DOG PARASITES IN THE LAND OF THE GODS
LIKE MANY westerners, I found enlightenment in Kathmandu. My gurus were a tapeworm and a Nepalese veterinarian. I arrived in Nepal, for the third time in my life, on the thirteenth day of the month of Mangsir in 2049. I thought, in my Western naivete, that it was November 28, 1992. But our calendars, whether Julian (Western) or Bikram Sambat (Nepalese), were largely irrelevant.
Crossing the footbridge over the Bishnumati River in the chill, dark predawn, I could see a series of fires on the far bank, men and dark shapes of water buffalo appearing and disappearing as the light flickered, a scene from summer camp or Dante’s hell.
As our little coterie of scientists drew closer, we could see several men grappling with one of the beasts, hammering a long, blood-covered spike into the base of the buffalo’s skull. The buffalo sank into a bed of straw on the ground as one of the men moved in to slit the throat and get a good blood flow. The man stood up to stretch his back, wiping his bloody hands on his jeans. He was in a winter jacket with a turned-back wool collar and big rubber boots. The men piled straw over the body and fanned it into flames to burn off the coarse black hair, then stood back to watch. When the fires died down, they rolled the stiffening body on to its back, and one of them leaned down to slit open the belly. One man, who was barefoot, his loose slacks rolled up to the knees, stepped forward to pull the great, bulging white, blood-flecked rumen out of the body cavity. Another, in a red sleeveless shirt, sweatpants, and a woolen toque, cut open the chest cavity and pulled out the heart and lungs. The team of young men waded around in the spilled guts, stomach contents, and shit, steam rising into the chilled air around them as they quietly went about the work of preparing meals for tourists and other wealthy consumers.
I rubbed my hands together to keep the blood flowing and zipped my windbreaker closed over my heavy sweater. As morning light exhaled and condensed down from the snowy peaks and across the valley, dogs and pigs nosed in and out of the fading darkness at the periphery of this tableau, repeated every few dozen yards along the riverbank.
Scanning the scene before me, I wondered what the big black lumps were on the branches of the huge trees stretching up from the muck. Fruiting bodies of some sort, I thought. One of them stretched his wings and glided away. They were vultures, I realized with a shudder, hundreds of them, and a giant murder of crows, thousands of them. Our guide through this world of blood and shadows was Dr. D.D. Joshi, soon to be friend and colleague, a Nepalese veterinarian with a passionate dedication to improving the lives of his compatriots. He loosened the scarf around his neck, tucked back the sleeve of his white shirt, and pointed to the riverbank beside us, where piles of buffalo feet, manure, blood, and offal spilled down in an inchoate mess to the small black trickle, which was all that was left of the river. Ducks, pigs, and dogs foraged for maggots and bits of discarded bone and fat, and, down by the thin stream of water through the muck, men and women defecated and washed.
“There used to be broad, stone stairs down to the river here,” Joshi said. “Somewhere underneath all that . . .” He waved his hand. “People would go down for their morning ablutions.”
We stepped up the steeply sloped alleys away from the main slaughtering area, past several groups of buffalo awaiting the knife. Kids clambered over them; this was the youngsters’ playground. We walked the alleys, noting a flow of dogs toward the slaughtering areas at the riverside and the curious pattern of how some groups of dogs would reach a cross-street and then stop, as if held back by some invisible force. We collected dog shit in little film containers and marked the slaughtering places on our tourist maps of Kathmandu. A little way up a narrow, potholed alley, the medieval, delicately carved wooden balconies leaning over us, we looked into a dank doorway. Inside, on a bed of filthy straw, several men were cutting up a carcass.
“Female buffaloes get killed inside,” said Dr. Joshi. “It’s illegal to kill females of breeding age. The government wants to ensure that there are enough work animals in the countryside.” He didn’t have to add that farmers will do what they have to do, cull the sick or lame, and sell them to butchers for a little income. But knowing me—knowing westerners—he did add: “Of course, we don’t kill cows, only buffaloes, because of their different religious significance.”
As we continued upward toward a small intersection, we passed a wall covered with half-dried pancakes of cow dung. Once dried, these burn with almost no smell, an important source of cooking fuel in a country with no oil reserves and an increasingly deforested countryside. The city was beginning to wake up. Inside houses everywhere, I could hear hacking and coughing and lung clearing. A great gob of phlegm was lobbed out a shop door past me and into the street. I recalled that lower respiratory disease and tuberculosis were both on the top ten killer list globally and were common in Nepal. A few seconds later, a woman in a well-worn sari stepped out, looked up and down the street, smiled happily at us, and disappeared back into the darkness of her shop.
