Final Week: Rural Villages

Another several hour drive over mountain passes brought us to Garagusain, which has been our base for camping and lodging. From here we took short car trips to nearby villages and set up health posts. Yesterday, we went to a larger village and actually worked in the local clinic there. It was reassuring, although somewhat surprising, to see consistent access to local health care available here. There is a pharmacist who sees patients there on a daily basis and provides medications. We took over the clinic for the day and saw all of the patients that came, but the pharmacist hung around as a consultant. I appreciated this, as he is familiar with the patients, their language, and the diseases that more commonly occur in the area. 

Dermatologic complaints have been a bane for our team. Many patients present with unusual rashes, and it is difficult to get a thorough history translated in Hindi to understand much more than whether it itches and how long ago it appeared. It would be great to know how the rash started, whether insect bites were involved, and if the patient has underlying chronic conditions, but these sorts of questions get mangled in translation. For significant rashes, we end up taking a shot gun approach of treating with oral anti fungals and/or topical steroids. We have seen a consistent amount of scabies, which usually has a more straightforward presentation and treatment. 

One day in clinic we saw a middle-aged woman who had a rash all over her trunk that had been there for a month and was itchy. She had scaly scab-looking lesions scattered all over her flanks and backside. Unsure of the diagnosis, we treated with with fluconazole and topical hydrocortisone. One of our attendings sent a picture of the rash to a dermatologist friend of hers, who didn’t know what it was and recommended we biopsy it. If only we had that sort of luxury!

Our last couple days of clinic were at an orphanage in a small village. We had the fortune of getting to host our clinic alongside a popup dental clinic hosted by the local dental college as part of a public health outreach project. I envied their ability to thoroughly educate their patients without a language barrier and with props! The orphan patients we examined had surprisingly better teeth than I expected, even better than the children at the monasteries. Together with the dental students we probably saw almost 200 patients over two clinic days. We even made the local paper!

We also examined many adult patients, who typically presented with vision complaints. Presbyopia and cataracts were the most common diagnoses. It was striking to me how much constant sun exposure without hats/sunglasses caused so many vision complaints, from watery eyes to pterygium to cataracts. This was a consistent pattern we have seen throughout the Himalayan villages. 

Once our last day of clinic was over, we inventoried all of our medicines and made a list of what would be needed for the next trip coming up in July. It’s exciting and reassuring to know there will be a team following us in a few short months, to carry on the work. 

As our trip comes to an end, I am humbled by how much there is still to learn- about medicine; about culture; about people. I feel invigorated to stay curious and absorb as much of my medical and life experiences as possible. The main goal for me for these sorts of trips is to do more good than harm for patients, and to open myself up to their world. I feel like I accomplished this, although there is still so much more to do! 

Monks turning prayer wheels at Namgayal Monastery (seat of Dalai Lama)

                                                    The Route: Map of our travels in northern India in Himachal Pradesh

                                            Our volunteer translators at one of the boarding schools. Future nurses and doctors!

                                                        One of our team members seeing patients at a monastery in Bir

                                                                Long 20 km trek over mountain passes in Billings 

                                                                Temple at one of the monasteries we stayed at in Kais

                                                Our team working together with the local dental students!

 From Michelle Disher (NCFM R2)

Week 2: Mountains and Monasteries

We wrapped up our time in Bir, and the next chapter of our travels has led us to even more rural and mountainous regions in the Himalayas. To get to them, our team elected to hike over a mountain pass by following a 25km trail. The first 7km were incredibly arduous. It was almost entirely up a steep mountain slope covered in a slippery bed of dry pine needles. After making it to the top of the pass, we walked the rest of the way over gravel roads and down grassy fields to make it to the bottom of a valley where our drivers were waiting to pick us up. The hike was as breathtaking as it was exhausting. Our path was littered with rhododendron blossoms from overhanging trees, and we were surrounded by constant mountain vistas. It was the farthest I have ever hiked in day!

