the Maoists (Balch 2014). The tourism sector, in contrast, only comprises 3% of gross domestic product, with 600,000 foreigners visiting in 2012. However, the rapidly expanding volunteering or ‘voluntourism’ industry has seen the creation of dozens of agencies, with over 80% of the country’s orphanages placed in tourist hotspots. An investigation by UNICEF found that 85% of children in the orphanages they visited had at least one living parent. Many of the children had been trafficked from
12 impoverished villages under the false pretence that the children would receive an education (Pattisson 2014).
Nepal lives in the shadow of regional superpower India and therefore relies on China to balance its economic dependency. So long as Kathmandu continues to stay silent on the struggles of the tens of thousands of Tibetan refugees living within its borders, Beijing will continue to support Kathmandu.
1.2 Women’s Narratives in Nepal
While political transformation in Nepal continues, what is clear is that through war and peace, monarchy and republicanism, nationalism and citizenship, the voices of women have been silent. The ambitious political experiment of Nepal would leave women out of the conversation. The historical account of women has been one of victimhood within a patriarchal society destined to be trapped in domestic slavery and internal displacement, which was contrasted with the narrative of women as propagandists and mobilizers, cadres and guerrillas presented by the Maoists. Rita Manchanda describes the status of Nepali women in her paper “Maoist Insurgency in Nepal Radicalizing Gendered Narratives”:
The abject status of women in Nepal—albeit mediated by differences of class, caste and ethnicity—is reflected in a Nepali saying: “If my next life is to be a dog’s life and I can choose, I’d rather be a dog than a bitch.” The faces of Nepalese women are of women trafficked, of anemic women who die neglected in childbirth, of poor and illiterate women behind bars for miscarriages or abortions, of menstruating women sequestered in cold and un- hygienic cauchholooi sheds, of women without a son abandoned or supplanted in a polygamous marriage and of culturally disadvantaged girl children burdened with a 1:4 ratio of labour load in comparison with their brothers. (Manchanda 2004, 244)
The gender inequalities experienced by Nepali women vary across social grouping, region and socio-economic status. The higher-caste Hindu women are often subjected to the strictest religious ‘exclusions’, while women from the Tibeto-Burman hill tribes often receive higher social autonomy. For instance, in the hill ethnic communities of Magar, Gurung, and Rai, widow remarriage is possible and divorce does not result in loss of ritual status (Manchanda 2004, 245). By contrast, higher-caste Hindu women
13 are often subjected to the practice of Chaupadi where a woman is segregated from familial activities during her period, often sleeping in sheds or outbuildings (Chitrakar 2014).
However, it is the women of the severely disenfranchised segments of Nepali society who face the challenges of trafficking, which is most prevalent in parts of Nepal where unemployment is high, literacy is low, healthcare is difficult to access, and road transport is unavailable (Perczynska 2014). It is estimated that more than 200,000 Nepali women and girls are working in Indian brothels, with more than 7,000 trafficked across the 1,800 km-long (1,118 miles) open border with India, for which Nepalese citizens do not need travel documents or work visas to cross (Williams 2013). Nepal has a long history of bonded labour, and, although the Kamaiya system of bonded labour was abolished in 2000, without any support, many fell back into the trap of indentured servitude (Williams 2013).
Figure 2 Kelly McIlvenny, Sadikshya Regmi and Surya Bhatta's wedding day, February 2013.
More than 40% of Nepali women are married before the age of fifteen, and give birth their first child by nineteen despite the legal age to marry being twenty (Perczynska 2014; Manchanda 2004, 245). Again, the prevalence of ‘love’ marriages varies across communities, regions, castes and ethnic groups, but recent studies show only 25% of
14 marriages are based on the girl’s decision (Perczynska 2014). Like other patriarchal societies, citizenship is passed through the male line, property rights being passed to only male members of the family. Marriage becomes a defining act of a woman in Nepal, a decision that most women are not a part of making. Beyond marriage, a daughter or wife’s role remains much the same for women outside of the main cities: she cuts fodder, bathes the water buffalo, cares for livestock and cooks food—once a mother, she becomes the caregiver to her children.
According to medical anthropologist Jan Brunson, Nepali women traditionally view birth as a natural process, an act that does not require preparation and is beyond human control. She clarifies:
By using the term “natural” I do not intend to invoke a romanticized vision of low-tech, “traditional” birth as the ideal form. Nor do I mean to equate a “natural” view of birth with a purely biological view of it; for “birth everywhere is socially marked and shaped”. Rather I am referring to a worldview involving a cosmic order in which many aspects of life are seen as beyond human control (although efforts or propitiations may be made in an attempt to influence outcomes) as opposed to the mechanistic materialism of modern science that rejects an ordered cosmic totality and instead articulates the world in terms of cause and effect. (Brunson 2010, 1723)
Birth becomes a product of cultural and political-economic processes. The implication of Nepali women stating that birth is a natural process is that childbirth neither requires expertise or assistance of a trained medical professional (including any type of local or traditional birth attendants). Brunson noted in her anthropological study on Nepali women who had access to biomedical care but choose not to access it that women were socialised to keep quiet about their suffering, and men made the decisions, such as what point a situation is dangerous enough to warrant a trip to the hospital. Nepali women are following the social script of a good daughter, good wife, which is “suggestive of the low status of young wives in patrilineal, partilocal societies—who must be self-effacing and not make demands” (Brunson 2010, 1724). However, men traditionally have no knowledge of the danger signs during birth, and historically were removed from the events of birth in order to be protected from the ‘polluting’ of birth and the aftermath—the fluids of birth seen as ritually polluting by the majority of Hindu castes. Historically, Nepali women gave birth in a shed outside of the home, often alone or with the help of a mother-in-law or female neighbour.
15 Further, there is little mention in the literature of one generation of women passing down information to the next regarding childbirth.
Today in Nepal, some women have the social capital to critique the status and treatment of young married women and the “predominant cultural dictate that birth is not a big deal,” (Brunson 2010, 1723), and may have more knowledge of the biomedical approach to birth and proximity to biomedical care (local clinics and hospitals). However, often they do not have the social power to demand emergency care, and men still view birth as the domain of the women and therefore are in the awkward position of making an un-informed decision—leaving both men and women in culturally defined positions and unable to act (Brunson 2010, 1723). However, as later recorded in this research, Skilled Birth Attendants (SBAs) have the skills and knowledge to make informed decisions on behalf of the women, and are developing the social capital to negotiate on behalf of their patients.
This discussion on household-level decisions, as noted by Brunson, can momentarily overlook larger structural issues of high rates of maternal loss—such as poverty among the severely disenfranchised segments of Nepali society. Brunson also notes the dramatic disparities in experiences of women during birth in rural areas versus those in urban areas, wealthy versus poor families—birth is a stratified experience. The urban/rural divide results in the most disadvantaged having the least access to biomedical care (Brunson 2010, 1726).
This research questions how such a substantial reduction in maternal deaths has been achieved within such challenging cultural and physical environments. While not wanting to glaze over the troubling narratives of Nepali women, this research questions how women were able to gain enough social capital to gain access to biomedical interventions. Travelling across the spaces of institutional care in the Baglung District Hospital to individual households, this research asks how international and national players have traversed this diverse cultural and physical space to influence social practice.
16 Chapter 2: Visual Methodologies
Four major factors contributed to the visual methodologies employed in this thesis. Firstly, the guidance and examples of mentors and teachers; secondly, key lessons I have learnt from the breadth of photographic art practice and history; thirdly, a critical investigation that I undertook of the visual canon that this research stems from; and lastly, the conditions that the ‘new’ photographic essay respond to.
2.1 The Guidance of Mentors and Teachers
My visual language has developed under the guidance of mentors and great teachers, among them Stephen Dupont (Reportage Workshop, Kathmandu), Jack Picone (Griffith University, Brisbane), Francesco Zizola (Reportage Festival Workshop, Sydney), and Trent Parke (Magnum Workshop, Perth). Dupont, Picone, and Zizola adapt their approaches to the stories they are telling. Creating affective intimate documentation that effects real change and sheds light on humanism in the darkest corner, their works display a profound dedication to uncovering the complex narratives of social abuses in the contemporary world.
Stephen Dupont’s documentary practice and artist books’ distinct power lies in the blending of multiple narratives. His large-scale portrait projects and exhibitions advocate a new place for photography, a kind of representation that allows both subject and author to be heard. His reportage of Afghanistan over the past two decades blends differing approaches from intimate portraits using Polaroid film to almost cinematic landscapes shot with his Hasselblad, to frantic and otherworldly documentation of the drama of war. When cast together, the differing approaches create a substantial opposition to the traditional narrative of war in reportage. He describes the place that publishing and exhibitions play in his practice:
Publishing books, having photo exhibitions and making presentations allows me to have total control over the outcome. You have responsibility as a single entity to provide the facts, to provide the story. There’s no hidden agenda. It’s the ultimate form of journalistic honesty. (quoted in Zubrzycki 2015)
His practice has deeply influenced my field research, since I also interweave different
17 photographic and literary practices based on situational circumstances and appropriateness. For instance, I move between portraiture and reportage, and between the traditional caption format and longer narrative pieces.
Jack Picone’s intimate images tell a story of the bipolarity of human experience. For instance, in his series The Rwandan Genocide (1994), he bluntly exposes the remnants of evil in one frame then depicts the deepest affection in the next frame, through capturing the extended clasping arms of two young patients in hospital beds. His work has impressed upon me the choices that the photographer faces, since he expresses a sense of deep sensitivity to his subjects. Even at its darkest moments, his work offers hope where there is none; in other images, he depicts a battle between the serene and otherworldly notions of tragedy.
Trent Parke, whose newest project Minutes to Midnight (2012) is put together like a short fictional narrative, has taught me to address my place in history and the emotional space that a time period can hold. His work speaks to dislocation and loss. In this series, he uses the familiarity that documentary photography offers to create a story that speaks to ‘feeling’ of a time and the emotion of a history by using the power of photographic narrative and visual details. He desired to tell the story of post-9/11 uncertainty through imagery of Australia’s rural communities in jarring and erratic sequencing, evoking a sense of disturbance in everyday life.
Likewise, Francesco Zizola’s almost cinematic series Born Somewhere (2004) is poetic and full of visual metaphors. Spending fifteen years developing the story, Zizola documents the conditions that children experience worldwide, exposing child rights abuses from war-torn countries (Angola, Sudan, Afghanistan, and Iraq) to privileged nations (Japan and the USA). Mostly devoid of adults, the images foreshadow the circumstances that cause the often desolate and isolating environments the children live in. Both Parke’s and Zizola’s series use the photographic document to ask poignant questions of the human condition; Parke through an almost fictional narrative evoking a nearly post-apocalyptic scene and Zizola through cinematic photographs that often ask what is going on outside the frame to cause such destruction and abuse.
18 In their editing, Dupont, Picone, and Zizola weave together complex narratives that span years and locations to create a unique dialect of visual storytelling, advocating for the continued importance of photographic record and documentary practice. They deal with the shame of contemporary human living that John Berger describes in his introduction to art and cultural critic David Levi Strauss’s Between the Eyes:
The shame begins with the contestations (which we all acknowledge somewhere but, out of powerlessness, dismiss) that much of the present suffering could be alleviated or avoided if certain realistic and relatively simple decisions were made. There is very direct relation today between the minutes of meetings and minutes of agony. (Berger in Strauss 2003, ix)
Dupont’s, Picone’s, Zizola’s, and Parke’s prolific bodies of work encourage society to make better decisions. My body of work seeks to honour decisions made to make child birth a safe experience for Nepali women in western Nepal, and asks how this has been done.
2.2 Key Lessons from Photographic History
“The eyes are organs of asking.” —Paul Valéry (cited in Strauss 2003, vii)
During the late 20th century, the postmodernist project radically deconstructed the photographic image and meaning, exposing photography as a persuasive agent. Originally, the medium used its growing influence to expose the “degrading conditions of workers in big-city slums, the barbarism of child labour, the terrorism of lynching, the devastation of war” through the eyes of practitioners such as Jacob Riis and Lewis Hine, while Arnold Genthe and Ernest J. Bellocq explored the street documenting social investigations of the ‘other’ (The Metropolitan Museum of Art 2000). Meanwhile, the documentation of the Mexican Revolution and World War I saw the inauguration of the citizen journalist, the embedded journalist, and the self- documenting solider; for the first time, political powers struggled to control the ‘image’ of the war, and wartime propaganda took on a new realism. In response, during the second half of the twentieth century, the idea that photography could hold any objective truth quickly died, and the critic would ask three important questions of photography: Does aestheticising human abuses create a compelling motive for change or an object to view with comfort and distance? What is the relationship of power between subject and photographer? Do we have the right to view what is being
19 exposed? In order to unpack these debates in relation to my method and practice, the limitations and strengths of the photographic image were considered.
