Last of three parts
At 1:30 a.m. on a chilly autumn night, the telephone rings in a brick house in North Baltimore and awakens Keith P. West Jr. Of a long list of possible callers from a dozen time zones, it turns out to be a cargo supervisor at Los Angeles International Airport.
A gray plastic shipping container the size of a dishwasher has toppled off a conveyor belt. White fog is seeping from the seams, and West's name is on the address label.
Should I call the fire department? the panicky cargo man asks.
No need, says West. It's just liquid nitrogen at minus 196 degrees Celsius, keeping frozen some blood serum from Nepal. Tip the tank back up and the fog should stop leaking, he says.
Then he goes back to sleep, leaving the airport's night staff to wonder at the strange stuff people send around the world.
West -- absent-minded professor of international nutrition, folk-rock guitarist, speaker of broken Nepali and rusty Japanese, doting father, accumulator of 900,000 frequent-flyer miles on United Airlines alone -- is founder of Johns Hopkins' vitamin studies in Nepal.
Twelve years ago, he built an information factory there, in a place as different from his Homeland neighborhood as it is possible to imagine.
It produces invaluable evidence of how vitamins can reduce deaths among malnourished people.
Yet the work raises difficult questions: about the obligations of scientists to their subjects, the different aims of aid and research, the conflict between gathering data and relieving suffering. West and his colleagues operate between two cultures, where short-term benefits and long-term goals often clash.
The nitrogen tanks that travel each month by mountain roads and air freight from the mud-and-dung huts of Sarlahi District to the gleaming digital clutter of the nutrition lab at the Hopkins School of Public Health shuttle between two extremes of human existence. They link illiterate Nepalese subsistence farmers who do not know their own ages with ambitious American scientists competing for multimillion-dollar grants.
Nepal's per capita gross national product is about $220 a year, compared with $29,080 in the United States. It is a nation of 24 million people, yet its budget of $1.32 billion is smaller than the $1.6 billion budget of the Johns Hopkins University.
Even the clock and calendar underscore the gulf between researchers and their subjects: In Nepal, today is the eighth day of Kartik in the year 2057. And the country has a unique time zone -- not an even nine hours, but nine hours and 45 minutes ahead of Baltimore.
The latest tank of frozen blood samples from Nepal will be analyzed on $50,000 machines that measure levels of vitamins and minerals, creating nutritional snapshots of hundreds of pregnant villagers. But for now, it goes to a bunker-like basement at the School of Public Health protected by electronic locks, video cameras and alarms. Here, inside dozens of industrial freezers set at minus 80 C, is what may be the costliest collection of bodily fluids on the planet.
Saliva from Russia. Blood from Peru. Breast milk from Indonesia. Urine from Bangladesh. And on and on -- a global sampling of malnutrition and disease.
The school spends $162 million a year on the strange alchemy of public health research: Human lives are reduced to data on zinc blood levels or pregnancy complications or measles incidence. Then the data are converted into programs aimed at improving human lives.
In the Nepal Nutrition Intervention Project, West, 50, has been such an alchemist. The work has required not only the solitary brainpower of any science, but also more practical skills: endless tea-drinking with skeptical bureaucrats, sharp bargaining for gasoline during a fuel embargo, lobbying for funds in the "Dilbert" cubicles of the U.S. Agency for International Development.
He leaves his wife, Hopkins biostatistician Marie Diener-West, and their 12-year-old daughter, Natalie, for months each year, traveling on airlines not known for their safety records to places not listed in any tourist guidebook. He has a habit of getting sick soon after arriving overseas; he recently had a memorable tangle with dengue fever.
But for the data these huge public health trials produce, West would put up with far more. He has an unshakeable faith in the power of rigorous experiments to find truth.
"If you can lock in a finding with real consequences -- if it can withstand the onslaught of scientific criticism and politics and changes in fashion -- it becomes permanent," he says. "It changes the world."
In the Nepal project's earlier phases, West confirmed that vitamin A can sharply cut child mortality and discovered that it may also reduce deaths of pregnant women. Now, as his colleague Parul Christian oversees the latest phase, he is building a parallel organization in neighboring Bangladesh for larger trials to confirm or disprove the results from Nepal.