We stopped for sweet, milky Nepalese tea at the corner, cupping the glasses in our hands to warm ourselves. Wondering if the tea were hot enough to kill the bacteria in the water used to rinse the glasses between customers, I spilled a little over the lip on the side from which I planned to drink. Soon the sky had turned from gray-pink to pale blue, a mist hanging in the early morning December air, veiling the white vistas of heaven. A rickshaw was being pushed uphill past us, and we stepped out to have a look at the pile of meat spilling over its sides.
Peter Schantz, a veterinary parasitologist from the CDC, pointed out a fist-sized, whitish, semi-opaque cyst in the lungs in the rickshaw. He rolled it bare-handed between his fingers. This was the parasite we—Canadian veterinarian Dominique Baronet (my graduate student), Schantz, Don de Savigny, from the International Development Research Centre in Ottawa (our funder, and a parasitologist himself), Dr. Joshi, and I—were here to understand and to do something about. There were a lot of problems associated with the dogs of Kathmandu, including bites from feral dogs, which might, or might not, be rabid, or perhaps just mean-tempered. But Joshi had not brought us halfway around the world to do something about rabies, as important as that was. He already knew what could be done about rabies and was already running free clinics to vaccinate dogs as often as he could get donations to do so. No, Joshi had brought us to this medieval city that was his home to help him figure out how to deal with a tapeworm of dogs.
In dogs, Echinococcus granulosus is a tiny, mostly harmless tapeworm. If you follow the dogs around the narrow streets of Kathmandu and carefully, painstakingly finger your way through piles of fresh feces (much to the delightful scorn of neighborhood children), or better yet (from an investigative point of view), thread your way through the yards of intestines in a freshly dead dog, you can sometimes find tiny, glistening bits of raw pasta. These are the adult tapeworms. Trying to find a living specimen is a lot like trying to find a grain of wet rice in a pile of dog feces.
Dogs pick up the infection by eating the fertile cysts of the kind we had seen in the buffalo lung; these large, fleshy balls of fluid and tapeworm heads are found in herbivorous animals of many kinds, the most important of which worldwide have been sheep. In the Arctic regions of the world, caribou, reindeer, and voles more commonly serve as intermediate hosts. The term “host” has a genteel, Emily Post resonance, as when the pathologists ask me to appreciate a fine lesion. But “host” refers to the larger animals on which the smaller animals (the parasites) feed.
The tapeworm is a good guest in the dog, in whom it does not appear to cause any disease or discomfort. The cysts are another matter.
Historically, as for many other multihost parasites, scientific investigators first discovered what they thought were several unrelated diseases in people and animals, each with a different story. In people, for instance, the slowly growing cyst came to be called hydatid disease. Such cysts have been described in both people and animals, going back to early naturalist-healers such as Hippocrates (third century BC), Aretaeus of Cappadocia (first century AD), and Galen (second century AD). While physicians tended to view such cysts as tumors growing spontaneously from various organs, as early as the seventeenth century some naturalists suggested similarities between the cysts in people and cysts in other animals and described what appeared to be tapeworm heads inside them.
Depending on where the cyst occurs, the clinical disease has different manifestations. Usually it settles in the liver, where, as it enlarges, it acts as a slowly growing tumor and causes abdominal discomfort. In severe cases, people look as if they are pregnant; in an alien-species-type way, they are: pregnant with thousands of tiny tapeworms. If the parasite makes a cyst in the lungs, such as the one we fondled in the rickshaw, it can result in a dry cough, or, if it ruptures, coughing of blood. One species of the parasite (Echinococcus multilocularis) occurs in the circumpolar region of the globe and is common in some parts of Tibet and northwestern China. E. multilocularis cycles between caribou and wolves or between foxes and voles, and has been found in coyotes, foxes, and dogs across Canada. In people, it behaves more like a malignant tumor, sending little buds and daughter cysts around the body.
There are few good treatments for hydatid disease. Surgery to remove the cysts can be risky, for if the cyst ruptures, hundreds of tiny “daughters” are spread all through the body, sending the patient into shock and leading to death. Antiparasitic drugs, which have been tried in various combinations and for different periods of time, are only partly effective in reducing cyst size and require long-term treatment.
