travel

Rwanda Entry 3 - Kibogora hospital and its children

dblatt — Tue, 23 Feb 2016 08:07:00 GMT

Walking down the steps of the hospital tours one through congested lines of local villagers. Amputations, blindness, open wounds and cough highlight the worry on the faces of the waiting. The angst expressions quickly dissolve into stoic intrigue as my scrub clad white skin passes by. A simple waive and utterance of "amakuru" (how are you) prompts a chorus of "ni meza" (I am well). This tends to break the ice, and smiles typically follow. The people waiting by reception may or may not be seen the same day, but they will wait until they are. They came with pots with some white rice and beans in anticipation of an extended stay. Patients must bring their own sustenance. Most did not bring extra clothes. Most don't have any. On the way to the pediatrics wards, a ramp leads past a three walled brick building. Smoke pours out of the clay shingled roof as pots of rice below sit atop wood fueled flames. This is where families can cook for loved ones as they hope to get healthy.

Up the path from the Pediatrics building is a UNICEF tent where cots were shoulder to shoulder, housing the sick children while the current building was under construction. The Pediatrics building opened within the past year. It's natural lighting and freshly painted concrete walls are a luxury compared to the adult units. The wards are divided into units. None more equipped than the other. There are the general peds wards, respiratory area, malaria unit, isolation and Intensive care unit. The beds are lined up like old smallpox wards, an endless row of mattress. There are over 80 beds, with sometimes more than 1 or 2 patients occupying each. Mothers resting with their children on stained sheets and old metal frames look up to malaria nets hanging above. There is a distinct lack of crying. I don't know if it's cultural or just my perception. Anywhere between two to five nurses and one general doctor roam the large dense building. That is not nearly enough staff.

Malnourishment is the standard. Almost every child has thin chest and looks to be at least somewhat protein deficient. You certainly don't see that much in the US. Most children have plenty of scars and chronic rashes in addition to their chief complaint. About 40-60% of the children have malaria. Almost daily there are a few new patients who arrive in a coma from the parasite. It's amazing how sick these children look, and how quickly some, and I stress the word some, get better.

Every child with abdominal pain will get a stool study. In the US, abdominal pain quickly brings to mind constipation. Our pre-packaged diets bolster our daily compaction of stool. In Rwanda, abdominal pain typically means a worm or parasite. It is not unusual to see the culprits without microscopy. There aren't many lab tests available at Kibogora, but testing for worms and malaria is a proficiency it can brag about.

There are a few things that are striking and unsettling about the medicine here. One being the lack of emergency response. A child with cerebral malaria, age 2, was in a coma. Mom is responsible for his tube feedings. The scarcity of nursing care did not make exception for this child who was clearly one of the sickest in the building. Mom pushed the porridge feeds through the syringe. As it tunneled his nasogastric tube the child started to choke and then seize. From across the room, while examining another patient, it was obvious that the one nurse who was around, did not know what to do. This was in the Pediatric ICU, a place when in the US, there would be well trained emergency response one on one nursing care. I ran to the patient and asked the nurse to bring intubation tools. There was no movement. This was not a common request apparently. I had to rummage through a disjointed and barren crash cart to find a tube that was too small and scope without a working light. The child was trying to breathe but no air movement could be heard. This child had aspirated and was going downhill fast. Surprisingly, the emergency intubation was successful and the trachea was suctioned. A true crisis was averted, but it was painful to think of how easily that child would have died. I know there are many lives that we are saving on this trip. Unfortunately, I know that inevitable death will also spread its touch.

To leave you on a high note, I'd like to take a minute to talk about a smile. We discharged a patient recently who had been in the hospital for weeks. As the child was running towards the door, as happy as always, her mother stopped and put out her hand in recognition. As the handshake developed, soft utterances of Kinyarwandan left her lips. I did not understand her words. That was alright as her eyes told the whole story. They were tired and had seen too much. They were also relieved. Her smile screamed happiness. That smile slowed down time and reminded all, that good is being done. It was a brief moment before the tugging on her dress by her daughter turned her towards the door. What a great day.

Rwanda Entry 2 - To Kibogora we go!

dblatt — Mon, 15 Feb 2016 04:22:00 GMT

It's not often in most developed nations that a large hazardous material truck would be laying on its back on the side of a well travelled mountain at the apex of a switchback with no guardrails, and not be cleaned up. Rwanda doesn't seem to think that's a problem. How would I know that it wasn't going to be cleaned up you might ask. Well, the driver of the disfiguringly dented vehicle had a tarp hanging over a well worn bed within the 10 foot area between the road and the drop to the bottom of the mountain. He even had a marked off roadside latrine area. I guess fate gave him a new home.

The six and a half hour drive from Kigali to Kibogora Hospital was a postcard-esque climb through the hills of Nguyen National Forest. Aside from the littering of downed tractor trailers, the steep switchback roads provided views of forest canopies and plants that could only have been drawn up by Darwin's trippiest imagination. The mutant sized aloe plants would defy gravity as they emerged from the cut away dirt siding. The arms would reach for the fervent passing of women colorfully clad in bright fabrics and men with handmade wooden carts. The women had heads which would be holding goods from bowls of fruit, to bags of rice, to bundles of firewood. Babys would be tied to their mother's backs with a simple cloth slung across the waist. They pay no bother to the passing traffic feet from their face. The men, tired and worn, mostly dressed in dirt stained rags raised their eyebrows as a bus of white foreigners, "Mzungus", point their cameras.