In such studies, the chasm between researchers and subjects can feed suspicion and misunderstanding. Villagers without adequate food or medicine often expect visitors from the West to help them. Instead, the foreigners engage in exercises that seem pointless or alarming -- drawing blood or collecting urine; asking endless questions about a child's death; offering health advice that clashes with local tradition.
Yet in international health research, extremes of wealth and poverty come to depend on one another.
Nepal could hardly have afforded on its own to conduct the research that led to its national vitamin A program, which saves about 20,000 lives a year.
But the Hopkins experts are equally dependent on Nepal. As they work to eliminate malnutrition -- and to win grants, publish papers, advance careers -- their studies require a supply of thousands of malnourished people.
When West went hunting in 1987 for a nutrition study site, he wasn't looking -- as UNICEF or CARE might have -- for the people most desperate for help. Instead, he needed subjects who fit certain criteria.
They had to be poor, with inadequate diets and miserable health, yet settled and stable. They couldn't be at war or in political turmoil. They couldn't have a government that would object or meddle. And for the convenience of commuting scientists, they couldn't be too far from an international airport.
In Nepal's Sarlahi District, West found what he was looking for.
A desperate stability
The sole hospital in this district of 500,000 people is a forlorn jumble of small buildings in Malangwa, near the Indian border. One afternoon, a man with severe burns moans in one bed; emaciated children occupy a dozen more. Only a couple of hospital staffers are working, and there's hardly any equipment.
A tiny 6-year-old boy, Sanjin Thakur, lies under a blanket, listless with dehydration after nine days of diarrhea. His grandmothers have arrived to take over from his parents for the night. The women say Sanjin's sister died of diarrhea at age 8. Between them, they have 17 living grandchildren; 10 others have died. They report this not as a calamity, but as a sad fact of life.
A fatigued nurse-midwife, Manju Shrestha, tells visitors that medical supplies are chronically short and that the doctors assigned to the hospital rarely show up. "Sometimes one nurse has to cover all 15 beds for 12 hours," Shrestha says. Asked how the hospital has changed over her 20 years there, she replies: "It's worse."
When West set out to create a living laboratory to study malnutrition, he was drawn by the poverty of Sarlahi, its bankrupt health system, even its social stagnation. He had just been forced to abandon a planned study in the Philippines after two years of groundwork. Hostile rebels spread word that the Americans intended to poison Filipino children, and the project dissolved in political chaos.
"There was no rational argument," West says, recalling the sound of gunfire and the kidnapping of foreigners. "It was a scary time. ... I don't mind devoting my life to vitamin A, but I didn't want to give my life for vitamin A."
The plains of south-central Nepal seemed a reasonable alternative. The region was desperately poor and densely populated, an extraordinary melange of ethnicity, caste, language and religion. Yet the people lived in peace. Buddhists and Hindus shared temples; villagers whose faces could pass for Chinese, Pakistani or Tanzanian lived side by side.
The area was within an arduous day's drive from Kathmandu -- "eight to 13 hours," says West, "depending on the landslides."
Sarlahi District has, in fact, proved an ideal testing ground for vitamin regimens that hold huge promise for Third World health. But against a backdrop of extreme poverty, the project's Toyota Land Cruisers, $1,300 baby scales and relatively lavish wages stand out.
Such spending, while necessary for meticulous research, inevitably raises questions about priorities. And the questions have grown more pointed in the past three years, as Nepal's political calm has been shattered by a Maoist insurgency that has taken more than 1,000 lives. Now the staffers avoid certain hill villages where the Maoists are active, fearing the rebels might target the foreign-financed project.
About half of the project's $1 million annual budget -- all of which is provided by U.S. taxpayers -- is spent in Nepal. It is a huge boon to the local economy. It is also more than Nepal's government spends each year on health care in Sarlahi.
The consequences of meager health funding are everywhere on display. Most of the time, no one is on duty at the government health posts, one-room concrete buildings equipped at best with a small supply of antibiotics and bandages.
The plight of any village family facing a serious health problem is poignant. One autumn day, a project supervisor points to a cluster of people descending a dirt path on a distant hill. "Want to see a Nepali ambulance?" he asks.
As the people approach, two young men can be seen carrying a wooden pole on their shoulders. Suspended from the pole is an old blanket. Inside is Kul Bahadur Tamang, 12, whose legs became paralyzed three weeks earlier.
