Reflections on Nepal

It’s hotter than I expected. Having never been to Nepal before, my imagination was dominated by photos of Sagarmāthā and its snowcapped reaches, but down here in Dhading Besi, the summer sun is unrelenting. We’ve been waiting on a hard-packed dirt field-turned-helicopter-landing-zone for a day and a half, awaiting our turn to be delivered via Indian Air Force helicopter to the furthest reaches of the district. The field looks like it serves as an intermittent parade ground for military formations, and the outpost off to the corner looks defensible. The bunkers are empty, but I recognize their sight lines are well-arrayed and the layers of concertina wire are carefully maintained, kept clear of debris and brush that might make them easier to leap over. I struggle to remember how long ago the insurgency had been and wonder what had happened to the Maoists. Asking some of the Nepali staff members what the result had been, they hesitantly say that they had been incorporated into the government. I remark that surely that meant they had truly been defeated, and I’m rewarded with a boisterous laugh among the normally quiet staff members. It was a good and heartfelt laugh, and I relax a bit while simultaneously berating myself internally for bringing up what could have been a very awkward and controversial subject. Reminding myself that a student intern is best seen and not heard, I continue to ponder the heat.

The Nepali Minister of Defense and President have landed their respective helicopters at the now quite crowded landing zone, both here to speak with the District leadership. And with them has come a horde of Nepali and International Press. Having waited the entirety of the previous day for a helicopter to no avail, I suggest that we move our supplies onto the field near where the big Indian military helicopter lands. I want to make sure the cameras can capture our piles of medical supplies sitting on the dirt field unused. Sure enough, the next time the Mi-17 helicopter flies in blowing a stinging cloud of dust across the field, we are motioned to start loading our supplies onboard. No stranger to military helicopters, or central Asia for that matter, I had drawn up a manifest of which personnel and equipment would go on each lift. Even though the Mi-17 could carry some 3600 kilograms, we will need two trips to reach the landing zone up in the high foothills of the Himalayan mountains. I’m more than mildly annoyed as the well-meaning but untrained NGO volunteers I am with scramble to grab whatever equipment they can carry and throw it on the helicopter, with no regard to weight distribution or allocation of critical food and water supplies. Fortunately, the Indian crew chief knows his stuff and cuts off the flow of supplies well before we overload the aircraft. Eager to ensure that nothing is forgotten and left, I stay behind for the second lift. About an hour later, the helicopter returns, and another scramble ensues, as we try to combine our remaining equipment with bags of rice to be dropped at some of the village between here and our final destination. Finally onboard, I try to get comfortable amid the boxes of antibiotics and bags of rice for the twenty-five minute ride up the valley. I relax only a little, my three previous helicopter accidents ever-present on my mind. Fortunately, a cargo run during the day is much safer than low-level flying under enemy fire at night, I hope.

We never quite land as we pass the villages leading up to our final destination, merely hovering a few stories above the ground as we pass bags of rice up to the crew chief, who unceremoniously dumps them out the door. The last one disappears out the door and the helicopter gains altitude and speed pushing to our final destination in the Jharlang VDC. The pilot circles over the landing zone in a wide circle, reviewing the area and turning to approach into the wind. As he does, we see a massive landslide that stretches for kilometers. At first thinking that it is a result of the earthquake, I notice a well-worn goat trail that crosses the upturned soil, it’s been there for years. I wonder if the soil will give way under our feet as we try to administer medical assistance. We’re flaring for the final descent now, and out of habit I brace to land and exit the helicopter as rapidly as possible. As we touch down on a farmers terraced field, we quickly pass supplies off the helicopter. I face away and brace for the familiar sting of dust and small rocks on the back of my neck as the Mi-17 powers up to lift off the mountainside and return to Dhading Besi for its next mission. For a brief moment, the sounds of the helicopter reverberate through the mountains, before gradually fading down the valley.