Dogs contaminate the environment with wriggling sections of tapeworm, each containing several hundred eggs. Intermediate hosts—sheep, goats, camels, water buffalo, swine—ingest the eggs, which (to simplify a more complicated story) slide down the esophagus and through the stomach and then migrate across the intestinal wall and through the bloodstream to some congenial resting place. There a cyst develops, within which daughter capsules bud off and little prototapeworms are formed.
This cyst stage of the parasite is not harmful to people. People could eat these cysts without becoming infected, though I don’t know of any good recipes offhand. It’s the dogs that get infected from the cysts. When the sheep or other host dies, and a dog or a coyote or a fox eats the viscera or is fed the cyst as waste from the slaughter, the baby parasites attach themselves to the intestinal wall and complete the life cycle.
In this cycle, people take the place of other livestock. This fact is a useful reminder, for those who might have forgotten, of our animal nature. Thus, we pick up the disease from dogs. In some cultures, such as among the Turkana people in Kenya, who live in an area where water is scarce, dogs may be used to clean off young children. Being licked by a dog might be better than no bath at all, but it can also transmit disease. In Lebanon, shoemakers once used a mixture of dog feces and water to prepare hides and thus were at special risk. Among certain groups of people in Kathmandu, Dominique Baronet discovered, dogs are valued members of the community for religious and social reasons. In many cultures, children snuggle up to dogs or play on floors in houses where dogs may have relieved themselves.
The unfortunate parasites that end up in human bodies find themselves stuck as strangers in a strange land, in what parasitologists call a dead-end host. People are not really a part of the natural maintenance cycle. In most cases, people don’t reinfect dogs; that’s the natural job of other livestock species. The reason for this is that we don’t normally slaughter people; well, that’s actually not true, although often we cremate them or make some attempt to hide the bodies after we have slaughtered them. More important, we aren’t usually eaten by dogs. An exception may occur among the Turkana, who sometimes bury their dead in shallow graves and whose dogs are hungry.
But in Nepal, humans were a dead end. In a survey of local hospitals, Joshi found that more than 20 percent of people who had surgery for cyst removal died during or shortly after surgery. However common or uncommon the disease might be, the prognosis of those who got it was not good.
By the late nineteenth century, scientists were beginning to understand the complete life cycle of the parasite; today, dog, livestock, and human diseases are often referred to by the collective term cystic echinococcosis. This parasite has a home on every continent except (possibly) Antarctica, although the prevalence varies from place to place, and a few countries have successfully eradicated it. It occurs at highest levels in parts of Africa, central Asia, and southern South America. In 2006, a team from Switzerland calculated that the global burden of disease imposed by cystic echinococcosis was on the order of a million disability adjusted life years.
THAT DAY IN 1992, having seen the animals being slaughtered, the cysts, and the dogs, we continued up the streets behind the fires—narrow brick and potholed asphalt streets curved up between ancient brick walls and finely carved, cracked, ancient wooden balustrades. We paused at Durbar Square, an area of ancient temples, small shops, wandering tourists, open markets, and the “old” city of Kathmandu. Freak Street, which led away from the square and which I had visited as a vagabond in 1967, had slumped into a quiet backwater. The place to be now for travelers was Thamel, a twenty-minute walk from Durbar, its bustling streets crowded with restaurants, and hiking and souvenir shops, a magnet for hikers, dope dealers, carpet sellers, and seekers of enlightenment.
We circled back down the main road to the Bhimsenthan Bridge. The vendors were laying out their wares on the sidewalk: brass pots, cotton shirts, and fruit. Tailors were tuning their sewing machines. Below, the pigs foraged in offal from slaughtered buffalo and open latrines. I looked up to cloud-shrouded mountains and then along the bridge. Nearby, a girl on the sidewalk very carefully stacked lychees and peaches in pyramids of five. With nimble grace and dignity, she crossed her legs and waited.
As we walked back to Joshi’s office, I noticed a small, thin dog sitting on a blanket near a door. An old Gurkha dozed in the doorway. A heap of dogs lay nearby, their bodies rising and falling in peaceful sleep. A little farther along, three small boys in rags were piled up like sacks of rice, sleeping. By this time, the sun was up and the temperature rising fast. By midday it was in the mid-seventies, and we had peeled off our sweaters and were down to T-shirts.
