Just Water? Exploring biological and social determinants of public health in Kathmandu, Nepal

Mentors: Laura Elder, Assistant Professor of Anthropology and Reena Lamichhane-Khadka, Assistant Professor of Biology
Students: Emily Castro, Victoria Chandler, Adrian Milos, and Julie Weilbaker

Participating in the National Seminar on Quality Pharmaceuticals and Safe Drinking Water, Kalimati, Kathmandu, June 5, 2017.

Project Abstract

Our goal was to use interdisciplinary tools of field research in collaboration with Nepalese partner institutions to analyze both determinants and potential avenues for remediation of water contamination in Kathmandu, Nepal.  As water management is central to development initiatives across Asia, we expect that our findings in Nepal will shed light on powerful inequities and vectors of contamination that are relevant across the region.  Social and environmental determinants such as rapid population growth, unsanitary disposal of wastes into water, and increased human activities in and around water sources, can all lead to contamination of water with pathogenic microbes.  In Nepal, urbanization and development have led to increased levels of microbiological contamination in streams, springs, and ground sources.  And, in areas with high levels of microbial water contamination, this may lead to a significant increase in the incidence and spread of water-borne illnesses resulting in impoverishment and increasing social inequality.

During our time in the field, we gathered data on the incidence of gastrointestinal infections in the local population from hospitals and healthcare centers.  And we worked collaboratively, with US students and Nepali students to analyze the microbiological and epidemiological data to determine the main locations of microbial contamination.  Students then collected water samples from rivers, taps, and tanks in neighborhoods around Kathmandu.  And students worked with Nepali undergrads from the Kathmandu Institute of Applied Sciences and other partner institutions to understand patient access to both Ayurvedic and allopathic medical care.  As intersecting indigenous medical systems and Western biomedical systems have been found to differentially impact women’s health and Nepali women are particularly vulnerable to the effects of water contamination, we decided to pay attention to gendered dimensions of water access and contamination.  Paying attention to the social determinants of contamination and, in particular to the effects of structural inequalities, together with local partners students conducted interviews and water-access histories with individuals living in affected neighborhoods in Kathmandu.  Then, students observed meetings of Water User and Sanitation Committees and other public venues of resource allocation and decision-making.

Much of the response to the April 2015 earthquake has magnified inequalities in access to healthcare, clean water, and gendered violence and we are continuing to analyze these kinds gendered effects in the valuation, distribution, and contamination of water.  Students are making significant contributions to analyzing and understanding not only biological factors, but also economic, religious, and cultural factors in the understanding of disease in Kathmandu and how these factors affect the morbidity and mortality of water-borne illnesses.  Our analysis of data is ongoing and we plan to share our findings with our partner institutions and include our partners in all resulting publications.  And it is our hope that our findings will be of use to local hospitals, NGOs, and regulatory agencies.

Julie Weilbaker

Julie Weilbaker, Emily Castro, Adrian Milos and Tori discussing the merits of different neighborhood interviewing sites at the Kathmandu Institute for Applied Sciences Laboratory, June 2017.

Conducting research on water contamination in Nepal allowed me the opportunity to gain meaningful insights into the lives of the Nepali people, and the challenges and obstacles they face to access quality water. The politics and social structures surrounding access to safe drinking water shape the lives of not only the Nepali people, but many others in Asia as well. Cycles of poverty and contamination cannot be attributed to merely one factor. Rather, the various social and political complexities surrounding the systems of power shape the lives of millions of people who work to gain access to not only water, but other valuable resources as well. In particular, water contamination affects women in a profound way as the caretakers of many households work directly with water in their daily tasks that affect their family and themselves. As one of the volunteers from the FEDWASUN Water Committee in Chitwan explained to me, what makes the real difference is the awareness and participation of women. One of their goals is to connect knowledge to access by addressing inequalities and thus fostering health.  And, as an aspiring researcher and physician, I share this same goal.  Engaging the stakeholders in their own community and in their own language with the help of translators taught me invaluable skills such as integrating knowledge and research methods from various disciplines including conducting interviews, water sampling and testing, analyzing epidemiological data and participant observation. These skills will prove invaluable as I enter medical school and prepare to serve others as a physician, accompanying patients on their path to healing and wellness according to their unique needs and situation in life.

After returning home, our team found new difficulties as we worked together to process the large amount of data collected. Each member offered new insights and perspectives on our experiences that allowed us to relay the information to an audience who didn’t have the opportunity to experience Nepal firsthand. One of the best skills I gained from the various presentations and writing a final paper was communication, not only with our team but with different types of audiences as well. I learned to navigate ways of communicating ideas to the public in a way that would be both relatable and comprehensive. I found that upon returning, the learning never stopped and we continued to push ourselves in new ways. I am so grateful for this experience, which taught me so much about the world and myself and brought to light my own desires to serve others through the use of these skills.

