FIRST REALLY MOBILE MORNING IN LEI, LADAKH: CYBERCAFE,
TIBETAN MARKET, THEN CLIMB UP TO LEI PALACE AND TSEMO
CASTLEAFTERNOON-SET UP THICKSAY CLINIC AND TOUR 14TH C. GOMPA
EVENING-LADAKHI CULUTURAL FESTIVAL OF DANCE AND MUSIC

July 20, 2001

The three long, wearying flights to get to this side of the world and up at this height were unremarkable except for a few technical glitches---my laptop could not work on battery-could not even boot. The waiting time at each airport got the opportunity to meet a few new joiners as we gathered up to our full strength of 24 in the team. The only flight for which I had a good deal of excitement, was the Jet Airways flight, a 737 flown by one of the few surviving private airlines in India, but not for that reason but for the excitement of flying up along the Karakorum Range and seeing the Gasherbruns-8,000 meter peaks in Pakistan along with the second tallest mountain on earth-K-2. I took a few clandestine, and illegal photos, since this is the very hotly contested borderlands where the borders are not defined and the subject of sovereignty is still a matter of shooting. We flew past Stok Kangri and came in to the valley amid the spectacular alpine desert scenery. We were greeted by a few of our crew and shuttled off to the Hotel Kangri-my home away from home in Lei. We gathered for breakfast in order to do the formal introductions and then unpack and just lay around getting used to the time and the altitude for a day.

I am now almost comfortable walking around in Lei, although I enforced a rather strict go-slow policy for the team of people assembled in pieces as we stopped in such ports as Frankfurt and Delhi, in each of which airports we had a little orientation session while each was introduced and asked some basic questions-like "Just where are we and where are we going?" Some of the participants look like they may stay in this state of bewilderment for some time, perhaps all the way through to the end. Or that may just be the result of being pulled out of their time zone and altitude as well as latitude---I hope not attitude!

Meet the Dramatis Personnnae
Of our Ladakh-'01 trek
(and compare this introductory acquaintance with our eventual
evaluation of the performance of each)

I had two residents-one Heather Moore, and Ob resident in Arizona, and Ken Chen, a pediatric resident in Milwaukee. This meant I had only two people who could see patients without a scond look on every one of them. Heather had taken care of the OB patients, which also fit well with the culture, since the pelvic exams are really acceptable only by women physicians.

Ken was often seeing children, but he waws used to the first world system of getting extra tests and technology rather than trusting clinical judgment. Peter DeVries, one of our only two senior medical studnts who would be a peditric resident next year, watned to see kids also, buty I tried to convince him he would have a whole residency to do that later.

I have only two senior medical students, one is Madeline Brown from MCP-Hahnemann in Philadelphia (whatever it is now called after the bankruptcy of Allegheny University which it became and the Drexel University which picked up the pieces on a fire sale. She is going into medicine, and carries with her an evaluation sheet which I am to fill out on her performance on this trip-as several others do as well. The second student I should know or have at least some ethnic affinity with besides his being a senior at University of Colorado Health Science Center-he even knows Tabby Harken.-and his name is Peter DeVries. He is going to go into Pediatrics and will stay behind for an additional two weeks inpatient experience at Lei Hospital.

There are two others from Colorado, both nurses and each are in some from of Nurse-Practitioner or specialist program. Meg Irwin is older and had another career in some from of business matters before starting in on clinical work, but had done some midwifery along the way-another with an evaluation form to be filled from the woman who runs the program and wanted her to have this experience as well as an additional one along with Peter at Lei Hospital. The second is Deborah Szymanoski, married to a Brit, and in a nurse specialist program. She is vivacious and sports a few tattoos and is very pleasant and sociable.

Martha Thompson I had finally met on the plane as we were in the air towered Frankfurt, after a year of email correspondence and a few phone calls. She had recently retired unofficially from a business which had involved her having made a good deal of money in reading and following the Wall Street Journal, and then taking care of elderly family in North Carolina before deciding she wanted to do something medical and, very specifically, surgical. She called the American College of Surgeons, and if someone talks to many of my friends about ideas that sound vaguely humanitarian and about four standard deviations off the norm, such an applicant will be found talking to me about an hour later since they inevitably find their way my way. Martha wrote me an introductory letter, "Lest you may think I am a Kook". I was not sure when I had first got the call, and had recent disastrous "add-ons" such as the Cuban Maria in Dharamsala, who, allegedly a retired nurse, was very demanding and wanted mostly to be taken out of the stuffy environment of sick poor people and entertained in something a bit more like the grand style she believed she was entitled to. I was worried about applicants I had not carefully screened, especially on such a special mission as this one to Ladakh, where the team interaction is critical. Martha is wonderful. She is here for all the right reasons without any background in anything medical, so just tell me what to do and I will see if I can set about doing it. I could always enjoy a couple of " Marthas" on any such trip-and this one I had two wonderful, and competent generalists.

