Wedding Crashers 2: Bollywood Edition

Today is my third day in New Delhi. My time here has passed by in a whirlwind. I was a bit apprehensive coming here from the mountains, where I most loved small towns and the friendliness of our patients and people in general. Fortunately, people here, though they come in a mass are just as friendly. I have been so impressed by people finding us bus seats, giving us directions, and one man even buying our metro tickets for us and getting us off at the right stop (even though he did have us go the wrong direction for one stop before I corrected him.)

We arrived in New Delhi the evening of Apri 27th and checked into our very nice hotel. It was shockingly nice after our more rugged accommodations of the past month. We watched "The Big Bang Theory," ordered room service dinner (butter paneer masala for about $4), and went to bed early.

The next day, the 5 of us from Himalayan Health Exchange (Sophie from Indiana, Cheryl from Indiana, Stacey from Vanderbilt, Mary from Washington [only with us this day then left for the airport] and I) spent the day traveling to tourist destinations. We started in Connaught Place--CP to the locals--a pretty shopping area of British design. We had lunch there at a McDonalds where we amusedly ordered Masala Macs and a McAloo Tikki (potato patty); there's no beef on the menu. In the afternoon, we went to the Lotus Temple, a Ba'hai temple built in 1986 in the shape of a lotus flower. It was surrounded by nice gardens. We got our first taste as Indian models as person after person stopped to take our pictures with or without a friend or family member jumping alongside us. We initially amused, but it's starting to wear a little thin. I jokingly ask to be paid 10 rupees per picture, but no one has paid up, yet. We also went to the National Museum, which was great. I listened to an Audio Tour. My favorite of all of the amazing pieces in the collection was a series of miniature paintings depicting the love story of Krishna and Radha, Hindu god and goddess, which had added sparkle due to the addition of beatle wings!

The Lotus Temple--also pictured above with me

 

That night, we went to Indian Accent, rated the best restaurant in New Delhi and apparently one of the best 50 restaurants in Asia. It was the 4 of us from HHE staying for the tour, 2 other women from HHE from U Texas Houston medical school, another HHE guy, and his friend, Ashu, really a friend of a friend who has grown up and lives in Delhi. We had an awesome time. The food was incredible. We did a 7-course tasting menu. I can't really pick a favorite: potatoes wrapped with pesto, the best tofu I have ever had, bacon naan, a mango sorbet pop... it was all crazy good. We had a lot of fun together. At one point, Ashu mentioned that he was taking Denton to a wedding the next day. So, of course, Sophie and I immediately remarked how awesome that sounded, and Ashu invited us to come, too! We were amazed, but he said it was no problem, we would be his guests. He called up his friend, the bride, who assured him that it would be great, and they would be happy to have us. So, we made plans to take the metro and meet him at a nearby stop the next day.

Sophie and I walked to the closest Metro station to start our journey. We first jumped onto a general car, which was the most crowded subway/metro car I have ever seen, worse than any in New York even at peak hours. We just smushed our way into a wall of people. At our first transfer, we realized that the trains come so frequently (no more than 2-3 minute wait maximum, apparently), there is no need to squeeze onto a general car when we can easily ride a nice, far less crowded woman's car. Wow, it was nice. After one more switch, we arrived at Dilshad Gardens, the neighborhood which is Ashu's home. He and our friend Denton picked us up from the Metro, and we walked to Ashu's house. His parents and brother immediately greeted us then began serving us food: water, mango milkshake, moong dal, cookies, sugary dough sweets, fried onions and potatoes with ketchup, and chai tea. Next, we started to arrange for Sophie and I to get saris. Ashu took us to his friend's house where the bride was getting ready (she had her henna on already and was getting makeup) where his friends helped us try on their sari blouses, but they were WAY too small for us. So, we went back toAshu's, and his mom brought out all of her saris, and fortunately her blouses fit us with room to spare. We each picked one out, which we were told were of a traditional variety but were assured they would be great for the wedding. His mom quickly pulled out a needle and thread and without even measuring, tailored the blouses perfectly for us in about 5 minutes. Then she and her housemaid wrapped the saris around us and pinned them in place. Voila!

Giddily wearing saris!

