I was standing on a mountainside in rural Makwanpur Province, the grass and earth of Nepal pressing into my bare feet, when the words from the poem The Hollow Men crossed my mind:  "Between the idea and the reality falls the shadow.”  In T.S. Eliot's poem, the idea and the reality are disconnected and lost to one another, but there I was in the brilliant sunshine, the idea and the reality perfectly connected, so what had fallen between the two?  

I thought back to my Public Health Program Planning class at New York Medical College during the winter of 2009, when my colleague, Sumitra Gurung, MBBS, from Pokhara, Nepal, and I received our assignment:  analyze an article in Lancet about the MIRA Project.  Sumitra and I laughed at our good fortune to have drawn by sheer luck a project located in her home country, which also embodied my heart's desire for a trip around the world, even though the assignment only required us to read the article, do some library research, and present a Power Point right where we were sitting in Valhalla, N.Y.  But there the idea was planted. 

MIRA stands for Mother Infant Research Activities, but Mira was also a Hindu poet (1499-1546) who devoted herself to the God Krishna and was considered the incarnation of his wife Radha (more about Radha later!)  MIRA was founded in 1992 by Dr. Anthony Costello of the Centre for International Health and Development in London and Dr. Dharma Manandhar, working with a group of leading perinatologists in Nepal to conduct research studies to reduce maternal and infant mortality. The Lancet article, "The MIRA Cluster-Randomized Controlled Trial:  A Scientific Approach to Program Planning to Reduce Infant Mortality in Developing Countries," specifically focused on women's empowerment groups using game cards to teach about safe birthing practices.  The research question was, "Can a community-based participatory intervention significantly reduce neonatal mortality?"  The research design was a rigorous randomized controlled trial utilizing Village Development Committees in 12 pairs, matching intervention groups with non-intervention groups.  It included a cohort of almost 30,000 women of reproductive age.  While both pairs received programs that strengthened health care delivery systems, the intervention groups had a local woman facilitator (not a health worker) who organized the participatory groups.  After two years, the research outcomes showed a 30 percent reduction in infant mortality, with the maternal mortality rate at 341/100,000 in the control groups and 69/100,000 in the intervention groups.  Rather than building hospitals or placing a doctor in every community, the intervention was all about community women empowering other women, all advocating for each other and changing health behaviors, instilling a sense of ownership in the process.  Sumitra and I got an A on our project, and I fell in love with MIRA. 

My interest in maternal mortality reduction and women's empowerment projects became more and more focused on home births in communities where there was little or no access to health care facilities for deliveries.  I delved into women's empowerment, social design and micro-financing, interviewed leadership from the White Ribbon Alliance, Averting Maternal Death and Disability, and the Birthing Kits Foundation, and poured over my literature searches.  But always the names of MIRA and its leadership and founders kept coming up, making my heart beat faster.  They became the rock stars of the cloistered little world that centered around my computer as I researched and wrote, sometimes from 7:00 a.m. to late at night, weekdays, Saturdays, Sundays and holidays.  In April, The Lancet published the Hogan study that documented the progress that women's education, poverty reduction, and assistance of birthing attendants had made in the reduction of maternal mortality in the past 20 years.  By Memorial Day I had submitted my thesis and graduated. 

Along the way, I bought a map of Nepal, in order to locate Makwanpur Province, Kathmandu, the Himalayas, Sumitra's home in Pokhara at the foot of the Annapurnas on the beautiful clear lake, and the winding mountain road that led to Hetauda, the location of MIRA's office.   

There was so much that fell between the idea and the reality:  the research, the map, Sumitra's invitation to visit her sister-in-law Radha, who became my Nepali sister, cruising Expedia for the best airfares, the vaccinations and medications, packing, not only clothes but cookies, baby pajamas, T-shirts, brochures about my child advocacy center, notebooks, flashdrives.  And on November 21, 2010, I stepped onto a plane pointed toward Delhi, India and then another that flew past the Himalayas and landed in Kathmandu.  After six days of warm sunshine, temples, monkeys, cows, hiking, wandering the streets of Thamel, observing and grieving over cremations by the river, my friend Keith's wonderful driver, Mehendra, drove me over the mountains to Hetauda, on that winding road I had traced so often with my finger. 

So there I was on the mountainside in rural Makwanpur, after having met with the MIRA staff, and driving deep into the Nepali countryside.  There were women, dressed in colorful saris and kurtas, and their beautiful children walking along a dirt road to a meeting place where we would all sit together on the grass to discuss the needs of their community, the stretcher program, the access to the local health center, the safe birthing methods they shared with their neighbors.  We were far away from my home in Piermont, from Valhalla, N.Y., from London, from the pages in the Lancet that documented the success of MIRA and the numbers of lives saved.  There in the grass among those women, animatedly talking to each other in the bright sunshine, was the reality, and not a shadow in sight.

Thanks once again to Karel R. Amaranth, MPH, MA, for her insightful stories of a life in public health.