The paradox of photography is that a photograph asks a viewer to consider, in a fraction of a second, what the photographer might have conceived for days, months, or years. Antonin Kratochvil regards documentary photography as an opportunity to interweave the complexities of a story. By placing multiple images together, documentary photographers (i.e., photojournalists) give viewers the chance to see beyond the most emotive second. Kratochvil writes
Photojournalism—in its instant shot and transmission—doesn’t show ‘life.’ It neither has the time to understand it nor the space to display its complexity. The pictures we see in our newspapers show frozen instants taken out of context and put on a stage of the media’s making, then sold as truth. (Kratochvil 2001, 27)
Photography theorist Susie Linfield expands on these limitations: Photographs don’t explain the way the world works; they don’t offer reasons or causes; they don’t tell us stories with a coherent, or even discernible beginning, middle and end. Photographs can’t burrow within to reveal the inner dynamics of historic events. And though it’s true that photographs document the specific, they sometimes blur—dangerous blur—political and historic distinctions. (Linfield 2011, 21)
However, the photograph’s ambiguity and frozen timeless state can also be perceived as its power to create reflection. To understand that the still frame is a suspended reality from a fraction of a second in the past allows the viewer to engage in the act of reflection in a way perhaps no other art form does. Jean-Paul Sartre states, “To determine the properties of the image as image I must turn to a new act of consciousness: I must reflect” (cited in Burnett 1995, 60). The silent act of viewing an image can still create that quiet space—a void—to consider a reality other than our own. In relation to reportage or ‘non-fiction’ photography, the imaginary leap the viewer takes to engage with the subject causes them to become intimate and yet detached. It is an uncomfortable state between being placed in another person’s personal place and time and needing to look—to really look—in order to take the leap to better understanding. Susan Meiselas describes the place that photography holds in society: That's where the understanding is key, if we are going to build bridges. I do think photography is a lot about creating the bridge. People still need to walk
20 over it. I think photographers are the people who perceive the bridge as a possibility. I think that goes back to that hope that people will feel the connection, and that connectivity is the opening of the door. (Open Foundations Society 2010)
Therefore, the void between the photographer, subject, and audience becomes its greatest weakness and its greatest asset. This void is filled with both the audience’s and photographer’s histories and cultural backgrounds—their preconceptions and beliefs. Linfield states that approaching photography with relentless criticism and suspicion makes it almost impossible to see the images themselves, crippling our capacity to “grasp what John Berger called ‘the thereness of the world.’ And it is just that—the texture, the fullness of the world outside ourselves—into which we need to delve” (Linfield 2011, 30). By regarding photographs as capitalist imperialist tools of oppression, we lose sight of the enemy that makes people suffer in “the documentation of their injuries and despair” (Linfield 2011, 30). If, instead, we regard the image’s ambiguity as the beginning of a dialogue into which the audience can thoughtfully and consciously enter through contextualisation, then a photograph can remain a piece of data open to interpretation and scrutiny like any eye-witness observation. In Chapter 4, I address how space, editing, and captions are used in my work to enhance this moment of reflective thinking that the photograph initiates in order to create an affective exhibition environment.
In Between the Eyes, Strauss (2003) argues for the importance of aesthetics in creating a compelling photographic practice. Strauss asks, “Why can’t beauty be a call to action?” (Strauss 2003, 9, original emphasis) He argues that the aesthetic is required to create tension. Without tension, the viewer is forced into a fragmentary moment of rejection or acceptance not delving into a more complex response. His argument is supported by the work of practitioners such as Sebastion Segaldo and James Nachtwey, which is both searing and beautiful while successfully advocating change.
In his tome Inferno (1999), Nachtwey’s unwavering eye on the destructive nature of war, the bodily carnage it leaves behind, and the lives forgotten, makes readers question their humanity. He asks them to look at grotesque, the horrific. While readers may feel vile and exposed, it is impossible to look away from his images. He
21 presents the side of humans that we are so desperate to forget: the one that leaves children in barred cells, women emaciated by starvation, and men slashed in half. His critics see his poetic, formal style as shameless and cold. To create form and lines in the chaos of war and disease is seen to be morally vacant. Yet, the alternative seems worse. Nachtwey is asking people to look; he is not asking them to approve of what they see. Instead he states, “The events I have recorded should not be forgotten and must not be repeated" (Nachtwey 1999, 471).
Linfield questions the critical analysis of Nachtwey’s work that has led many to call him a “grim reaper” and a “sniper” (2011, 213). Placing him within the context of modern warfare, she proposes that Nachtwey’s aesthetic “tells us, instead, that beauty—and its attendant, tragedy—are not the sole property of the peaceful, prosperous West; stubbornly, defiantly, they insist on appearing even in those places where the social world has been vanquished” (Linfield 2011, 213).
Furthermore, Strauss argues that aestheticisation is one of the ways for disparate people to perceive themselves in one another (2003, 10). He succinctly summarises the role of the aesthetic in photographic practice:
To represent is to aestheticize; that is, to transform. It presents a vast field of choices but it does not include the choice not to transform, not to change or alter whatever is being represented… aesthetics, which often deal with what is not there, imagining things into existence. To become legible to others, these imaginings must be socially and culturally encoded. That is aestheticization. (Strauss 2003, 9, original emphasis)
This sentiment will be further developed in this thesis, as the research developed a keen interest in using the combined strengths of visual contextualisation through visual ethnography presented in the quiet of images—the details—paired with the compelling tension of more dramatic moments. Strauss also highlights, “What they [photographs] do most persistently is to register the relation of photographer to subject—the distance from one to another—and this understanding is a profoundly important political process” (Strauss 2003, 10). To understand this observation, the moment of exchange between subject and photographer begs important questions. For example, what right does the viewer have to view what is being exposed? And what power does the photographer hold in the relationship between photographer and
22 subject, and subject and audience? These questions will be addressed in the following section, which critically engages with the visual canon that this research stems from.
2.3 Visual Methodologies
This research began amid a growing number of photographers focusing on maternal mortality in low-income nations, who include Lynsey Addario, Anna Kari, Alixandra Fazzina, Marco Vernaschi, and, Jean Chung, and Susan Meiselas, to name a few. Addario’s Maternal Mortality in Sierra Leone : Maternal Mortality (2013) and Kari’s Dying Mothers - Sierra Leone (2010) approach the subject manner in similar way, following a woman from the hours before her death to the funeral given in her honour in their respective homes (Addario 2016; Kari 2010). They show the tremendous effect that one life lost has on the family and community. Their ability to establish rapport with the grieving families, denoted through the access they are able to gain during this most intimate time in a family’s grieving process, is a testament to their work. Vernaschi and Fazzina both construct essays that document the world inside a clinic, expressing the reality of health care in the developing world (Vernaschi 2009; Fazzina 2008). Award-winning South Korean photojournalist Jean Chung shows particular interest in the topic of maternal mortality worldwide, producing both Qamar’s Story: Maternal Mortality in Afghanistan (Chung 2012) and Fight for Life: Maternal Mortality in Sierra Leone (2012). In 2011, in partnership with Human Rights Watch and Magnum Photos, Meiselas produced In Silence, a photo-film depicting the circumstances that led to the death of a young woman, Kiran, in remote India (Meiselas 2011). My research aims to develop upon these photographers’ works by using photography as a tool to represent the complex reality of childbirth, while also documenting the changing practices of midwifery in Nepal.
This inquiry also stems from a long line of social documentary practitioners who have worked alongside non-profits or other advocacy agencies to create visual narratives that represented an issue of the time in order to affect change. An early example is The Pittsburgh Survey (1907–8), which included the work of Lewis Hine, who saw himself as a sociologist using the photograph as a tool for social reform. Later, the Farm Security Administration (FSA) (1935–44) hired photographers and writers, including Walker Evans, Dorothea Lange, and Gordon Parks, to document the plight
23 of the American farmer in order to rally commitment to social reform via the New Deal interventions. These initiated the role that documentary photography would play in visually recording the social and economic crises that affect the marginalised citizens of our globe in an effort to compel policy makers to change legislation and convincing the general public to insist upon it. Many practitioners effectively achieved their goals, and in the process revised histories by revealing marginalised stories.
The FSA generated a critical investigation of the medium of photography: a real consideration of the paradigms of author-versus-commissioner and photographer- versus-subject (Frazier 2014). The idea of cultural/economic imperialism and the role the photograph plays in the writing and rewriting of histories become apparent, especially when considering the photographic record in instances of perceived power (whether economic, gender, age, race, or colonial). However, in order to look beyond photography as a tool for objectifying and disempowering marginalised ‘others’, it is worth discussing the photograph’s potential as a tool of cultural exchange. Therefore, important lessons from the arguments of the late-twentieth century need to be considered.
In the opening paragraph of “Orientalism Reconsidered”, Edward W. Said eloquently summarises the balancing act of multicultural research thus: the representation of other cultures, societies, histories; the relationship between power and knowledge; the role of the intellectual; the methodological questions that have to do with the relationships between different kinds of texts, between text and context, between text and history. (Said 1985, 1)
In considering Said’s text in the context of photographic documentation, the importance of contemplating the ever-changing relationships between document, context, and history is made apparent. Throughout the process of documentary photography, the relationship between the creation of the document and its various interpretations is in a state of change—from the relationship between photographer and subject, to the role of the photographer and how the documents are presented or contextualised.
24 Said’s work is particularly interesting in the context of documentary photography, since he provides a probing set of questions with which to examine such work and intent. His text raises the important questions of how knowledge is created, for what context, and for whose benefit. He asks if it is possible to produce “knowledge that is non-dominative and non-coercive…in a setting that is deeply inscribed with the politics, the considerations, the positions and the strategies of power?” (Said 1985, 2).
While never colonised, Nepal faces the same representational issues of many post- colonialist nations in South Asia. Kevin Bubriski, a documentary photographer who lived in Nepal during the 1970s and 1980s and whose body of work spans four decades, recalls that “in 1975, there were a handful of very fine old, traditional Nepali photo studios” (cited in Sett 2015): They were famous for having done the royal portraits and glass plate negatives in the early 20th century. But apart from this, Nepal was represented by Western photographers who were only interested in the snowy mountain peaks and sherpas carrying heavy loads. (Bubriski cited in Sett 2015)
However, the lack of Nepal’s representation was not limited to Western media; and NayanTara Gurung Kakshapati and Bhushan Shilpakar Kakshapati established Photo Circle and the Nepal Picture Library for exactly this purpose, since they realised
What archives did exist, professional and amateur, were inaccessible to the public; they weren’t adding to public knowledge as they could. Essential photographic histories of the region lay nascent in disparate personal archives. The generations that had seen Nepal find its independence and transition from monarchy to democracy would soon pass. These documents needed respect and preservation. (Sett 2015)
In the late nineteenth century, the Rana courts employed early Nepali photographers to document ceremonies, marriages, and important events in the royal family’s lives. In the early twentieth century, small studios began to open to serve the expanding Kathmandu middle-class. Jebin Gautam (2016) observes, “Photographs afforded these early consumers a sense of self-importance and social progression. In the decades prior to the 50s, photography was one of the only forms of western import openly consumed by this small group.” It was not until the free press was established in 1990 that professional Nepali photojournalism emerged. It principally covered the political upheaval of the next two decades until the emergence of social documentary with practices of photographers, such as Kishor Sharma and Sailendra Kharel. Both use an
25 elegant visual language to explore issues of displacement and marginalisation in Nepalese society. Their practices fit neatly into the language and role of a traditional social documentary practitioner, documenting the ‘perceived other’ of their communities. These projects are largely personally funded and promoted. After the earthquake in April 2015, the rich archives of familial albums and the documentation of social experiences by peace corps volunteers embedded in Nepali rural communities were both displayed for the first time at the 2015 Kathmandu Photo Festival. The exhibits explored the concept of time and preservation.
Arguing for an expanded role of photographic practice, the exhibits promote the notion that a photograph is not a static object; through reflective engagement, a nuanced understanding of the social environment can be realised. Furthermore, these exhibits elevated local photographic representation to a larger audience, and presented a place for both foreign and local eyes in photographic representation. Social documentary photographers traverse social classes, gender, and other archetypes of exclusion in order to use the medium to represent issues or document and preserve cultural significance. When representing a perceived ‘other’—whether socio- economic factors, gender, or nationality separate the photographer from their subject—only critical contextual understanding will build rich, complex narratives and histories. Said calls for multiple viewpoints with “a concentrated awareness of the situation—political, methodological, social, historical—in which intellectual and cultural work is carried out” (Said 1985, 8).
The traditional Western documentation that engages with a culture while glazing over traumas and delighting in their differences continues the cycle of racism or ‘othering’—or, as Slavoj Žižek describes it, “adopting a benevolent ironic distance towards different customs, taking pleasure in observing local peculiarities while filtering out the really traumatic data, amounts to postmodern racism at its most essential” (Žižek 2011, 39). All photographic material is the account of history in millisecond intervals. To use this material to universalise themes or values from another culture without endowing them with a specific historical and geographical contextual space is to commit cultural imperialism (Žižek 2011, 39).
26 In this research, I have been mindful of the role I play in continuing this problematic history of Western interpreter, representing and translating local culture for and to a Western audience (as well as back to a Nepali one). My approach engages with the arguments set out by Said, but, like him, I have not established how to solve or create the most “natural” representation. As established earlier, all visual text is inherently subjective. During the 1980s, photographers of Western privilege seemed to address this conundrum by refusing to produce works that overinterpreted the subject matter presented or that could be to easily unpacked. The works of Gilles Peress, Susan Meiselas, and Alex Webb collected respectively in the books Telex: Iran (Peress and Sāʻidī 1997), Nicaragua (Meiselas and Rosenberg 1981), and Under a Grudging Sun: Photographs from Haiti Libéré (Webb 1989) abandoned the moral position of their forbearers, acknowledging the inherent tension of their medium between artistic practice and reportage, between visual information and comprehension, and between foreigner/interpreter and subject (Grundberg 2010, 194). These images present an onslaught of visual information that is compositionally sophisticated, but lacks the clear essayist form of Eugene Smith. Authorship is acknowledged, but narrative and context are almost incomprehensible. Like all new art practices, these works found refuge in the halls of museum and pages of artist books.