It's as if there are no borders. The people never stopped presenting themselves. From Kigali to Kibogora, there is no one without neighbor on either side. The thin colored metal and stick houses were just a natural progression of the path through the landscape. We stopped suddenly in a seemingly meaningless area of the jungle to find a baboon and her baby look down at us from a mounted bush. Our first extra-sapien primate experience silences the loud games we were playing to pass the time. We were then on full alert. We bacame very good rangers as a colobus monkey was waiting for our group at a turn not too much farther up. He had one hand fidgeting and a stump of an arm tucked in by his other side. I assume it was a he, because its more fun to imagine a stupidity induced, testosterone based brawl resulting in his amputation.

Our turn from the surprisingly paved road onto a dirt and stone menagerie signaled our arrival into town. We passed a stretch of about 100 yards of shops advertising fabrics, fruit and tools. Everyone was outside. They were just being. No rush or care was evident in their naturally stoic faces. The first emotion we saw was of a horde of children escaping the gates of school to play for the afternoon. Bright white contrasted grins spread across their faces as pinkies fled from thumbs and wide waving hands pleaded a return hello.

Kibogora Hospital is a Christian hospital perched atop a large tree filled-hill overlooking Lake Kivu. It started as the house of a western pastor, in the 1960's, to whom the villagers would come even for medical needs. It sounds as if many a band-aid were provided. He then hired a nurse and eventually a doctor. Today, Kibogora stands a legitimate hospital. It has many concrete buildings, housing operating rooms, men's and women's wards, an ICU, ophthalmologist, maternity ward, NICU, dentist, physical and occupational therapy, radiology (with x-ray and ultrasound), a basic lab to test cell counts, malaria and HIV, and of course, the most important of all, Kibogora has a pediatrics building. No one would ever mistaken Kibogora for a western facility. However, the infrastructure and quality of health care professional astounded me considering how far from a city we were. It is evident that a lot of love and hard work went into taking care of the community's health.

One thing that really stood out to me was the amount of children here. I don't know for sure, but I think that the skewed paucity of adults compared to their little ones is due to a concerted and subconscious effort to repopulate after the genocide ravaged the census in the mid 1990's. There will be plenty of patients for me who will certainly have many tropical diseases, of which I have only imagined from textbooks.

I am very excited to provide you all with some serious color commentary on all of the fun and strange diseases to come!

Rwanda Entry 1- Guesthouse Rwanda

dblatt — Fri, 12 Feb 2016 07:45:00 GMT

Ever since I was little, I had a fascination with the exotic. Things, people, places, and foods that were not common to be found in my Upstate New York childhood always drew me in. For a science report in elementary school, I wrote about the sea cucumber, simply because I thought it would be more unique and much more interesting than everyone else's dog and cat papers. It wasn't. I did a research paper in 5th grade on Mozambique because that was the country who's name I had the most trouble pronouncing. My strange interests in combination with my inabilty to sit in one place naturally piqued my desires to travel. Over the years, the exploration button in my brain has been pushed down and rusted in place. It has taken me to many places, and certainly not enough. More important than the places I have been, have been the stories procured, friendships discovered, and the lives hopefully impacted. Many people travel, and travel for the sake of travel is not what I am looking for. I am not looking for my passport to be mantalized between a stuffed unicorn head and a fabally large fish. There are no lists to be checked off. Travel, and I mean real, adventurous, emotional and sometimes nerve invoking travel inevitably changes who you are and the people you meet, hopefully for the better.

This wisdom and my dashingly good looks have not always been available to me. Most of my experiences have come come under the shelter of work or medicine. It is much easier to spend all of one's money on a series of plane tickets and cheap food and shelter if you can trick yourself intto thinking that it is your duty. I have travelled under the narrative of medicine twice before. The first time, I was a transitioning second year medical student going to Egypt, who's skills included saying "whoa, cool surgery" and the exceptional ability to nod and agree. My second foray into international medicine afforded me the opportunity to create my own version of National Geographic in the indigineous backcountry of Nepal. At that point in my life, I had just finiished medical school and I was killing time before residency without any previous work as an actual MD. Those were two badass incredible experiences, but the medical work was only a small part of the story. As a pediatric resident, there isn't a lot of free time to travel. Luckily, I was able to take advantage of a great opportunity to use actual MD experince as part of my training for a month in Rwanda.

Most people think of a well known movie when they hear the name Rwanda. This is for good reason. In the not too distant past, Rwanda went through a horrifying civil war and genocide. The people there have seen, done and experienced things that bring them unimaginable pain. The country has put in extraordinary efforts and has had even more impressive results to ensure It's people's peace. The Rwandan people strive to protect past horrors from resurfacing. Rwanda is now considerred to be a very peaceful country with welcoming citizens. This does not in any way mean that they are living well. The majority of the people are still very poor. Tropical diseases run rampant with rudiemntry, inaccesible health care. Dirt floors, infection-breeding living conditions and zero income plagues many well intentioned, hard working people. This is truly an area that deserves and welcomes some refuge.

