Beyond The Valley: A Wicked Problem on the Roof of the World
As Jet Airways flight 501 descended over the Kathmandu valley, I looked out across the terraced rice paddies. It was early May, and through the morning haze, I could pick out the brightly-coloured clothing of women trekking along hill tracks under massive loads. In the distance, the sun touched the jagged white peaks of the Himalayas.
I was here to learn about a new medical school based in Kathmandu and to make a short promotional film about it. Going in, I was aware that starting a medical school in Nepal would be a wicked problem; I did not realize how difficult shooting a movie would be.
When the plane touched down I was plunged into the chaos of Kathmandu: the eye-irritating smog, the potholed streets clogged with mopeds, roaming cattle and smoky cars, bearded Western backpackers and ragged street urchins.
I had visited Nepal a couple of years earlier as a tourist, and, like so many who visit the country, had seen how the splendor of Nepal’s mountains stands in stark relief against the desperate poverty of its rural people. No thinking person could fail to be moved by the contrast.
Soon after my visit, I was given an opportunity to make a small difference through the Patan Academy of Health Sciences (PAHS), a Nepali initiative to educate doctors who would serve in isolated rural areas. The PAHS model of education engages villagers in community health and can bring desperately-needed care to millions of people. Through student support, a curriculum emphasizing rural medicine and rotations in rural areas, the PAHS vision is to develop doctors who can not only treat the sick, but improve the overall health of rural communities.
As the only non-medical member of the PAHS International Advisory Board, my role was to raise funds – a task that was new to me, but one that I nonetheless relished: PAHS seemed capable of making a sustainable difference to the lives of the rural poor in Nepal. As soon as I had a chance, I scheduled a trip to Kathmandu to visit PAHS’ founder, Dr. Arjun Karki, and learn as much as I could. As things turned out, I learned a lot more than expected.
The following day, I was to meet a film crew who had volunteered their time and energy to make a short movie about PAHS. Robby Reis and Dan Popa had graduated a couple of years prior from Montreal’s Concordia University and set up their own film company, Natali Film. PAHS captured their imagination: as filmmakers, they could see great visual possibilities in Nepal, and as humanitarians, they were excited by the idea of using their talents to make a difference in the world.
Back in Toronto, we had meticulously planned the film. True to my consumer-goods background, I had prepared a written film brief, complete with objectives, target audience, key messages and so on. Robby and Dan had responded with a detailed outline of what they intended to do: develop a compelling, emotional film based on stories they expected to hear about rural medicine while in Nepal.
Robby and Dan would arrive early the next morning. But before then, I was to meet the visionary behind PAHS. Arjun Karki arrived at my hotel that afternoon. A Nepali-trained physician who had practiced as a specialist in the U.S., he had returned to Nepal determined to help improve living conditions in his native country. I had met him briefly on my previous visit, and recognized him instantly when he arrived at my hotel. Karki was a quietly serious man with deep, soft eyes that betrayed many late nights. His presence was the reason so many volunteers were committed to the project, and I instantly saw why. His dedication to the project was single-minded and complete.
As we sipped lukewarm tea in the ornate hotel lobby, we launched into a discussion of PAHS, its history, his vision, its context. This was Arjun’s life’s work, and he was keen to share it with those who were willing to listen.
With crushing poverty, the most rugged terrain in the world, low levels of education and bureaucratic corruption, rural medicine in Nepal presented the wickedest of problems. PAHS was an original way of addressing these conditions: students would be brought to Kathmandu to upgrade academically, if needed, before entering a five-year program that included rotations in rural areas in which they would work on community health initiatives. Upon graduation, they would be expected to practice in a rural area. The project was in advanced stages of planning, with the first cohort of students scheduled to enter in 2009.
Early next morning, Robby, Dan and their friend Morris staggered out of the airport laden with equipment, and were immediately latched onto by a coterie of small boys clamoring to carry duffel bags larger than themselves. Many tips later, we were in a taxi on our way to the hotel.
Assaulted by the sensory overload of arriving in Kathmandu, they reacted as true filmmakers: equipment was extracted from bags and before we knew it, shutters were snapping and cameras were rolling. The shoot was under way.
