You kind of had to be there...

My trip to India with the Himalayan Health Exchange this past month was one of those experiences that proves nearly impossible to share with those at home. There are nuances of sight, sound, taste, and spirit that defy all medium of communication. That being said, I will attempt here a simple summary of our itinerary in an effort to offer a glimpse into what was a truly life-changing journey...

At Logan Airport I met Patrick, Kendra, Regan, Kristen, and Pete, the other members of the 'Boston Crew' flying via Air France to Delhi. We had an uneventful flight to Paris Charles de Gaulle and settled in for a lengthy layover at the gate for our connecting flight. While we were camped out chatting, stretching, and snacking on $14 (7 Euro) croissants, we were found by Mike, who was mistakenly put on an Air France flight from NYC to Delhi even though he's from D.C. Anyway, the flight to Delhi was lovely - good food, good movie selection, good sleep - up until the landing. There was bad weather over the city so we had to circle for a while (may I advise NOT watching the little real-time map that shows the plane forming loops around your destination in such a situation). The circling was interspersed with panic-provoking, nausea-inducing, prayer-invoking lurches and dips which forced me to hunch over with my eyes closed and hands clasped until the wheels made contact with the blessed runway.

At the airport we were greeted by Peter, a member of the HHE staff, who packed us into cars which took us to our hotel for the night. Since we were an uneven group of seven, one of us had to volunteer to take a single room. Patrick, a true Southern gentleman, gave up Mike as his roommate so that I wouldn't have to be alone in a strange Indian hotel overnight. Excellent. Up until the point Mike and I open the door to our room and discover a single ROUND BED. Yes, you read that correctly. Needless to say, it was a hot, hot night. So hot, in fact, that we slept on far corners of the round bed (yes, it is possible... necessity is the mother of invention) with occasional inadvertent grazing of stray limbs.

In the morning we met several other members on our trip on our way to the train station. We took a train to Chandigarh where we met more staff members and our retinue of drivers and Jeeps which would become a cornerstone of our routine. We had a very bumpy, long drive up to Dharamsala, specifically McLeod Ganj, a tiny mountain town where His Holiness the Fourteenth Dalai Lama and many Tibetan refugees now live. We stayed there for one night, but I was already in love and couldn't wait for the two days in McLeod Ganj at the end of our trip. In the morning we loaded back into the Jeeps for another long bumpy drive to Chamba, our first clinical site.

None of us were fans of Chamba. The city is fairly modernized and there are a few hospitals and medical centers. Our services seemed superfluous as we set up clinics in nice buildings and saw patients with very generic complaints of joint pain and gastric reflux. Indeed I did lose my sanity on our last day of clinic when every single school-aged child showed up and claimed to have "teeth pain" so they could satisfy their curiosity about the strange American doctors. Don't get me wrong - I love kids. Just not bratty, uncontrollable kids messing up our clinic.

Needless to say, we were all glad to leave Chamba and begin the first of many hair-raising drives along narrow mountain roads. There's no better cure for a fear of heights than looking out of the window of the Jeep and noting the sheer drop into a lush valley just as an enormous bus approaches from the opposite direction and the shepherd behind you decides at that moment to urge his flock to pass your vehicle. We arrived in Bir, a beautiful town with monasteries and lovely views of snowy peaks in the distance. Our 'campsite' was the definition of luxe camping since we had large tents with cots, linens, and electricity, as well as separate bathroom facilities with hot showers and Western toilets. We set up a few clinics there as well as provided routine care to the monks at the Sherabling Monastery, which was a lot of fun.

From Bir we embarked on an incredible trek from Billing at 10,000 feet to Barot at 7,000 feet. I was still suffering from lingering knee pain after my car accident, but my colleagues provided unparalleled support and care to me so that I could participate in the trek safely and comfortably. Regan, aka Osteopath Extraordinaire, wrapped my knee with athletic tape and Gabe, aka My Personal Sherpa, fashioned a walking stick for me and carried my day pack in addition to his own gear. I couldn't have enjoyed the trek as much as I did without the generosity and selflessness of my teammates.