Who knew, but the plane ride to get to eastern sub-Saharan Africa is kind of a long ride from little Mobile, Alabama. Littered with new release blockbusters and tiny prepacked meals, it certainly didn't feel as if I was headed to the African rainforest. The two 8 hour flights, with a layover in Amsterdam offered me just enough time to become the right amount of sleep deprived to vivdly day dream about saving the world from the likes of malaria and tuberculosis. I then had a few glasses of wine and dove into some beautiful minutes of sleep.

It only took about 20 minutes or so to get to the Good News Guesthouse. This is a beautiful one story building overlooking the city of Kigali. During our drive there, our giant bus of Americans with suitcases pouring out the windows were easily spotted by the locals. My ideal medical mission would include going to a developing nation, blending in with the culture seamlessly, and being misconstrued as a local. That is not very possible with such a large group in such large caravans of American goodies.

I thought for sure, that any move we made in Kigali would be met with stares and bewilderment. Our first night in Rwanda went wonderfully. It was capped off by a group of us taking a stroll down the main road that led to the guesthouse. No one blinked. No one turned their heads. No one scowled. No one was surprised. And these are the locals I am talking about. Now, us Americans, we were snappng pictures, updating social media and selfying the shit out of our first night in a Africa. Our excitement was evident, but we had yet to even begin the meaty portion of our trip. I soon realized that in the capital of Rwanda, the people here must be used to outside visitors. I didn't think that this would be the case in our next destination, Kibogora Hospital, smack dab in the middle of the Rwandan jungle near the border of The Democratic Republic of Congo. Our 6 hour or so bus ride the next day to the hospital would surely open a little window into the poorer part of this wonderfully beautiful contry that has been through so much hell. There is no way that we would not be amazed.

Entry #6

dblatt — Sat, 10 May 2014 13:37:00 GMT

Healthcare in Nepal is by most western standards, rudimentary. It also seems as though, at least in this village of Bhaunne, to be a fairly novel establiishment. The reason I say this, is that most of the patients we have seen think that there is a definite medicine for everything and that everything needs a medicine. Like in the U.S and I assume most parts of the world, some patients think they know exactly what they need and some defer completely to the physicians discretion. However, almost every time I suggest that no medicine is necessary, the patient becomes wary. They assume every cough require cough syrup and every fever requires antibiotics. Rarely is a patient happy to hear that they do not need anything. Interestingly, although they want to be overly medicated, many will then also refuse to do anything to a child that will make them cry. This includes checking their ears and making them drink the requested medicine.

Blood pressure is another touchy subject here. We have quite a few patients who daily check their pressures with an insignificant change casing elation or despair. A "good" blood pressure is equated by many to mean "good health". We have one frequent visitor, an elderly gentleman, who sees us and the local shaman about his blood pressure which is consistently alarmingly high. Ritually he visits the shaman who gives him cures such as "walking barefoot" and then immediately comes to us. If by the time he settles down to get checked, his reading is a couple points lower, he tries to convince us that the shaman's advice was valid. if the opposite occurs, he says that it needs more time to work and will come back later.

We see many different pathologies in Nepal than what I'm used to in the U.S. Although there hasn't been a malaria outbreak in this specific area in a few years, that remains a concern. Japanese Encephalitis is in a similar boat. What is seen quite often are different parasitic and helminthic infections. Every year children get "de-wormed". Every abdominal pain has liver parasites in the differential. The most over-self-diagnosed problem that I have seen is liver pathology evidenced by jaundice. It is a very common problem, so much so that any skin discoloration at all is rushed to us to have liver function tests done. LFT's are one of the few evaluative tests we have in our lab along with a microscope for stool, HIV, Syphillis, and glucose monitoring.

About a week ago, a young girl, 5 years old, presented with fever and lethargy. Suspecting viral heritage, We sent her home with tylenol and orders for rest and fluids. She returned after seven days, still the thermometer read 102 degrees Fahrenheit. Starting to get a little worried that this might be some tropical illness I was not prepared for, I decided to give it one more day. I told her to continue her current treatment and in a fervor, spent many hours that night consulting the few medical books laying around. Because Bhaunne is mostly isolated from a lot of outside interaction, there hasn't been much of a chance for HIV to enter the community. That quenched one thought that was still in the back of my mind. Luckily, because I had now more questions than answers, she arrived seemingly as healthy as ever the following morning. This had certainly put me on a bit more alert as to problems I might not know how to ideally deal with.

A few more tidbits I have noticed about the rural Nepali villagers:
There seem to be two primary concerns amongst most of the people. The first being who is marrying who. The second being any focus of religion. Whenever gossip is being spread, it always seems to come down to some social politics of marrriage. Who is good enough for who and what caste is taking a downgrade by an upcoming nuptual. Villagers would try to explain this to me through a thick language barrier, but I think I generally got the drift. These conversations would invariably somehow lead to questions about what religion I was. Being a white American, they assumed I would answer "Christian." Obviously I didn't and when i tried to explain that I wasn't really religious (not wanting to get into a debate about it) they would not comprehend the statement. They would give a blank stare and ask the question again until I succumbed in submission of "Jewish." I thought this would certainly bee enough of an answer until it became clear that this was just as flabbergasting. They simply didn't know what "Jewish" was or that it existed. When I tried different ways of saying it, they would just assume I meant Christian and was a poor conversaionalist. Life here is focused much more on the immediate surroundings and social structure than in the U.S. Taboos of family and religion hold a lot more weight and create a large impact of the village life.