I bend down to grab my bag, and go to grab another, before realizing that someone else has already taken it. Our colleagues who landed in the first lift are here, and they are not alone. First dozens, then hundreds of onlookers have rushed down to the landing zone to see what new curiosity the helicopters have deposited on their doorstep. This is my first introduction to the Tamang people. The kids, some who look younger than 8, scramble and fight with each other to run with our bags up to the site the first team has proposed for our clinic. Those of us who are newly arrived breathe heavily, trying to adjust to the sudden increase in altitude. I am glad to not have to carry the heavy bag of IV fluids I had been reaching for earlier, but somewhat embarrassed as it flies up the mountainside lifted above the head of a kid who should be in elementary school. My colleague, a nurse who had just recently been fighting Ebola in west Africa, refuses to give up her bag of supplies and impressively manages to hold onto it the whole way, rebutting multiple offers from the local residents. Our trek is halted briefly as two water buffalo fight on the trail in front of us, until one of the older Tamang teens drives them off by pelting them repeatedly with fairly large rocks. We make it up to the site, and I conduct a quick survey alongside our wilderness survival expert to ascertain the safety of the location and put into place a contingency plan for landslides, flash floods, and additional earthquakes. This should work.

The Tamang have been hit hard by the earthquake. They are among the most geographically, socially, and economically isolated members of Nepali society. Their rural existence means that most of them have to walk an hour or more across some of the most difficult terrain on the planet to get to the nearest health facility. Although we are just barely there in time to help those injured in the earthquake, we are able to provide primary healthcare services to a population that is wildly underserved. I hope that we can help. I hope that our presence doesn’t undermine development of local health infrastructure. I hope our ride on the helicopter didn’t delay another village receiving their food rations or shelter delivery. I hope we can do more good than harm in this unfamiliar place we barely understand.

Over the next few weeks, alongside the staff from our Nepali partner organization, we suture wounds, treat coughs, examine children and babies for signs of malnutrition, and see some 1300 patients among a population of 9500 in the Jharlang and Reegaon VDCs. Patients make their way through our system of Triage, Examination, and Pharmacy. We make adjustments and get better, allowing our incredibly experienced nurses more autonomy in triage, and tailoring each clinic to the needs of that location. Usually we start getting really good at it just before we move on to the next location. I am working 8-10 hours a day on the clinic, then working another 4-6 hours at night collecting data and analyzing it. It’s exhausting, but I love the work. The kids hang around while I read documents by headlamp and type information into the laptop, then tap on my tent in the morning to wake me up. A few of the Tamang come through the clinic line 2-3 times, just as any Emergency Department in the US has repeat customers. Some come for chronic issues we have no hope of curing. How can we tell a herder or farmer to take a few weeks to rest their aching legs and back? We can’t write them a referral to physical therapy, nor can we expect a prompt orthopedic consult. Other problems are too easy to fix: a skin rash from scabies, an acute micronutrient deficiency from a diet with too much maize and not enough protein, a complicated laceration that can our lead Emergency Medicine Physician expertly stitches back together, or a worm infection that we can cure with a single pill. If only all problems could be solved so readily.

In each village we pass through, the Tamang are primarily curious, and upon finding out our purpose, incredibly grateful for our presence. I can tell they are new to foreign aid workers. We have to work hard to manage expectations. We didn’t bring an optometrist and lens maker with us, we don’t have the ability to do surgery except under the direst of circumstances, for such things they will have to make the long and dangerous trek down the valley and take the bus to Dhading Besi, if the roads have been cleared by now, that is. They will have to risk injury and a lonely death on the treacherous trails to get what we consider basic medical care. Some of them are angry at us. I am angry at us. I wish that they hadn’t gotten their hopes up that we could fix their glaucoma. I wish we could do more, that we had greater capability. I wish they didn’t have to choose between austere self-sufficiency and urban poverty. But there isn’t time for reflection. The line is starting to back up, and we don’t have many more hours of sunlight left. Next patient.