In particular, I became very interested in how water contamination and distribution affects the lives of women, for whom water plays such a vital role in their family life. Expectations and social norms placed on women may correlate to serious health issues and extend to health issues of the whole family since women are the caretakers of many households. This only furthers the cycle of poverty and poor health, but is an issue that reaches beyond the borders of Nepal and even Asia to every corner of the world. For me, recognizing this reality has transformed my perspective on women’s health both locally and globally.

Moving forward, I would love to return to Nepal to continue this research. After recognizing how the politics of the scarcity of resources in Nepal affects and directs the lives of millions of people in the surrounding countries, I am excited to consider pursuing research in other areas of Asia where water scarcity is also continuing the cycle of poverty and illness. In the upcoming year, as I enter medical school at Burrell College of Osteopathic Medicine, I will continue to bring this new knowledge of Asia and its people to my patient care. Given the high percentage of Americans with Asian heritage, this experience has been essential to my formation as a physician seeking to care for the underserved populations in our country, and I am excited to be able to bring this new experience into every encounter I have with patients.

Victoria Chandler

Group Photo: Laura Elder, Muna Fuyal, Julie Weilbaker, Emily Castro, Adrian Milos, Reena Lamichhane Khadka, Tori Chandler, and Sagar Rayamjhi at the Bhaktapur Durbar Square, June 2017.

While in Kathmandu our team worked together to understand the causes and the effects of water contamination in Kathmandu.  We attended meetings with government officials to understand and discuss solutions on water problems and shortages in the valley and we also attended some cultural and World Heritage site excursions with the Nepali students that we worked with in Kathmandu. Through our interviews and cultural observations, we were able to see the importance that water plays in Nepal’s Hindu and Buddhist faiths and through some of our interviewing and cultural excursions.  Cultural rituals and political inequality can sometimes cause people to interact with contaminated water against their best interests and thus increase the incidence of water-borne illness.  I felt at ease with the people I met in Nepal and enjoyed what I found to be a culture of friendliness very different from the culture of distrust that I am used to.  I was able to work on leadership skills throughout my time in Nepal.  And I was also able to develop quantitative analytical skills in by collecting and interpreting numerical data for our epidemiological study.  I hope to be able to use these skills in the future through a career in field of anthropology.

Data analysis is another skill that I have been working on as we process our data back in the United States. As a student who studies the Liberal Arts, I often do not look at numbers to make interpretations. But, coming back to the US, our team has been sitting down and reviewing the data that we have received from different hospitals while in Nepal. We have been looking into how age groups and gender are likely affecting the incidence of gastrointestinal infections caused by water borne illness. In October we presented our data at our home university, Saint Mary’s College, in front of an audience of professors and community members. During that presentation we received a great interest, even though we were at the beginning stages of our data analysis. My initial theory, that men were more likely to be affected by contaminated water, has not been supported by our data. But, as a group we have seen that age matters, for example, younger children are less likely to be treated for water borne illnesses.

I will take the knowledge I have gained and put it towards education on immigration and human rights law. I do plan to return to Nepal sometime in the future to keep the connections I made during my time abroad. I felt at ease with the people I met in Nepal and cultivated friendships with many of the Nepalese I worked with. The culture of Nepal is incredibly welcoming and the people I met on my journey were wonderful cultural guides. I enjoyed hearing about Hinduism and Buddhism and how they have now become so intertwined that you often find one monument mixing religious symbols. I enjoyed seeing the women in dark, rose colored saris and older gentlemen sporting colorful Dhaka hats and I felt completely blessed to be able to try on one of those dark, rose colored saris that one of my new Nepali friends dressed me in. I hope to one day be able to return some of the amazing help that the people I worked so closely with in Nepal gave to me.

Emily Castro

Muna Fuyal, Emily Castro, and Adrian Milos at Shivapuri National Park, June 2017.

Our research was conducted in Kathmandu, Nepal as a collaborative project between faculty and students from Saint Mary’s College as well as with Nepalese students and organizations. Our goal for this research project was to use interdisciplinary tools in collaboration with Nepalese students to analyze biological and social determinants for water contamination that ultimately give rise to gastrointestinal infections as well as possible methods to decrease contamination and infections. During our investigation, we applied different research tools, such as participant observation, interviews, microbial contamination testing, and collection of records for gastrointestinal infections in Kathmandu. We have currently finished interviews and the collection of records and water samples for testing. The next step in our research project is to analyze our data to determine patterns and hypothesize reasons for the differences in prevalence among the population. Along our journey, I learned more about trust and collaboration as well as how to overcome the obstacles I face during research. I learned to trust and work with a group of people that I had known for a very short period of time. It was important to be open, honest, and have good communication with each other. I learned to communicate with the Nepali students, such as Yasmin whom helped translate all interviews, in order to have good communication with the locals.  In fact, as she was so careful in eliciting people’s thoughts and feelings, I learned to trust Yasmin on our first day.  I also learned more about Asia and the Nepali culture, including traditions, food, history, and religion, by immersing myself, collaborating with the Nepali students, and exploring Kathmandu.  Most of all, I discovered more about myself.  I have a better understanding of what obstacles I could face during this type of research.  And I believe that the skills that I acquired from my research in Nepal will help me overcome future obstacles as I continue to pursue a career in medical research.