Eventually, we made our way to the wedding ceremony, and we walked in just as the bride and groom were placing flower garlands over each other's head, a big part of the ceremony. After that, all family and friends walk up to them in turn to bless them and take a picture with them. The bride's sister excitedly came up to us and asked us to step forward. We happily did so. Everyone seemed SO excited that we were there. It was great to see the bride's friends that we had met earlier; they were sooo nice and even apologetic for her saris not fitting. They continuously thanked us for coming, to which we replied with vigorous thanks for letting us attend. After our official picture, many more friends and family wanted pictures with us, too. We tried not to draw too much attention, but that was a lost cause. After pictures, we were served a banquet meal, which was awesome. Some of the food we had had before (or some version or it), but there were some new vegetable dishes and an awesome dessert of dough in a sweet white sauce that we loved. The bride and groom after pictures are ushered into a sort of temple or ceremonial room outside the main banquet hall. Doors were open, so we could watch (and we were invited in, but it was soooo hot). Around a square fire, along each side are: the bride and groom, bride's parents, Hindu priest/master of ceremonies, and groom's parents. There is a ceremony that takes up to 2 or so hours, so we just watched part of it.

 Part of the wedding ceremony: bride and groom circling the central fire 7 times as guests throw flower pedals on them.

After watching this more interactive part, we decided that it was probably time for us to part, especially since Ashu offered to drive us to do whatever we wanted in the city. Sophie and I needed to get back to our hotel for a meeting with our tour group, so we did that.

Ashu, me, Denton, Sophie. Behind us is the stage where the bride and groom initially sat (garland exchange and blessings portions).

Before leaving, we took more pictures, and the bride's parents came over specially to thank us for coming. After profuse thanks on both sides of the conversation, we left. Ashu told us that this event was a small wedding (about 100-150 people) because it is a "love marriage" as opposed to an arranged marriage, at which there may be 1000-2000 guests. His brther invited us to go to another wedding tonight, for an arranged marriage, but we turned him down since we are on our tour now and leave early tomorrow for Jaipur.

That night, we met up with our tour group, consisting of 11 young adults from the U.S. (us 4), Australia, England, and Canada. We have a tour guide who is a native Indian originally from Mumbai but who has been living in New Delhi for some years and has led tours for about 7 years. After meeting, we walked around the area of our hotel (Karol Bagh), through its famous market, and to dinner. I was pretty full from the wedding feast, so I opted instead for mango ice cream. Basically, I want to eat mango-flavored everything.

Karol Bagh Market at night

Today we started with a tour of the city with our guide. We took a bus into Old Delhi and went first to Jama Masjid, the principal mosque of Old Delhi, built in 1650 AD. It houses up to 25,000 worshippers. I paid extra to climb to the top of one of the minarets. I was the only one, so as a single woman it was not allowed for me to travel up there alone. I had to wait for someone else to come along before I could be guided up to the top. Our group then walked through Chadni Chowk, the old market, and some back alleys of Very Old Delhi, which were tiny and awesome. Some of the houses were beautiful, but about 4 feet from their across-the-street neighbor. There were also wires hanging everywhere since they were built before the introduction of electricity. We saw some special areas: the fireworks market (across the street from the fire department), the wedding supply street, and my favorite, the spice market. We then went in a back alley to the old spice market, where they now sell spices whole-sale. We all started coughing and sneezing immediately. ha!

Rickshaw ride in Old Delhi! Only a little terrifying haha mostly awesome.

We also went to a Sikh (branch of Hinduism) Temple. They were playing beautiful music for their daily prayers. One drum and two piano/harmonica hybrid instruments. They also do a lot of community service, including free meals for anyone who needs one and a residential area for housing those that need somewhere to sleep. I joined in and helped make a couple pieces of flat bread and was instructed by one of the Indian volunteers. We took a series of bus, metro, autorickshaw (or tuk-tuk), and bicycle rickshaw today, rally got the whole gambit of Delhi transportation.