In my own practice, I seek to engage in developing approaches that allow for critical investigations into the social, economic, and environmental factors that are enabling or inhibiting social change in an ethical and consented collaboration. I use layered and emotive visual language that allows for reflective/interpretive viewing, alongside narrative and textual accompaniments that provide the work with context. I follow the examples of practitioners such as Mary Ellen Mark, whose consensual environmental portraiture takes her viewers into worlds that usually remain unseen and unspoken. For instance, her series Falkland Road (1978) documented the brothels of Falkland Road, Bombay, by peering inside the caged world of the prostitutes who lived and worked in the street (Mark 1978). The photographs are empowering, empathetic, and confronting. While they are distinctly Indian, the portraits richly describe the universal plight of women working for the gratification of men. They envision the textual, colourful world of Bombay, but most strikingly they show the absence of pleasure, the routine, and the camaraderie. While they are empowering, they do not glaze over the harsh reality of these women selling their bodies for a living. On her
27 website, Marks describes in detail how she gained access to these spaces and what happened within them. The narrative adds a layer to the visual documentation, allowing the audience to imagine they are there sipping tea and conversing with these women. She overcomes the distance between the subject and the photographer. In Mary Ellen Mark on the Portrait and the Moment, she describes the responsibility of access in relation to working on the project Ward 81. For this work, she documented Ward 81 Oregon State Hospital, a mental institution for women who are considered dangerous to themselves or others. She relates: I got to know the women well—their moods, their issues, their hopes. They learned to trust us, and I learned about what a responsibility access is, how far you can go before you must put your camera down. Trust is a very important issue. Laurie was in the bathtub, and I asked her to look at me. It’s clear that she knew I was taking the picture and was relaxed, used to me. (Mark and Baxter 2015)
Her sentiments reflect on the power of the gaze in her work; through the gaze, you see the subject’s agreement—the subject knows Mark is there. My own work in Nepal reflects this methodology, flipping between portraiture and reportage, always with the consent of the subject and their knowledge of my presence. When asked in an interview for Bomb Magazine, Mark explains how impossible it is to answer the question of how to give back to a subject: People all say, “What do you give back?” “Do you pay people?” Well, I don’t believe in paying people, first of all, I don’t think you can. What we did after that story was, we took the family out and got them groceries, stuff that they would need and that was payment for us but no amount of money can ever pay for what people give you in a photograph. (Frame 1989)
She goes on to advise:
Not to be ashamed of the fact that, particularly in documentary work…the fact that you are a voyeur—you’re stealing something from people. You have to be able to live with it. You have to accept the aggressiveness of it. And to try constantly to be better, to constantly try to learn. (Frame 1989)
Giving back is also an important aspect of my practice. Each time I go back to Nepal, I bring prints from the time before. Every subject is given a card with my contact details and where to find the project online. Many of the women have contacted me through Facebook, often through younger family members on a growing mobile network. Furthermore, by working at the invitation and behest of One Heart World- Wide, I am under clear instructions to document, which allows the work to directly
28 integrate into an avenue to create further change. The images are given to One Heart to use for fund raising and advocacy, from its use in presentations to the Nepali government to advertisements in the US for fundraising to reporting to donors on ongoing projects. While One Heart does not direct the content, it is important for me that the work lives on outside of the project, helping to continue the efforts of social advocacy. Working with One Heart’s all-Nepali team in country gave me insight that would otherwise be impossible. I worked and lived with the trainers whose own experiences and histories enriched the research. But at the end of the project, it is never enough, and I am indebted to the women who share moments of their lives with me, however willingly.
2.4 Exploring the ‘New’ Photographic Essay
Thirty years after publishing Falkland Road, Mary Ellen Mark commented on the place that such stories have in today’s society: Today, no magazine would sponsor a project like Falkland Road. The real everyday world is—for the most part— no longer seen in magazines. The only documentary photography we see is of war, disaster, and conflict. Most everything else has been replaced by fashion and celebrity photography. (Mark 2005)
The current environment of photographic practice calls for new approaches that consider the context and limitations of the contemporary image. The fates of photojournalism and documentary photography are intertwined in the contemporary era, as shrinking editorial space pushes both into the precarious but expansive space of the Internet and the quiet reflective spaces of the gallery. Photojournalism has always endeavoured to be the first line of history, to document, to ask questions of a moment to be later debated and re-contextualised. It keeps pace with the events of its time, visual data points in a sea of evolving contemporary narratives. How will we contextualise these images after the fall of the daily print news audience (where one event followed yesterday’s), instead of the bits and bytes of feed-driven news? Meanwhile, documentary is not a singular situation, but a moment followed by an infinite number of moments/situations woven together to reveal the layers and unfettered experiences of life; through visual metaphor and emotional response, the medium asks poignant questions of the human condition (Kratochvil 2001). How will these stories find their way to the public in an increasingly segregated Internet space? Both photojournalism and documentary photography are inextricably intertwined as
29 practitioners move between the two practices, as images are repurposed and realigned. For instance, many of Mary Ellen Mark’s projects discussed earlier began as assignments and then were extended and continued to become the social documentaries they are now. Both documentary and photojournalism share visual strategies and methodologies: both call for ethical practice and the aesthetic alignment of instances in people’s lives. They both face the challenge of evading the “intimate alcoves and elective communities” (Boeglin 2015) of the web 2.0.
Despite the challenges of feed-driven readership and the selective nature of online communities, photojournalists and documentary photographers are finding refuge on the web where editorial budgets do not reduce the selection of images. Websites such as Council on Foreign Relations and Human Rights Watch have worked alongside documentary photographers to represent the incredibly complex situations leading to conflicts and abuses. For instance, the Council of Foreign Relations’ recent project on the Eastern Congo explores the historical context of the ongoing conflict in this area (“The Eastern Congo” n.d.). It uses the work of photographers, including Marcus Bleasdale, alongside the expert testimonials of researchers and local journalists. In this way, they perhaps endow the documentation with the context that Linfield defines as necessary and that Walter Benjamin hoped would save photography. Similarly, the project Too Young to Wed, launched in 2012, is the outcome of a combination of Stephanie Sinclair’s ongoing photographic documentation of child marriage, Jessica Dimmock’s cinematography, and the United Nations Populations Fund’s statistically driven information (Sinclair 2013). Created by the multimedia platform design company Bluecadet, the website integrates the three seamlessly. In both of these projects, the photographic and film narratives visually explore what is evident in the textual and audio material, providing the reflective space for the audience to reframe and consider the information. In the hyper reality of the Internet, the photograph has become slow.
My investigation of the practitioners discussed in this chapter has directly informed my approach to this research in the following ways: the effectiveness that photography has when partnered with social development agents (e.g., Jack Picone’s work; Too Young to Wed); the ability of photography to provide visual narrative unseen in more numerical, medical, historical texts (e.g., the Council for Foreign
30 Relations’ “The Eastern Congo); and the weaving of differing affective visual methodologies (e.g., the work of Stephen Dupont; the work of Mary Ellen Mark). Direct fieldwork was conducted in order to find a method to integrate the strengths of these disparate methodologies to effectively document the complex network of individuals who have created the environment in which the women of the Baglung District are no longer dying from complications in childbirth. By conducting this field research, including photographic documentation and interviews with mothers, nurses, clinic workers, and female community volunteers, my ambition is to provide visualisation to these women who have become the agents of change in Nepal. During the fieldwork described in the next chapter, I experiment with both the traditional reportage essay, more layered images, environmental portraiture and portraiture that removed the subject from their environment in order to find a visual language to represent this complexity. The final presentation is an expanded photo essay in exhibition form alongside detailed narrative captioning and a corresponding website in order to synthesise the textual/numerical information with the interpretive visual narrative.
The work not only seeks to contribute to the advocacy and continued support of the programs and individuals who made this significant positive change possible, but also to be a perceptive representation of the social environment that shapes birthing practices in Nepal. Although seemingly distinct, the two purposes this that project proposes are intrinsically linked, as one helps shape the success and meaningful engagement with the other. In her recent monograph, The Notion of Family (2014), which explores the residual racism and economic downfall of small town America, Latoya Ruby Frazier describes her intentions for the book as follows:
As the work has grown over the years, I have tried to edit and frame it in ways so that viewers can imagine themselves a part of it. We all come from families and communities that are affected by local economies and industry. Themes like the body and landscape, familial and communal history, and private and public space are all universal. When viewers look into my photographs and texts I want them to feel deeply touched in a way that transcends race, class and gender, if only for one moment… This book is more than an art book of photographs. It is a history book that lends itself to art history; the history of photography; American history; American studies; women gender and sexuality studies; comparative literature studies; health studies; social and economic studies; labor studies; race relation studies; and more. It is my testimony and fight for social justice. (Frazier et al. 2014)
31 While Frazier’s methodology is dissimilar to mine used in this project, her understanding of the linkage between document to history and document to change inspired the format the final outcomes would take. In order to document, the invisible reality of the woman seeking safe birth in and the powerful changes taking place in the foothills of the Himalayas, requires looking past the shame of the lens and into the comrade of the women acting as agents of change.
32 Chapter 3: Fieldwork
3.1 Overview of Practice and Methods
This research investigates and engages with layers of intervention involved in Nepali women seeking biomedical care during pregnancy and childbirth through the agency of photography, interviews and participant observation. Documenting the layers of medical intervention in this manner allows for a cultural critique of how such immense social change, visible in the statistical analysis of maternal health indicators, is playing out on a micro level. This research engages with the women who have gained enough social capital to influence birthing practices both in biomedical intervention and social practice. This research is based on photographic documentation and participant observation conducted with women either in the process of birth or afterwards whose survival is due to the assistance they have received. Therefore, I consider these testimonials both a result of changed practice in maternal care in Nepal, but also give insight into those women who are missed in this research in areas where intervention is not implemented. In order to survey the changes at the institutional, community, and individual level, I do not present a detailed photographic study of an individual woman. However, by engaging with the layers of human intervention and the role of women at each level, the research documents the success of this evolving system, which utilises a combination of home and hospital deliveries, a variety of skilled and semi-skilled practitioners. However, it also engages with the fact that this system is undermined by women not being able to access emergency obstetric care when giving birth at home due to transportation and geography. Through practice-led research (an original investigation in order to gain new knowledge by means of practice and the outcomes of that practice), the works created serve to document changes over time, but also as a record with which to engage with the significant challenges of providing maternal care in the physical and cultural environment of Nepal. All research was conducted in accordance with the ethical guidelines and procedures established by the ethical protocol in consultation the Griffith University Human Ethics Committee (QCA/20/12/HREC).
33
Figure 3 Google Maps, Map of Nepal, 2015. Sourced: https://maps.google.com/
In September 2010, I began communication with the INGO One Heart World-Wide about the possibility of collaborating with their infield staff to document the work I had heard so much about. I was invited by One Hear World-Wide’s CEO and Founder Arlene Samen to join her on an upcoming trip to Nepal to visit the small team of Nepali trainers who were trekking the countryside to provide in-depth knowledge and training to Female Community Health Volunteers (FCHVs) regarding maternal care. In late January 2011, I joined Samen in a small village, Narayansthan. Over the following three weeks, I met with FCHVs who had been provided with the One-Heart training, mothers who had been saved by these women, and community health leaders. The field trip resulted in the production of a short video that visually describes the training One Heart provides to these women, using text overlays to narrate the film (McIlvenny 2011). During the scope of this research, One Heart World-Wide, guided by its mission to surround every mother with a network of safety, provided both training and equipment at every level of care—from the mother to the local clinic, to the hospital, to the government. In 2010, One Heart World-Wide began their work in eighteen communities within the Baglung District of Nepal. By 2013, the organisation had expanded their programs to all fifty-nine communities in Baglung. In these three years alone, One Heart has upgraded thirteen birthing centres (local health clinics where village women can come to give birth with a midwife) and has trained 1,263 ‘Foot Soldiers of Change’ (FCHVs) and 412 health providers.
34 From this initial visit, I questioned what facilities were available to these women once they understood the importance of skilled practitioners’ presence at birth, if they managed to get to the hospital two hours down the mountainside and a bus trip up the other side of the valley. The following Honours work, Welcome Labour Room, was the result of that simplistic question. By documenting the District Hospital, I met the staff who are providing the main source of critical care for the 324,000 people of Baglung District. The work documents the socio-economic factors that lead to poor maternal health through the photographic documentation of the Kalimanti Health Clinic in Kathmandu, where women access low-cost health care, helping alleviate the overrun city hospitals.
The experience of Welcome Labour Room led me to believe Baglung would be the ideal location to study social change at the micro level. Nestled in the foothills of the Himalayas, the Baglung District of Nepal is a three-hour drive on a semi-paved road from Pokhara, the second-largest city in Nepal. However, the district headquarters in Baglung Bazaar is where the paved road ends and this research begins. The maternal mortality rate for Baglung District was 399/100,000 in 2010 when this study began; only three years later, it was 43/100,000. With the only paved road in the district leading into Baglung Bazaar, the rural villages that make up the rest of the district are geographically remote enough that women traditionally continue to give birth at home with no other easy options. However, Baglung is not as geographically challenging as the mountain regions, where the geography and weather would make significant change slow.
The following photographic documentation traces the region’s journey to better health care, each trip intersecting at a layer where significant change has occurred. The 2006 Demographic and Health Survey (DHS) documented the partially successful efforts of national and international players to combat maternal mortality by modest increases in the following: the percentage of births delivered at health facilities; the percentage of women making four antenatal care visits; the percentage of births assisted by an SBA; and the percentage of women receiving postnatal care. At the time, 81% of births took place at home. Only 18% of births were delivered in a government health facility, and less than 1% of births occurred in a private health facility (Brunson 2010, 1720). Beginning with the villages closer to Baglung, I met the Foot Soldiers of this health-
35 care revolution, the FCHVs of Resha, Lekhani and Batakachaur. These women have all been selected by the mothers of their community to represent them and receive training from the government in partnership with INGO, One Heart World-Wide and local partner SWAN. From here, I travelled back to the Baglung District Hospital in 2014 to witness the drastic change that has occurred since 2011. In my final field research trip, I would move farther from the epicentre in Baglung Bazaar to the villages of Pandavkhani, Hatiya, and Gwalichaur to meet the SBAs who are performing deliveries in small birthing centres in order to prevent woman giving birth alone at home. This has resulted in the multimedia production of the website Foot Soldiers of Change (www.footsoldiersofchange.com).