In Barot, we were camping for real. In a muddy cow-patty covered field. In the nonstop rain. Whee. We did have access to three Western toilets but showers were a thing of the past. Instead, buckets of water were warmed each morning for us to use in dark stalls next to the toilets crawling with spiders from the set of King Kong. Our first clinic day there was as delightful as our living conditions. Despite being indoors in a community health center, we were as cold as if we were outside since none of the windows had intact glass. The wet, chilly draft blew through the building mercilessly and I had to wear two sweatshirts, a hat, and gloves to be marginally comfortable. Luckily the staff made lots of hot tea and procured some coal heaters which we huddled around at lunchtime. I was not sad to leave Barot.

Our next stop was the village of Ropa, seated deeper in the mountains but at a lower, more temperate, altitude. We were greeted at our campsite by a sudden hailstorm and strong winds, the terrible weather apparently moving with our caravan. Luckily, this was the case only for that single day. We were thrilled to wake up the next morning to bright sunshine reflecting off the clear stream that rushed along next to our campsite. Trees with thick green leaves grew along the banks and there were plenty of large boulders perfectly suited for reading and journaling in the sun. This was the most rural site we had camped in thus far. There were no Western toilets or private bathing options; the thick trees and sizeable boulders provided convenient cover for these necessary activities. For the first time in my life, I discovered the exhilaration of relieving oneself in the great outdoors. Even better, after a long day in clinic, we were overjoyed that the sun was hot in the sky and the cool water of the stream was a lovely place to bathe. I found a nook between some large rocks and reveled in the feel of fresh water and soap on my skin. Just washing my face and hair immediately refreshed me, a simple pleasure for which I had a new appreciation.

The next village and final clinic site was Gadagusain. Once again we were at a slightly higher elevation of about 8,000 feet and the chill in the air was evident. We did have access to two Western toilets and bathing rooms, but the government-owned building was poorly maintained and the bathrooms were among the more filthy I have ever used in my lifetime. Feeling the need to walk on the tips of one's toes despite wearing all-terrain hiking shoes in a bathroom is a bad sign. Drawing on my new ‘survival’ skills, I decided that bathing was not required and that four days without cleaning myself was quite acceptable. Fortunately my tent-mate had a similar philosophy so I didn’t feel self-conscious about any unpleasant odors I may have been emitting in our tiny living space. Our clinic at Gadagusain was unique in that we were able to pitch our medical tents in the open space just next to our campsite. This proved to be a double-edged sword. While it was quite convenient to stroll to clinic after breakfast instead of piling into the Jeeps for an inevitably bumpy drive there and back, it was evident that the local villagers saw our private campsite as an extension of the public clinic. As such, many children and a few adults would comfortably position themselves for hours on end on the fringes of our camp, seemingly fascinated by our daily activities of eating, doing laundry, and even simply reading or journaling. In all honesty, I found this voyeurism a bit unnerving since I am not accustomed to being watched during my routine goings-on. More than that, however, was the feeling of utter lack of privacy or solitude. In the few stolen moments by myself in my tent or even relaxing in the sun, I felt the presence of several human beings and found it difficult to ignore. In addition to watching our every move, the villagers were quite shameless about observing closely as we would interview and examine their neighbors. HIPPAA has not yet spread its influence into this part of the world. For the most part, this was more of a nuisance than a hindrance, and simply closing a tent flap would solve the problem.