In Frankfurt Airport, I was met by a rather forward and forceful young man named Trevor who had with him a young Indian girl who was traveling with him from his school. When I asked what he was doing, he said he was a senior. "Oh, good," I said, "I have been worried since we have so many freshmen medical students. What are you going to be doing next year?"

He replied "I think I will just travel." Oh? "Yeah, and I will think about whether I would want to apply to medical school." Oh, dear.

Trevor was a very young, but also very pushy kid from South African Jewish refugee parents, and I could never quite figure out what his relation with Pryah was. She was quiet and was a US-born college student of Indian born parents. She was almost always the target of any Indian Army soldiers or other street swains who would always zero in on her as if she were a Bombay movie star of the kind that are flouncing about in the vapid romance movies that are the babble of Bombay-the largest movie makers on earth. I do not mean that Pryah acted like the coquettes of the screen, it is only that every driver, or soldier's dream is an Indian woman who is like them in all ways except liberated and wealthy-e.g. -any American Indian immigrant. Trevor and Pryah were a traveling team and occasionally I had assigned them to work teams, but he would always push ahead, and usually beyond the limits of the job. He would stop the works occasionally to ask for the meaning of a word or a general question that did not have to do so much with medicine as what was happening. He would have been a real problem if he had not also had a playful streak where he realized he was out of his depth and though short on self-restraints, he did not object when the brakes were put on He became the blood pressure taker, and would instantly refer anyone who's blood pressure he found to be out of line to the head of the line, with a note that they should see Dr. Geelhoed immediately-hardly an emergency to disrupt the flow of events, but he was never shy about carrying out his actions.

FRESHMEN MEDICAL STUDENTS-THE MAJORITY
AND THE "VIRGIN VOYAGE" FOR EACH IN ANY CLINICAL
EXPERIENCE-FOREIGN OR DOMESTIC

That leaves the majority of the team---all freshmen, most of them clueless. This was not only the first foreign medicine encounter for most it was the first clinical encounter of any kind, foreign or domestic, for many of them. They came from several different schools across the US and Western Ontario, and each encounter with every patient had to be monitored for every one of them from beginning to end of the clinics.

I should start with two of the "Home Grown"-two GW students. Jamie Lin and Kevin Bergman are "typical" GW students-that is, considered "atypical" anywhere else. .
Kevin is superb. I had recruited him to join us after he came to me and I had heard about him-and we rendezvoused over the Holy Cross lecture on African Goiter. We already were full and had put a dozen on the "wait list" but I was eager that he join us. He is about eight years older than the other freshmen, and this age difference showed in several ways. He was more mature, and perhaps more intent on learning the clinical skills and knowledge. He had been a medical software salesman in business covering South America, so he knew both Spanish and Portuguese and serves as a volunteer in the Clinica del Pueblo from GW. He is the kind of student I would like to have identified as a GW product, personable, and eager to learn with a real world experience before this trip.

Jamie Linn is Taiwanese, and product of proud parents still knowing the language. She is quiet and I knew less about her other than that she was GW freshman when I had first approved her joining us. She carried some fancy camera gear and had concentrated on facial portraits, and always sought out the kids.

The next 'Pair"-at least with respect to the origin in Western Ontario medical school, were possibly an "item" since they had been touring India earlier and joined us at Delhi. She was, Karen, a blonde who had been an air hostess for Air Canada, seeming to specialize in the Jamaica where passengers would hiss at her for additional free drinks and if she did not respond, they would slap her on the rear. I am not sure this was expressed as a complaint, since she seemed to use that extremity effectively. My initial impression was that the "Air Princess" was a lightweight, and that seemed to get more airy as the trip went on.

David was her classmate at least, and she would say things periodically about what a nice voice he had, which made me think they may have had other connections. David was very eager. He would launch into things with a lot of breathless enthusiasm, and ask personal medical questions-such as, "I was wondering if I should start on Bactrim now"-putting the presumptive treatment ahead of the illness which had not yet been described or even yet occurred. He was a novice and that feeling is unsettling so he tried to make it into a more sophisticated question about each encounter he had to learn more about how to fell comfortable than to effectively fix problems.

I COULD PAIR UP Noah and Eric, each of whom were freshmen who seemed a bit lost at the start and may have continued that along the way. Noah had contactred a prior freshman medical student I had taken in 1998, now a Columbia MPH student-Rachel Welner. I have treid to reach her ever since I gave the Grand Rounds at the University of Conecticut, but I had lost her email address. So, Noah may have put us back in contact. Eric was lost in the start up at Delhi, as his luggage did not arrive, but they caught up with him in Lei.

Another student who had put a current trip particpant in touch was Sonia Szlyk who had graduated from Bates College, and I took her picture at Khardungla Pass, and that was published in the Bates Alumni magazine, which is how the University of Irvine student Robin came to be here.

A pretty blonde young woman named Jennifer officially but going byu the name Sam was also a freshman-but not in medical school but in Osteopathy. She was quite gfood and improved. Lawrnece was a tall dark and quiet fellow from Univerwsity of Rochester.