36 3.2 Welcome Labour Room: Analysis and New Approaches
Figure 4 Kelly McIlvenny, One Heart World-Wide's Foot Soldiers of Change, 2012.
The Welcome Labour Room film proved to be valuable to One Heart for both marketing and fundraising. Since its inception, the film has been updated to include both Mexico and Nepal , publishing an updated version, One Heart World-Wide’s Foot Soldiers of Change in early 2012 (McIlvenny 2012). Again, this short film was useful to the organisation, especially in its ability to be infinitely portable. Samen uses it to present at seminars and conferences, while her communication staff use it online to promote and create an understanding of what the organisation is accomplishing.
However, these two short videos did little to deal with the issues and context that creates the need for One Heart’s training and support. Therefore, in 2011 I set out to create a project that began to explain the complex circumstances and issues facing women in childbirth and pregnancy in Nepal. The resulting work, Welcome Labour Room: The Story of Maternal Health in Nepal is the photographic documentation of the issues surrounding pregnancy and childbirth in the developing country of Nepal. The work is presented in an eight-minute-long video, with still images guided by a narrator. Taking the viewer through the ebb and flow of the Baglung District Maternity ward, the first-person narration, spoken in my own voice, touches on both
37 the highs and lows of maternal health in the remote Kali Gandaki valley. Each image adds to the last, building a complexity—weaving from sympathetic to journalistic to empathetic. The work is accompanied by an essay I wrote entitled “Life, Death, and Childbirth in the Kali Gandaki Valley: The Story of Guardian Angels in the Himalayas”. This short essay develops upon the ideas of the video, bringing individual voices to the themes of maternity in this remote region. The photographic work and written accompaniments can be found at www.welcomelabourroom.com (McIlvenny 2011). Welcome Labour Room: The Story of Maternal Health in Nepal took a visual leap forward when compared to the original piece. More importantly, the narration and web platform gave the images much-needed context and evoked empathy.
Figure 5 Kelly McIlvenny, Welcome Labour Room: The Story of Maternal Health in Nepal. Images from the exhibition of Welcome Labour Room: The Story of Maternal Health in Nepal at the Airport Gallery North in Sydney and the Gallery on the Lane, Gold Coast, 2012.
The multimedia work was transformed into two exhibitions, one of which was held at the Airport Gallery North, as a part of Head On Photo Festival in Sydney in May 2012; and the other displayed alongside work on Raphaela Rosella We Met a Little Early, but I Get to Love You Longer at the Gallery on the Lane in Southport, Queensland in June 2012. The work was given an honorable mention in the 2012 International Photographer Awards for both Photo essay/ Feature Story and in the category of Deeper Perspective. The work has also subsequently been published in an online exhibition curated by the International Museum of Women in late 2011. The critical conclusions and feedback from these initial exhibitions proved immensely valuable. The grid format used at the Gallery on the Lane allowed the images to take
38 on new meanings, and the images spoke to one another in a non-linear fashion; the dark shadows allowing the eyes to find respite between powerful moments of labour and quieter fragments of daily hospital life. However, I was unsatisfied with the presentation of context and sought to rectify this in the subsequent outputs.
Figure 6 The International Museum of Women, MAMA: Motherhood Around the Globe, Welcome Labour Room was presented as a feature story in the MAMA exhibition curating stories on motherhood from around the globe, 2011.
39 3.3 A Positive Complexity: A Discussion of Maternal Health in Nepal (Field Research)
Calendar
At school there is a calendar, where my young, moonfaced teacher marks off the days with a red crayon.
On the mountain we mark time by women’s work and women’s woes.
In the cold months, the women climb high up the mountain’s spine to scavenge for firewood. They take food from their bowls, feed it to their children, and silence their own churning stomachs.
This is the season when the women bury the children who die of fever.
In the dry months, the women collect basketfuls of dung and pat them into cakes to harden in the sun, making precious for the dinner fire. They tie rags around their children’s eyes to shield them from the dust blowing up from the empty riverbed.
This is the season when they bury the children who die from the coughing disease.
In the rainy months, they patch the crumbling mud walls of their huts and keep the fire going so that yesterday’s gruel can be stretched to make tomorrow’s dinner. They watch the river turn into a thundering beast. They pick leeches from their children’s feet and give them tea to ward off the loose-bowel disease.
This is the season when they bury the children who cannot be carried to the doctor on the other side of that river.
In the cool months, they prepare special food for the festivals. They make rice beer for the men and listen to them argue politics. They teach the children who have survived the seasons to make back-to-school ink from the blue-black juice of the marking nut tree.
This is also the season when the women drink the blue-black juice of the marking nut tree to do away with the babies in their wombs—the ones who would be born only to be buried next season. (McCormick 2010)
Patricia McCormick’s vignette of life for women in rural Nepal highlights the particular burdens the women there bear due to a lack of health resources and knowledge. It poetically and simply engages with some of the key challenges to health in Nepal—the extreme geographical challenges, the weather’s role in
40 increasing geographic separation, the role of women, and the lack of resources. However, this tale is changing as the Nepali government have, over the past thirty years, aimed to distribute health resources and knowledge. Even through extreme political instability, the changing Nepali government worked to understand the factors that cause maternal and infant mortality within the nation. In 1996, the Nepali Department of Health Services conducted the Nepal Family Health Survey, which would result in the Safe Motherhood Program of 1997. The aim of this program was to increase women’s access to health care and elevate her status (Sharma, Sawangdee, And Sirirassamee 2007). The Department of Health Services followed this up with the Nepal Maternal Mortality and Morbidity Study in 1998. To monitor key health factors, the Nepal DHS was again conducted in 2001 and 2006, as well as the Maternal Mortality and Morbidity Study conducted in 2008/09. From the analysis of these surveys, it can be concluded that, “In spite of the violent conflict, Nepal made progress in 16 out of 19 health indicators over the period of 1996–2006” (Devkota and Teijlingen 2010, 6). The maternal mortality rate had been reduced from 539 to 281 per 100,000 (Devkota and Teijlingen 2010, 4).
There used to be a time when Nepal's health statistics were the worst in the world. The country's maternal and child mortality figures were off the charts, and worse than many countries in sub-Saharan Africa.
Nearly 1,000 mothers out of every 100,000 died at child-birth because the simplest delivery techniques and knowledge were not available with rural midwives, or remote area health posts. Child marriage was so common that many mothers gave birth at 15, were severely anemic, under-nourished and over-worked.
Children died of simple infections and vaccine-preventable diseases. Diarrohoeal dehydration and acute respiratory infections meant that one in every five children did not live to be five years old. Three-fourths of all children were undernourished. (Nepali Times 2012, 1)
Published in August 2012, the Nepali Times article “A Nation’s Health” reviewed the state of national healthcare in Nepal, assessing both the achievements of the past twenty years and the continual challenges. The main success it cited was the incredible reduction in maternal deaths, despite little change in rural healthcare facilities. The article attributes the higher levels of literacy (in particular, among young girls), the raising of the average marriage age, the improved levels of nutrition,
41 the increased transportation infrastructure, and the tens of thousands of FCHVs as leading to the improved statistics (Nepali Times 2012, 1).
Similarly, the article “Access to Health: Women's Status and Utilization of Maternal Health Services in Nepal” published in the Journal of Biosocial Science cites the following factors as contributing to the overall increase in women accessing care: “programme interventions such as outreach worker’s visits, radio programmes on maternal health, maternal health information disseminated through various mass media sources and raising women’s status through education” (Sharma, Sawangdee, and Sirirassamee 2007, 671). In particular, the educational status of a woman and the number of home-based health worker visits showed an important relation to the woman accessing care. However, it was also found that socioeconomic and demographic factors (including household economic status, number of living children and place of residence) had strong associations with the use of maternal health services. The article concluded that variables such as the effect of distance to the health facility, availability of transportation, and quality of the services a woman has access to are important factors that were not included in previous studies. Likewise, a woman’s control over family financial decisions, her own decision-making power, and freedom to move are important issues as to what a woman’s status might be in the community/family (Sharma, Sawangdee, and Sirirassamee 2007, 690).
42
Figure 7 Kelly McIlvenny, View from the Baglung Highway, 2013.
Figure 10 demonstrates the barriers created by the landscape in the Baglung District of Nepal. The Kali Gandaki river runs along the Baglung Highway, which can just be made out at the bottom of the cliffs on the right hand side of the frame. The river is approximately 600 metres above sea level, with the cliffs on either side quickly reaching between 900 and 1200 metres, then continuing to rise to heights of upwards of 2000 metres. Baglung Bazaar, the capital of this district, is located about a thirty- minute drive from this spot along the Baglung Highway. Narayansthan is located up on the plateau on the left side of the river.
These statistical variables are quickly translated into real life in the Kali Gandaki valley. On a small plateau overlooking the bazaar, two hours’ hike from the bottom of the valley, the small village Narayanstan would be my first field trip with One Heart World-Wide. Their role organically changes throughout the district, depending on need, but includes educating local FCHVs in life-saving techniques and knowledge, supplying the health post with equipment, supplying the district hospital with equipment and training, and, more recently, establishing birthing centres in remote villages where access to the hospital is difficult and unsafe.
43
Figure 8 Kelly McIlvenny, The Narayansthan Health Post, February 2011.
Figure 9 Kelly McIlvenny, The suspension bridge over the Kali Gandaki River that connects Narayansthan to Baglung when the steep dirt road becomes impossible to travel on due to weather or damage.
Figure 10 Kelly McIlvenny, Standing in front of the Narayansthan health post, you can look across the valley to Baglung Bazaar. Later in this research the geographical challenges become more apparent as the field research penetrates deeper into the district.
The Narayansthan health post sits on the inner edge of the plateau, overlooking a soccer field that the local school has created with nothing more than a few metal posts. Beyond the field, the land begins its steep slope into a pine forest and eventually drops off down sheer cliffs. At the bottom of the cliff, the Kali Gandaki River runs towards Pokhara. A steep path leads down to a small suspension bridge
44 across the river to the small village of Kusma, where villagers can hail local buses to Baglung. This is the journey that the women of Narayansthan and villages further up the range must take to seek help from Baglung Hospital.
Tilkumari Kolpata, 58, sits in a small office above the four-roomed health post. Her eyes are bright and kind, while the corners of her mouth always seem to be edging into a smile. Tilkumari has been volunteering for fifteen years in Narayansthan. When asked why she volunteers, she answers simply: “To serve the pregnant women, children, and newborn baby” (interview with the author, 2 July 2011). The women in her ward face many challenges. “They all are poor, so they cannot afford to go to Baglung Hospital,” she says. “They cannot pay for transportation…they cannot afford to eat nutritious food.” Recalling a case in her village the previous year, she states, “There was one breached delivery, the baby died on the way to hospital.” She explains that they delayed their trip to the hospital because of money. They could not afford the transportation. “So these are difficult things,” she says.
Figure 11 Kelly McIlvenny, Tilkumari Kolpata, 58, has been volunteering as a Female Community Health Worker in Narayansthan for over 15 years, February 2011. In a more recent case, she visited a young woman who was four months pregnant. The young woman works planting and picking millet, “carrying them from here and
45 there”. She had heavy bleeding, so Tilkumari advised her to go for a check-up at the health post. Coming to the small health post, “The health worker said if there is heavy bleeding the baby will die, you will lose the baby. They really insisted if you stop (carrying millet), the baby will survive.” Tilkumari proudly reports that the young lady “is doing well now”. Tilkumari’s story points out the distinct role both socio- economic factors play in the health of mothers in Nepal, and how the responsibilities women have within the Nepali village structure can also contribute to the health of pregnant women.
In his journal article “Cultural Diversity and Pluralism in Nepal: Emerging Issues and the Search for a New Paradigm”, Hari Prasad Bhattarai points out the importance of the social constrictions that women face in Nepal.
The women, dalits, and ethnic minorities in particular are more underprivileged in this regard. Women among them are the most deprived groups. They are not yet economically independent. They have either to depend upon people belonging to high castes or to their male counter parts. More importantly, they have marginal existence in the spheres of politics and other public domains of decision-making. In spite of four decades of development efforts, poverty remains high and the incidence is pervasive for some particular groups. (Bhattarai 2004, 321– 22)
His article cites the continual challenges that the new Nepali government faces to include the diverse groups contained within its state borders, and continue to raise the status of women among differing cultural and social backgrounds. The article only touches on the fact that women have little to no representation in traditional government and governing bodies. However, this is changing as the Nepali government seeks to integrate rural communities into the health system, finding it almost impossible without the help of women.
3.4 Foot Soldiers of Change (The Female Community Health Workers)
The following documentation shows the Nepali government recognises that the distribution of health knowledge and resources is highly important to its geographically challenged and ethnically diverse nation. There is a long history of the
46 government encouraging community participation in public-health activities (Suwal 2008). Interestingly, the early community volunteer programs would highlight the important role women play in the health of a community. The first community health program based on volunteers was introduced in 1980 in sixteen districts, and was originally named the Community Health Leaders (CHL) program. Five thousand volunteers were chosen to represent their community, all of whom were men except for those in one district (Houston et al. 2012, 82). Upon reviewing the CHL program, it was discovered, “that it was not as effective as expected in improving health practices, in part because of Nepal’s socio-cultural environment, where women were reluctant to discuss their personal health issues or seek services from men” (Houston et al. 2012, 83). However, the single district that had recruited women as volunteers was discovered to be better at relaying messages, and the program was revised to only recruit female volunteers.
Figure 12 Kelly McIlvenny, Bina Kumari B.K., 31, has been volunteering in Narayansthan S. Namunagow for seven years, February 2011.
Bina Kumari B.K., 31, has been volunteering in Narayansthan S. Namunagow for seven years. The women in her village are shy about speaking about their diseases and illnesses. She describes their hesitancy to come to the health post for an antenatal
47 check up. “They won’t check because they feel shy to expose in front of male. In their house, their husband doesn’t let them go out, and mother-in-law says, ‘oh you don’t have to go for check ups.’ The women don’t have decision-making power. That is the problem” (interview with the author, 2 July 2011).
