I want to revisit a topic I blogged about a couple years ago exploring the idea of “treating a community like a patient”. Though I still agree with the philosophy, practice and experience have evolved my opinion on the matter.
In November 2015 I wrote as general advice (and specific advice to my future self):
“Trust in the innate capacity of the Nepalese people to heal their own communities. They may have been shaken, but they’re resilient and know what’s best for their families. Look for obstacles you can help to remove. Consider what tools and skills they’ll need to support their recovery. Empower them to take control of their own development.”
This blurb continues to sum up our approach to working in Nepal. It’s great advice (thanks me!) and though simple in words, proved to be quite an ambitious task (thanks me!). Here’s a few lessons learned along the way:
1. Engaged participation in and of itself is not the whole picture.
In other words, participatory programs often need sustained support from “the top”. Ideally this should be the local and national government. For example, a government should be the ones to implement major infrastructural projects like roads. If the government has no role, such a task is not likely to be done. If they build without local input, the road could disrupt local life in ways not imagined from the distant capital. If local people are engaged in the process, the road will not only get built, but is more likely to be successful in the short and long term.
For the last 20 years in Nepal there’s been no local government, and we’ve seen a blend of inaction and poorly-planned action from the national government in most regards. This has been an obstacle. Since the historic election this winter a local government is finally in place, and, at least on paper, appears to want to interact with local groups in a meaningful way. We hope to see engagement in large infrastructure projects and grants for smaller projects. Such governance would be so helpful for rural recovery, and we at ParticipAid are watching eagerly.
2. An endeavor in Participatory Development is not exactly replicable or scalable.
No two communities are the same, and their uniqueness is what is respected and even cultivated in a participatory project. Additionally, it’s clear to me that without a handful of remarkable individuals in local leadership, our work would not be possible. It doesn’t compute to scale remarkable individuals and unique communities, and that’s OK.
Participatory Development as a methodology is, however, generalizable across similar communities. I’m happy to see that this is actually trending in Nepal from the bottom up and the top down. Similar organized groups (of mothers, farmers, forest users, etc) exist across Nepal’s diverse rural landscape, even though the power relations between them can be vastly different from one village to the next. The new local government bodies are talking the talk about engaging these groups in development projects, and new national policies require district plans have certain elements of participation from a local level. ParticipAid's own Dr. Kamal Phuyal has even been contracted by the government to help design some of these programs. But the Nepalese people are accustomed to the right talk followed by inaction from their government. We are still watching to see if they walk the walk.
1. The trajectory of a participatory project is rarely a smooth curve.
We see ebbs and flows, and progress occurs in fits and starts. To hold fast to the goal of objectively measurable outcomes while leaving space for flexibility and patience is a real balancing act. I might add to my blurb up top that in this approach, healing occurs on their terms. They set the goals, and the path and pace by which they get there. That’s not to say that the facilitator or funder’s voice doesn’t count, but rather that expectation-setting from the very start should be realistic to local schedules and rhythms.
Funny, I can still translate all of this into truths about working holistically with patients.
1. An epiphany is not always enough to cause a positive shift in healthful thinking or behaviors. That could be it, but the path to health is not always so direct. Sometimes patients need to be nudged, reminded, or supported in one way or another.
2. We are each individuals with unique patterns of health and disease. No two paths to health will look exactly the same.
3. Healing comes from within, and the patient is really the only one that can do it. The doctor’s timelines for patients mean little in the grand scheme of things.
In both community health and individual health, I still believe that dogged persistence of simple interventions may have the most profound results.