When he didn't get better, his family decided to seek help. They began walking from their remote village at 7 a.m.; it is now 3 p.m.
All day, they carried him along treacherous hill paths, with Kul crying out at every jolt. Now at the edge of the plains, they figure they have about three more hours to walk.
But the project staffers squeeze the boy, his mother and his uncle into their Land Cruiser. After a short drive, they reach their destination, a crowded medicine shop in the market town of Nawalpur. The "doctor" -- actually a health assistant who trained for three years in India -- examines the child briefly before turning to the mother and uncle.
"I can do nothing for him," he says. Only two hospitals in the country are capable of diagnosing the boy's problem, he says; one is a 12-hour bus ride away in Kathmandu, the other is about the same distance in eastern Nepal.
The mother and the uncle, their faces grave, consult quietly. They don't have the money for such a trip, but they cannot face simply turning around and walking back to their village in the hills.
Expectantly, they look toward the prosperous strangers. But the project staffers have to get back to work. Awkwardly, they offer sympathy. Then they depart.
On their rounds in the villages, project employees encounter such routine disasters at every turn. They see children in agony with curable ailments or disfigurements easily corrected by surgery; women suffering from worm infestation; men succumbing to untreated tuberculosis.
In one village, a haggard woman of about 30 in a green sari hobbles on a walking stick toward a group of project staffers and cries out: "Why don't you give me medicine? Why? I've been sick ever since my baby was born two years ago." The staffers walk by without answering.
In another village, a new mother complains that a breast infection is interfering with her ability to nurse. Parul Christian, the Hopkins nutritionist, advises her to go to the health center a few miles away for antibiotics. Afterward, out of ear-shot, Christian remarks: "But how can she get there? She has five kids and her husband's away working."
Yet Christian does not divert a worker to fetch medicine. "There are so many problems," she says, "that if we started trying to solve them all, that's all we'd do."
The project operates an eye clinic and offers some services to the women in the study: tetanus shots; worm medication; "safe-birthing kits" containing a bar of soap, a sterile plastic sheet and a razor blade to cut the umbilical cord.
Yet in this place without running water, outhouses or even chimneys to vent the cooking smoke that leaves many people with a chronic cough, there are obvious questions: Wouldn't it be better to spend that $1 million a year -- indeed all $12 million spent on the nutrition project since it began -- on the crying needs of Sarlahi villagers? If there's money to spend, shouldn't it be spent helping people instead of studying them?
Keith West has asked himself such questions many times. To understand his answer, it's necessary to know how a child of comfortable American suburbs came to be obsessed with distant, destitute lands.
Attack at the source
There was nothing exotic about West's childhood outside Philadelphia as the second of three sons of a biology professor at Drexel University. It was the 1960s; his passion was the guitar, and his rock band even made it onto a local TV show.
He followed his brother to Drexel and selected the same major: food and nutrition. The choice was made without much consideration. "I'd been eating all my life," he says, deadpan. "So that seemed like an important field." But West felt the pull of the wider world. "I've always had this wanderlust," he says. For a college paper, he read about Bangladesh, then emerging from civil war, and filed it away as a place of mystery and trouble he would like to visit someday.
After graduation, with a low draft number and Vietnam raging, he joined the Army as a dietitian. In 1974, stationed in Okinawa, Japan, he attended a dairy conference in India -- then hopped a flight to Dhaka, the capital of Bangladesh.
He landed in the midst of one of the worst famines of the century. It was an unnerving sight for a naive 25-year-old American, who climbed off the plane at dusk lugging a huge wooden case containing the sitar he had bought in Delhi.
"There were little fires and encampments all over the airport," he recalls. "People mobbed us as we got off the plane."
West made his way to the headquarters of the Irish aid agency Concern, which gave him a quick course in Third World disaster and the courage of those who try to help. In three days, he visited amputees from the civil war, saw feeding programs mobbed by stick-thin children and toured Dhaka at 4 a.m. with a film crew documenting the famine.
"It was incredible, coming from a U.S. Army and middle-class American background. I was completely overwhelmed. I was exhausted. I had bad diarrhea," he says. "I can remember everything from those three days. It just bludgeoned my brain."
Some might flee from such an introduction. West knew he had found his life's work. "I said, 'How am I spending my life? Do I really want to devote my career to helping people lose weight?' I felt that in the Army, while it was interesting work, it was directed at curbing excess in an affluent world, versus helping horribly underserved people in Bangladesh."