I gave a talk to the students about how to avoid offense at the many religious relics and holy places like Mani Walls and prayer flags and something about the geology of the area an the brief history. I cautioned them to take it easy about the first s4 hours and then sadi I would go out for a run on the second day, and maybe even do a bit of climbing later. I measured the oximetry saturations on a number of them, and each of which were about 88%. I listed the GPS marks-and sent them back in the brief arrival message seen in Jul-B-3 which I sent out from the cybercafe in Lei, before strolling through the Tibetan refugee markets, and around the streets for a chanc eto go iotnthe temple wher the Einstein qupote on hoe the religion of the future would look most like Buddhism if we are to survbive at all.

The objective of a number of people was to shop and I did as well-to buy a few postcards. We acclimatized and got comfortable after the long flights and ate a few times and treid to catch up on the sleep and to try to get adjusted to the new time zone. The muessein makes his call to prayer pre-dawn for the first two calls at least, and the dogs that lie all day in the sun or shade all come up for a 3:00 AM chours of howling.

I planned to get out and about a bit, and Friday was the right day. We started out in the town it was a walk up from the backstreets to the point wher we got on the steeper ascent to get to Lei Palace and a side trail to Tsemo Palace with a ridge route covered by prayer flags. It was a good initial exercise, and we were redy for it, and had carried a bottle of water and cameras, so we could look back over Lei and its environs up against Stok Kangri, the highest peak in Ladakh, and a moujntain I was hoping to climb at the end of this trip until it became apparent that I wouild be making the extended trip that was originally p;lanned for Lingshed. But, that was going to take place by helicopter, and the helicopter crashed that would have taken us there. But the extesniosn will still take place, but now in a place called Panamik along the Shyok river instead. So, the fourth venue of our clinics, two full days in each of four places will be with about half our current ful strength with the full team available for the first three venues.

So, our first half day at Lei in further acclimatizinfg involved the climb up to Lei Palace. The afternoon would invlve the trip over to Thiksay Clinic and then tour the Thiksay Gompa. We would meet some of the local professionals at Thiksay, but Dr. Devla, the Chief Medical Officer for all of Ladakh, had met me last year and is eager to get me to leada other teams out into still more distant and remote sites.

THIKSAY CLINIC,
AND TOUR OF THIKSAY GOMPA

After we had climbed down from the Lei Palace dominant position overlooking the town and had lunch, we got into the bus that would take us out past the rows of cortens and the ponds of sacred fish along the road that we would travel several timesthsi week. It is a road that coujld not possiblyh show more starkly the value of water in making life possible. Thje Indus river flows by the valley near Thiksay, where the Gompa is high on a hill behind the clinic where we would be working. On one side of the road is a bleahk and barren desert, and on theother side are streams of meltwatere diversions from the snow-capped Stok Kangri that can be seen in the backgornd, with a green right side of the road and a brown dry and stgerile left side of the road We met the clinc dentist and the medical officer at the Thiksay Gompa and also a few of the nurses who remembered me from last years' mission here. We had the obligatory tea stop, then got a guide and climbed up to the top of the hill and saw the paole working on the Gompa-a few shaving wood off trees to make a fine furniture for the Gompa. There was a queue of workers throwing rocks up hill in a bucket brigade. I posed one of the fellows who was dusty and grubby but had a special feature that made him photogenic-he was wearing a "Big Blue" UM tee-shirt! This about rounds out the number of ploaces on earth where i have seen a UM tee-shirt walking the streets in a highly functional position.

From the top of the Gompa-a place only we males can go-thank you very much-remember we will have to resp0ect the indigeno0us religions and traditonis, please!---and the whole of the Indus River valley spreads ouot as a green sward-like the Nile viewed from above in the deolation of the Libyan desert.

Thiksay Gompa was built in the 14th century---not too many thikngs in America were, of course, so that gives it seniority from the get go-but the elaborate and serence Buddha which is several stories high is then flanked by little "chapels" wherfe smaller Buddhas are seen with as many different hand signaols as can be sent by a droopy lidded Buddah-even when his ribs are showing from his self-induced emaciation of starvation

THE LADKAHI CULTURAL FETIVAL
PUT ON IN OUR HONOR

I remember the events from last year with the highly stylized local folkloric dance in the elaboratge marrage costumes of the Ladakhi women, eacho fwhom are expected to add morfe trurquoise to the famly jewels which they wear as ealoborate headdresses-if they can carry that much wealth. After the elaborate tea ceremony portrayed before us as the men all carried their teapots on their heads to be among those selected to serve the "chai" to the king, we were driniknig Godfather and Kingfisher b eer in our tutns. Which is just as well since I know that the final act is that we all have to go up and join the p[erformers to dance with them. We did, but by that time at this cold high dry environemtne with so little water in the desert air to modulate the tgem[parature switch, it got cold. We retreated inside to dinner and a celebvratoin of Sam's birthday, complete with a litel treat and candles.