Patan hospital is a large brick building in Lalitpur, close to central Kathmandu. Arriving there the next day, we were shepherded through dimly-lit corridors to the PAHS office, identified only by a typed sheet of paper taped to the door. The Nepali PAHS team was very excited about the film and immediately set about arranging interviews for the team with the CEO of the hospital, the chief surgeon and several doctors. Dr. Karki even arranged for us to interview the Nepali health minister. Arrangements were set in motion for a visit to a rural area to film the conditions there.
As the next few days passed, however, I began to appreciate how challenging an endeavour we had taken on. We had embarked on this project with a clear idea of what we wanted to do, but the logistical challenges of working in Nepal made many aspects of this difficult. For example, one part of our plan was to interview a rural doctor who was planning to visit Kathmandu. But due to a strike in that area, he was unable to travel.
Getting from place to place was in itself a wicked problem. Routinely, our best-laid plans were stymied by weather, strikes, bad roads, gas shortages, unreliable vehicles and a host of unpredictable obstacles. It was the beginning of the monsoon season, and torrential rain filled the muddy potholes in the roads. Drivers queued for several hours to buy their ration of a few litres of gas. Rotating blackouts made it difficult for the film team to charge their equipment.
The election of the new Maoist government had shaken up the fragile stability of Kathmandu. On one occasion, a man was beaten to death by Maoists in a southern town, and opposition politicians declared a general strike, which shut all of Kathmandu down for a day. Its beleaguered citizens, long accustomed to the intimidation that accompanied these events, simply stayed home and the city ground to a standstill. Since Buddha’s birthday occurred just before the strike, nothing moved in Kathmandu for a full three days.
With the Beijing Olympics approaching, there were regular demonstrations by groups of Tibetan monks outside the Chinese Embassy and at other points around the city. Just as regularly, the demonstrators were rounded up and carted away by police.
Coupled with all this was my emerging sense that the Nepali team and the Canadian filmmakers had different mental models about the film. From the Canadian side, an emotional approach that focused on the problems of getting adequate health care would be most motivating to Western donors; for the Nepalis, the project needed to be authoritative and the embody the hope of a new Nepal.
In the table below, I have summarized the film team’s model and my sense of that of the Nepalis, along with my interpretation of how each side’s model appeared to the other.
| How It Appeared to the Film Team | How It Appeared to the Nepali PAHS team |
Film Team’s Model | We want to shoot an emotional film that tells Westerners about Nepal and convinces them to donate, by telling stories about rural Nepalis and their problems in getting adequate health care. | They want to show poverty in Nepal and portray us as a basket case. They are missing the point that this is an important initiative supported by government and eminent individuals. |
PAHS Team’s model | They want us to do a lot of dry, serious interviews with officials and bureaucrats, and show happy, healthy villagers in idyllic surroundings. This will not motivate Western donors. | We want to see an authoritative and inspiring film that motivates donors and supporters, by showing how Nepalis are taking control of their future. |
It seemed to the film team that, where they were aiming to produce an engaging, emotional film, the Nepalis would have been happier with a series of interviews with stuffy administrators and bureaucrats. Where the film team was looking for emotion, they were instead hearing high-level officials talk about the importance of PAHS to Nepal.
There was a cultural aspect to the disconnect: Nepal is an hierarchical, even feudal, society with a host of unwritten conventions around caste and social status: a ‘high context’ society, in the words of anthropologist Edward T. Hall. At the time of our visit, the king of Nepal was still on the throne as an absolute, if unpopular, monarch.
But there was more than culture involved here. Nepal has a long history of failed social initiatives, many sponsored by well-intentioned Westerners like us. While these have failed for a variety of reasons, the endemic corruption in Nepal had played a large part. For the Nepalis, it was important to reassure the world that this project was different and the best way to do so, as they saw it, was to show that important individuals were committed to it.
It was also a unique moment in history. With the election of the new government, there was a sense of genuine hope for the first time in many years: the decade-long civil war seemed over and the corrupt monarchy would soon be ended. PAHS was a symbol of this new hope. The film should capture this sense of optimism.
This model clash was especially evident in the film team’s visit to a rural area, a visit that both Nepalis and Canadians saw as essential to the film. With all the inevitable logistical hurdles, this took some time to arrange, but in the last few days of our visit we finally set off for the district of Makwanpur in the fertile Terai region. Our hope was to film some emotional content: we envisaged very basic conditions, which we would film but treat delicately in editing.