Soon he left the Army, moved to Dhaka and went to work helping run a food program for Concern.
He knew the work was important -- children got better virtually before his eyes. But he soon found it dispiriting. "You'd help a malnourished baby, and then you'd send it back to the situation that produced the malnutrition," he says. "Every day, you'd be faced by a line of mothers waiting with their malnourished kids."
The experience led West to the fundamental idea underlying public health -- that because the world's population cannot be saved one by one, death and disease must be attacked at their source. It was what William H. Welch had in mind as he launched Hopkins' School of Public Health in 1917, quipping that he hoped to put the medical school next door out of business.
After two years with Concern, West enrolled at Hopkins. In 1981, hunting for a topic for his doctoral dissertation, he met ophthalmologist Alfred Sommer, who was looking for a nutritionist with Third World experience for a vitamin A project.
The two clicked. Sommer and West collaborated on groundbreaking work in Indonesia that discovered the powerful effect of vitamin A on child mortality. West has since carried on the micronutrient work in Nepal and around the world.
West has inspired a reverence for accurate data in the Nepal team, down to the village women who hand out vitamins. At the same time, he has come to admire the wisdom of the unschooled.
"There's a literacy of the village that we don't appreciate: the ability to read the environment, to judge the wind from the leaves, to know when the monsoon will begin and when it's going to end," he says.
Back in Baltimore, at an institution where big egos are as common as big grants, West's style is disarming. He will throw out his schedule to counsel a prospective student or answer an e-mail query from a stranger overseas. He leavens every budget meeting with humor, plants a joke slide in every nutrition lecture.
His mind filled with the biochemistry of beta carotene and the myriad details of the overseas studies, he can get distracted. Before departing on a long-postponed trip to Nepal and Bangladesh in February, he first forgets his laptop at his office after working late; then he rises to catch a 5 a.m. ride to the airport -- and leaves his wallet on the kitchen counter at home. "Post-50 shrunken brain syndrome," he calls it.
In his work overseas, West has avoided the arrogance of the foreign know-it-all. "If you come into a setting thinking of yourself as a high-powered international expert, you'll pay the price," he says. "You'll find yourself tolerated only because you represent funds."
If Nepalese officials sometimes bristle at foreigners' advice, West understands. His office is surrounded by the slums of East Baltimore, a daily reminder of America's own failings.
"Imagine the reverse," he says. "Why do we need the Nepalis to come to Baltimore and tell us our children need to learn to read? Why do we need the Nepalis to tell us that we shouldn't shoot each other on the streets?"
Dr. Subarna K. Khatry, 46, a worldly Nepalese eye surgeon who serves as in-country director of the Hopkins nutrition project, says West's humility contrasts with the hubris of wealthy tourists who wield huge influence in Nepal.
Khatry is furious, for example, that a major hydroelectric project in the country was canceled recently because of international pressure. The foreigners who fought the project, he says, would not dream of going without the electricity produced by power stations built in their own lands long ago with little regard for the environment.
"They did that 50 years ago and enjoy the benefits today," he says. "Now they want to preserve Nepal for their vacations."
Neither does Khatry share the rapture of Americans for the Himalayas. When his colleagues pull off the road for a view of the mountains, he says, "I walk off and smoke a cigarette and say, 'You want the mountains? We'll sell them to you and make some more farmland to feed the people.' ... We need to improve the lives of people in Nepal."
That is the ultimate goal of the nutrition research. Yet after more than 20 years in public health, West says he still feels the ethical discomfort of treating desperately needy people as research subjects.
"You find an extremely malnourished child, and there's really no place to take that child," he says. "You can refer to the health post, but nothing is likely to happen. You can refer the child to the district hospital, but that may actually increase the risk. So what do you do?"
A few times in Nepal, he says, he has been so shaken by a child's plight that he has handed a parent the equivalent of a dollar or two for food or medicine. Usually, West takes comfort in a paradox of public health, whose impact is often visible only at the intangible level of statistics. While he cannot point to any particular child and take credit for that child's survival, he is certain that thousands of children are alive today because of the Hopkins vitamin studies.
