A View From Nepal
The farmer wanted to know why his three-year-old son couldn't walk or talk.
I sat opposite him in a dark, cold classroom converted into an examination room for a four-day medical clinic last spring in the village of Lapa, high in the Himalayas.
Wind whistled through the stone walls; rain pounded on the tin roof. The room's single ceiling bulb kept flickering and dying; I had to use a camping headlamp to see my notes. And communications were hampered, to say the least: We conversed via two translators--from English to Nepali, from Nepali to the local Tamang language, then back again. It sounded a bit like the telephone game, and had similarly uncertain results.
Still, one look was all I needed to make the diagnosis: Down syndrome. I found the telltale single hand crease, eye folds and wide gap between the first and second toes and asked about the boy's medical history: he'd never seen a doctor; sometimes he had diarrhea, fever or a cough.
I thought back to my journey here, the last leg of which had begun five days earlier. With two other doctors, I had left Nepal's capital, Kathmandu, on a winding, bumpy, eight-hour Jeep ride up into the Ganesh Himal range. As we drove higher, the sheer mountainside drops grew more terrifying, but we didn't notice them much, mesmerized as we were by the stunning views and the farmhouses hanging off the nearly vertical terraced hillsides. At day's end, we joined the field team who would take us the rest of the way to Lapa--a four-day trek by foot.
Our trip had been organized by Himalayan HealthCare, an independent, nonsectarian nonprofit cofounded by Anil Parajuli, a Nepalese trek operator.
Nepal, sandwiched between Tibet and India, is one of the world's poorest countries. Since its royal family was wiped out by a murder-suicide in 2001, it's been torn by clashes between an unpopular monarchy and insurgent Maoists, with killings, disappearances and detentions on both sides. The majority of Nepal's people are subsistence farmers living in inhospitable mountain villages like Lapa. Himalayan HealthCare aids several such villages, using its shoestring budget to fund medical treks, train villagers as health-care workers and teachers, provide for orphans and foster commercial projects such as handicrafts and cardamom-growing.
Each day of our trek to Lapa, we hiked steep, switchback trails up to 14,000-foot-high mountain passes, only to descend the other side and camp overnight in the valley below. The next morning, we'd ascend again. Our staff, cooks and porters greatly eased the journey by carrying our gear and making us comfortable in our tents, delivering sweet chai tea first thing in the morning and a hot water bottle at night.
As we carried our day packs, the diminutive Nepalese porters went on ahead lugging our dining table and chairs, stove and kerosene supplies. They bent double under their dokas, overloaded bamboo baskets supported by bands across their foreheads. Many wore only flip-flops; a few, wearing no shoes at all, left naked footprints in the snow.
Lapa badly needed health care, having had none in the four years since its sole health-care worker was kidnapped by Maoists and held prisoner with a string of grenades around his neck. (After Himalayan HealthCare paid his $300 ransom, he left.) Many of our patients had never left their villages or been examined by a doctor. Their most common complaints--painful knees and breathlessness while climbing--were the legacy of lifetimes spent carrying heavy burdens long distances and dwelling in wood-smoke-filled houses.
We saw a wide range of ailments, from tuberculosis of the lymph nodes to chronic ear infections, gastritis, worm infestations, severe cataracts, stroke, rheumatoid arthritis and asthma or chronic obstructive lung disease. But in most cases, the only treatment we could offer was enough acetaminophen or ibuprofen to provide a few weeks of relief. We sent a few serious cases to the hospital in Dhading besi, three days away, but only if the patient could make the trip on foot--or carried in a doka (our "basket cases").
I looked at the man in front of me. He was a typical Nepalese farmer--tiny in stature, weather-beaten, shy, gentle, patient, worn down by life. "Down syndrome"..."genetic abnormality"..."chromosomes"... these words would hold no meaning for him. Mainly, I reasoned, he just needed to know whether there was something horribly wrong with his son. It was unlikely that the boy would ever go to school, but he would grow up to farm alongside his parents. I reassured the man that his son eventually would walk and talk, and gave the boy a multivitamin and an empiric treatment for intestinal worms.
We parted with small smiles, a slight mutual bow and a simple "Namaste," pressing our own palms together as if in prayer. I wondered what the man thought of our encounter; I hoped that he came away feeling more hopeful.
In all, my colleagues and I saw 450 people in Lapa, working far into the final evening. It was difficult to feel that we'd given them much. But perhaps our offers of Band-Aid medicine and modest comfort meant more than we realized. Our patients' "Namaste" always sounded thankful, and they did seem grateful to be seen and listened to.
We in turn had been challenged physically and mentally, walked the Himalayan foothills and had the privilege of sharing the lives of the Tamang people. An outsider in a community so different from my own, I felt welcomed and accepted by my patients in a deeply personal way. As they confided their intimate concerns to me, I felt strongly connected to them. And in this remote setting, far from the daily hassles of American health care, I felt my love of medicine renewed.
This was their gift to me.
About the author:
Caroline Jones MD is a family physician on the faculty at Saint Joseph's Medical Center Family Medicine Residency Program in Yonkers, NY. She has participated in medical missions to Ghana and Nepal. "I have always found that traveling to a different part of the world to work in that culture is a rewarding experience. Medicine is amazing in that it allows me to step into other people's worlds, to ask them important questions about their lives and to appreciate their strengths and their struggles."