We were gathered around a wooden table in a small room at the National Zoonoses and Food Hygiene Research Centre. The center was Joshi’s modest two-story house with a large black-and-white sign at the gate. I could almost imagine that we were a revolutionary cell of scientists ready to bring hope, enlightenment, clean water, less garbage, and an animal inspection act to the dark chaos around us.
As we settled down with our tea in Dr. Joshi’s house, we knew that to understand this parasitic disease we would need to do surveys of infection in livestock, in dogs, and in people. We would need to understand something of livestock movements, since many of the animals being slaughtered in the valley came from elsewhere and hence would have been infected elsewhere. We would need to understand something about how people and their dogs related to each other. In some ways, it was a relief to have all these details to focus on. These things were doable. Good basic science. And if we understood all these things, could we not also make them better? Didn’t knowing the problem take us halfway to having solved it?
Later, filled with a sense of confidence and purpose, some of us (the westerners) went out to Mike’s Breakfast, an open-garden restaurant near the luxurious Yak and Yeti Hotel. Mike had come from Minnesota in the 1960s as a Peace Corps volunteer and, like many others, had stayed. His restaurant was still the best place to get great coffee, yogurt, and fruit and listen to Mozart and eavesdrop on trekkers planning an ascent of Everest.
That evening, I stopped my bicycle in the middle of the bridge to gaze up the valley. I recalled a visit earlier that week with one of the keen young lions in the Ministry of Health. I was there to inform him that we had some human rabies vaccine available, not just for our researchers, but for use by Ministry of Health people in the area. He proclaimed that Nepal had its own perfectly good vaccine and that the human diploid vaccine recommended by WHO caused cancer. He seemed annoyed that we (outside scientists) were starting a research project when the answers were already obvious. The way to get rid of both rabies and hydatid disease, he said, was through mass gassing of street dogs.
I did not have the temerity to ask how this would be accomplished. I was, after all, a visitor, and his implication was that scientific imperialism had somehow insinuated itself into the niche left open by the political imperialists. The accusation had a ring of truth, and I was left feeling angry and disheartened. How did one demonstrate global solidarity without falling into the old patterns?
But now, on the bridge, in this warm, lucid light, I again felt hopeful. The sidewalks on the bridge were crowded with hawkers selling shirts, sweaters, shoes, fruits, vegetables, live chickens, and pots. Below me, the Bishnumati River snaked its dark, sluggish way between the herds of buffalo awaiting slaughter, the pigs, the dogs, people defecating, piles of offal and bones, chaos of life and death. The narrow, medieval streets of Bhimsenthan rose up from this visceral chaos of life and death to the centers of commerce and contemplation at Durbar Square. And above the river itself, above the dark silhouettes of the near mountains, I caught a glimpse of the white, heavenly peaks. For no logical reason I could think of, it filled me with a sense of timelessness, peace, and hope. We would prove that Ministry of Health official wrong. There were better, more democratic, more humane ways of learning our way into a healthy future.
We were going to save wards 19 and 20 in Kathmandu. And if we could reclaim this small part of Shangri-La from the depths into which it had fallen, was there not hope for the whole world? Might there not be a path into a sustainable, healthy, convivial future?
IN JUNE 1995, as I flew into Kathmandu from Bangkok, my mental landscape was in turmoil. I had been reading a Newsweek article about the environmental catastrophe, the cesspool of garbage and muck that was the riverside in downtown Kathmandu, the area where my collaborators had lived and worked for the past three years. The comments of one of my Canadian colleagues back home rang in my ears: “Kathmandu is an ecological disaster, a write-off. We might as well let the place crash, and start over from the ashes.” Was he right? I had been taught that epidemiology is an applied science, that the reason we went to all this effort was to solve real-world public health problems. Why hadn’t the work of our research team made any discernible impact?
The science part of this equation involved gathering evidence. The applied part was to persuade policymakers to take up the knowledge we generated and use it.
We had certainly gathered evidence.
SINCE WE HAD begun our work in Kathmandu in 1992, Dominique and Dr. Joshi and the other researchers had doggedly pursued the demands of good, conventional, normal science. Working with our Nepalese colleagues, Dominique spent many hours documenting the behavior of dogs in Kathmandu and collecting fresh dog feces. She then put fluorescent collars on the dogs, took pictures of them, and injected them with vaccines for rabies and antiparasitic drugs. She developed a veritable mugs’ gallery of the street dogs of Kathmandu. She not only probed through dog feces searching for those rice-grain-sized tapeworm segments but also, working with a new laboratory test, searched the feces for bits of tapeworm too small to be seen with even the best microscopes.