Entry #5

dblatt — Mon, 5 May 2014 16:21:00 GMT

This past weekend was a nice adventure. Friday, I finally met the founder of the clinic, Debendra Karki, when he made his way back from a mountain trek to the village. He one of the only tall nepali people I have met. In fact, he is one of the few Nepali people people who are even taller than I am, which is kind of ridiculous as I am not tall by any stretch of the imagination. He is well travelled, having studied in the U.S and New Zealand and having lived all over the world. After getting his Master's in Public Health, he worked for the World Health Organization which he hated. He started this clinic to do something more tangible in public health rather than "push papers".

After a full days work, he invited Kate and I to go away with him for the weekend. Our first stop was a Hindu wedding, the bride being related to him in some obscure way. The wedding was in Biratnagar, one of the places I travelled through to get to Bhaunne. It was about an hour and a half away, We were sardined into a hot bus, standing the whole way. The wedding was on the hottest day in some time and even the locals were feeling it. Grasping for both food and shade, we feasted on some great dishes, which I still have a hard time distinguishing from one another, yet always enjoy. The dress was elaborate and traditional Nepali. Flowing robes, colorful scarves, decorated foreheads. The Groom arrived with a full ensemble of dancing friends and trumpets singing harmonious notes. I later learned that the trumpets were only to be played by a certain lower caste, a system of which is still alive and omnipresent in Nepal. Although Nepal boasts kindness, hospitality, and supposed tolerance for all. Once born into a caste, identified by one's last name, you are relegated to certain social limitations not all that unlike institutionalized racism.

The Bride accompanied by her own posse of colorfully clad women, met the groom under a large awning. Rituals involving painting tika, cleansing feet, and dawning jewelry enriched the upbeat ceremony. I have been to two Hindu weddings in my life, both amongst the most fun times I have ever had. This one involved a lot more stray goats running around.

It was a great time, but the weekend's excitement was still young. Debendra let us know that the the next day we would be traveling to a temple mostly unknown to foreigners. Halesi is a Hindu and Buddhist temple built into a cave in the foothills of the Himalayas. Foothills is a loose term because the hills would most certainly be looked at as large mountains most other places in the world. We got into another bus which would turn out to be excitement all on its own. On this bus we all had our own seats, which was probably a good thing considering it was about a 10 hour ride up and down many of these large hills. The roads were narrow and hardly roads at all. Our bus, lacking much suspension sped a little too fast for comfort traversing up and down mountain faces. Looking down out the window was a long long drop with no guard rail or much buffer zone. The driver was gracefful in avoiding oncoming vehicles, but I think he must have been able to defy the laws of physics considering the road width. The bus attendant continually handed out plastic bags in case vomiting ensued. A few of the passengers made use of these bags and luckily I had not. There were houses here and there on each hill we climbed, accessed only by hand carved stairs into the mountainside expanding thousands of feet in elevation. The stairs took at least a hundred years to carve as the huts they led to were dismantled and rebuilt higher and higher. In this area, all water is collected near the base of the hill and carried up. The same goes with many raw materials. Why they built the huts so high up I do not understand. We travelled for hours up and down these winding mountain roads until we reached our destination.

Halesi has a small village where a few people live, there is also a Buddhist monastery on the hilltop inhabited by what I think is a lot of monks. Three Hindu prayer sites, two residing in caves, one carved naturally into the mountainside are the pride of Halesi. After dropping our backpacks off, we ventured to the first cave. In it were many groups of praying Hindu followers and a few meditating monks. The inside of the cave was covered in stalagmites and stalactites. Many of which were painted and decorated in honor of Shiva. Throughout the open cave were narrow passages where if you can contort your body to fit through, you are considered to be holy and lucky. I am now both.

One young woman from our bus was sitting cross legged on the cave floor shaking violently. A man was kneeling in front of her, arms outstretched speaking some important sounding words. He was supposedly curing her lifelong epileptic disease. Although her shaking did not look like seizures and I somewhat doubt the curative abilities of the incantations, it seemed as though I was in the minority when onlookers cheered at her recovery.

Nepali people often stare and ask to take pictures with me as I walk by. They don't see many white people. Or any. Because Halesi is very off the beaten path, and virtually no foreigners hear about it let alone travel there, my presence was magnified. Most had confused looks. A few, at separate times, who knew a little English asked me "why are you so white?" At first I was at a loss of words, then I responded with some basic scientific answer about European ancestry and the lack of sun. The last time I was asked, I responded with a look of confusion, a glance down at my white arm and subsequent facial expression showing horror and bewilderment. That was kind of fun. Once people got over the initial shock I provided, I was given gifts of symbolic necklaces, colorful paints and bracelets by passerbys.

I happened upon a Hindu priest and Buddhist monk sitting cross-legged, engaged in conversation. Gingerly I walked up and sat down next to them. They loved it and welcomed me with words I do not understand. The Hindu asked to take a picture with me when he saw my camera and after the first snapshot, I asked if he would do another with the stipulation of a thumbs up. That made my day.

I was escorted to the one prayer spot carved into the mountain. It was a short but steep hike to find the hidden treasure. Constellations of lava rock formed statues resembling crocodile teeth and lion paws jutted out of the side of the rock. They were painted and had candles placed around. Buddhist prayer flags by the hundreds were draped overhead blowing in the wind. It was beautiful. that night we had a nice homemade meal at the house that offered us a place to stay. A few beers with the locals and my companions and I topped off another pleasantly surprising day.