After a terrifying roller-coaster drive through the mountains on narrow switchback roads, we arrived late at night at the city of Hetauda. Even in darkness, it was easy to see that this was, by Nepali standards, a relatively prosperous place. The streets were clean and well lit, and there were well-kept buildings all around.
We were taken to Hetauda hospital the next morning. To Westerners, Hetauda hospital was basic, but it was evident that patients were receiving a reasonable level of care. If we wanted to show the need for PAHS, this would not be enough. We were promised that we would be taken to a small village that afternoon, and we hoped to enrich some of our stories there.
The road approaching the village told the whole story: a smooth, straight, immaculately-groomed pathway through the forest. Many villages in Nepal – those with the most pressing problems – are not even accessible by road. Instead, this was a model village. We interviewed the local nurse/midwife (also pharmacist and entrepreneur), a dedicated woman who ran an impeccable clinic. But we did not come away with anything that would illustrate how difficult conditions were in a typical Nepali village.
By now, it was clear that the Nepali group had never intended to show us any really wicked conditions. The reasons for this were partly logistical – to do so would mean several days travel on foot – but mostly, I felt, to do with the dignity of Nepalis. Nepal had been portrayed as a basket case often enough in the past, and with the new government and the impending abolition of the monarchy, there was a feeling, albeit a tentative one, that things could be different in the future. They were proud of all they had done with virtually no resources, excited about what they could do, and they wanted to the world to see the future, not the present.
From the film crew’s perspective, the Nepali vision of the film was uncomfortable. They were becoming impatient with hearing the same line about how important the initiative was to Nepal, how things were progressing, etc., far from the compelling personal stories they wanted to film. Tensions were beginning to show, and the crew complained to me about the time they were wasting in interviewing officials.
Despite their frustrations, for three weeks the film crew acted as sponges, absorbing everything they could, filming in Kathmandu and beyond the city itself in Bhaktopur, Nagarkot and Hetauda. With a limited amount of time, we had to be sure we had everything in the can that might possibly make it into the final film. Yet as we boarded our flights back to Canada, we were still at a loss as to how we might satisfy the needs of Nepalis and those of Western donors in one film.
Over the summer, Robby and Dan spent many hours on editing the film. They consulted with me and showed me some previews, and I eagerly awaited the final cut. The PAHS film was screened at PAHS’ first fundraiser at the University of Toronto’s Hart House in September 2008. Robby and Dan came to Toronto for the screening, shuffling nervously into the room like proud parents about to show off their baby, hands trembling slightly as they switched on the video display.
They need not have worried. The film was a beautiful, sensitive, portrayal of Nepal and the PAHS project. The audience responded warmly.
The film opened with some beautiful footage of the Kathmandu valley set to Nepali music. The remaining scenes focused closely on the Nepali team who had dedicated their time and energy to the project and with the Minister for Health. Arjun Karki was presented as the inspiring leader of the project, and two Western members of the international board were also interviewed. In the closing scenes, the theme returned to the beauty of Nepal with a portrayal of some religious singers.
Having traveled so far on this journey with them, I was impressed with their ability to reconcile the two mental models in one the film. Throughout the film, the visuals and interviews made it clear that this was a Nepali project, established and managed by Nepalis with minimal involvement from outside. This would, I felt, both satisfy the Nepali desire for dignity and motivate Westerners through the evident dedication of the team.
Footage showing the beauty and cultural side of Nepal was both informative and inspiring: perhaps irrelevant to Nepalis, but essential to Westerners. In their portrayal of the rural hospital and its patients, they had struck a fine balance between the pathos needed to motivate a Western audience and the self-respect of Nepalis. And by showing interviews with the health minister and the international board, they had achieved a high degree of authority.
As I write this, I am preparing for another trip to Nepal to meet with the Nepali team, who have yet to see the film. I must admit I am still a little nervous. In spite of our best efforts to understand the Nepalis’ perspective, we may still have got it wrong.
The film, of course, was only one small challenge in the wicked problems that PAHS is designed to address. There will be many more such challenges along the way.
Robbie and Dan named the film Beyond the Valley. I thought the title very clever, as it neatly captured the challenges to rural Nepal outside the Kathmandu Valley. But there was another valley here: the valley between two cultures, two distinct ways of thinking. As a team, we tried not so much to bridge this valley as to move beyond it, not to compromise but to transcend.