A Common Preexisting Condition

A healthy sixteen year-old girl passed away yesterday, within a few miles of our hospital.  She had no history of illness or trauma.  Her only preexisting condition was having been born female.  In Achham, and much of Nepal, women of child-bearing age spend their monthly week of menstruation separated from their families, as part of the practice of chhaupadi.  Menstruation is viewed as impure, and women undergoing this biological process are segregated in order to prevent “contamination” of those around them.  Traditionally, menstruating women are sent to sleep in a cow or goat shed outside their house, though some families provide more comfortable spaces for their female members.  They are not allowed to enter the kitchen or use the family’s water source, and are often made to wash their sheets and blankets each day.  This particular young woman had started a small fire to try to stay warm in her chhaupadi shed, and was found by family members the next morning, having suffocated to death.

Hers was the third chhaupadi related death in Achham this year alone and such incidents, unfortunately, are not uncommon, particularly in the winter months.  When trying to decipher some sort of reason behind this needless, completely preventable loss of life, the deep-rooted complexity of such issues becomes apparent.  Perhaps she was cold because she did not have adequate blankets, or because the blankets she had were still damp from having been washed that day.  Perhaps the shed in which she was sleeping was not adequately sealed from the cold winter air.  Her family may not be able to afford adequate blankets for everyone, and she may share a bed or blanket with a sister most other nights.  If these reasons fully explained the issue, it would seem that her death was due to the simple but ever-present dangers of poverty.

The truth of the matter is, however, that poverty is not the only answer.

Education, like poverty, could provide some clarity about how these things happen.  It is very possible that, in the same way that we see countless elderly female chronic obstructive pulmonary disorder (COPD) patients, who have been cooking indoors over open fires their whole lives, this young woman simply did not know the dangers of concentrated smoke inhalation.  Had she known, she may not have built a fire in her small room, or may have left a window open.  This would also be a simple answer; an answer which correlated clearly with poverty and social marginalization.  But these simple answers do not fully explain such a death.

In such a recent post-conflict region, there is a distinct and widespread sense of stoicism, embodied by people of all ages.  Small children come to our emergency room with multiple fractures, their eyes devoid of tears.  Women give birth silently, with no local or other anesthesia.  This quiet yet tangible sense of fierce independence, limited trust, and conflict avoidance, frequently results in a “grin and bear it” mentality.  Perhaps the family did have extra blankets, but the young girl did not think to ask for them or the family did not think to give them.  Perhaps the fact that the tradition of chhaupadi has been practiced for generations contributes to elders believing that “If I did it, so can you.”

Potentially the most difficult contributing factor to address in our effort to make sense of this nonsensical situation, is the fact that a female life is not valued in the same way as a male one.  In this patrilocal culture, daughters are raised with the understanding that they will eventually be “lost.”  Sons are expected to bring wealth upon a family, and to care for their aging parents later in life.  Daughters are raised into their teens or twenties, and are then married and moved into the households and families of their new husbands.  Newborn sons are greeted with open arms, while it is not uncommon to see the new mother of a baby girl in our maternity ward wistful and withdrawn, laying with her back turned to the infant.  Perhaps this young woman would have been offered another blanket, or would have felt comfortable asking, had she been graced with a Y chromosome.

As with all such questions, there are simple answers and there are complex answers.  The problem is that these answers are tightly intertwined, and cannot be logically separated.  We are already conducting menstrual education programs in local schools, in an effort to increase understanding of the biological processes that the female body undergoes.  The local community could join together to distribute blankets to those in need, or could launch an educational campaign about the hazards of indoor fires.  These things would likely help, and may actually reduce the incidence of chhaupadi related deaths.  It is, however, unlikely that these efforts alone would prevent another woman from meeting the same fate.  These are but a few of the deeply entrenched challenges faced by the people of Achham, following the years of war that left no one untouched.  Just as infrastructure is redesigned and rebuilt, so must lives be.