Main entrance to the Red Ford

Our guide then took us to a South Indian restaurant for a lunch of dosai and pineapple milkshakes. It was awesome to have something different than North Indian food, which I have loved, but am enjoying a few different things, too. We split up after that, with Sophie, Stacey, and I heading to the Red Fort, a world heritage site and important example of Mughal architecture. It also had a small museum about the Indian struggle for independence, which was also great. It makes me want to watch "Gandhi" again. We leisurely strolled around before taking the Metro back to our hotel, led by an exuberant helper, a Punjabi man who cut in line to buy us tokens, walked with us through each stop and transfer, then walked us off the Metro, almost getting in a fight with a Metro worker when the machine basically ate Sophie's token haha. wow.

Tomorrow we head to Jaipur via train!

Mcleodganj

Yesterday we arrived in Mcleodganj, the northwest most point of my travels. This town houses many Tibetan refugees and has become a backpacker and tourist hotspot. Today I visited the temple and monastery of the Dalai Lama. Apparently, he was in town yesterday, but left early this morning to do some public talks farther north of here. While at the temple complex, we also visited the Tibet Museum, which documented the history of the Tibetan exile. Tibet was invaded by China in 1949. After some failed attempts at resistance, it was basically usurped by China, and the Dalai Lama, after being threatened by the Chinese, fled to India several years later. He set up the government-in-exile here in Mcleodganj. Since then, China has assumed total control of Tibet, and the cultural revolution led to the destruction of, according to the museum, three quarters of Tibetan monasteries, nunneries, and important Buddhist texts and sculptures. The museum also cited 1.2 million as the number of Tibetans who have died due to the Chinese invasion. The exhibition made special attention to provide evidence that Tibet was a sovereign, independent state prior to 1949. Some of the devastating effects of the Chinese invasion are on the environment: Tibet is now used as a nuclear testing site, forests are being cleared, and lakes considered sacred to the Tibetans are being polluted. Tibet is much larger than I realized at two-thirds the size of India. There was also an exhibition about the Panchen Lama, the chosen successor to the Dalai Lama. He was born in 1989, and at the age of 6, in 1995, he was identified as being a very special person. On May 14, he was visited by the Dalai Lama, who confirmed that he was the Panchen Lama. Three days later, on May 17,  he was abducted and remains missing today. It is suspected that he is being held by the Chinese, possibly tortured or brainwashed. Although the information I received today was all one-sided and provides only the Tibetan point of view, it is all very disheartening. On our first night here, there was a candlelight vigil for two people who had recently self-immolated (set themselves on fire and died) in protest of China's continued holding of Tibet. Hundreds of people walked through town and to the temple.

On a more light-hearted note, today I also went for a walk to the next town over, Bhagsu, and a pretty cool hike through a valley to a waterfall. I went with 2 friends in my group, Sophie, a student from Indiana University, and Charlotte, an Australian med student.

After that, we walked to the other side of town and saw the church, St. John in the Wilderness, dating to 1853. It was built for the English governor and other Brits. It's in a beautiful, quiet forested area. There is also a large cemetery (unusual for India because Hindus and Buddhists practice cremation). The cemetery contains the remains of many victims of a large earthquake that hit here in 1905. Another was an early church leader who died of a bear attack!

Just some cows in the road. Fun.

Yesterday I sported an Indian suit, salwar kaleez, that I had made for me during my time in Bir. I picked out the fabric and pattern from a fabric store, then took it to a tailor who had me choose the design/pattern, and then he measured me. Two days later, I had a hand-made, tailored outfit! While in Bir I also had my eyebrows threaded (kind of like waxing: shaping using strings of thread to capture errant hairs, but it's more common in India to use this technique for finely detailed work). It cost 15 rupees, which is about 40 cents; apparently, it can cost $15 in the U.S., according to my Indian-American friends on the trip. What a steal! I feel pretty, oh-so-pretty... 

With my trip roommate, Rashim! She had this blue suit made while we were in Manali, and she helped me navigate the process of getting a suit made.

Tomorrow, I travel back to New Delhi via Chandigarh. It will be a long travel day. We leave our hotel here at 7:30 a.m., and my flight arrives in New Delhi about 6:30 p.m., then it will take probably an hour to collect bags and make it to my next hotel. I'm a little wary of traveling to the big city after all of my favorite time in small towns and villages, but it should be fun. I'll be with 3 other women on my HHE trip, too. Can't wait!