We awoke the next morning at sunrise, about 4:30, to bathe at some holy site. We were led down a stone path to a pipe jutting out of rock. The water that was spewing out was considered holy and was carried by underground river originating from an Everest glacier. It was certainly refreshing. After cleaning, we were shown the second cave, which was much larger but less decorated than the first. A monk had been living in it for years and had a small mattress tucked away in the corner.

Walking out of the cave, down a small path, I saw Mt. Everet for the first time. About 400 km away, It was prominant and clear. It was surrounded by a few other mamoths but it was obvious which was king. The Himalayas are beautiful, Everest is the crown jewel.

We left Halesi that day to go back to the village. A very long trip led to an experience I never thought I would have. It's hard to believe how lucky I am to be having these opportunities welcoming me when most people never get the chance. 13 hours later, and a bus seat that I was definitely too big for, I collapsed, exhausted, under the starry nightlight.

Entry #4

dblatt — Mon, 5 May 2014 16:19:00 GMT

It's starting to get a bit more hot nowadays. I don't quite know the degree, but let's just note that it's squarely in the range between "Always Sweaty" and "Ouch". It has come to my attention that rather than sprawl out on my mat hoping for a crosswind, there is a perfectly fine roof on top of the clinic, with a more than comfortable blacktop bed. The migration to what surely must be the top of the village, this being the tallest two story building, concludes a full day of horticulture, hymns, and head injuries.

Today I awoke to the sound of the well being pumped outside my room. Groggy and a bit disoriented from my deep but sweaty slumber, I shuffled outside to find Loxmi and Yamuna digging with a swift and precise movement. They were starting an irrigation system next to the untapped earth behind our clinic walls. Greeting me with the normal "Boy!" I grabbed a hoe and started churning soil. The earth, seemingly paradoxical considering the lack of rain, is incredibly fertile. In a few hours before the clinic doors opened, we constructed and planted a sizable garden with tomatoes, ocra, cucumbers, and many vegetables whose names I cannot tell you.

One of the regular children visitors did not have school today and walked in with his mother. Like many other days we chatted, the child translating, and enjoyed some tea. Unfortunately with calmness and purpose his mom informed me that this visit she would also like me to "heal her". The woman, about 45 years old explained the pain in her left breast. Right away I was able to find a concerning mass. Informing her of my inability to make an accurate diagnosis, yet revealing my worries, I convinced her to take the trip to the nearest hospital. Luckily she was making her monthly trip out that way soon and it would not be too much trouble for her to stop by and get further imaging or biopsy. Both family members were grateful and appreciative, neither outwardly stressed.

The rest of the day was slow, only a few patients here and there with common symptoms of acute, non threatening illness. The fun started at nightfall. One of the boys I had sewn up a few days before came by with his mother and invited us to their house for some singing. Jumping at the invitation and walking down the street, we were welcomed by a group, about 15 people of all ages beating drums, drinking some beverages, and singing some sort of upbeat, bravado hymns. The fire in the center of the circular festivity drew on a nearby wall, shadows of dancing and drum beating. Not knowing at all what I was doing, I joined in, dancing movements that clearly required practice and singing words I could not pronounce or understand. That was a whole goat load of fun.

Fed, entertained, and again sweaty, I made my way back home. It was very late, thus very dark. The stars here are bright and beautiful. Sleeping on the roof looked like a very good idea during that walk back. It was. I hauled up my thin straw mat, a mosquito net and a sheet. Preparing to collapse into a slumber, I heard some voice down by the front enterance. My headlamp shone on the faces looking up at me. A boy and his parents. Meeting them by the doorway I saw the blood running down the boy's face, his hand covering a wound. I let them in and called around to see if any of the staff were around. They weren't, probably home and asleep. He was a shy kid who most likely never played rough in his 9 year old life. From what I gathered, which is suspect due to the language, he threw a glass soda bottle in the air which came crashing down on his upwardly gazing forehead. I think he knew more English than he originally let on, because when I brought out the suture materials, he said sweetly, "is there no other solution?" There wasn't, although it was clean and not complicated, he required a few stitches. He never flinched during the procedure. Using my headlamp, I brought over the parents to see that he was fine and the wound closed nicely.

I fell asleep to what will surely be the first of many on the cool roof. Mosquito net propped up with string and brick, stars glimmering through the webbing, and the hordes of goat, chickens, cows, and buffalos saying their very audible goodnights.

