Remote Area Volunteers to Nepal
Nepal is a country with incredible scenery and rich cultural diversity. But it is also poverty stricken and saddled with a largely inefficient and corrupt government, a situation which has worsened since the king, and several members of the royal family -- including the royal heirs -- were killed three years ago. Maoist rebels have been increasingly active attacking army posts and police stations, with many lives lost. Civilians have been largely spared and tourists have not yet been targeted although, not surprisingly, tourism has sharply decreased.
Nongovernmental organizations, which are extremely active and vital in Nepal, are finding it increasingly difficult to perform their duties due to the political climate. The area we were scheduled to visit was extremely remote and difficult to reach. To date, Nar-Phu valley had seen no political trouble.
It was into this context that our team of 12 arrived in Kathmandu in late March to work with Remote Area Medical Volunteers (RAM). RAM (www.ramusa.org) targets areas of the world that are so remote they are mainly ignored by their own governments and many charitable organizations. To date, their expeditions have primarily been to South America and Nepal. Planning the trip was a major undertaking and took 10 months.
This year's team consisted of two physicians, two nurses, four optometrists and four support personnel. Six team members had been to Nepal previously, and this mix of veterans and first-timers worked extremely well.
Couch potatoes need not apply
After acclimatizing over several days in Kathmandu, we flew a 15-seater plane to Humde, at an altitude of 3250 metres, and began our trek to Chame. For the next two-and-a-half weeks, we would undertake two days of arduous trekking -- six to seven hours a day -- to arrive at a village, set up and run one- to two-day clinics. The first medical camp, at Meta, at 3600 metres, was a very busy one. From Meta, we trekked long and hard over two days to Phu, just 12 kilometres from the Tibetan border. At 4350 metres, this is one of the highest permanent villages in the world. Our first day was very busy; the second was planned for education. A few of the women on our team ran a Women's Group to discuss village and female issue and some of the optometric team climbed to a nearby monastery to provide eye care. From Phu we trekked two days and climbed to Nar (4000 metres), where we again ran a two-day camp.
These villages may see a healthcare worker once a month or receive no medical care at all throughout the year. Any access to care requires a two- to three-day trek to the nearest medical post or a three- to four-day trek to a hospital. Locals refer to these treks as "carrying them out" -- referring to their sick relatives. Needless to say, we were welcomed with open arms. Villagers draped us with katags (prayer scarves) and sprinkled us with barley flour as a sign of thanks.
Last year, the Kang La Pass was impassable due to snow. This year, the team got through, peaking out at just over 5180 metres. This trek was probably the most difficult, given the vertical climb, thin air, rocks and snow at the peak. A descent lasting several hours was equally hard on the knees due to the scree (loose rubble). Except for muscle aches, pains and fatigue, all made it safely.
The members of the team we travelled with were for the most part seasoned travellers and many had done previous volunteer trips. Individuals attracted to these trips are always unique, some would say crazy. Volunteering requires self-funding your trip, leaving your job and family for a few weeks, trekking at high altitude in cold temperatures and sleeping in tents where the average temperature is -5°C. Before leaving for the trip, the team had been well briefed on what to expect and provided with lists for the gear, first-aid supplies and medication that would be required. However, as the two team physicians, we ultimately felt responsible for their well-being.
Treating the Team
From the start, an open discussion of any symptoms, aches and pains was encouraged. Small ailments can quickly become huge problems in remote areas if they're not dealt with promptly. It's not uncommon for people to hide symptoms of altitude sickness, since they don't want to be the one to "go down" or "go back." We all elected to take Acetazolamide as we climbed to fairly high altitudes -- 3200 to 5300 metres -- in a relatively short amount of time. Our route had been planned to allow acclimatization, as we needed to be healthy and functional to run our clinics. Apart from mild breathlessness and lightheadedness, we generally experienced no problems.
Other ailments among the group included four cases of traveller's diarrhea; two with fever and vomiting requiring antibiotic treatment. Six members of the team developed respiratory infections, again some appeared bacterial and required antibiotics. The respiratory infections were felt to be largely caused by the pollution in Kathmandu and exacerbated by the constant dust on treks. The three asthmatics on the team needed our guidance to best manage their inhaler doses. Several members of the team suffered from sore knees and backs as well as the inevitable foot blisters and abrasions. There was always one member of the team that we were concerned about.
The next group we provided medical care to was our support staff. We were accompanied by over 50 Nepali porters, cooks, translators and guides, all essential to the success of our mission.