From Bir to Barot

Our time in Bir continued with 2 days of clinic in the mountains above town. We stayed at the same site for 2 days and had the local primary care doctor, Dr. Raj, with us for clinic so that he could help us understand what medications he had for follow-up (we don't want to prescribe something once that the patient will not have access to again) and other local questions, such as can a patient with an ear canal full of ear wax find mineral oil at the local pharmacy to clear it out? At this site, not unlike our others, I had lots of patients with eye complaints (I worked in the Internal Medicine tent). With their outdoor work as farmers and elevation above 6000 feet (for every 1000 feet of elevation gained, there is another 4% penetration of UV radiation), it was not surprising to see many patients with pterygium (sort of a growth over the eye, usually benign unless it grows very large and obstructs vision) and cataracts. With all of the vision complaints, I am gaining a new appreciation for the work done by Unite for Sight, with whom I traveled to Ghana in 2007. I would suspect about one quarter to one third of our patients have eye complaints. We have plenty of reading glasses and antibiotic eye drops/ointment, but there are so many complaints for which we do not have the proper tools. We do not carry distance glasses, a tonometer to check for glaucoma (or the drops to prevent its progression), artificial tears/saline drops, drops for allergic conjunctivitis, and no opthalmologist or ophthalmology trained nurses who are especially skilled at using a portable ophthalmoscope.  Unite for Sight could have a very busy traveling clinic in this region.

Himalayan traffic jam! On the way to clinic.

We also helped Dr. Raj by doing landscaping for his clinic. We cleared the land of rocks (well, mostly, it's pretty much an impossible task), planted trees, painted his fence and gate, and cleared off grass and weed growth over the paved driveway. This was a special project for Ravi, HHE leader, who wished to use our example to convince the government to fund this type of project.

I learned a lot from Ravi about some local politics as they relate to health care access and cost. First, this state, Himachal Pradesh, is leading or nearly leading the country in education and health care, partly because there is a smaller population, and their budget is large enough to cover a lot of services. First, the "below poverty level" is set at earning less than 250 rupees (about $5) per day. If you are BPL, then all of your health care is free, and there is a sliding scale after that point. Also, if you earn less than that, the government will pay you 250 rupees per day for some improvement projects. For instance, we saw a group at work clearing a landslide and another building a support wall to prevent landslides onto the room. Both of these groups were doing this government work. In terms of education, the state of Himachal pays you to send your children to school. At first, Ravi said this led to some fraud and people all claiming each other's children as their own, but now it's a pretty well established program.

After our FUN time in Bir, we set off on 4/22 for Barot, a town deeper in the mountains. The cars drove around Bir for about 3 hours to bring supplies, but most of us opted instead to trek to Barot! We were driven to Billing (the city from which paragliders jump), and then hiked along then over a ridge and down into a river valley, crossing the Taj River, and hiking along the other side until our cars picked us up again (about 6 hours from when we last saw them) and drove us the rest of the way (45 minute drive) down the river to our beautiful campsite right along the river.

Rhododendron trees all along our trek

Holding a snowball!

Doing the "Lion King" pose.... Aaaaaaachee ween yaaaaaah baba beeeee chee baba!

One of the scariest bridges I have ever crossed: made of corroding metal, cement, rocks, and sticks.

More monkeys!! This time, a different species: the gray (or Hanuman) langur, from my best guess. You can see it in this picture right in the middle among the red rhododendrons: it's white-gray with a long tail. These differ from the rhesus macaques we had been seeing along roads. Obviously, I was pumped to see another species of monkey!

We all had a great time in Barot, too: our last campsite. We did 2 clinics, one near where we finished trekking, and the other up a river that feeds into the Taj. I was on gynecology/medicine the first day, and pediatrics the second: aka the last clinic of the month and hence MY LAST DAY OF MEDICAL SCHOOL! We had some really interesting patients: 4 cases of hand-foot-mouth (Coxsackie virus), a little girl with amblyopia who we had to refer to an eye doctor, and, as my final patient, a little boy with probably the loudest heart murmur I have ever heard in a child (except maybe for those in the midst of 2 or 3 heart surgeries for Tetrology of Fallot). We could not entirely decide what the problem was, except that it was definitely valvular, perhaps mitral regurgitation (rheumatic heart disease still occurs not too infrequently here). He was asymptomatic, but on his last check-up, his primary care doc told his dad that he had a "hole in his heart," or that was the story from the dad's point of view, and it prompted him to take his son to our clinic, basically for a second opinion. We referred the patient to the closest cardiologist, someone known by Ravi. HHE sponsors a few patients a year to pay for surgical costs not covered by the government. Ravi took down this family's information and hopes to sponsor this patient if he does indeed need valve surgery, which our pediatrician suspected he might. I hope to continue to hear updates about this patient.