Bina works as an advocate for the women within their own families. “In my village lots of women die during pregnancy, and babies die during childhood”, she says. “I want to serve them, and I don’t want to see the women and children dying.” Describing a labour she attended only nine days prior, Bina explains that she told the mother to call her when she started to feel labour pain and she would take her to the hospital, insisting, “I will help you. I will go by myself with you.” The family seemed cooperative, and the mother-in-law agreed to call her when the labour started. The woman fell quickly into labour, after coming back from planting millet. “They didn’t have a chance to call me, or get a chance to take her to hospital, so she gave birth at home.” Three days after giving birth, the woman had “a really bad fever, a really high fever”, so Bina quickly instructed them to seek help from the health post, where the woman was able to receive some medicine. Bina beams, “She is feeling well now.”
Bina experienced the fear that many of her patients go through, when fifteen days after the birth of her last child, she had heavy bleeding. “It was lots of bleeding and it was all around the floor.” She explained she had a big clot in her vagina: “I was nearly dying. They took me to the clinic; there is one clinic up in a village. If I was not there in time, I would have died. I was unconscious, totally unconscious.” Bina says the health worker from the clinic was also afraid and said: “I cannot do anything, take her to Baglung Hospital.” He managed to do an IV infusion, giving Bina some energy, and possibly making the difference between her death and her survival.
Bina is one of 50,000 FCHVs across Nepal working with the mothers of their individual communities to educate and protect themselves from the same preventable complications of pregnancy and childbirth. The FCHV program was established in 1988, initiated in twenty-seven districts, with the idea that one volunteer would be stationed in every ward, eventually expanding to all seventy-five districts for a total of 48,000 volunteers by 1993. The objective of the program was “supporting the national goal on health through community involvement in public health activities. This
48 includes imparting knowledge and skills for empowering women, increasing awareness on health related issues and involvement of local institutions in promoting health care” (Houston et al. 2012, 83). This ward-based program was revised in 1992 to a population-based program in order to account for the “different population densities in the country’s various ecological zones” (Houston et al. 2012, 83). Of the current total of 50,000 FCHVs in Nepal, 97% of them are based in rural areas (WHO Country Office Nepal 2012, 1).
Although the program has been increasingly more successful in the distribution of educational messages, the FCHVs continued to struggle “to show impact on behavior” (Houston et al. 2012, 83). However, in 1993, the FCHVs were given a direct role by the Ministry of Health in the distribution of Vitamin A capsules to all children 6–59 months old, twice a year. The National Vitamin A Programme (NVAP) would, “establish the FCHVs as tangible service providers and simultaneously elevated their status in the community’s eye and raised their motivation. The community’s positive feedback proved to be a powerful incentive for FCHVs to continue their work” (Houston et al. 2012, 83). According to a recent USAID report, the FCHVs “have made Nepal the first country to deliver vitamin A supplements every six months to 3.5 million children nationwide (ages six months to five years) preventing at least 12,000 child deaths annually” (USAID 2012, 1). They became responsible for the distribution of pediatric cotrimozazole tablets to treat childhood pneumonia, providing iron tablets to pregnant women, administering misoprostol to women who had recently given birth, managing diarrhea in children, and, recently, have taken on the community new-born care package (Houston et al. 2012, 83).
Each of these programs was phased in gradually, as originally there was great hesitation in allowing semi-skilled workers to provide antibiotics and other pharmaceuticals. However, a comparison between two programs implemented to treat pneumonia in children under five would prove the effectiveness of the FCHVs’ direct interventions. In the first program, the FCHVs assessed, diagnosed, and treated children with pneumonia. The second program similarly followed a diagnosis and assessment procedure, but then referred the children to local healthcare facilities for treatment. The first program resulted in a better management of pneumonia in children, due to its ability to reach “poor people, those living in remote areas and for
49 times when other providers were not available” (Houston et al. 2012, 85). Eventually, the FCHV pneumonia diagnoses and treatment program expanded to all seventy-five districts, and “programmatic evidence and survey data has shown repeatedly that FCHVs, literate and illiterate, are able to correctly classify a child as having pneumonia, and provide correct treatment for age” (Houston et al. 2012, 86). The importance of this literature is that it cements the importance of these female workers within the health community and within their own communities, raising their status and respect.
Besides the responsibility given to the FCHVs, as semi-skilled workers, on behalf of the health ministry, another key factor in the success of the program is the proximity of the volunteers to the community they serve, both physically and culturally. The FCHV program is unique in that it does not require the volunteers to be literate. This allows for females from lower socio-economic groups, ethnic minorities, and remote areas to be accepted into the program and perform the important duties instilled in the FCHV role. A 2007 report by USAID, New ERA and the MOHP affirmed that “38% of FCHVs were illiterate”; furthermore, “that illiterate FCHVs have performed as well as their literate colleagues”(Houston et al. 2012, 83). Of the FCHVs 42% have never attended school; 16% have attended school but did not complete primary school; and 16% completed primary school (Houston et al. 2012, 83). The program has the remarkable turnover rate of only 4% per year, despite the volunteers not receiving payment for the wide range of services they provide (Houston et al. 2012, 83). Many countries have community health workers, but the success of this program is based on the presence of FCHVs in all wards of the country, the degree of responsibility given to the semi-skilled worker, and the allowance of illiterate women to participate and become volunteers (Houston et al. 2012, 86).
These women fill a large gap that is created by a lack of human resources in the health sector. According to a recent study by the British Medical Journal, Nepal continues to have the worst doctor-to-population ratio in Asia, citing a ratio of only two doctors per 10,000 people, and with only 27.2% (193 doctors) working outside of Kathmandu districts (Zimmerman et al. 2012, 1).
50 Dr. Tarun Paudel, the head physician at the Baglung District Hospital, which provides the major healthcare facilities for the entire Kali Gandaki valley, explains the lack of human resources in Baglung District despite improvements made in the past decade. Dr. Paudel, who has worked at the hospital for thirteen years, explains the hospital needs to serve over 600,000 people in the district and surrounding areas. It is the only hospital in the district with an operating theatre. Sitting among the training midwives, he is calm and smiling, seemingly at home with the female banter. He chuckles to himself: “You must be a general doctor here; specialists only stay in the city. A Family physician must be multi-skilled. Multi-skilled means everything from geriatrics to infants.” Well attuned to the needs of his community, he has watched the hospital grow from only having twenty-five beds overall and himself as the only doctor to over twenty-five beds just on the maternity floor alone and nine doctors on the staff.
Figure 13 Kelly McIlvenny, Janaki K.C. proudly shows me the sole operating theatre in the district, fortunately for the mothers of this district the operating theater is located just meters away from the delivery room in case of an emergency, July 2011.
Janaki K.C., who has been working as a nurse for the hospital for over twenty-five years, adds “Not sufficient: men, money, and materials.” When asked what poses the biggest challenges for women in the area, she pauses for a moment, before listing
51 each complication carefully as if feeling the weight of their meaning: “After-delivery hemorrhage, post-abortion complications, transportation and geographic location, uterus prolapse, obstructive labour, and the failing electricity…are the main issues”, she says (interview with the author, June 2011). Sipping on her cup of sweet Nepali milk tea, she quickly adds that for babies, the most common complications are pneumonia, diarrhea, and infection. With the help of the young SBA next to her, Janaki estimates that the hospital receives 100–120 normal cases a month, including vacuum delivery and manual removal of the placenta, as well as seven to ten emergency cases a month. Janaki smiles grimily, quoting a Nepali saying: “Giving birth is like the fracture of 206 bones”, giving credence to the vulnerability of both mother and child during pregnancy and childbirth.
The Nepali Times recognised the important role that women are playing in combatting maternal and child health issues, exclaiming, “Tens of thousands of Female Community Health Volunteers scattered across rural Nepal have done more for the improvement in maternal and child survival than anyone else” (Nepali Times 2012). However, the program continues to face challenges. There continues to be a backlog of FCHVs who have not received their initial training. The volunteers’ performance is related to the availability of supplies and support. It is only the lack of supplies that prevented “FCHVS from treating one fifth of the children who came for diarrhea treatment, according to the latest Nepal Demography Health Survey” (WHO Country Office Nepal 2012, 5). Similarly, the study indicated, “that FCHVs need additional training on issues relating to pregnancies, delivery and child health care to promote community-based maternal and newborn care” (WHO Country Office Nepal 2012, 5). While 85% of women who had seen a FCHV during pregnancy also received antenatal care from the FCHV, only 30% of the FCHVs mentioned the use of a SBA, 11% mentioned preparing for possible emergencies, and 4% discussed a birth plan (WHO Country Office Nepal 2012, 2).
My first field research trip explored the role these FCHVs are playing in a birth- preparedness program that encourages preparation for normal birth through promoting the selection of an SBA and place of delivery; preparing essential items for delivery, such as a clean delivery kit; providing knowledge of danger signs for mother and newborn, as well as when, whom and where to seek help; and the arrangement of
52 access to funds and means for emergency transportation and medical care. These small interventions show substantial change to the cultural acceptance of a biomedical model and risk framework; in contrast to “when birth is considered a natural event, it does not require planning” (Brunson 2010).
Figure 14 Google Maps, Map of Baglung District, 2015. Sourced: https://maps.google.com/
I travelled to Lekhani, Resha, and Batakachaur, all visible in the Google map (fig. 17). Batakachaur is not highlighted, as there is no documented road from Baglung Bazaar, but it can be located at the bottom centre of the image. It took us fifteen hours, spread out over two days, to reach Batakachaur from Baglung. It takes five to six hours to travel to Lekhani from Baglung by jeep, and I hiked for four hours to travel from Lekhani to Resha. I travelled with One Heart World-Wide trainers Manju Rana (Resha and Lekhani) and Sunita Adhikari (Batakachaur), and we worked together to document the newborn health and refresher training they were there to teach the FCHVs of these communities.
53
Figure 15 Kelly McIlvenny, The Female Community Health Workers of the villages of Resha, Lekhani, and Batakachur during a week-long course, training them in newborn care and emergency resuscitation techniques, 2013.
The trainers refreshed the FCHVs’ knowledge of danger signs during pregnancy and childbirth, as well as how to use a clean birth-kit. They were provided with new supplies corresponding to their new training module Newborn Health, which included the following: a scale to weigh the newborn after birth and during post-natal visits; a thermometer to measure the temperature of the newborn; small pieces of clean fabric to use during a home delivery or as nappies; a booklet to record the information they gather from the mothers; a flip book to help them explain the information they gained during training to their community; and a bag and mask with dili suction tube to revive an asphyxiated newborn. The program lasted six days, with the FCHVs receiving a small stipend to cover the cost of not performing their normal duties. Taught through a series of group activities, the women applied their new knowledge. They are then asked to meet with their respective mothers’ groups in their ward to explain their new skills. While being involved with One Heart allowed me access to witness this training, it was the corresponding placement within the homes of female community health workers and the villages themselves that provided the unique vantage point to engage with these women as social agents within the cultural context of their community.
As well as undertaking traditional reportage, I interviewed self-nominated FCHVs as well as the midwives of each village. Through these interviews, the FCHVs began to share their own experiences as mothers, not just as volunteers. In order to honour their role and give them agency over their own stories, I asked if any would like to write their own stories down to be photographed and translated. While not many chose to
54 write their own stories, those who did took great pride in their ability to compose their own narratives.
Figure 16 Kelly McIlvenny, Maya Devi Gautam (top left), 31, has been working as an FCHV for eleven years in Resha, Bainthan. Dhanmaya Shrish (top right) has been serving as a FCHV for 17 years in the village of Lekhani. She is the mother of three healthy daughters, and here tells the story of her second child who would not live to see their first day. Luxmi Kunwar (bottom left), 21, has been serving as a FCHV for one year in Resha, Anchusmuni. Bhumi Devi Hiure (bottom right), 38, has been working as an FCHV for eleven years in Lekhani, January 2013.
In order to include those who chose not to write their story, either because of a lack of time or confidence in their literacy skills, I decided to take portraits of each of the women. These simplistic and formal portraits are perhaps the most valued of all the images taken on this trip—it provided an opportunity for me to give back to them but also records their presence, which, to this point, is missing from the literature. Despite their significant role in changing the health culture of Nepal, there is little to no photographic documentation published of their visual appearance or stories. Their role as mentors is apparent, but it was also their ability to lead by example, as mothers themselves. Pictured below is a young FCHV receiving a antenatal check up from the midwife posted at the health post, something she said she would not have done before her training that week.
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Figure 17 Kelly McIlvenny, Skilled Birth Attendant, Devi Korki, 30, checks on 36 weeks pregnant Sita Khadka, 20, who recently became a female community health worker, January 2013.
Upon returning to Australia, I produced a photo-film The Foot Soldiers of Change, which embeds the volunteers in a larger network at work to save the lives of women across Baglung. For the first time in the research, I was able to visually connect the women of these villages to the biomedical interventions playing such a substantial role in keeping them safe during pregnancy and childbirth, but also envision the women themselves as actors in this change. The photo-film was published by the International Museum of Women as a part of their Imagining Equality online exhibition exploring perspectives on women’s human rights and their hopes for the future (http://imaginingequality.imow.org/content/foot-soldiers-change).