To do household surveys, we needed detailed street maps, which were easier described than found, given the warren of unnamed alleys and small courtyards that characterize old Kathmandu. It took major detective work and days of waiting in offices with the sunlight filtering down beams of dust to yellowing piles of paper for Dominique to get detailed city maps. At least here, in contrast to Indonesia, where I had worked previously, city maps were not considered military secrets. Based on her maps, and many days of walking the alleys of wards 19 and 20, Dominique was able to conduct a random survey of households in the area to see how people related to their dogs and to assess their knowledge of disease and hygiene.
The picture that emerged from our evidence was complicated. Our team was able to establish levels of infection (and reinfection) in dogs, livestock, and people. There were cysts in 5 to 8 percent of the buffalo, goats, and sheep slaughtered along the riverbank. Many of these animals came from India and Tibet, so the primary cycles of infection were probably in those countries. Only about 6 percent of the dogs in Kathmandu were infected, and reinfection rates were very low, suggesting that the disease was still primarily an import.
Infections in both dogs and people were not, we discovered, restricted to the butchering areas. Butchers did not trim out the hydatid cysts but sold them along with the meat, which was priced according to weight. Thus, it was the squeamish consumers who cut out the cysts and fed them to their dogs. Working with the veterinary clinics we had recruited throughout the city, we were able to identify dogs in “suburbia” that were thus infected. Many of the dogs were valued as pets or guard dogs.
About 60 percent of the dog owners in the areas where livestock were slaughtered were feeding raw meat, offal, bones, or cysts to their dogs. Unlike people in North America, where feeding raw meats to dogs has become a health-food fad, these people fed their dogs raw meat because they didn’t have many alternatives. In whatever country one lives, feeding raw meat to dogs is a great way to spread all sorts of diseases from livestock to dogs and to the people handling the dog food.
Usually the work went on as expected. It was the surprises that gave some of the most useful information. While Dominique was working, some artifacts were stolen from a local temple. For some of the residents, a reasonable explanation of these events went like this: Canadian woman comes into our neighborhood, injecting dogs with strange drugs. The dogs, who are our community police, die. The thieves move in. Fortunately, Dominique had built up a lot of goodwill in the community, and we could continue our work despite the suspicions.
Another complication arose when we went through our test results from people. Although 35 to 40 percent of households in the slaughtering neighborhood had at least one person test positive on an initial screening test for Echinococcus, these tests were not confirmed by a second test done by the CDC.
Peter Schantz suggested that maybe we were looking at another parasite, the so-called pork tapeworm, called cysticercus cellulosae in its larval form. The adult tapeworm, Taenia solium, inhabits the guts of people, and the bladder-like cyst housing the heads of the tapeworms lives in pigs. In poor countries throughout the world, the pigs get infected when they eat human feces, sometimes the only food available to them. Where clean water is not available, people may infect themselves, with tragic results: the cysts spin through the bloodstream throughout the body and can end up in the brain; the resulting inflammation may lead to epileptic-like seizures and psychotic-like personality changes. This disease is called neurocysticercosis. Cate Dewey, a veterinarian from Guelph, spent several years studying the connections between epilepsy and this parasite in poor villages in eastern Africa. The villagers, trying to supplement their meager farm incomes, and to support AIDS orphans and to send their children to school, had been given pigs to raise and sell. Without knowledge of the parasite, adequate feed for the pigs, or easily available clean water and latrines, the disease has become a serious burden.
Parasitologist Robert Desowitz described an epidemic of burns among the Ekari people in what was once Western New Guinea, now called (by the Indonesians at least) Irian Jaya. The epidemic occurred several years after Western New Guinea was absorbed by Indonesia, and President Suharto’s armies brought a gift of Balinese pigs to soften up the local population and prepare them for an influx of impoverished refugees from overcrowded Java. The pigs were infected with the cysts of T. solium. The Ekari, who were fond of quickly barbecued pork (a.k.a. slightly warmed dead pig), subsequently picked up the tapeworm. Lacking both refrigeration (which over time can kill the cysticerci) and ample clean water for washing their hands, they suffered an epidemic of neurocysticercosis; during the seizures, especially on cold nights, sufferers would stumble into the fires around which they slept.