The drive back from our first clinic site near Barot. The Taj river runs through this valley.

Our camp site from the road above. The sound of the river at night was calming.

The walk up to our last clinic.

My last clinical day as a medical student! Pretty sweet way to finish.

To celebrate the end of medical camp, we (students/doctors, drivers, and other HHE staff) had a big party! It started with our dinner: trout from the Taj River... soooo good. We have generally been eating SO well, but they really pulled out all the stops on the last 2 camp nights, making dinners of trout, grilled vegetables, potato patties and pasta one night; pizza, french fries, and fish curry with lemon rice the next; and our favorite desserts, chocoballs, and a celebratory cake. Then we all had a big dance party!! Car stereos attached to the staff members' phones provided the music. I pulled out my bhangra moves and was complimented by the staff on my dancing. We ended the night singing and talking around a campfire.

Prayer wheels at the Dalai Lama's summer residence.

Today we drove from Barot about 6 hours to Mcleodganj, which is the residence of the Dalai Lama and the Tibetan government in exile. We made a lunch stop at his summer residence, where we walked around, saw the temple, spun prayer wheels, and looked at Tibetan handicrafts. Now, I stay 2 nights in Mcleodganj, just relaxing and enjoying the final few days of my part in the Himalayan Health Exchange.

Tahee Delay!

 "Tahee delay" is "hello" in Tibetan, spelled phonetically. Our past 2 days of clinic have been at Tibetan Buddhist monasteries, and we are currently staying in a Tibetan settlement. A couple of my patients who have been older monks speak only Tibetan, so we get a translator from Tibetan to Hindi, and one of our translators transfers Hindi to English. I'm already a little concerned that things are getting lost through one translator (like my COPD patient, who originally did not smoke, never smoked, only to find out later from a re-interview with a resident who speaks Hindi that he smoked for about 40 years and only quit 4 years ago. The guy was audibly, dramatically wheezing.) The translation is probably the most frustrating part of this experience. I really wish I could speak Hindi. I'm learning a few things (greetings, numbers to direct patients to specific tents, a few simple commands and medical terms), but it's still hard. Having our drivers serve as translators makes sense logistically, but I think it would be helpful for them to receive a little more training in medical translation and in medical English vocabulary. Some of them are AWESOME, but some of them are clearly more new and they sometimes have a hard time, especially with complicated patients.

Well child check with a young monklet. He was fine, except for some tinea capitis, which you can see on his scalp.

Triage tent! At this station Shushma, Stacy, and I took every patient's blood pressure (if an adult), pulse, and temperature (if an infectious-type complaint).

Our clinic set-up, Tents 6 (pediatrics), 7 (usually ob-gyn, but not at the monastery, since it's typically all men except for some villagers who came to the clinic), and 8 (pharmacy). The monastery proper is in the background. The whole place was a huge complex that houses 700 monks and also a Buddhist school.

Posing at the Dzongsar Monastery near Bir.

Also at the monastery: the largest Buddha I have ever seen.

Sunset view at Bir. A beautiful town. Bir is well-known for its production of tea. The tea gardens/fields are beautiful. In this picture, there are wheat fields and Tibetan prayer flags, seen all over town.

Today and tomorrow we have clinic at a village in the hills above Bir. Day 1 went well, and we're set up for Day 2 there tomorrow.

Monkeys and Mountains

One of the awesome things about clinic during our first 4 days was that we could walk to or home from most of the clinic sites and enjoy views like these!! The Beas River runs in the valley separating the land containing the village (bottom right) from the set of mountains in the background. At our first campsite we were at 7000 feet, in Manali we were at about 6000 feet, at the Garagusain campsite we were at 7786 (according to my friend Denton's google app), our hike that day took us up to about 10,000 feet, and now we're a bit lower than that in Bir.