Photos: Bhaunne

dblatt — Tue, 15 Apr 2014 22:06:00 GMT

Entry #3

dblatt — Tue, 15 Apr 2014 21:53:00 GMT

It is now the year 2071. Today is the Nepali New Year. We celebrated by making a small pilgrimage to a Hindu temple. We had to take a bus down the main road out of town. While walking to the bus, there was a "shuttle" driving by our clinic. This happens every so often as a local driver drives up and down the road. I think he must drive fairly long distances, because the vehicle was packed. We ended up having to sit on the roof for a couple miles, feeling every one of the many bumps on our local road. When we reached the main road, hopping into another crowded bus was a chore. Physically, it was hard to squeeze in. There was no one on the roof, but lining the sides were passengers hanging on for dear life. It was hot and sweaty and we rode for a couple of hours. Somehow Loxmi and Yamuna knew where to get off, because if you asked me, our stop looked like any other, and there are never any signs in sight. We then proceeded to walk down a dirt road by huts with children playing in a stream. This took about an hour and a half. Considering I had no idea how long this journey was, I was ill prepared for the lack of water and increasing thirst. As cruel fate would have it, we came upon a clear wide, easy flowing river of water I could not consume. In this water were hundreds of Hindus offering colorful decorated rocks to the liquid. We did the same, decorating our stone with red and yellow paints and perching it upon a larger river bed rock with its apex exposed and dry. Walking along the water edge another half of one mile, an ornate building boasting gold and red curves came into sight. Removing our shoes allowed us entry. In the coming room there was a man with dreadlocks swirled into his beard and beaded necklaces hanging from his neck. His eyes spoke of ages with stories of mischief and wisdom. His red robes preached humility and prestige. Like the building surrounding us, his balding head was red and yellow. He greeted us like all others do, with kindness and a bow. After he put a tika (the red and yellow paint) on my forehead we laughed at our broad and cumbersome language barrier. The priest showed us prayers before we rang bells to call the gods to listen. The journey to get to our pilgrimage destination was much longer than our stay, but it was a fulfilling and certainly fun experience.

Cheers,

Dan

Entry #2

dblatt — Sun, 13 Apr 2014 21:49:00 GMT

I've been here almost a week now and the past couple of days have been exciting. Each day starts with one of our neighbors bringing some freshly uttered milk. It is obviously delicious rich whole milk, but even after its necessary boiling, tastes much more full bodied than I am used to. Most mornings Shisir and Nokul make their way up the stairs to our living area. Shisir is thirteen years old and Nokul, Fifteen. Both boys almost act if I am their male figure in life. Both of their fathers leave for about nine months at a time to work in some sand mines in Dubai. Apparently the mining companies come and recruit villagers for cheap labor.

I've gotten very close with Shisir. He and I took a mini day trip to a park called Betany. To get to Betany, we walked towards the main road a couple of miles. From there we hopped on the bus passing by. The Bus is essentially a large van, packed with people upon people, many hanging off the sides or hlding onto the roof: luxury at its best. Luckily everything around here is incredible cheap due to lack of money. Shisir and I cost about twenty cents to go to our possibly 5 miles away destination. Betany is actually very nice. Large wooded palm lands surrounding a small lake where you can rent a paddle boat. Again, essentially for no cost. Although I did not witness it, Shisir was telling me how he sometimes is able to dive into the lake and catch a fish with his bar hands. I really hope this is true, and he is very insistnt that it is.

Almost as soon as we returned from our day at the park, their were 3 pregnant women arriving to check on the heart rates of their babies. The babies were fine but it was still great to see how excited they were to hear the beating little heart muscles. About an hour later an 11 year old boy showed us his lacerated wrist. He fell off of a ledge and reopened an old scar. There was too much blood coming out of his arm for what I thought was a small cut. Once I started cleaning the wound it was clear that it was deep and long. Clearly exposed muscle and tendons. I asked him to move his fingers and he could. He was able to feel his distal extremities. I was relieved, Suturing fascia and skin is in my repertoire. Hand and wrist surgery is not. At this point there was no power and therefore no good light. I grabbed a headlight and went to work. Scrubbing the layers of dirt around the wound took longer than expected. He had not been cleaned in quite sometime. Small rocks and dirt laced the inside of the deceivingly large opening. The constant dust carrying wind did not help. It took longer than it should have, mostly due to lack of light and intact equipment, partially due to my inexperience. The sutures were brttle and the tools dull and rusty. I finally sufficiently cleaned and sewed the wound back together. The boy was tough. He stayed relatively still and calm without the aid of painkillers. It was satisfying and a bit nerve wracking. It is much different suturing in a hospital setting with supervision than it is on my own with inadequate materials and a much less than ideal environment.

Every day there is a man, couldn't be more than 70 years old, who comes to get his blood pressure taken. It is always a pleasure. He walks in, sometimes tapping on my door if I am still asleep. Sometimes sitting idly by during dinner. He wordlessly stares at me, minutes at a time. Not in an intimidating way, not even out of curiosit; more like he is offering an extended greeting. If I go to get the cuff too soon, he motions with his eyes for me to sit. He wants to rest more before an accurate reading, or more likely a lower reading will be displayed. Every day I take his pressure. Every day is too high. Every day after the heightened reading, he tries to explain, in Nepali, which treatment he experimented with that day. Today he is walking barefoot. Advice from a shaman in town. The blood pressure was still way too high, but he was grateful nonetheless. Today, or more specifically, today at 7 pm, like he does every day, he ended the encounter with a "good morning". His palms held together, pointing up, he walked away very proud of himself.

Until next time,

Dan

Entry #1

dblatt — Sat, 12 Apr 2014 21:45:00 GMT

It's 3:45 am, and I am in my private sanctuary of netting, mosquitoes hovering a safe distance away. These past three days have been tiring, but I can already see how satisfying a decision it will have become to embark on this adventure. Although the planning began long before I started travelling, I choose to introduce you to my travels with my bus ride away from home. Sitting at the terminal waiting for the double decker to arrive, amongst the bevy of Yankee hats, designer suitcases, and way too large sunglasses, I was getting excited about the idea of spending a day in New York City dressed for a safari.