It appeared that a similar situation could be unfolding in Nepal, given the widespread presence of scavenging pigs. The tests for hydatid disease were probably cross-reacting with proteins from this other tapeworm. If so, treating dogs would do no good.
We had hoped that the epidemiological studies in Nepal would, through the sheer weight of evidence, persuade people to change their ways. The solutions were, on the face of it, obvious: have health inspectors at the slaughtering areas to cut out cysts and dispose of them properly; close in the slaughtering areas, and educate the public so that the dogs didn’t get access to raw, cyst-infested meat; educate the public about hand washing after handling their dogs and about cleaning up dog feces to decrease fecal contamination of streets and houses; control the dog populations. Dominique prepared a video that was shown on TV. Dr. Joshi ran public education clinics and talked to members of the government about legislation. Yet after several years of hard work and good science, nothing seemed to have changed. Why not?
VIEWING THE HEAPS of animal parts and feces, the dogs and pigs and people foraging and defecating and washing up along the riverbank, I reconsidered previous attempts to “fix” problems of animal slaughtering, garbage, and disease transmission in Kathmandu. In the 1970s and 1980s, the Danish foreign aid agency built a large, modern abattoir (just like in Denmark!), the Germans built up the garbage disposal system (just like in Germany!), many countries helped train medical workers, and public health officials sneaked around at night dropping strychninelaced pieces of meat for the street dogs (just as in Walt Disney’s nightmares!) as a way to control rabies and hydatid disease.
In 1995, the Danish-built abattoir stood almost empty, the streets were again filling with garbage, well-trained medical workers were going back to their mountain villages to eke out a living from the barren soil, and the street dogs were doing just fine, fed and celebrated by members of the community.
These programs were based on good science and apparently sound logic. What was missing was any deep sense of culture: why did people behave in certain ways and not in others?
Scientific information is assumed to be objective and globally true, but that assumption is based on laboratory studies of basic phenomena. Can there be a science of place, one that explores phenomena that are locally true?
The earliest, most successful control program for echinococcosis was started in Iceland, where sheep rearing and sheepdogs go back many thousands of years and have long been an important part of cultural life. In 1869, Harald Krabbé, distressed at an overpopulation of dogs and the widespread distribution of “liver disease” associated with them, wrote a pamphlet in Icelandic explaining the life cycle of the disease. He then freely handed it out to every householder. Given the long, dark Icelandic winters, and the fact that this pamphlet was only the third document written in Icelandic (after the Bible and the Icelandic sagas), one can imagine that the idea of hydatid disease control became deeply ingrained in the Icelandic psyche. Even with that national breadth of understanding and a commitment to eradicate the disease (which included some drastic dog-control programs, such as legally forbidding dog ownership in the capital, Reykjavik), it took almost a hundred years for Iceland to get rid of the disease.
The success of the Icelanders emboldened many sheep-rearing countries to embark on similar control programs. The success of these programs has varied; even the most successful of them have depended on a well-educated population, regulated slaughtering facilities with veterinary health inspectors, and an attitude toward dogs that allowed for eradication of free-roaming dogs. In some cases, that success has depended on the degree to which Nepalese or Kenyans or Peruvians could be persuaded to behave like western Europeans or North Americans.
New Zealand’s program was instructive; it began as a combination of education, dog registration, and provision of treatment drugs to dog owners. Education was directed at children in schools and at sheepdog owners, who were brought together to have their dogs treated with a purgative so that the feces could be examined for parasites. The program was much more successful among settlers of European descent than among the native Maori, for whom dogs played a different social role.
All of the successful hydatid disease control programs took decades to make progress and required a lot of public commitment and money. I wondered if it were even possible in Nepal.
One thing was clear: scientific work that tried to address issues that were policy-relevant, science for the public good, had to be embedded in a sense of social and ecological history. Budi Tamang, one of the Nepalese researchers on our team, recounted a story about a German development organization that went to Kirtipur, a city near Kathmandu, and installed a row of new toilets. The decision about where to place them and how to design them was most likely based on a proper scholarly assessment of public health needs in the community. For some reason, however, the people there wouldn’t use the toilets. When asked, they told their benefactors, “Don’t worry, maybe tomorrow we will use them.” But they never did.
The Germans sent an anthropologist, who moved into the community, learned the Newari language, and joined the people’s daily lives. This is what he found: During the unification of Nepal, the people of Kirtipur twice repelled the invading “unification” king. The third time, he approached from the west, although they expected him from the east. There followed a massacre. Since that time, the people of Kirtipur only defecate with their bums facing west, as an act of spite. The German toilets, as you might have guessed, were oriented so that the bums faced east. Once this mistake was rectified, the toilets were used.