 Our first campsite at Panjain! This is the view of our little tent village from my tent. I share a tent or room with Rashim, a med-peds 4th year resident, soon-to-be endocrine fellow at a hospital in Detroit!

At our second day of clinic, we worked from a helipad, so basically one of the highest points in the region that also had a flat surface large enough for our 8 tents. The views were incredible. You can also see the winding road cutting through the hillside. The roads through the mountains are certainly precarious. They are wide enough for 1 car at most points, with some areas wide enough for 2. We have experienced some Himalayan traffic jams when 2 cars are trying to pass, but there isn't much room for passing, then there are other cars behind them that need to back up first in order to create the room. Ridiculous. As a group, we travel in a fleet of white jeep/SUVs.

Another view from the Helipad clinic day. It's hard to capture the snow-capped peaks in pictures sometimes, but it was clear enough this day that I got it! boom!

Some proof that I'm doing work! This young patient was at the Himalayan Buddhist School. (I'll only be posting pictures of patients who (a) gave permission to be photographed and (b) cannot see their face to protect confidentiality.) The kids there were timid at first, but eager to be in and take photographs. There was also a group of teenage girls helping organize the younger kids throughout the clinic who, at the end of the day, sat down with me and my friend Sophie (fourth year med student at Indiana, matched there in peds/psych/child psych triple board) and asked us all sorts of questions. I think this was their chance to talk to some young, less intimidating doctor-types. They also sweetly told us that they all want to be doctors and asked us advice.

INSANITY. This is our solid work-out crew. We gather at 6:30 a.m. every morning to do some cardio and circuit training. Joseph, Sophie, Julian, and me. Here we're posing after a work-out on the rooftop of Dhakpo Monastery. Tomorrow we're stepping it up a notch and working out for 10 extra minutes, starting at 6:20 a.m. I think we've all adjusted to the altitude by now!

Bir: paragliding mecca. There is apparently an awesome paragliding jump from the town of Billing, tucked somewhere in the mountains in this picture, and the landing site is in Bir! I saw 2 paragliders land in the designated landing site on our first day here. This paragliding jump holds the record, I am told, for the longest paragliding jump (not sure if it's by distance or by time, but it's one of them). It's rated as I think the second best paragliding site in the world, after somewhere in the Alps.

Indian outfit day! Today, a group of us all dressed in salwar kameez, a popular Indian suit. From left to right, Carolyn, Shushma, Rashim, Rachel, Azure, Jobin, Nima, Kavya, and me. The two on the far left had their kurtas (shirt part of the suit) before the trip, the next 5 had theirs tailored in Manali (in less than 24 hours!), and I brought my suit, borrowed from a friend who worked in a clinic in India before starting medical school. It was a lot of fun dressing up today, and one of our Indian drivers was so pleased, he took a picture of us, too.

Monkeys!!! There are 2 macaques in this picture... can you spot them?? We have seen monkeys a few times on the trip, mostly in lower altitudes. We see them on the roadside in the river valley (along the main highway: there are 2 lanes so you know it's a big deal), in Manali (sort of surprising since it has pretty good altitude), and we saw them today at Sherbling Monastery, where we held clinic. At one point, there was a whole troupe of them complete with big, fat alpha male, many females, and many juveniles, one clinging to its mother's belly.

At clinic today we saw 189 patients. A lot of them were well-child visits for the young monks, but there were also monks with health problems (I had a 12 year old who was getting a check-up after abdominal surgery for peritonitis) and some local villagers who came to clinic, too. I thought a lot about the cultural constructs of disease when one patient described to me chest pain he felt only while angry. After ruling out signs and symptoms of heart disease and other more serious conditions, it became clear that he was describing normal human emotional response and physical manifestation of his emotions. Interestingly, we in the U.S. tend to associate chest pain with anxiety fairly frequently, but he denied any feelings of anxiety or nervousness, and instead insisted that he only had this pain when angry. For instance, he is an artist, and he had one episode of chest pain after someone yelled at him about the quality of his work. He also complained of eye strain, since he works for hours on appliqued art pieces. No surprise there.

