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The Himalayas' Hidden HungerCathy Shufro

The Himalayas' Hidden Hunger (cont'd)

Finding the Right Kernels
Sabina Maharjan is out of breath when she arrives at a sturdy stone-and-mud house on a narrow terrace high above Sitapur. She has been climbing for half an hour to reach this place, one of 38 scattered homesteads that make up the roadless village of Durkatta. Maharjan has scheduled this interview for early on this summer morning, before the family's workday has begun in earnest.

She greets the head of the household, a relatively prosperous farmer in his mid-40s. He and his wife have four children. Maharjan perches on a shaded wooden veranda in front of the two-story house, and the man faces her on a woven bamboo stool. Maharjan asks him the first in a series of questions and follow-up questions that will require two hours to complete. Does he own this house? Does it have electricity? How many fans are in the house? Radios? Bicycles?

She marks answers on a form fastened to a clipboard.

How does the family treat its water: simply allowing sediment to settle, boiling, adding chlorine? Who fetches the water, and how long does that take? Where do children under 5 defecate? In a household toilet, outdoors near the house, in an open field, in a river? Do animals live inside the house?

After answering a few questions, the man darts inside the house and returns with a topi, a traditional cloth hat commonly worn by older Nepali men. Donning the hat suggests that he takes the interview seriously, but he laughs as he does so, making fun of his own self-consciousness.

Stunting is an intergenerational issue.

A few minutes later, his older son appears at the top of the trail, bent over, a tumpline across his forehead to support the weight of the grasses he's cut for the family's two water buffalos. By this time, Maharjan is asking a long series of questions about farming: Which of 22 crops does the family grow during the wet season? And which ones during the dry season? What crops did they eat themselves, and what did they sell? She asks which animals they keep, from bees to pigeons to pigs. She asks if they vaccinated their buffalos.

To do this job, Maharjan attended six weeks of training in Kathmandu. All 66 "enumerators" were women because of the intimate questions they would ask mothers and mothers-to-be. Each trainee had to master a 180-page manual.

"There was a lot to digest," says Swetha Manohar, who oversaw the training. "She has to understand what crop rotation is, but she also needs to know what a micronutrient supplement is. She has to know what contour lateral irrigation is, versus pipe-based irrigation."

Maharjan and the others also had to learn how to standardize data so similar responses given to interviewers in the mountains and the plains would be marked the same. For instance, how would "two oxen can plow my land" translate into hectares? If a girl was promised to a man at age 12 but moved in with him at 18, how long has she been married?

Choosing survey questions required restraint. For the people interviewed, taking several hours to answer questions is, as West puts it, "expensive." Participants lose time from gathering wood, mending roofs, cutting fodder. Even in urban Kathmandu, many people have to fetch water from rivers or haul it up from wells. "The poor don't have time," says West, "so we've spent a lot of time to find the kernels of information that are probably important."

Maharjan is asking about household finances when the man's teenage daughter brings out rice with milk, breakfast for her 4-year-old brother and a visiting child. The boys attack the rice, then tip up their bowls and contentedly slurp the milk. A typical meal in Nepal consists of a mound of rice and a dish of dal (lentil gravy), and perhaps a few tablespoons of vegetable curry. The diet tends to be low in micronutrients and in protein.

By the time Maharjan asks her last question, it's mid-morning. She will return the following day to interview the man's wife, who has by now departed for the rice fields. Maharjan will record what the woman has eaten in the past week, ticking off a list of 49 foods that begins with rice and ends with Wai-Wai, packaged fried noodles that are popular in Nepal. She will ask how much the woman knows about keeping children healthy. What would she feed a child who was sick? When should she wash her hands? Maharjan will also ask about the woman's power within the family. Who decides whether to use contraception? Who decides when the woman can visit her mother?

Then Maharjan will weigh and measure the woman and her 4-year-old son. If the mother was randomly selected to give a blood sample, to measure hemoglobin, Maharjan will take a few drops.



    Montgomery Village, Maryland 04/09/2014 02:37:07 PM

    Last July I was in the Hemachal Predesh in norther India with a medical group. I saw the same issues, abundant water, tillable land, active farming with a wide variety of produce and stunting, even some Kwashiorkor in two children. Rickets and night blindness cases presented themselves. I applaud your study and the article. This June I return closer to the Indo-Tibitian border and expect will see the same. I will share this article with my students and preceptors. The caloric requirements at high elevation and modest to lower temperatures also pull on needs for growth. Endemic worms in the pediatric population is another. Again thanks for this essential work and timely documentation. Very readable Judy Thierry, DO, MPH JHSPH 2005

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