"I think I'm doing a lot more at a population level for people's health than I ever did one-on-one in programs in Bangladesh," West says. "In Nepal, there's a program that reaches 3 million children now, and that's a direct result of our research."
A slow advance
This month, as the monsoon season ends and the dry, cool weather begins, Nepalese villagers celebrate Dashain, honoring the Hindu goddess Durga, whose power saved the world from the thousand-headed devil that held humankind in misery.
Villagers build giant swings, called pings, that hang from a framework of bamboo poles tied with vines. In the hills, the pings are sometimes built atop cliffs, and children swing out in hair-raising arcs above the void. The idea is to swing high, to get as close to heaven as they can.
To foreign visitors accustomed to a world of car seats and bike helmets, it is a terrifying sight. But every Nepalese village child faces worse risks by the simple fact of where he was born. Malnutrition and disease, like the thousand-headed devil of legend, return year after year to consume the young.
By the end of this month, the last of the 4,000 babies born in Christian's prenatal vitamin study will have been weighed. By spring, deaths in the first six months of life will have been recorded. The Baltimore lab will have analyzed blood samples from hundreds of village women.
The researchers will pull together their data, and they will learn something no one knows today, something of huge consequence in the developing world: what vitamin pill for mothers, if any, can increase their babies' birth weight and boost the chances of survival.
"If we saw a 30 or 40 percent reduction in mortality," Christian says, allowing herself to dream a little, "that would be huge. Governments would really jump up and take notice." UNICEF is already interested in developing a prenatal multivitamin for the Third World, and the project could provide critical guidance.
But even if the results prove to be that stunning, the researchers know what they will do. They will celebrate -- and then repeat the whole study in Bangladesh.
"If you've found something of public health importance, you have to do it all over again," West says. "Otherwise, you have a nice study and a nice publication -- and nothing changes."
So West has spent the past year commuting to Dhaka, where his career in international health began, mapping and numbering 130,000 homes, schmoozing with local officials and hiring a staff. He is building another information factory, even bigger than the one in Nepal.
If the deliberate pace of science is necessary, it can also be agonizing. In the villages, West and his colleagues know, the tragedies that drive their whole enterprise never pause.
One afternoon a team of workers on the Hopkins project is searching for the home of a family whose infant has died. They wade across the Lakhadei River, where teen-age girls splash as their cows and oxen drink, and hear the sound of a drum from the village of Chheda.
On their way to record the death of one child, they have stumbled across the death of another.
In a dark room, the grieving family sits on the dirt floor with two Buddhist priests who chant prayers. Small candles flicker. Chicks scurry noisily in and out. On a grass mat, wrapped in white muslin cloth, lies the body of a 3-year-old girl named Nirmala Tamang.
Outside, neighbors say it was fever. The girl's father, emerging numbly into the light, says it seemed like pneumonia. She recently had measles, he says, but appeared to be recovering.
"She went out, played all day," he says, bewildered. "She came home and ate rice." During the night, Nirmala cried out for her parents, who found her struggling for breath. She lived about two more hours.
Next door, a 13-year-old girl sobs noisily. Across the path, a naked baby boy lies in a hammock, staring at patterns of sunlight and shade.
With the priests supervising, men build a stretcher from green bamboo. Someone brings a pungent bowl of smoking juniper wood. Two uncles carry the dead child outside and walk in a circle as neighbors throw rice, then lay her gently on the stretcher.
There is a stir and Nirmala's mother suddenly emerges, wailing, staggering, a whirlwind of grief.
"Nir-ma-la!" she cries, drawing the name out into a scream as relatives press near to hold her up. "Nir-ma-la! I lost my daughter! My only daughter!"
By custom, only the men are to attend the funeral pyre, for which neighbors have been gathering wood since early morning. Alarmed by his wife's condition, Nirmala's father decides to stay with her. He asks his brothers to preside at the pyre.
Down the winding path from the village, past a school and a soccer field, the child's body is borne. Several dozen men follow, talking as they go of seeing Nirmala play with the wooden car a villager carved for her; of the tatuwa petals pressed to the foreheads of mourning family members; of the recent deaths of other village children.
They reach the piled wood and gently place the stretcher on top. Villagers stand in a wide circle, speaking in low voices. An uncle lights the fire.
The flames rise and crackle, almost transparent in the sunlight. They dance around the green bamboo, and soon, roaring by now, they embrace the white bundle.