After finishing work, we were given a brief tour of the monastery and their clinic, complete with some traditional Tibetan remedies. Their pharmacy is pictured above. It looks like jars full of chocolates, but they are coated herbs. The monks seem open to both Western medicine and more traditional or homeopathic therapeutic styles.

Bir! Here is one of the views from the roof of our hotel. We met at the rooftop for teaching cases. Each person in our group prepared a short presentation prior to leaving for the trip, and we have about 3 presentations a night on the nights we have clinic. Today we had talks on TB, leprosy, and trauma. I presented while at Garagusain on the topic of leishmaniasis, which is an emerging disease in this state, Himachal. It is likely emerging because of changing migration and environmental patterns: laborers are coming in from an endemic state, Rajisthan, to work on hydroelectric dam projects. The disease is transmitted by sandflies, so it is highly dependent on environmental characteristics.

ANIMALS:
My mom asked whether I have seen any elephants? Nope, no elephants, injured elephants, lost elephants, or elephant-induced injuries. Yet. I'm hoping to see an elephant in Jaipur, at the beginning of May. I have seen plenty of cows (just walking around the streets willy-nilly), tons of dogs (I went on a run one day, and one from our campsite followed and ran with me; others just bark through the night--let's just say Bob Barker's advice about controlling the pet population has not taken hold here), not many cats, plenty of goats, sheep, horses, donkeys, crows... what else... Himalayan golden eagles! They're giant birds who can take out goats! They are also known for picking up bones and dropping them on rocks so that they can eat the marrow out of broken bones. We have also seen a monal, which is a beautiful blue peacock-like bird with cool tailfeathers. When we were in Manali we also saw a yak and some Angora rabbits, with whom their owners were trying to charge us to take pictures. I also had the delightful surprise of finding 2 little lizards, I think skinks if my study of reptile books at Huron City serves me correctly, in my tent one night! I caught them in a water bottle and freed them outside the tent.

We have another clinic day at a monastery tomorrow, then we're scheduled to help with some landscaping at one of HHE's partner clinics, whose doctor, Dr. Raj, is attending clinics with us this week. He has been able to help us figure out which medicines can be easily replaced locally and determine where patients should receive follow-up medical care. He is a great local resource; I generally think it's always best on these types of trips to have strong support in the local community, particularly with physicians or other public health figures. We are working with him this week and with a medical officer at the monastery.

Jackie, Day 18, Clinic day 11.

Namaste!

Hello again! Finally! After quite a while without internet, I have returned!

Last I wrote, I was in Manali, a great town for trekkers and backpackers, but also with some local flair, as I found out a little too well. Manali has 2 great temples, Hadimba and Mannu. As we walked past Mannu, they were sacrificing a goat! I narrowly missed seeing it beheaded, but unfortunately looked over just as they were skinning it. yikes. The rest of my time in Manali was spent shopping around, eating the most delicious Indian restaurant food (complete with butterscotch ice cream), and walking around town.

Manali skyline: apple orchard in the foreground. I wish I could have gotten to ski here! There's a ski town about 30 kilometers away.

Mannu Temple in Manali.

The next day, we left Manali, drove about an hour, then stopped at the edge of a river. We packed up supplies, crossed a bridge (see picture in previous post), and walked to the Himalayan Buddhist School to do well-child checks, which was a really fun clinic day. Most findings included dental cavities. Sometimes HHE travels with dentists, but not on this trip, so we wrote a lot of referrals for a local dentist. After the fairly quick clinic, we traveled to Dhakpo Monastery and settled into their guesthouse. (picture in previous post of the view out my guesthouse window, amazing, and playing cricket in the schoolyard). We did 2 more clinics, one at the monastery and one at the nunnery, which was about an hour away. There were a lot of similar findings compared to our first 4 days of clinic, with some exceptions. The first 4 days of clinic were only with Himalayan Indians, who work mainly as farmers, so the older group had a lot more osteoarthritis and joint pain than the monks. Also, among some of the younger monks, who all have shaved heads, there seemed to be an outbreak of tinea capitis (fungal infection of the head), and we suspected that perhaps the practice of shaving may have been contributory to spreading the infection, though we are not sure. This portion of our trip was also memorable for a great hike we did up a river valley. On our way back, the 5 of us on this hike befriended a man also on the trail who had 2 horses with him; one of our group even rode one of his horses back for a while! Then we got a little bit lost trying to take a shortcut back, well, not lost per se, but we did cut through some wheat fields and an apple orchard.

