When reached the summit of Ecuador鈥檚 Cotopaxi in September, she took a deep breath of sulfur-tinged air. The amputee, then 47, had been pushing herself so hard, moving for so many hours鈥攁nd for so many years鈥攖hat she finally allowed herself a moment of respite on top of one of the world鈥檚 highest volcanoes. She peered into the听crater and then looked out over the sweep of land before her. 鈥淢iraculous,鈥� she said. Nine days later, and thousands of miles away, she听completed her first marathon, in Chicago, in six hours and seven minutes.听

Pico鈥檚 journey started ten years ago, after discovering听that the chronic pain in her ankle that had sidelined her for years was a slow-growing听tumor. By the end of 2009, she had endured four rounds of chemo, which reduced it in size but didn鈥檛 eliminate it. She then made the decision听to amputate her left foot above the ankle to fully eradicate the tumor.

The night before her surgery, Pico dreamed that she was racing in a marathon. She hadn鈥檛 run since she was 18, when the ankle pain began, and that had just been for fun; she had never competed in a race.听After her surgery, Pico connected with David Krupa, an American prosthetist in her hometown of Quito, Ecuador, who outfitted her with a prosthetic foot. She was thrilled. But听after her first step, she realized how heavy her new limb was听and how weak her body had become from the chemo, early menopause due to the chemo, and the surgery. 鈥淚 thought, 鈥楳y God, how am I supposed to run in this?鈥欌�� she says in Spanish through a translator. Pico spent two years in physical therapy, building up her muscle mass and getting used to the extra weight. She signed up for her first race, a 5K,听in October 2012, although听her prosthesis was only made for walking,听and听she had to take the three miles听at a slow pace.

After a couple of years with her first prosthesis, Krupa听contacted Pico听about receiving a running blade听through the Range of Motion Project (), an organization he听cofounded听that donates听prostheses to South American amputees. 鈥淚t was perfect,鈥� Pico says. 鈥淪pectacular.鈥� She began building up her stamina as a runner, racing through the narrow cobblestoned streets of Quito and scaling vertiginous alleyways.

In 2015, Krupa asked if Pico wanted to be part of a new initiative through ROMP, in which听amputees from around the world would scale听mountains and raise funds for prostheses. 鈥淚 thought it would be easy, because I could just walk,鈥� Pico says. But听when she first tried climbing a steep hill in a park in Quito, her legs gave out. Her training partners had to push her up from behind to reach the top. The muscles for scaling mountains, she discovered, were different than those used to navigate听hilly streets. A prosthesis adds another layer to the struggle, as the differences in the muscles used are even more pronounced. For amputees wearing a prosthesis, along with a mountaineering boot and crampons, every added ounce feels much heavier听than the same gear would feel on a normal听limb. 鈥淭hat鈥檚 when I found out that I really had to develop the muscles I had that were dormant,鈥� Pico says.

To build these muscles, she听started walking up and down countless flights of stairs and performing exercises to strengthen her glutes and back. She did more cardio, swimming, and听cycling, and she made changes to her diet, eliminating fat and any processed foods, eating smaller portions five to six times a day, and dining on a regular schedule without skipping any meals. Gradually, she adjusted to the lower oxygen levels found at higher altitudes. 鈥淭he first year was very difficult, very tiring, very emotional,鈥� she says. 鈥淚t felt like starting all over again.鈥�

After a year, though, Pico felt the same passion for climbing that she felt for running. She听ramped up her workout regimen, training at 4 A.M. before her job听as an accountant began and picking it back up as soon as work was over. In the following two years, she scaled smaller peaks throughout Ecuador鈥擱umi帽ahui, Pasochoa, Rucu Pichincha, Iliniza Norte, Cayambe鈥攂ut nothing as tall as 19,000-foot听Cotopaxi. On September 28, 2018, Pico reached Cotopaxi鈥檚听icy summit with the climbing team from ROMP on their听first attempt. 鈥淚 got rid of my left foot so I could plant both of them on the ground,鈥� she听says.

Soon听Pico听was on the move once more. Crossing the finish line at the Chicago Marathon听last听October, Pico felt like she was moving through the dream she鈥檇 had nine years earlier. Thinking about that feeling again, she begins crying. 鈥淚 never could have imagined I would be an athlete until after the surgery,鈥� Pico says. Looking back, she says it was all worth it: the years of frustration and sacrifice, the relentless training, even the procedure itself. Her athletic accomplishments made it seem听as though the prosthesis had become a part of her.听

Pico recommends that听all athletes starting a new sport听gradually ease themselves into it. Begin听with longer walks, then runs,听before diving into听mountain hikes听or marathons.听鈥淭he听key is to have patience. Every dream that is built takes time,鈥澨齭he says. 听

Pico plans听to continue running听one or two races a year, including听in the New York City听Marathon this fall. And she will keep听climbing mountains with ROMP and its team of elite amputee climbers, chasing the听feelings that come with听standing on top of the world and crossing the finish line. 鈥淭he small moments in which we lose our breath鈥攖hat鈥檚 what life is about,鈥� she says.听

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On the day Binsa tried to end her life, it took two hours for her cousin and sister-in-law to walk her to the emergency room in Dolakha, a remote, mountainous district of Nepal just east of Kathmandu.听

Binsa, whose name has been changed to protect her privacy, was 24 when her husband died in an accident. After her in-laws took away her young son to raise him in India, Binsa鈥檚 life felt empty and meaningless. When she reached the hospital, she met with doctors hired by the New York鈥撎齛nd Nepal-based nonprofit ,听who听referred her to its peer mental-health counselors, located just down the hall.