3.5 Our Sisters (Skilled Birth Attendants)
The lack of SBAs continues to present a challenge to the health and wellbeing of pregnant and delivering mothers. Conducted in 2011, the latest Nepal DHS also indicated that,
although 58 percent of babies received antenatal care from a doctor or nurse/midwife for their most recent birth, only 36 percent of babies are delivered by a doctor or nurse/midwife, and 28 percent are delivered at a health facility indicating that Nepal has a long way to go to meet the Millennium Development Goal target of 60 percent births attended by a skilled provider. (Population Division Ministry of Health and Population et al. 2011, 13)
Nepal currently has approximately 2,400 SBAs; however, according to a recent article in the Kathmandu Post, this number needs to reach 6,500 in order to meet current
56 needs (M. Gautam 2012, 2). The same article reports that in order to encourage women to deliver in a health facility, the government provides financial incentives: “Rs 1,500 in the mountains, Rs 1,000 in the hills and Rs 500 in the tarai regions as travel costs for each delivery” (M. Gautam 2012, 2). However, it also cites that “none of the mothers who delivered in hospitals knew that they got the money as a transportation incentive” (M. Gautam 2012, 2). The lack of personnel leaves hospitals with little time or ability to counsel mothers after their delivery, which is where the continued training of the FCHVs in how to advise and educate mothers on pre-natal and post-natal care will continue to bridge the gap between mother and health facility.
This gap between mother and facility nearly caused Taulkumaripun to become one of the 170 women out of 100,000 that will die during pregnancy and childbirth in Nepal this year, according to WHO. I meet Taulkumaripun in the “after labour” room of the Baglung District Hospital maternity ward.
Figure 18 Kelly McIlvenny, when I first met Taulkmaripun, the silence was almost intrusive, as she lay almost motionless while the nursing staff and students surrounded her to check her drips, 2011. She is quiet in a room of chaos and clatter. Tulkumaripun’s small frame sinks into the dark turquoise sheets of the Baglung District Hospital Maternity ward; the bright green of her traditional Nepalese dress blends into the sheets. A new mother, her
57 pained stillness seems out of place. Around her, a group of women in lavender saris gather, young nursing students on placement in the district hospital. Worried expressions cover their normally excited faces, and their chatter lowers to a hushed discussion. Taulkumaripun barely opens her eyes, emitting only a soft moan as the drip’s position is modified. The lavender mob straightens her blankets, and then leaves her to rest.
Dr. Paudel explains in the training hall at Baglung hospital that Tulkumaripun had arrived there the night before after an eight-hour journey. The young nurses had said she was from Niskut in Magdi district, a couple of hours away. Dr. Paudel explained that Tulkumaripun’s baby’s hand had come out first during labour, leaving the baby stuck in the birth canal. The family had then carried her down to the nearest road, where they bartered for transportation to Magdi hospital. When they arrived at the Magdi Hospital, the staff immediately recognised that she needed surgery, and put her into an ambulance jeep to Baglung, where Dr. Paudel gave her an immediate cesarean section. Janaki K.C. chimes in: “She was very lucky.”
Figure 19 Kelly McIlvenny, Janaki K.C., a staff nurse at the Baglung District Hospital, checks a newborn girl’s skin and damaged hands. She explains the blue around the mouth and limbs is not normal, indicating the new life is not obtaining enough oxygen, 2011.
58 The next day, Taulkumaripun’s eyes are open. Her head is propped against a small pillow so she may watch over her newborn baby girl, while Janaki K.C. unwraps the newborn from her many colourful layers to check on her hands. The hand that had come first out of the birth canal is bandaged in white gauze; the other tiny fingers are almost blue. Janaki explains the child has cyanosis—lack of oxygen—and will be sent to Pokhara with the mother’s sister, where the child can receive further treatment.
Figure 20 Kelly McIlvenny, The mother’s sister gathers up layers of fabric for the nursing students to wrap the newborn girl in preparation for taking her to Pokhara, where she can receive further treatment, 2011. In preparation for transport, Sofia Jhapa, 19, a nursing student from Pokhara, carefully wraps the child in layers of colourful fabric, the tiny face peering back at Sofia’s sweet smile. She places the now double-sized bundle into the nervous hands of the mother’s sister, who is escorted to an ‘ambulance’—a pick-up truck with two benches fixed in the back and an oxygen tank stuck in the front cabin. The pick-up truck scuttles down the dirt road past the worn posters along the wall of the hospital towards the main road out of the bazaar. The highway to Pokhara hugs the river valley before winding over the range that separates the two valleys. The road is cracked and worn from years of landslides and the heavy rains of the monsoon season. Nevertheless, it is a lifeline for those women who are able to reach Baglung Hospital, as that same road feeds training and supplies into the valley from the larger cities.
On my final research trip to Nepal in November 2014, I documented three SBAs serving as midwives in three newly establish birthing centres in Pandavkhani,
59 Gwalichaur, and Hatiya. In the small village of Pandavkhani in Western Nepal, Heema Shiris, 38, has been working as a health worker at the Pandav Khani health post for twenty years. She moved to Pandav Khani from Regha VDC, Baglung, after marrying her husband. Travelling with her to visit her previous cases, I can hear that many of them call her Bhauju, which translates as ‘wife of my older brother’—a sign of familial respect. In Gwalichaur, Kalpana Sapkota, 30, has been an SBA at the Gwalichaur health post for two years, and an Auxiliary Nurse Midwife (ANM) since 2002. Around the village, the mothers we visit refer to her as ‘our madam’, enclosing her in the familial circle. The section on the website devoted to these women has been named ‘our sisters’ in honour of the social position these women have gained within their communities as agents of change.
While we had planned to be there during the childbirth of some of the participants, unfortunately labour runs to no schedule and the women went a few weeks overdue, so I was unable to witness the use of the birthing centres for childbirth. Instead, I captured a series of ‘near misses’—women who had complications during their birth, but, through the skill of the midwives, were able to be saved. I used environmental portraits to document women who for the first time had accessed the biomedical knowledge and interventions that the SBAs provide. In interviews with the SBAs, the cultural and significant social changes of their villages come to light, as well as the personal and introspective knowledge of their own experiences with childbirth.
60 3.6 Heema Shiris: Pandavkhani
Figure 21 Kelly McIlvenny, Heema Shiris, the Skilled Birth Attendant for Pandav Khani, November 2014.
Heema Shiris tells me there is a sloka (quote) in Sanskrit that goes: Janani Janmabhoomischa Swargadapi Gariyasi (trans. ‘Mother and motherlands are greater than heaven’). She moved to Pandav Khani from Regha VDC, Baglung, after marrying her husband. They have two boys, 18 and 14, now living in Kathmandu to attend school. When asked why she chose to pursue a career as a health worker, Heema immediately told the story of her mother’s passing:
I came to know that my mother died of cancer when I was two-and-a-half years old. But what exactly happened, I did not know. Later on when I was older I started to search for the reason. Then I found out she had cancer in her uterus. There was lots of drainage and pus. At that time people used to believe in the treatment of witchdoctor. My father brought witchdoctor for her treatment. He sacrificed a lot of goat and chicken. He also sold a plot of land to arrange money for witchdoctor treatment. After the witchdoctor of our village failed to treat her, he also called the renowned witchdoctors from another VDC called Ransing, believing that they will cure her. But back then they do not believe that you should take them to the hospital. There was a hospital in Tansen; it is the only hospital. My mother wanted herself to be brought to the hospital. My mother requested to be taken at least once to the hospital. Maybe she would have survived if they had taken her. But nobody
61 realized this at the time. I was small and I have an elder brother and sister. But even they did not realize it. So because of uterus cancer, I lost my mother when she was 42 years old. After understanding what happened, I wish that back then I was in the same position I am in right now. I may have saved her by taking her away, and my mother may not have died. This thought always haunts me. I want to prevent other mothers from dying this way, without proper treatment, only being treated by a witchdoctor. I am determined to do this. (Interview with the author, 13 November 2014)
The powerful story evokes the social difference most at issue in medical realms in Nepal, which distinguishes so drastically between traditional villager and modern cosmopolitan (Pigg 1995, 18). Little is known and documented on how people in the hills experience and understand their position within these shifting cultural, political and economic realities, or visually represented in the narrative of Nepali development as projects in the Third World heavily rely of the narrative of modern progress (Pigg 1995, 21–22). In much of the anthropological, touristic, and development policy writing on Nepal, the word ‘village’ conjures up images of poverty, isolation, and unchanging tradition. However, is this view of the contrast between shamans and doctors an artifact of Western social imagination? The mass media’s commentary on tribal wisdom uses the witch doctor “to construct commentary on the relation of the Western self to the exotic other,” evoking an apparent naturalness in the contrast between shamans and doctors (Pigg 1995, 29).
The following research instead bespeaks of a long history of intermingling of religions and cultures, traditionally a mixture of shamanic practitioners (bijuwa and baidhang) and those possessed by spirits and giving divinations (jokhana). That the hill people of Nepal show medical pluralism is in the eye of the beholder; practitioners make a distinction between Ayurvedic and Western medicine, while patients do not (Pigg 1995). Anthropology Professor Stacy Leigh Pigg explains that the Nepali people:
Already know, for instance, that some illnesses are “inside” the body (bhitrako betha) while others are manifestations of external disturbances. They know that many kinds of influences affect people’s well-being: the pull of the planets; the balance of hot and cold in the individual body; the relationships with ghosts and spirits; the malevolence of witches…They know that to cure an illness you have to deduce what kind of influence is primarily at work on the sick person; usually the only way you can know for sure what caused an illness is by seeing what cures it. (Pigg 1995, 26)
62 From this perspective, Western-style medicine works simply on the types of illnesses they identify as “sicknesses of the body” (jiuko betha). Nepalis would equate the gathering of knowledge from the body through physical testing like checking the pulse or temperature with the “tests” (janch) performed by local healers when they suspect bodily illness. However, they continue to seek the spiritual guidance of traditional shamans when the illness is not of the body—but of the spirit” (Pigg 1995, 26). For instance, Heema continues with traditions such as Chaiti—on the sixth day after a baby is born, the extended family stay up all night and sing bhazjani (God’s song) and place a notebook and pen under the pillow of the newborn with a diyo (oil candle) burning. Heema explains, “We believe that a Bhabi (guardian angel) will come and write the baby’s fate on that day. We cannot let the diyo burn out during the night” (interview with the author, 13 November 2014).
All the midwives interviewed said there were no ceremonies regarding childbirth, but noted that it was traditional for the woman to give birth outside the house or in the animal shed. Prayers would be said for a speedy delivery. All participants named the baby on the eleventh day after birth in a ceremony called Nwaran. Then, at six months, there is another ceremony for the baby’s first feed of rice.
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Figure 22 Kelly McIlvenny, The top photo shows the village nestled into the side of a 4,000-metre peak taken from the road leading into town. In the second image, one can see the health post, the white building on the right hand side located near the bottom of the village in the densely populated centre of town, November 2014.
Pandavkhani’s location, roughly ten hours by jeep to Baglung Bazaar, links the isolation to time, not traditions, meaning the village’s isolation is not cultural but physical. Heema’s role as the only midwife is crucial to the safety of the women in her care. Before the birthing centre was established, women were obliged to give birth at home. Since the birthing centre opened, forty-six deliveries have taken place at the centre in two years. Heema discusses the challenges she and her patients still face, stating that women from wards 1 and 2 (a two to four hour walk away) still do not come to the birthing centre because there are no roads traversing that side of the ridge, and no ambulance or vehicle to transport women from the birthing centre to the hospital. In order to correctly detect many of the complications during childbirth, an ultrasound is required, but the nearest one is in Baglung. Women choose not to go because the road conditions are bad and it will cost them too much to travel. She continues:
Providing health service is easy there because educated and elites live in the cities. But it is difficult to counsel and make people aware in the remote villages and remote parts because they are uneducated and also have low income. There are several challenges while working at community level.
64 Some people refuse our request to bring pregnant woman to the health institution. Due to the lack of awareness, people think that undergoing delivery at home will make no difference. Counselling them is also difficult because they lack understanding. Similarly, scarcity of medicine is another common problem facing the patients. Many of women are suffering from anaemia, children are suffering from malnutrition in the village. It is remote area. The people are not much interested to go to the health centres. Lack of resources and financial problems are the major challenges. Similarly, conservative attitude of people is another challenge as some people still think that women should give birth to their babies at their home. Similarly, no sufficient rooms are available for patients and their attendants. There is no toilet inside the building. I take all these problems as challenges. (Interview with the author, 13 November 2014)
While the challenges are numerous, it is clear over the days we spend with her, visiting families in the village, that she has gained the social capital to be valued in the decision making process during pregnancy and childbirth. Dammar Shrees describes the night of their first child’s birth with admiration for Heema, respectfully referring to her as his sister-in-law even though they are not related. Heema describes consoling the family while delivering three babies that night. Little Rhythm had become breeched in his mother, Rupa Shrees’s birth canal early in the evening and she was unable to deliver him until late in the afternoon the next day. Without Heema, Rupa would have needed to be airlifted out of the village, sending the farming family hundreds of thousands of Rupees into debt would have to be risked, without assurance they could pay back the loans. Otherwise, Rupa’s life travelling by road to the hospital, most likely not reaching the maternity ward in time to save both mother and child. The couple are pictured below twenty-four days after the birth of their baby boy, Heema checking on both mother and child. Likewise Rupa Pun, 19, pictured with her fourteen-month-old daughter, Qurina Pun, faced a similar fate with Heema negotiating unborn Qurina’s legs first from in her mother’s birth canal.
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Figure 23 Kelly McIlvenny, Rupa and Dammar Shrees, pictured above, 24 days after the birth of their baby boy. Heema Shiris checking on both mother and child. Likewise, Rupa Pun, 19, pictured below with her 14-month-old daughter, Qurina Pun, faced a similar fate with Heema negotiating unborn Qurina’s legs first from in her mother’s birth canal, November 2014.
66 3.7 Chandika Sapkota: Hatiya
Figure 24 Kelly McIlvenny, Chandika Sapkota, Skilled Birth Attendant of Hatiya, November 2014.