Even such a simple thing as having a national act to regulate animal slaughtering—which Dr. Joshi had been working for years to get enacted—was stalled by political events. When our research team had started its work, Nepal was moving from a dictatorship to democracy. Many of the people we worked with were active in the pro-democracy movement. The political scene was exciting but chaotic. Every time the proposed act was near debate or about to be voted on, the government would collapse, new coalitions would form, and often new elections would be called. The chaotic emergence of democracy in Nepal (itself a good thing) was hindering another good thing, public health.
From a system of the king’s rules, Nepal seemed to have moved rapidly to a system of no rules. Now when I bicycled around the crowded valley, I saw that the once-green rice fields of the valley were strewn with new, hastily erected, already-crumbling buildings. Everything was now for sale: intricately woven Tibetan carpets (made by Nepalese labor, polluting Nepalese water, using New Zealand wool and Indian dyes), gold and silver jewelry, turquoise and opal, Tibetan Buddhist artwork, fat laughing Buddhas and elephants from India, fierce Tibetan mastiffs, cuddly Lhasa apsos, and cheap imitations of Tibetan carpets. For the “alternative” tourists, there was the wilderness for sale: mountain climbing, white-water rafting, mountain vistas, cows, ducks, chickens, and dogs in the streets. There were also gambling casinos. In a sense, the romantic idea of a good-hearted and happy people of Nepal who worshipped strange, many-armed gods was also for sale as part of this exotic landscape.
This economic activity was bringing in a lot of money. In the best of all worlds, it would be translated into drinkable water, fresh air, and adequate food for the citizens of Nepal. But in Nepal, it was translated into impossible consumer demands and piles of garbage. How could the chaos be used as an opportunity to create something new? Many politicians, as well as the slaughterhouse owners and butchers, were responding to the demand for meat from tourists and the newly wealthy in this free-for-all economy. Could they be persuaded to reinvest in the health of their communities? How could we engage them in the work so that they would see its importance? My view of the relationship between science, policy, and public practice was shifting.
IN THE 1990S, several international networks of scholars were struggling with how to understand the complexity of the world we live in and to manage it, or adapt to it, in such ways that the human species could have a long and convivial sojourn on this planet. From these networks emerged organizations that, under banners with names such as EcoHealth (short for ecosystem approaches to health) and One Health, looked for ways to integrate the health of people, other animals, and ecosystems. We talked about, measured, and promoted the health of individuals, families, and even cities. This being the case, could we not talk about the health of whole social-ecological systems?
I thought about the web of connections, as well as the facts, that our research had uncovered. They explained a lot about why some previous attempts to improve the well-being of the urban citizens in Kathmandu had been unsuccessful.
Family and cultural traditions of butchering perhaps once sustainable in sparsely populated rural areas were brought into the very different, more crowded urban setting of Kathmandu. Butchers didn’t want to give up family traditions and become wage laborers in an animal-killing factory.
The economic, cultural, and family bases of human-dog relations, butchering practices, and the many dependent occupations of small-scale meat transporters and butcher shops throughout the city could not be altered simply by decreeing that it should be so or by making public health pronouncements. The street dogs were not only threats to public health but were also community police. Butchering and food hygiene practices depended not only on knowledge but also on the availability of clean water and affordable fuel for cooking, thus competing directly with economically powerful activities such as the carpet industry, which used—and wasted—huge amounts of water.
Even if the dogs could all be treated with an effective drug, it was not clear what the environmental consequences of the drug-in-feces would be. In the end, the communities involved would still be left with serious public health, economic, and environmental problems, many of which appeared to be considerably more pressing than this particular parasite. Of all the places these communities could spend what little spare cash they might have, why would they want to spend it on an anti-parasitic drug or control program for dogs? Whatever would be done to respond to this parasite would have to be embedded in a much more comprehensive program of social transformation. If ecosystem-based approaches offered a viable way of thinking about, and working with, complex public health problems, Kathmandu seemed to be an ideal case study.