Every morning and afternoon, Sunita听Jirel,听a counselor who told Binsa鈥檚 story through a translator,听worked with Binsa听on calming techniques including deep breathing, meditation, and progressive muscle relaxation. With the help of another counselor, they addressed the reasons Binsa went to the hospital鈥攖rauma, anxiety, and suicidal ideation, among others鈥攁nd the ways she might begin improving her mental health. The counselors also recommended that doctors prescribe two medications for anxiety and depression. After three days, Jirel says, Binsa was well enough to return home. She came back in a week to follow up听and has returned every month or so for therapy sessions for听the past year and a half.

In Nepal, and home to only a of psychiatrists and psychologists, mental health care is vanishingly听rare. The Nepalese听government set aside roughly听听for all health care in 2019鈥攃ompared to the U.S. government鈥檚 health budget鈥攚ith less than 1听percent dedicated to mental health.

Yet psychological conditions afflict Nepalis at higher rates听compared with the rest of the world. Researchers analyzing several recent studies on mental health in Nepal for the scientific journal found that more than one-third of Nepalis experience some issues with mental wellness, including anxiety (28 percent) and depression (30 percent). In comparison, about 7 percent of people worldwide have听anxiety disorders, and an average 3.2 percent of men and 5.5 percent of women experience depression. Nepalis also have a 鈥渉igh burden鈥� of PTSD鈥攏early 听of the country suffers from the condition. In discussing these high rates, researchers pointed to a decade-long civil war that tore the country apart and a magnitude-7.8 earthquake that rattled it once more in 2015, as well as a lack of mental health care throughout the country.

But despite the high prevalence of mental-health issues, there is still a stigma against seeking the appropriate听care in Nepal. 鈥淧eople with mental-health problems are generally poorly treated, pitied, and even despised in Nepal,鈥� says Kul Chandra Gautam, former assistant secretary-general of the United Nations and author of 听(he also formerly served听on Possible鈥檚 advisory committee). 鈥淭hey are often seen as a burden to families and are ostracized by their neighbors.鈥�

Possible Health, which now has more than 350 employees, launched in 2008 with a focus on chronic diseases, malnutrition, and maternal and child health in Achham, a region hit hard by the civil war. It听later added mental health care, in 2016. Immediately after the 2015 earthquake, the nonprofit expanded primary-care offerings to another hospital, in Dolakha, where the majority of health-care facilities were damaged or destroyed by the quake. Although Possible always planned听to add听mental health care at the hospital, the earthquake made this need more urgent, and it听started offering services in 2017, shortly听before Binsa arrived.

According to Gautam, the nonprofit opened at a time when mental health in Nepal was still being听neglected. 鈥淚t is a completely unaddressed issue we have to conquer. We simply don鈥檛 have enough mental-health specialists in the country鈥攅ven in urban areas and major hospitals,鈥� he says. 鈥淢ental health has not been a government priority, given other pressing priorities.鈥�

While the World Health Organization and other nonprofits recommend integrating mental health care into primary care, that often means听physicians听simply听prescribe medications for anxiety and depression. Possible鈥檚听model is unique for the country because it听offers psychosocial counseling under the same roof. And those counselors speak with psychiatrists every week about each case, to help them catch mistakes or听something they might have missed. No other program in Nepal does听that, says听Bibhav Acharya, a psychiatrist and cofounder of Possible.

Acharya says that听improved mental-health services have been a 鈥渟ilver lining鈥� of the 2015 earthquake, with the event听bringing international attention鈥攁nd some funding鈥攖o the gaps in Nepal鈥檚 health care. There are only 54 psychiatrists and psychologists in the entire听country, which has more than 28 million people, he says, and many doctors in Nepal at all. But experiencing the quake themselves helped improve the听doctors鈥� empathy. 鈥淭hey finally realized how scary it is to have anxiety, how scary it is to be traumatized, to witness death and loss,鈥� Acharya says. A crisis like the earthquake鈥攐r, before it, the Maoist civil war鈥攃an uncover previously hidden and untreated mental issues, he says.

Addressing mental health as part of overall health care makes it easier for patients to find relief and for Possible to听skirt around the difficulties associated with discussing mental-health problems in the country. For example, counselors avoid听talking outright about depression, which is still a taboo subject; instead, they focus on听symptoms, like sleeping problems or headaches. From there听the counselors can explore听treatment options听such as听therapy and medications.

Typically, the two Possible counselors in Dolakha each see between听seven to ten patients per听day. Peer counselors undergo a six-month psychosocial training, and they keep in close contact with a regional psychiatrist, calling every week to discuss each patient鈥檚 case. The psychiatrist visits every three months for training and observation, but both of Dolakha鈥檚 counselors are from the region, which is helpful to听understanding patients鈥� backgrounds and building trust.

In the future, Possible will train more community health workers, especially those able to go to patients鈥� homes and villages, to recognize and begin treating mental-health issues alongside physical issues. This year听it began operating a third hospital,听in Achham. 鈥淭he overall goal is to develop a blueprint for what remote health care delivery looks like,鈥� Acharya says.

The counselors continue to work with Binsa, who has changed dramatically from the day she checked into the hospital. 鈥淪he鈥檚 totally improved,鈥� Sunita Jirel says. Binsa still has not been able to see her son, but recently she was able to speak with him on the phone. At her most recent appointment, she told the counselors that she now has听a reason to keep living. 鈥淪he thinks that, no matter what the shortcomings are in her life, she will fight through them,鈥� Jirel says. 鈥淪he feels stronger.鈥�

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