The real challenge of crowd control presented itself one morning when business as usual was brought to a halt by an acute issue. A small crowd of men hurried up to our cluster of tents, carrying with them a wheelbarrow-esque contraption in which lay a young woman. At first, I thought the woman was elderly and possibly disabled and had no other means of coming to our clinic. When I realized the woman could not have been much older than me, I looked closer. The woman’s eyes were closed and fresh blood was dripping from her lower lip. In rushed, frantic Hindi they told us that this woman had fallen while walking with them earlier that morning, and it had taken them three hours to carry her down in their makeshift stretcher from their fields to our clinic. We immediately hollered for Joe, an emergency medicine resident, and he calmly joined our team as we tried to orient ourselves to this developing trauma case. Joe exuded the calm focus so crucial in emergency medicine and talked me and two other students through a neurological assessment of the patient which revealed a diminished level of responsiveness. Since we didn’t have a collar to stabilize her neck, my friend Patrick donned gloves and held her head still, lest a spinal injury become worse. A few other students managed to fashion a collar out of some stiff foam, but it was sadly inadequate as the patient began to stir and was moving her head despite the restraint. Joe gingerly examined her mouth but was hesitant to be too aggressive since we had limited tools and would be unable to intervene effectively in case she had loose teeth or worsening bleeding with a thorough exam. Her level of responsiveness improved rapidly as we began wiping her face clean, and she began waving her arms and shaking her head, still unable to open her eyes or make a sound. Restraining her was a task, and the need to get her to an adequately equipped medical facility became urgent. Satisfying ourselves that she wasn’t in mortal danger, we transferred her from the ground to a ladder on which she was carried to the backseat of one of the Jeeps. The ladder was too long for the door to close, so we had to remove it, extremely displeased that she had absolutely no immobilization of her spine. Her husband jumped in the Jeep with her, and the driver sped off to the nearest hospital which was two hours away. Throughout this dramatic scenario, a thick throng of villagers collected around us. At one point I looked up and realized the reason the light was suddenly dim was because of so many bodies blocking out the sunlight. More than once I had to loudly instruct the crowd to move back, which they would hurriedly comply and inevitably surge back slowly. Although this was obstructing our ability to care for the patient in that our team members had to elbow their way in and out of the crowd with supplies, I couldn’t help but notice that the look on everyone’s face was not one of morbid curiosity but rather of genuine concern. In such a small, insular community, this woman’s plight was everybody’s business. Even after the Jeep had left, a small crowd lingered on the road in the dusty wake of the car, undoubtedly feeling that there was still something more that they could do to ensure their neighbor’s health and well being.

After this incident, I became far more forgiving of the nosy women who would peek into the tent as we elicited a detailed sexual history from one of their neighbors. The perception of sexuality is one of shame and taboo in any case, so whether we had complete privacy or utter lack of it, most of the women were not going to be forthcoming. This was further evidenced by the fact that women would present to triage with a chief complaint of shortness of breath and then would casually mention bothersome vaginal discharge, usually to a female member of our team. This attitude about their bodies had to dictate in turn our approach to examining them. If a pelvic exam was indicated, there was no need for the ideals of ‘informed consent’ and ‘patient autonomy’ which we strictly adhere to in the US. Instead, it was expected that the patient would refuse the exam but with enough insistence and directives, she would ultimately submit to the exam. This was naturally quite off-putting for our American sensibilities at first, but over time it became obvious that there was no other way to obtain necessary information for our management of certain patients. In the end, it comes down to the simple fact that healthcare is taken for granted in the Western world, and the right of refusal is upheld. Just as people in impoverished nations don’t have the luxury to develop anorexia or bulimia, these women didn’t have the prerogative to avoid receiving medical care that was so hard to come by. Even though this paternalistic mindset was in direct opposition to my own beliefs about patient autonomy, I knew that in this setting it was not optional. Accepting our limitations in the care we were providing was necessary for our own sake. While this type of attitude can in the worst of times encourage the arrogant mentality physicians are too often guilty of, I knew that it was only applicable in these extenuating circumstances. If anything, I now have a greater tendency to encourage patient autonomy with American patients since I know for so many people it isn’t possible.

