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.