The ASIANetwork conference was the first one I attended that specifically included research studies done in Asia. I found it to be interesting to learn from faculty and other students. I also felt at ease while presenting and standing in front of others because we all believed how important it was to think creatively and research issues that are rarely covered. I enjoyed learning about the different backgrounds of students and how that affected their interests in research. I learned from many other students and saw how they viewed interdisciplinary research to be as important as we did. I learned more about the different topics of research and I gained experience presenting to people at a conference that I can use during my career.

Overall, this past year, I gained experience and improved my writing skills. I was also able to gain experience using an interdisciplinary approach to writing a professional research paper with the help of my professors. These experiences prepared me as a writer and a researcher for the future. For the future, I will look towards continuing my education to receive a master’s degree in global health or a PhD in epidemiology. Currently, I can use the collaborative skills I gained from this experience working in a laboratory for a nonprofit organization and continue on the path of public health.

Adrian Milos

Adrian Milos and Tori Chandler preparing lab materials at the Kathmandu Institute of Applied Sciences.

Adrian Milos and Dyksha Puri deciding on a water sample collection site along the Bagmati River, June 2017.

Those who know me can easily say that I possess the “if I’m in, I’m all in” mentality but having the opportunity to travel to Nepal as my first international experience was something I do not think anyone could have prepared me for.  I like to say that it was breathtakingly beautiful, emotionally affecting, and jarringly challenging all at once.  I appreciated being able to cultivate friendships and learn from the Nepali students, as well as visit national heritage sites, and see the ongoing reconstruction after the 2015 earthquake.  While there, we collected water samples from sites around the valley and also from the Chitwan area.  And, in order to understand the social context of water use in these areas, we interviewed people living there.  In particular we focused on where families get their water and how they use it.  I also gained insight into Nepali culture, such as the centrality of faith and family ties and the resilience of communities after the earthquake.  And I returned to Chicago with a much different mindset than prior to my trip: my eyes had been opened to how people living with limited resources are able to not merely survive, but actually thrive, embracing their faith and family life.  I believe that I will carry this new understanding of the developing world with me and it has already affected how I interact with new people.  Indeed the skills I developed in Nepal have undoubtedly changed me.  When I achieve my goal of becoming a doctor one day, I hope to be able to do more than merely diagnose someone’s back pain or stomach problems, but rather truly contextualize why they are having these problems and address structural and environmental aspects of health and healthcare.   In this way, I believe I am better equipped to relate to and serve patients.

Since returning I have taken advantage of every chance given to talk about my research.  One extremely interesting opportunity was attendance to the ASIANetwork conference in Philadelphia, Pennsylvania, with one of our mentors.  Even though this travel was not nearly as far as Nepal, it still gave me the opportunity to experience Philadelphia, another place I had never been before involvement with this program. Furthermore, while at this conference, I experienced a taste of various countries around the world through speaking to other students about where they had conducted their research.  I recall being extremely impressed by all of the work students had done and inspired to share my own story.  I absolutely loved presenting our poster and the genuine interest and support from the professors and other students as we shared in our research.

I have been able to implement the skills gained through my work in Kathmandu, Nepal here at home. I am working on engineering an estrogen biosensor that will detect estrogen or estrogen-like compounds in water sources that have potentially detrimental effects.  Exposure to increased estrogen will have varying effects on the gendered body, in men it may lead to gynecomastia, while in women it may lead to headaches and mood swings.  This biosensor will be specifically designed for developing countries such as Nepal, as it will be easily deployed in the field and also inexpensive.  In summary, this experience has completely broadened my perspective to include recognizing the needs of different countries and cultures.  Now in my future endeavors as a doctor, I will hopefully be able to help not only people in the United States, but also those in other countries.

US students and Nepali students touring the Kathmandu Valley Drinking Water Corporation’s lab and facilities June 9, 2017.

Emily Castro, Adrian Milos, Julie Weilbaker, Dyksha Puri, and Muna Fuyal at the Swyambunath Temple, June 2017.