Leaving Gadagusain was bittersweet. I was glad to be returning to Dharamsala, one of my favorite places in the world, and looking forward to a hot shower and a real bed indoors. But I knew I would miss the starkness of the mountains, the slightly damp chill in the air that no amount of warm layers could completely eliminate, the surprising freedom I felt relieving myself behind a tree. Mostly, I knew I would miss the blatant honesty of the local villagers, their lack of self-consciousness, their minimalist simplicity which was borne of necessity yet demonstrated so many truths about how lucky the Western world is.

Back in the domain of the Dalai Lama and his people, I had plenty of the solitude I so sorely missed. I was able to reflect on the journey, both physical and spiritual, which I had just concluded. I was desperate not to lose the clarity I had in that moment, the profound understanding of the order of things and the power of the human spirit. Being in the midst of so many deeply spiritual people was a blessing as it served to solidify the lessons I was still learning. We were able to visit the Norbulingka Institute, a fortress of Tibetan culture built as a replacement for the original palace which was destroyed by the Chinese army. There is a beautiful doll museum depicting every aspect of life in Tibet, a remarkable effort to capture the essence of a way of life which is gravely endangered.

We stayed in Dharamsala for a couple of days, then boarded a bus for an extremely bumpy overnight journey back to Delhi. Benadryl is a beautiful thing. We stopped in Delhi for the day and did a bit of the tourist thing. I've never visited Delhi as a tourist so it was a great experience. We visited the Lal Qila (Red Fort), the seat of the Mughal empire when they controlled the northern Indian provinces, and a gigantic temple built in homage to a famous Hindu priest. Then it was back to the airport for the long air voyage back home. While I felt nostalgic and sentimental about bidding my dear colleagues farewell, I was also more than ready to sleep in my own bed, drink untreated water, and eat a frickin' cheeseburger.

So, there you have it. If you managed to read this entire post, I thank you. I do plan to return to this region, hopefully within the auspices of HHE, either as a resident or attending. Even if I couldn't return, I would be truly blessed to have had such a phenomenal opportunity.

Lessons from India

I just returned three days ago from a month-long journey through Himachal Pradesh in northern India. Under the auspices of the Himalayan Health Exchange, I was among a group of 40 medical students, residents, physicians, and support staff who traveled to various remote villages to set up medical camps for the locals. After my first year of medical school I lived and worked with my aunt who is a practicing OB/Gyn in a small community hospital in Bangalore, India.

This experience was nothing like what I did in 2004.

Aside from the fact that I now have four years of medical school behind me with plenty of clinical experience, I have grown and changed so much that my perception of things is completely different now than it was four years ago. Among other things, I have cultivated a real sense of independence and self-sufficiency which I dearly lacked when I started medical school. Part of this is related to inexperience with the ways of the world which led me into many unhealthy relationships, both romantic and platonic. Only after making those mistakes could I really look at who I was and who I wanted to become. At that point, I realized that the unhealthiest relationship of all was the one I had with myself. Thus I embarked on a journey to rebuild everything from the ground up. Psychiatry played a big part in that journey, revealing diagnoses of generalized anxiety disorder and seasonal affective disorder. Once I was undergoing effective treatment for the biological aspects of my poor mental and emotional health, I could focus on the spiritual aspects of my quest.

The most difficult hurdle in the path to self-discovery are the bright lights and ringing noises of the people around you. When everyone you identify with starts making decisions about their lives that don't make sense for your life, a true identity crisis sets in. So many people get engaged and married as the end of medical school approaches, and as much as I know I am nowhere near making that sort of a sacrifice and commitment to another person, it did throw my goals into doubt. Finding kindred spirits helped to overcome those doubts, but it was the more arduous task of constantly reminding myself that I was responsible for my own happiness which really shaped who I am today.

What does all of this have to do with India?

India is an unforgiving, starkly beautiful place which strips away the trappings of Western life and forces the visitor to face what is revealed. Because of this, I was able to examine myself and realize that I have made great progress on my quest for self-definition. The journey will go on for a lifetime and I am looking ahead to whatever the future holds.