The porters were especially a delight to observe. They carried up to 32-kilogram loads, some wearing only flip flops, yet travelled at twice our speed. They were often singing and yelling in excitement to each other when they came upon an especially high and scenic view -- and there were many of these. At night we could hear them from our tents as they drummed, danced and sang around the fire. Their demands on our medical services were minimal; requesting occasional analgesia or cream for a rash. We were humbled by their spirit and endurance.
Not the Average ER
Medicine at the village clinics was varied and challenging. We brought with us large boxes of useful medications we had obtained from Health Partners International (www.hpicanada.ca). We had also collected additional medication samples from our office throughout the year.
The clinics were generally held in small rooms in the village schoolhouse or administrative offices. These consisted of two-and-a-half by three-metre rooms with dirt floors and mud walls. We would arrange our medications on a small wooden table, provide wooden benches for the patients and small camp chairs for ourselves.
The four support staff on the team were invaluable. Joan Robertson and Emily Hopkins, nurses from Ottawa and Toronto, functioned in the same role as physicians. The RNs and MDs worked as teams of two in the same tent or school room. Marcia Verploegen was the essential medical support person, transcribing diagnoses and treatment plans and helping with all aspects of running the medical clinics. She had been to Nepal on a trek to Everest a few years prior, so knew what she was in for. Kim Ostrom did the intake information for each patient from which a lot of the statistics came. Her son Devon was wonderful in creating banners to identify what each tent or schoolroom would be used for, and he was the master of crowd control.
We will be eternally grateful to our Nepalese translators who travelled with us from Kathmandu and who sat tirelessly through hours of clinics describing the patients' concerns.
In order to appreciate the villagers' health problems, a brief description of their day-to-day lives is necessary. Locals live in two-storey homes, with their livestock on the first floor. Families live on the second floor, reached by a log carved out with steps. The living quarters are generally one room heated by a central fire, often unvented, and family members sleep on small animal skins on the dirt floors. These are mainly subsistence farmers and tending to their cattle or fields requires long walks up and down the mountain, as do fetching firewood and water. They are constantly exposed to the strong winds and dust. Their average life span is 45 years and there is a high rate of infant and child mortality mainly due to infectious diseases.
As a result of the environment we treated abundant arthritic knees and backs, along with asthma and chronic skin conditions. Intestinal worms are ubiquitous and all patients either requested or were offered deworming medication for themselves and their families. Many children presented with poor weight gain, abdominal pain and diarrhea. From past experience, we knew that many would improve with worm medication. In villages with reliable healthcare workers, we were able to leave medications for these chronic problems for the year to come.
About one-third of the cases we treated represented acute problems, which made our presence fortuitous for those we saw. We treated many cases of pneumonia, otitis media, impetigo and cellulitis. We were able to reassess a seven-year-old girl who we had managed to airlift out last year with osteomyelitis of her right humerus which appeared septic. She had received aggressive antibiotic treatment in Kathmandu and was now thriving and had in fact been helping dig a ditch outside the village the day we arrived.
One young boy had fallen from a roof two weeks prior to our arrival. He presented to our clinic obtunded with unequal pupils and abnormal reflexes. We advised the parents the quickest way to evacuate him to Kathmandu but unfortunately his prognosis was not favourable. We were unable to discover the fate of this poor child.
Several women in each village had gynecological concerns ranging from yeast vaginitis, confirmation of pregnancy, checking that IUDs were still in situ and early labour. Pelvic exams were carried out in a small separate room with the patient on a wooden bench and the female physician wearing a head lamp!
In the two villages in which we did sessions on dental hygiene, we provided the children with toothbrushes. On their own initiative, many team members had brought clothes, school supplies and toys for the children. We made house calls in each village to reach elderly patients who were unable to attend the clinics. It was an opportunity to address their many concerns as well as a fascinating view of their homes and family dynamics.
The eye clinic was well attended and a few hundred villagers were thrilled with their new glasses. Lubricating or anti-infective eye drops were dispensed as necessary.
Our final trek was to the village of Braka. We were now below the tree line and it was good to see green again. After lunch, we trekked back to Humde and, the next day, boarded a large 24-seater Russian helicopter back to Kathmandu where we all relaxed, shopped and had a gala dinner before going our separate ways to North America.
While population density and distances are obstacles to serving the health needs of remote regions, RAM hopes its continued presence in Nepal will have a spin-off effect on local governments and community organizations. We view our visits as an opportunity to make a small difference in the lives of the villagers we treat and a personal journey for ourselves to areas of the world rarely visited. We all learned from this experience and will never forget the privilege of getting close to the Nepalese people high in the mountains.
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