Arriving in Manhattan, loaded up with a hiking pack, day bag and a large green handbag full of medical supplies, I started walking with confidence, I kept a secret that would change my life for the better. My cliche life changing experience would be anything but cliche. It quickly became obvious to me that I must have looked rather the opposite of that confident feeling. Loaded down with bags, covered with too many clothes, wearing boots not yet broken in, looking lost in a crowded city, I most likely aired more of a pathetic vibe.

In my past travels I have often seemed to have pretty great luck running into people that I know. When arriving in New York, not more than twenty minutes after disembarking from my bus ride, did I see a familiar face. An old friend from ultimate frisbee crossed my path. I got to spend some time with her walking too far on my aching feet, enjoying a city who's greatness often escapes my opinion. The day was closing and after saying my goodbye, I made my way to Andrew Silverman's apartment. Andrew was the younger brother of my long time friend Ben (who's name also happens to end with Silverman.) We reminisced with stories of our past and plans for the future, as any long time friends would. It was a pleasant prelude of my journey to come.

The next morning, making my way from lower Manhattan to JFK airport, proved to be much more cumbersome than I thought. The dense green duffel bag full of bandages, ointments, soaps and unforgiving heavy liquid antiseptics made a valiant effort at removing my arm from my shoulder. The hour and a half subway ride showed great relief when it allowed me to check my two heaviest bags before my dauntingly long flight.

Regardless of what anybody says about the UAE, United Arab Emirates has a hell of an airline. Flight attendants toting comforting Arabian hats on their perfectly groomed hair, food that could pass for good in a decent Middle Eastern restaurant, free booze, and a movie selection blowing Netflix out of the water. Not a bad way to spend 13 hours in a crowded steel box hurtling through the atmosphere at speeds certainly higher than evolution intended us to travel at.

Landing in Dubai was as if I spent the night at Caesar's in Vegas. Herded through labyrinths of designer perfumes, clothes and liquor, I finally made my way to the train entrance. After getting off the 5 minute ride to Gate B, I had to then get on a 10 minute bus ride to what I can only imagine is the peasants terminal. This airport is bigger than most cities, and my flight to Kathmandu was the heroin laced, broke, over the hill stripper section of the Vegas strip. A place no good Jewish boy find himself with intention. The four and a half hour flight to come would be welcomed.

Kathmandu's airport is different than Dubai's. Very Different. It is one room, no shops and a possible homeless man behind a folding table offering to change currency, sell visas, declare customs, and trade his shirt for yours, specifically mine. I declined the offer. I was greeted by about thirty taxi drivers, who all seemed to know the best place to take me. They were good friends of mine. As a good friend, I declined to take their gifts of the best prices for tourists. I just wouldn't know how to repay them. Instead I settled on the man holding up a sign that read "Chisang Clinic". What a great coincidence that was, because that is where I was going. He drove me down what at the time I thought was the wrong way of a one-way road. It was actually considered to be a two-way, 4 lane highway. Pedestrians were encouraged to use any lane they liked as a sidewalk. From above I imagined this looked like the most epic battle of childhood, the black ants versus the white ants on the TV screen when you turned the dial to a channel that did not quit exist yet.

The house was a Spanish style abode in a sea of poor. The winding cross streets and hills brought me to the house of the founder of Chisang Clinic. I was greeted by his son and his parents. His son, Pratik is a 17 year old with perfect English looking to atttend college in the U.S next year. He was nice. He translated the niceties exchanged by his grandmother and I before walking me to his grandfather's bedroom.

He was sitting up in bed and motioned for me to rest next to him. He, speaking no English, and me, no Nepali got along great. Laughing about what we didn't know and smiling about stories we did not share, he became an instant friend. According to the way too young looking 16 year old house boy, this man was an ex-prime minister of Nepal. I'm not too sure at this moment how true it is, but I'd like to think it is.

My travelling is not nearly complete. Exchanging bows, palms pressed together, fingers pointed up with our hands held high out of respect, we all said our "Namaste" and I was gone. Back at Kathmandu's airport, this time at the domestic "terminal", the realness of my remote travels hit my thoughts. The room was packed with rugged backpackers, religious Hindu and Buddhist travellers and the not-so occasional Chinese Tourist. Most were going to Pokhara, a supposedly beautiful mountainous district of Nepal; the trekking paradise. I was not. In fact, the only people who had the same color ticket as I, were a select few who assuredly were from my almost final destination of Biratnagar. Yeti Airlines was my guide and their probably not up to code prop plane my vehicle. After a shakier takeoff than I care for, the flight was gorgeous. The Himalayas out the left sided windows looked like pearly shark teeth jutting through the flimsy hull of the boat made from clouds. Beneith our vessel lay digital-like steps carved into the side of any usable hill side. This was surely the only ladder to the houses of the rural inhabitants below.

Biratnagar is billed as an industrious city. I wouldn't be able to make that description myself. Its airport was a countertop, bambo roof above. Its roads, loose rock and dirt. Its industry, rusty bicycles, goat herding, and foreigner staring. The car I met at the airport took me through a congested and adrenaline producing seventy five minute drive. We turned down a non descript path for a few miles past more goats than I knew existed.