-Doing the Chewbacca wookie call on the hike.

After 3 nights at the guesthouse (complete with 1 bathroom per 4-6 people, but our own cook and outdoor cafeteria tent), we again packed up and moved on, this time up into the mountains again (the monastery was more in the Kullu valley). We REALLY tucked ourselves into the mountains this time, driving 5 1/2 hours to the village of Garagusain. We left the monastery on a beautiful morning, but storms settled in and when we arrived at our new campsite, it was pouring rain with thunder and lightening. No one was terribly excited about our new digs at this point. It was again full camping except for 1 guesthouse with 2 bathrooms, a bedroom (for 2 students who got sick), and a room holding our bags and keeping them dry. It was also much colder at this campsite.

-Yellow 2-person tents where we stayed, black bathroom tent, and beige shower tent for bucket baths.

Clinic was held just a bit down the hill and at the same site for the next 3 days. Over those days, we saw about 520 patients, bringing our total to over 2000. Our patient population was very similar to that of the first 4 days (the first campsite at Panjain), except for some reason, we had a lot less children, possibly because at Panjain we were next to a school for a couple days.

The weather remained, for the most part, disappointing. We would often wake up with some sun, only to have the sky cloud over and rain through the afternoon and evening. One afternoon, we got a respite from the rain, so 4 of us went on a hike up a river/stream. We went far enough to see a snowpile, and we then had a snowball fight, which was great fun, and really lifted my spirits in the dreary weather. We were also lucky to have one absolutely beautiful afternoon, so many of us (probably 12-15 total) set off in smaller groups up a hike that the locals told us led to great views. They were not wrong. We walked through town, then hiked almost straight up a small path for about an hour, then spent another hour traversing a ridge through villages. I was in a later group, and 2 were leaving as I reached the final village along with one friend. We were greeted by a crowd of 8-12 children, who spoke about 5 English phrases but were quick to learn. They acted as our tour guides and led us further up the ridge until we picked a great look-out spot. We had 270 degrees of amazing mountain views with snow-capped mountains in the not-so-far distance. After a long photo shoot with the 2 of us (me and my friend Phoebe, an Australian med student), and the children, we finally decided it was time to go. The kids walked with us for quite a while, and I made them play a silly walk game, where I started doing a silly walk then they all mimicked me, which they LOVED. When they finally said good-bye (after several fake-outs in which they said good-bye, then chased us down the steep path), they repeated some of my silly walk actions and sounds, too. It took us about an hour to get back down. This hike was the highlight of the Garagusain portion.

-At the height of our hike. Note the terracing of the land to the right of me: this is some of the more wide strips of land for farming, most are more narrow on steeper slopes. To the left of my head, if the image was a little more crisp, you would see a snow-capped peak.

A few other remarks on this portion of the trip:
As a group, we grew together playing lots of games: Catchphrase, celebrity (aka Tijuana Family Fun Game), mafia, and Circle of Truth. I think my groupmates learned about my competitive side...
On our final day of clinic, a hail storm broke out! It was the largest hail I had ever seen: the size of grapes, I would estimate. We were all pretty amused, until it left our clinic site in pond-sized puddles, and saddened us when we heard that the ten minutes of intense hail could have wiped out the local crops, including peas.

Today we left Garagusain and made our way 6 hours to the village of Bir, a Tibetan settlement. We are staying in a hotel with wi-fi and showers, so you can imagine, we are all pretty excited! I'll update more as we stay here the next 5 nights. You may catch me on skype or gchat! (I'm 9 and a half hours ahead.)

It took all the internet power I could muster to post these pictures! The first is on the drive up to our first campsite, second is a macaque hanging out in Old Manali, third is at Dhakpo Monastery, fourth is me playing cricket with the kids at the monastery school, fifth is on our hike to the Himalayan Buddhist School where we did well child checks for all of the students.