Forty-year-old Chadika is from Gulmi Wanmisaksar, two hours by bus from Hatiya. She has been working at the Hatiya health post since 2002, and has been an SBA since 2006. She is married with two daughters and one son, 16, 13, and 8. Pictured above, Chandika hovers in the doorway to her bedroom describing the birth of her two daughters. She had been in the kitchen when she first felt labour pains. Making her way to her bed, her neighbours heard her cries and came to help her. She would be unassisted during both deliveries, stating simply there were no other options back then. Without a mother-in-law, there was no one to advise her during the births of her daughters. Much like many mothers around the world, she describes her day around her children, “Early morning wake up and I work at the house—washing, cooking, cleaning and sending the kids to school. And from 10am to 3pm I work at health post. If there is any emergency then sometimes it is until 5pm at night, but if not, then 10am to 3pm. After 3pm, I return to house and make some snacks. Take care of my shop, and again cooking, cleaning. The same as usual household work” (interview with the author, 16 November 2014).
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Figure 25 Kelly McIlvenny, Chandika Sapkota, Skilled Birth Attendant of Hatiya, completing her daily duties at home, November 2014.
Sitting texting on her mobile phone during another quiet afternoon at the health post, Chandika described how she used to make calls. Less than ten years ago, there were no roads, so one had to walk to another village to stand in a queue for two to three hours in order to make one call. To get to Baglung, one has to walk over the ridge to the nearest road, which is impossible when pregnant. Sitting on the main road to Baglung, modern life has slipped easily into the village, Hatiya; however, the villages surrounding remain cut off from easy access to medical treatment. Women walk up to three hours to the health post.
Figure 26 Kelly McIlvenny, Chandika Sapkota, Skilled Birth Attendant of Hatiya enjoying a quiet moment at the Hatiya health post. November 2014.
68 Kalpana Sapkota Acharya: Gwalichaur
Figure 27 Kelly McIlvenny, Kalpana Sapkota Acharya, Gwalichaur’s Skilled Birth Attendant, feels the skull of 28-day-old Ritesh Kharel, Gita Kharel, 19, child, November 2014.
Kalpana Sapkota, 30, describes the medical conditions present when she gave birth: “Back in those days there were very limited medical facilities. You have to Taksar, Palpa. Some died on the way to hospital. They would bleed out on the way to hospital. Placenta would get stuck on the way.” However, her own experience was quite different:
On 25 July 2005, I delivered by first child. On that day, at 8am in the morning there was a little pain in my stomach. I suspected it was labour pain, and I did have a midwife book—Midwifery B book. So I kept reading the book, and I suspect it is labour pain. Then I talked with my husband and he brought the health worker. After that at around 9pm at night, I delivered. He administered oxytocin and delivered the placenta using the CCT method. Just that’s it: there were no complications. No tears, nothing. (Interview with the author, 19 November 2014)
The social capital Kalpana has created within the network of villages surrounding Gwalichaur becomes clear when young Manju, 18, comes into the health post, complaining that she is bleeding. Kalpana suspects that the young woman is having a miscarriage, and hooks her up to an IV, watching over her while she rests on the low
69 wooden cot. I find out that Manju and her husband ran away from home in what they call a ‘love marriage’. They are now working in India in a hotel. She tells me they made the two-day journey home for a local festival that starts tonight. Her grandmother-in-law does what she can to help the young girl. Kalpana takes Manju into the labour room to check to see if there is anything stuck inside. Kalpana explains she does not have the correct tools to do a proper extraction; if Manju continues to bleed, she will need to go to Baglung. For now, there was little more they could do except keep her on an IV and keep a close eye on her. A couple of hours later, the bleeding has completely stopped, and she is carried home by her husband, with Kalpana’s reminder that if she experiences any symptoms, to call right away.
At this final village, I return to the formal portraiture of my first field research trip; this time to capture the families affected by the introduction of biomedical services. Upon interviewing the families, it becomes clear that, while tied to the land and locality, the villagers are participants in a social and economic web reaching far beyond the rural areas of Nepal to global cities. With five out of nine husbands working as migrant workers abroad in Dubai, Malaysia and India, most have never met their children, leaving soon after conception.
Figure 28 Kelly McIlvenny, (From left to right) Bishnu Pariyar, 30, with eight-month-old Skikha; Kopila G.C., 22, with two-and-a-half-year-old Jibika; Shanta Ghimire, 24, with one-year-old Shiru; and Bashanti Acharya, 29, with five-month-old Shanti, November 2014.
The remittances fund development back home; as Kalpana describes:
When I arrived here, there were no lights. We used to work at home using kerosene lantern. There were no boarding schools, just a government school. There was no road; to come here we had to walk from Baglung. No vehicles. There was no mill. But now there are several mills nearby. They use ox and
70 bulls to plough the field, but now they are using tractors and modern equipment. (Interview with the author, 19 November 2014)
The immediacy of this way of life is directly linked to the global economic network; it brings new challenges to the hills, but also new opportunities.
3.8 Returning to Baglung Hospital
On my second field research trip, I returned to the Baglung District Hospital to find the space completely changed, but the staff exactly the same, except for a new group of nursing students. The hospital is now a three-storey building, and the one-storey maternity ward is converted into doctors’ offices. It is hard to move past the physicality of the space, but the tools have remained much the same, with the exception of the operating room. As this documentation “narrows its focus to medical ideas, medical behaviours, and medical consequences, it is easy to lose sight of the ways that people’s actions with respect to health and illness contribute to and are shaped by a much broader social process” (Pigg 1995, 18). How could I document these women among the modern healers in a way that could possibly capture the complexity and a meaningful response to suffering? (Pigg 1995, 18)
The question seemed insurmountable until I met Kamala Karki. After experiencing another contraction, she cries out “Didi” (sister), calling for the nurse. The young nursing student here on placement from Pokhara, Nepal’s second largest city, three- and-a-half hours’ drive from here, comes to Kamala’s side. She seems to be assuring her, her voice soft but confident. The pain passes, and Kamala turns back to me, seemingly eager for company. With the nursing student preoccupied with forms to fill out, there is little I can do for translation. In broken Nepali and English, we agree to take a portrait. Leaning down beside her, I peer at her whole face closely for the first time. Despite having been here since 2am, and now almost 10:30am, she is beaming through tired eyes. The sides of her mouth creep up into a confident grin. I click a shot, and then show her the image on the back of the camera. She grins from ear to ear. I take another, this time she intently stares back at me, no longer grinning, but locked on in a gaze. The nursing student comes back to check on her IV, and we exchange names and details for the first time.
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Figure 29 Kelly McIlvenny, Kamala Karki, Baglung District Hospital, February 2014.
Her family, gathered on a spare bed outside, seem pleased to have someone watching over her. Milan Baruwal, a thirty-two-year-old staff nurse explains who I am and why I am here. She then explains to me that Kamala is a relative of hers from Majphant village, in the neighbouring Parbat district. The family has travelled one hour by foot, then one hour by bus to get here. Kamala’s first child, a six-year-old girl, is climbing all over Dipak Karki, her husband. While in labour with her first child, Kamala required a caesarean section and was referred to Pokhara. The surgery went well, but Kamala became severely infected and was referred to Kathmandu. Because she had a caesarean for her first child, she can no longer give birth naturally. Believing there are lower complication rates in Baglung, the family has chosen to come here. Back in the delivery room, the nurses are preparing her for surgery. Three nursing students help Kamala from her bed, carrying her IV along beside her as they walk her into the operating theatre. Helping her up onto the operating bed, they cover her in turquoise sheets, while the anaesthesiology technician is scrubs his hands in the corner with Dr. Paudel.
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Figure 30 Kelly McIlvenny, Kamala Karki is taken into the operating room to undergo a cesarean section at the Baglung District Hospital, February 2014.
Up on the table, Kamala is hooked up to the heart monitor. Her heart is racing at 170 beats a minute, and she is shaking with nerves. Her relative, Milan, now in the room laying out the required equipment is confidently chatting with her fellow nursing staff. Kamala’s heart continues to race as the anaesthesiology technicians roll her onto her side, curling her into the foetal position so that one of them can place the needle into her spine. Once the technician is happy with the placement, Kamala is rolled back onto her back and Dr. Paudel takes over. Quickly covering Kamala in another sheet, the nursing staff all take up their positions. Each in their place, the doctor tells me he will begin. I step out at regular intervals to see how the family is doing. Kamala’s husband Dipak is preoccupied with their six-year-old.
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Figure 31 Kelly McIlvenny, Kamala Karki’s husband Dipak holds their newborn child for the first time while his wife is still in surgery at the Baglung District Hospital, February 2014.
Across from Dr. Paudel is Janaki K.C., the staff nurse who has been working at the hospital for over two years. The two of them working together seems natural in what is a most unnatural environment. Soon, Dr. Paudel has made it through the layers of skin, muscle, and fat tissue that surround the uterus. Making his final incisions, the doctor and Janaki K.C. begin to pull the incision open. It seems like a violent, aggressive motion, but soon the head is peering out, and Dr. Paudel delivers the baby, with a few strategically placed pushes. In this moment, I know I could be anywhere: the nursing staff confidently take over the care of the newborn, clearing out his airways and wrapping him up in layers of cloth. And, for the first time since beginning of this research in Nepal, the nurses take the newborn out to meet his father. Normally, it would just be the mother-in-law outside in the waiting room impatiently waiting for her grandchild.
The next day I find Kamala fast asleep in the post-operation recovery room. The room is quiet, with all the ladies wrapped in layers of colourful blankets—most of them sound asleep. Dipak is sitting in the corner next to the only crib I have seen in the hospital, the newest addition to their family fast asleep; a small white blanket protecting his tiny eyes from the direct sun pouring in the window. The sunlight a
74 warm retreat from the winter air trapped inside the concrete hospital building. Dipak gently uncovers the tiny crib to reveal the bundle of blankets inside, a small face just visible in the heap. Both mother and newborn are healthy and taking some much- needed rest. I wish Dipak well and tell him I will return the next day. Kamala will be staying at the hospital for at least ten days so that the doctor can monitor her recovery.
Figure 32 Kelly McIlvenny, Kamala Karki rests with her two-day-old wrapped in layers of blankets to protect them from the winter chill inside the post-operation room, February 2014.
Perhaps their family is a singular occurrence, a break from the norm, or perhaps they are a reflection of a change in social behaviour. However, sitting a couple of beds down is another couple who have travelled to the hospital, a one-and-a-half-day trip from their home in Bongadoban, in order for Jalmaya Sunar, 17, to have a caesarean due to an arrested labour. The man in charge of the Bongadoban health post, Topargu, travelled with them and kept a close watch over Jalmaya during the surgery. He said their journey started with a three-hour walk, ending here in the Baglung operating theatre at 9pm. The newborn boy is 3.75 kilos; his large size probably caused him to become stuck in the mother’s birth canal. The parents are posing below for a portrait while their newborn takes his turn in the one cot in the caesarean recovery area.
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Figure 33 Kelly McIlvenny, Jalmaya Sunar, 17, and her husband travelled one-and-a-half days from their home in Bongadoban, in order for Jalmaya to have a caesarean due to an arrested labour, February 2014.
76 Chapter 4: Creative Outcomes
Much of the photographic process is quick; days seem to compress into seconds when you are caught up in another’s world. The editing process would begin while I was sitting with my laptop perched on a wooden frame, often with my host’s eyes peering over my shoulder. Later, when I was back in Australia, the fragments would begin to line up, with stories joining across villages and families. At first, listening to their voices amid the modern noises of my neighbourhood seemed disjointed and jarred; I was at a loss as to how the images could make sense in the world outside. I was aspiring to what Emmanuel Levinas called the “transcendence of self which calls for epiphany of the Other” (cited in Strauss 2003, 49).
After my first doctoral field visit, I began making the photo film The Foot Soldiers of Change (2012), which built upon the photo film I produced for Welcome Labour Room. This time, the film’s script was translated into Nepali and spoken by Sunita, a trainer from One Heart, so that the film could be used both inside Nepal and outside—allowing for a local and a foreign audience. For the first time, the images and text connected the women (both as trainers and mothers themselves) to the clinics and education they were receiving, showing the landscape and texture of the living environment. The film was simplistic in narrative—linear and clear—but effective in creating a visual connection between mother/foot soldier, and the societal and environmental challenges they overcame in order to provide safe birth practice in their villages, as discussed in the last chapter. While it does not have the reflective qualities I sought to endow the final body of work with, it was useful for One Heart in explaining the effective organic structure of their programs. This is where the dilemma of matching the desire to create a layered, reflective practice contrasts with the necessity to impart the work with the critical investigations of text and supporting contextual framing. In the end, the creative outcomes rectified this need for balance by using the reflective space of the gallery to create an expanded photographic essay where the nuances of social change in the Baglung district could be reflected upon and contextualised by detailed and narrative captioning. Likewise, the continued use of a website to create a space for the project and work to gain critical feedback and remain as a resource is important to the purpose of the exploration.
77 The multimedia website Foot Soldiers of Change (www.footsoldiersofchange.com) leads the user through the research topics on a one-page scroll, where new ideas are introduced through full-width images and text, followed by snippets of the stories. Visually placed in Nepal, the website introduces the work with a map to help users orientate themselves and create expectation. The user is introduced to the Female Community Health Workers through the video Foot Soldiers of Change, and then to the individuals through testimonials, followed by a section that details the history of the program. Much like a Nepali mother from one of these villages, the website then introduces the user to the SBAs and the women they have helped. Reaching the hospital, users are shown the Welcome Labour Room video before fast forwarding to the present-day hospital and the stories that cement this work as a survey of social change. Finally, they are introduced to Arlene Samen and the organisation One Heart World-Wide, so that they can understand their role in this research, and access more information about them should they choose to. It was important for me that this research be linked to a direct means to continue to fund the programs that make the work of the women documented here possible. The main structure is fixed, but content will be added to keep the website live leading up to the exhibition of this work at the Queensland College of Art in Brisbane.