At dusk, I sat nursing a beer on the roof terrace at the wonderful old Vajra Hotel, with its wood-carved walls, gardens, and traditional statuary, on the hillside up toward Swayambhunath, the Monkey Temple. I looked out over the darkening valley, the scattering of lights in this still-medieval city, the satellite dishes along the rooftops. The scent of dung and of wood fires and the clashing sounds of popular Indian and European music drifted up past me and into the cool, almost clean mountain air. If these new ideas about the health of social and ecological systems, combining community participation with systemic ecological understanding, could work here, they could work anywhere.
POSTSCRIPT
People often ask me what happened to hydatid disease in Kathmandu. I don’t know, in part because it wasn’t a priority for the citizens of wards 19 and 20. I do know, however, that the conditions that made it a problem have changed for the better.
In November 2001, we had the final workshop of a community-based ecosystem health project. Our research team this time included butchers, street sweepers, veterinarians, politicians, shop owners, anthropologists, and community activists.
Later, I took a picture of Dinesh Kadji, dynamic young chairman of the butchers’ association, standing outside in the clean, sunlit courtyard beside the river. I told him that I thought there used to be an old water pump here. I had a picture of a woman taking water, with her children squatting around her, and, in the background, animals being slaughtered. It’s right over there, he said, pointing to a clean, well-kept building across the yard, and he laughed.
The Dante-esque riverbanks I had first encountered in 1992 were transformed. Public parks with shrubs and trees and benches to sit on had been created next to the Bhimsenthan Bridge. A man and a woman took care of new public toilets, as well as the gardens. The fees they charged were shared with the municipality. Although people were prohibited from defecating at the riverbank, I could see a fellow coming up out of the riverside grass, pulling up his pants. Still, it was much cleaner than it had been a decade previously. There were some piles of garbage, but many fewer than before. There were fewer dogs, as well. The trees were empty of vultures.
Next to the public parks, farther along the riverbank, were walls of tall grasses, and small private flower and vegetable gardens. Beyond that, rows of composting cow manure and stomach contents were aerated by plastic pipes, and flocks of ducks wandered among them, feasting on the larvae. To my right, away from the river, were cardboard and plastic recycling yards. A line of water buffalo were walking slowly along the street, followed by a lone herder. The herder guided them up a side street to a corrugated metal door. I slipped through the door after the animals. Around a brick courtyard were covered sheds. This was one of the twenty or so new, mid-scale slaughtering places scattered throughout wards 19 and 2 0. At a freshwater tap, women and children were pumping water into their brass pots and plastic pails.
Back outside, along the side streets, I came across the perpetually running stone taps. These taps are set in washing places below ground level for general community use and are maintained by traditional religious caretakers. Once filled with garbage, some of these washing places were now cleaned out and painted and were being used.
Since 2001, Nepal has been into and out of turmoil several times. In June 2001, Crown Prince Dipendra killed most of his family in a rage during a royal dinner, allegedly because his mother had disapproved of his choice for marriage. One uncle, Gyanendra Bir Bikram Shah, who was not at the meal, stepped up to the throne of this constitutional monarchy. Until he came to the throne, mainstream politicians had negotiated a delicate relationship with the Maoist party of Nepal and were bringing this rural insurgency group, fighting for economic development in the countryside, into the political process. When the new king came to power, this fragile peace fell apart.
In 2003 and 2004, as the Maoist war heated up, I became increasingly concerned that larger events could overwhelm a decade of good work and community learning. On the one hand, there had been a bomb near the Bhimsenthan Bridge, where the young girl had once waited with her peaches and lychees, and the king had dissolved Parliament and received military aid from the U.S. to fight the “international terrorists,” thus enabling him to back away from negotiated settlements. On the other hand, I received optimistic e-mails from one of our researchers, who was now heading a group in Nepal that builds on people’s skills and strengths to achieve their hopes and dreams.
At one of our research workshops, the participants had been asked what stories they wanted their children to tell about them. What I hear from Dr. Joshi is that the communities are continuing their work, fighting for their democratic rights, creating stories of resilience in the midst of the battles among the tiresome capitalist, royalist, and Maoist ideologues. They have been monitoring water quality. Joshi himself is still running dog-vaccination clinics. The social-action Nepalese partners I worked with have mounted programs to improve the nutrition and health of the people in wards 19 and 20.
The people there have discovered the story they want their grandchildren to tell, and it is one of local democracy and commitment, of clean water and a thirst for knowledge and an impatience with systemic poverty and repression. I often think back to 1992 and remember the small girl on the bridge, waiting patiently with her lychees and peaches, and I hope she has a happy role in that story.