Bhaunne village is in the Morang district of this small country. Morang is the lowlands of south east Nepal. It has a hot jungle like climate with incredible fertile soil that would let even the most incompetent stay full. The villagers don't see a lot of outsiders, especially those with my skin complexion. They are self-sustaining, growing any fruit or vegetable they eat and rising any livestock they use for food, milk or harvest. Water is pumped from wells dispersed throughout and shared freely. Although Kathmandu is close to equal parts Hinduism and Buddhism, Bhaunne seems to be Hindu with some Buddhism sprinkled in. It definitely appears to be more of a cultural and social significance than religious.

One of the few concrete-made buildings in town is the Chisang Clinic. The only medical service around was founded three years ago. The structure looks much older than its age, with worn paint, broken cement floors, and uneven doors. An open air edifice with walls only providing shade, not wind or rain protection. After being looked at like a mutant while driving through the village, pulling up to the clinic, I was welcomed with happy and energetic faces. Degu and Kate were the first people I met. Degu is a Tibetan looking late 20's woman with a large smile perched on her face. Her home village is about a nine hour bus ride away and moved here to work at Chisang. Now she lives next to the clinic. She is a "medical assistant". Kate is another volunteer (which is unusual to have two at once, due to the scarcity of volunteers in general.) She graduated from Georgetown last year and took this past year off beffore she starts medical school this fall at the University of Virginia. They walked me through the clinic's front doors into a small waiting room which also housed the book keeping desk and served as a examination area. One bench, one table, 3 plastic stools. Attached via curtain was another examination/storage room. Exams in that room were for those that required any serious privacy or a place to lay down. Storage included all of their medical devices: an old ophthalmoscope, an ultrrasound and a reflex hammer. Walking past the main area is a larger room with a few cabinets hosting knock-off Indian medicines, expired antibacterial creams, a collage of various bandages and suture equipment. It's actually quite advanced considering the surroundings. Perhaps the most impressive aspect of the clinic was the side room of the back cabinet area. This held the laboratory. The lab has a small centrifuge, vials for blood and urine, test strips, along with equipment for drawing blood and a microscope. Yamuna runs the lab, she is also a woman from a far away village who came for the job.

After my brief tour, which included stocking the cabinets with the supplies I brought (thanks to a few friendly donations), I was led upstairs. The floor is uneven, cracked concrete. Walls a pale yellow, begging for some reprieve from the dusty breezes. A corrugated tin roof donated shade to half of the living area. a few clothes-lines reached across from two of the roof bearing poles. The room has two walls and is much more of a large balcony than a room. There are 3 bedrooms with screened doors to the open main area. Simple rooms with a few beds draped with mosquito nets in each.

Also attached is the kitchen. A six feet by five feet enclosed room. It has a sink, countertop and burner with gas tank underneath. Loxmi runs the kitchen and maintains the clinic. She is the only permanent resident of the building. She is tall and slender, about thirty years old and has more swagger than she knows what to do with. Often quipping with the local children, she acts like a big sister/mother hybrid to the young villagers. Not to mention a great cook.

The building does have some electricity. For a couple hours per day we can use artificial light before the inevitable blackout. That is much more than most people around can say. There is a water well right through the back door, where after a few minutes of pumping comes the clear, cool liquid. But this is not fit for drinking, at least not for someone with my delicate westernized gut colony. As the Village natives drink freely, I must carry the water to the kitchen and boil it using a gas burner rivaling a cheap piece of camping equipment. Generally I don't find boiling water to be too refreshing so I let it sit overnight before indulging. On the roof there is a large covered bucket with a hose leading down to the well. Every morning, we hope to be able to turn on a pump which drives the water up to the roof. That determines our running water availability for the day as the bucket is hooked up to a sink in the kitchen and a shower next to my bedroom. We do have a toilet. Nepal actually makes sure that there is no public defecations unlike neighboring India. Our toilet is a small room with a hole in the ground that resorbs all that is placed in it.

Now that I've talked about the feces, time to move onto the food. The food is great. Mostly rice based, it is decorated with cooked vegetables and a lot of lentil combinations. Sweet hot tea is enjoyed a couple of times per day. People here wake with the sun and rest with the moon (unless there is a late night drum circle happening). Breakfast is generally around 7:30 am, lunch at 10:30, large snack at 4 and dinner around 7:30 pm. This rice and the constant baked goods might give me traveller's diabetes, but aside from the constant sugar spikes, the diet is fairly nutritious. Walking down the street from our home, I am treated like a celebrity. Little children ring out perpetual cries of "Hi" and "Bye." To which I can only respond with a hand wave and similar diction. But the best perk is always being invited into people homes to enjoy some freshly made local eats, or slaughtered goat.

The healthcare at the clinic has been primitive but adequate. As there is no true doctor or nurse for that matter, a standard algorithm of symptom and corresponding medicine is followed. It is nice to be able to teach the staff things like cough syrup isn't always the answer for a cough. Within the first couple of days I've mostly seen some cuts and scrapes, some requiring me to suture, skin infections, helminthic worm infections, corneal abrasions, and the usual cough, vomiting and diarrhea. I've certainly been able to enjoy helping out in a hands on experience with very limited medicine and resources. Being the only doctor in town (no matter how freshly out of school) has taught me well very quickly. Most notably how to deal with the responsibility of being the lead decision maker.

I have walked down the road about an hour to find a few minutes of internet. I hope this message finds you all well and that you enjoy reading it. Forgive any grammar or spelling mistakes as this is being typed essentially on a notepad and not a word processor. I will send more updates soon.

Namaste,

Dan Blatt