Originally, the exhibition was to follow a similar linear approach to the website, leading the viewer from the mothers in the village to the hospital. Grids of images were to be used in order to create the textured and layered response to each environment—from home to clinic to hospital. These grids were to be broken by the interviews and collected narratives of the female community health workers and skilled birth attendants. However, during the final preparation for the exhibition, a devastating earthquake took place on 25 April 2015 in Nepal that killed over 8,000 people and destroyed over 500,000 homes. I returned to Nepal in June 2015 to document the role that the volunteers and midwives were playing in protecting the women of their districts from further harm or suffering, despite significant damage to the structures and lack of steady supplies. It quickly became apparent to me that these images would need to be included to further contextualise the real value of these programs, which include the education of these women and their ability to use that knowledge to advocate and protect new mothers in Nepal.
78 The exhibition was held at the Webb Gallery at the Queensland College of Art from 26 August to 5 September 2015. The first wall of the exhibition opened with a situational landscape that showed the traditional roles human beings play in this environment, both being shaped by and shaping their landscape. The second wall was a mixture of reportage and portraiture, meant to introduce the viewer to the familial environment, the textual details of rural Nepal, and for them to begin to piece together the story of the women and the SBAs who support them. The third wall was a grid of portraits broken by images of handwritten text—a sea of faces trying to evoke the individual in an ocean of individuals working to provide safe birth care to Nepali women. The handwritten notes were translated on the didactic, each a story chosen by the volunteer to share. The fourth wall was a double hung row of reportage images starting with four from the original piece Welcome Labour Room before moving into three stories from the new hospital. The choice to hang them in succession without a break was meant to imply the routine and messiness of the labour room itself, with one case leading to the next. The portrait of Kamala hung in the middle; a reminder of the intrusion of the camera into this private space, but also the subject’s knowledge and acceptance of that intervention. The fifth wall revisited the familial environment post-earthquake, acknowledging the role these women play in the survival and prevention of further suffering, but also the precarity of the women’s lives as they live with new challenges. The final images reflected the opening landscape; however, this time half the frame was filled with rubble, with a woman carrying water to her home in the background. This image was meant to evoke the idea that life goes on, but the women of Nepal continue to face perilous marginalisation exacerbated by the natural disaster of the earthquake.
Editing down to the final set of images, I looked for moments of affective emotion, images of layered information, and textured details, each adding to the story and comprehension of the exhibit. Each trip developed new insights into the network of factors contributing to the successful reduction in maternal and newborn deaths, and this was reflected in the structure of the exhibition. The exhibition functioned as an extended photographic essay, slightly narrative in structure. However, it was important to me that the continued challenges of these women not be forgotten or lost, and the exhibition provided some insight into the influences of modern life. The strength of the exhibition was the use of compelling and affective photographic
79 research, adding to other more numerical and textual elements to create an affective understanding of the cultural, social and physical challenges.
80 Chapter 5: Conclusion
While this research is confined to the Baglung District in Nepal, the challenges described reach across the nation; the fact that “Nepal is an Asian country with a population of 28 million; its mountainous topography and poverty (annual gross domestic product $300 (£193; €245) per capita)” continues to “create barriers to adequate healthcare” (Zimmerman et al. 2012, 1). The complex nature of maternal health in Nepal is both a positive example of internal initiatives to create and implement change and a continual battle to elevate the status of women in a society whose traditional nature is patriarchal.
Using the photographic medium to investigate this complex cultural and social environment, the research substantiates the historical relevance and social significance of this inquiry into female community health practices in western Nepal. This work provides an affective photographic document of the social, cultural, and environmental nuances affecting maternal care in western Nepal. While not inventive in the method of photographic practice, the extensive field research has yielded insightful depictions and recorded dialogues that show what is absent from the textual data. By detailing the extended networks at work to improve maternal care, this research’s sustained inquiry has provided a layered investigation into the practices of maternal care in Nepal. The collective narrative that plays out across disparate environments is compelling, and the photographic document is used as a bridge to conversation by entering these women’s lives at times of familial quiet and the dramatic moment of childbirth. The textual details of the work speak to the national narratives, community networks, and kinship relations discussed in the initial investigation that play out in the details: a cellphone being handed into the frame is a nod to the modern influences impacting village life; the SBA slipping easily into the home of a mother like an auntie coming for a visit is an acknowledgment of the relationship she has built with her community; the absence of the husband when the woman climbs the steep muddy hill to the birthing tent post-earthquake is a reminder of the cultural, physical, and societal challenges that remain here.
The effectiveness of the documentation is a result of its use of visual narrative with narrative captioning and the more advocatory practices of the website. The website
81 lacks some of the more layered responses to environment, texture, and colour that added inventiveness to the exhibit. Following future trips, the website will continue to be refined to enhance its affective properties, moving away from the more traditional linear advocacy of photo-films. The exhibition is currently being translated into a book, where the rich archive of photographic, interview, and textual information can be fully explored. The book aims to have the same loosely narrative approach as the exhibition, but will include more textual pieces in the Nepali language to allow for a cross-cultural reading of the work. It is important to me that the work makes it back to the women who have shared so much of themselves with the project. While the work has reached a Nepali audience being used as documentation of the programs to discuss what is working, what needs to improve, and the importance of bringing these programs further into the mountainous regions of Nepal. I imagine the photography will continue to reinvent itself: one part family album, one part activist record, one part historical acknowledgement to the women of Baglung District, and one part memory. It is a detailed story of the societal and cultural challenges that women face in order to give birth, but also an acknowledgement to the women who are acting as agents of change in the foothills of the Himalayas and whose daily histories are rarely discussed. These elements of the project are site- and culturally specific; however, the methodology of sustained inquiry into the communal and community initiatives could translate to a sensitive engagement with other localities, and key lessons discussed can be transferred to future projects in disparate communities.
82 REFERENCE LIST:
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84 Kratochvil, Antonin. 2001. “Photojournalism and Documentary Photography.” Nieman Reports 55 (3): 27–31. Laird, Thomas. 2001. “Rain of Shadows.” Outside Online, August 7. http://www.outsideonline.com/outdoor-adventure/Rain-of- Shadows.html. Lal, C. K. 2001. “Nepal’s Quest for Modernity.” South Asian Survey 8 (2): 249–60. doi:10.1177/097152310100800209. Light, Ken. 2000. Witness in Our Time: Working Lives of Documentary Photographers. Smithsonian Institution Press. Linfield, Susie. 2011. The Cruel Radiance: Photography and Political Violence. University of Chicago Press. Manchanda, Rita. 2004. “Maoist Insurgency in Nepal Radicalizing Gendered Narratives.” Cultural Dynamics 16 (2–3): 237–58. doi:10.1177/0921374004047750. Mark, Mary Ellen. 1978. “Falkland Road.” Mary Ellen Mark. http://www.maryellenmark.com/books/titles/falkland_road/300D-003- 053_falkrd_520.html. Mark, Mary Ellen, and Laurie Rae Baxter. 2015. Mary Ellen Mark on the Portrait and the Moment. New York: Aperture. McCormick, Patricia. 2010. Sold. Disney Book Group. McIlvenny, Kelly. 2011. Welcome Labour Room: The Story of Maternal Health in Nepal. Multimedia Website. www.welcomelabourroom.com. ———. 2012. One Heart World-Wide’s Foot Soldiers of Change. http://vimeo.com/22418156. Meiselas, Susan. 2011. In Silence. http://inmotion.magnumphotos.com/essay/silent-maternal-mortality- india. Meiselas, Susan, and Claire Rosenberg. 1981. Nicaragua, June 1978 to July 1979. New York: Pantheon Books. The Metropolitan Museum of Art, Department of Photographs. 2000. “Early Documentary Photography.” Heilbrunn Timeline of Art History. http://www.metmuseum.org/toah/hd/edph/hd_edph.htm. Nachtwey, James. 1999. Inferno. Phaidon Press. Nepali Times. 2012. “A Nation’s Health,” 17 August, 618 edition. http://www.nepalitimes.com/issue/2012/08/17/Editorial/19548#.UJig N4VhNL-. Open Society Foundations. 2010. Expanding the Circle: The Engaged Photographer. Youtube video, 6:12. Posted 12 October. https://www.youtube.com/watch?v=B5wTr0taLI8&feature=youtube_gda ta_player. Pattisson, Pete. 2013. “Nepal’s Maoists Face Struggle to Win over Disillusioned Voters.” The Guardian, 18 November. http://www.theguardian.com/world/2013/nov/18/nepal-maoists- struggle-disillusioned-voters-election. ———. 2014. “Nepal’s Bogus Orphan Trade Fuelled by Rise in ‘Voluntourism.’” The Guardian, 27 May. http://www.theguardian.com/global- development/2014/may/27/nepal-bogus-orphan-trade-voluntourism. Perczynska, Ola. 2014. “Child Marriage in Nepal: What Do You Do When It’s by Choice?” The Guardian, 25 February.
85 http://www.theguardian.com/global-development-professionals- network/2014/feb/24/child-marriage-trends-nepal. Peress, Gilles, and Ghulām Ḥusayn Sāʻidī. 1997. Telex Iran: In the Name of Revolution. Zurich: Scalo. Pigg, Stacy Leigh. 1995. “The Social Symbolism of Healing in Nepal.” Ethnology 34 (1): 17–36. doi:10.2307/3773861. Population Division Ministry of Health and Population, New ERA, MEASURE DHS, and U.S. Agency for International Development. 2011. “Nepal Demographic and Health Survey 2011 - Prelimary Report.” Demographic and Health Survey Reports (DHS). Kathmandu. http://www.google.com.au/url?sa=t&rct=j&q=&esrc=s&source=web&cd =2&cad=rja&ved=0CEAQFjAB&url=http%3A%2F%2Fsgdatabase.unwom en.org%2Fuploads%2FDHS%2520- %25202011.pdf&ei=phjRUNzxHfCSiAf77oGQBw&usg=AFQjCNHrmZ8- YBIkXJ5GGPBv997AedAKFQ&sig2=9k5cWD- AvQgMZ9r2h9xpFw&bvm=bv.1355534169,d.aGc. Said, Edward W. 1985. “Orientalism Reconsidered.” Cultural Critique, no. 1 (October): 89–107. doi:10.2307/1354282. Sett, Alisha. 2015. “People’s Histories and Archives Central to a New Photo Festival in Nepal.” Medium, 26 August. https://medium.com/vantage/people-s-histories-and-archives-central- to-a-new-photo-festival-in-nepal-e6732fde42ce#.aucq6w1t3. Sharma, Sharad Kumar, Yothin Sawangdee, and Buppha Sirirassamee. 2007. “Access to Health: Women’s Status and Utilization of Maternal Health Services in Nepal.” Journal of Biosocial Science 39 (5): 671–92. doi:http://dx.doi.org.libraryproxy.griffith.edu.au/10.1017/S0021932007 001952. Sinclair, Stephanie. 2013. “Too Young To Wed.” Too Young To Wed. Accessed March 26. http://www.tooyoungtowed.org/. Singh, Maina Chawla. 2005. “Motherhood and Maternity.” In New Dictionary of the History of Ideas, edited by Maryanne Cline Horowitz, 4:1507–13. Detroit: Charles Scribner’s Sons. http://go.galegroup.com/ps/i.do?id=GALE%7CCX3424300505&v=2.1&u =griffith&it=r&p=GVRL&sw=w. Strauss, David Levi. 2003. Between the Eyes: Essays on Photography and Politics. New York: Aperture. Suwal, Juhee V. 2008. “Maternal Mortality in Nepal: Unraveling the Complexity.” Canadian Studies in Population 35 (1): 1–26. Symmes, Patrick. 2001. “The Last Days of the Mountain Kingdom.” Outside Online, January 9. http://www.outsideonline.com/outdoor- adventure/The-Last-Days-of-the-Mountain-Kingdom.html. Thapa, Manjushree. 2005. Forget Kathmandu: An Elegy for Democracy. New York: Penguin, Viking. USAID. 2012. “USAID Telling Our Story: Nepal - Empowering Female Community Health Volunteers.” USAID. http://transition.usaid.gov/stories/nepal/fp_nepal_female.html. Vernaschi, Marco. 2009. “Guinea-Bissau: Dying for Treatment | Pulitzer Centre.” Pulitzer Centre, 16 June. http://pulitzercentre.org/projects/africa/guinea-bissau-dying-treatment.
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87 GRIFFITH UNIVERSITY HUMAN RESEARCH ETHICS COMMITTEE
16-Jan-2013
Dear Miss McIlvenny
I write further to the additional information provided in relation to the conditional approval granted to your application for ethical clearance for your project "Motherhood, Resilience and Poverty: An investigation of the human factors operating in maternal health in non-western cultures through the agency of photography." (GU Ref No: QCA/20/12/HREC).
This is to confirm receipt of the remaining required information, assurances or amendments to this protocol.
Consequently, I reconfirm my earlier advice that you are authorised to immediately commence this research on this basis.
The standard conditions of approval attached to our previous correspondence about this protocol continue to apply.
Regards
Rick Williams Manager, Research Ethics Office for Research Bray Centre,†N54 Room 0.15 Nathan Campus Griffith University ph: 07 3735 4375 fax: 07 373 57994 email: [email protected] web:
Cc:
At this time all researchers are reminded that the Griffith University Code for the Responsible Conduct of Research provides guidance to researchers in areas such as conflict of interest, authorship, storage of data, & the training of research students. You can find further information, resources and a link to the University's Code by visiting http://www62.gu.edu.au/policylibrary.nsf/xupdatemonth/e7852d22623 1d2b44a25750c0062f457?opendocument PRIVILEGED, PRIVATE AND CONFIDENTIAL This email and any files transmitted with it are intended solely for the use of the addressee(s) and may contain information which is confidential or privileged. If you receive this email and you are not the addressee(s) [or responsible for delivery of the email to the addressee(s)], please disregard the contents of the email, delete the email and notify the author immediately
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