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.