Several times over the course of our clinic days we have been able to intervene or diagnose some major conditions. Today I had a 9 year old pediatric patient who presented for a general check up but had a blood pressure of 140/80. He had no symptoms suggestive of heart or kidney disease, and his urinalysis was normal. Luckily we have a portable ultrasound with us, which we used to discover multiple bilateral renal cysts suspicious for poly cystic kidney disease. We were able to also scan his mother, and she had multiple cysts as well. Their family was referred to a local physician for definitive diagnosis and treatment. It was rewarding to make such a catch! Other diagnoses made by our team included a young boy with hypertrophic cardiomyopathy and an unfortunate older woman with likely endometrial cancer. 

The past few days have involved breathtaking mountain views and once in a lifetime experiences at Buddhist monasteries. We have stayed at two monasteries so far, which have been home to boys ranging from elementary school through high school age. It’s been heartwarming to see the  ancient Buddhist burgundy and gold robes dressing little boys playing with a deflated soccer ball and old cricket bat. I’ve learned that children can start training to become monks if they choose to leave their families by their own volition. They are then looked after by their older counterparts at the monastery.

Our clinic days have consisted of doing well-child checks on these boys. Perhaps it should be no surprise that these kiddos have a lot of cavities! They get soda and other sweet drinks as offerings that the local townsfolk bring to the monastery. They also apparently love to chew lots of gum. We also spent a day at a nunnery which looked and functioned analogously to the monastery of boys. Interestingly, tinea capitis is a recurrent issue for these ladies because they share the razor blades they use to shave their heads. 

 From Michelle Disher, M.D. (NCFM, R2)

First Week: Dharamshala and Bir

I’m coming near the end of my first week working with a great group of people from all over the US to offer clinical evaluations to children and adults living in local villages nearby. Himalayan Health Exchange has designated areas that are filled with medical providers every couple months or so. This month I have the privilege of being one of them . 

Alongside me are U.S medical students, a fellow resident, and a few attendings who supervise our work. 

Our journey started in Dharamshala, the sacred home of the Dalai Lama. We spent our first day here resting from a long trip that involved a total of 19 hours flying and 2 hours of driving on winding roads. There was a rather chaotic and smoggy trip from Delhi to the Dharamshala airport that I’ll spare you the details of. The area of Dharamshala  is mountainous and serene. We had the honor of getting to tour the compound of the Dalai Lama and ride a gondola to tour the rural towns scattered nearby. 

From Dharamshala we traveled to Bir, another rural town that is famous for its paragliding. The town is surrounded by small farms and prayer flags, with towering mountains of the Himalayas in the backdrop. There are small clinics in town, but they can be a challenge to get to both from a financial and a transportation standpoint.

We hit the ground running on our first day with pediatric screenings at one of the local schools here. The goal was to see nearly 600 students over the next couple days between 13 providers: 4 attendings, 2 residents, 7 medical students. 

The schools here are like boarding schools, with the students living together on a large campus overseen by teachers and “house-mother.” Overall, the children are relatively healthy here, though they do have some issues that are more common in low income countries. A handful of them had scabies. Parasites are a ubiquitous issue, which the government has started addressing by giving all children yearly albendazole treatments. Malnutrition and stunted growth is also much more common. Many of the students I saw were < 10%ile for their weight/BMI on their growth chart! Finally, my pediatric exams weren’t complete without noting numerous cavities and rotten holes in their molars. 

Over the course of the week, out team brought pediatric screenings to two large boarding schools. We saw over 400 students in two days at the first school, a bit shy of our goal of 600. We managed to see all of the students at the next school, which was more that 500 patients. 

In between pediatric screening days, we set up health outposts in fields of rural villages that were open to everyone. Evaluating and treating adults introduced several new challenges. Often patients would come to us with chronic conditions such as hypertension or poorly controlled diabetes, which we could not properly treat with a few weeks worth of medications. Sometimes they would have conditions that were being managed by a physician already but the patients were still struggling with their condition. 

In many of these cases, we play an important role keeping these patients looped in with their doctor. One of my patients came to me with terrible joint pain and psoriatic plaques on his extremities. He brought with him a packet containing physical X-rays, as well as physician reports and medication list from a rheumatologist. The medicines he was on either ran out or weren’t working. There was nothing in our traveling pharmacy I could offer him besides a wimpy hydrocortisone cream. I encouraged him to return to his rheumatologist, who would know his medical course and have a better idea about what immunologic to put him on.