APR-C-11
THE SECOND FULL DAY OF CLINIC OVER-RUN
IN BORAT,
WITH MY TRYING TO BRING THE TEAM UP TO SPEED,
IN MOVING THE PATIENTS THROUGH IN TIME
FOR THE STUDENT CASE PRESENTATION TUTORIALS
AND THEN A BRIEF TOURIST TRIP TO THE HIGHEST VILLAGE
IN THIS VALLEY, LAHORI, TO WALK THROUGH THE QUAINT TRAILS
OF THIS REMOTE MOUNTAIN VILLAGE TO WITNESS EVERYDAY LOOMING,
TAILORING, CHARCOAL IRONING AND WHEAT MILLSTONE
GRINDING BY MILLRACE WATER POWER—
EVEN GETTING INVOLVED IN A HIGH ALTITUDE
VILLAGE VOLLEY BALL GAME
April 26, 2002
The day began bright, even if still cold, as opposed to the very cold windy and rainy status to the present morning in the high village of Borat. If ever there is a draught in India, just call upon me, since my services should be invaluable as a rainmaker. “It never rains in Spiti Valley” was a phrase I heard over and over on my first tip there in a1998, when it rained every day and hard in this highest of the arid valleys in the rain shade of the Himalayan Range. They had never seen anything like it before or since I am reminded each time I remind them of the “It never rains.” Reassurance. But, this April 26 is fully six weeks away from the late June beginning of the monsoons, and the last few days have had rains heavier than the monsoon rains in this very atypical very cold day. So, I can bring weather to places that have never even thought of having rain before my arrival.
I had scurried home to my crash landing in the doubled up Guest House room in order to take the two packs out of storage in the Mahindra Jeep where they were being kept mainly for the later trip to Nepal, containing such items as gloves, parkas, wool clothes and down-stuffed winter gear—all expected items for the Nepal Kumbu Ice Fall, but not for the warm subcontinent of India in the last stages of its hot dry season. I got out several layers of warmer things on return last night, and before getting ready for bed in many of those same layers after typing up my observations of international medical education pedagogy (APR-C-10), I was glad I had them to replace the light summer weight tropical traveling duds I had worn since takeoff from Maryland’s record setting April heat days upon my departure from UVA and Derwood, even if much more hasty and delayed than that which was planned.
We gathered at breakfast and I announced that now the efficiencies about which I had preached yesterday would have to be put in practice today, since the clear cold (at lest, non rainy) weather had doubled the number of patients that were already waiting for us over those we had seen the day before, and if it were both clear and warm the following day, it would redouble still again. A few of the students responded to this call for efficiency, but a couple looked like they would have to try another line of work, before the tense business of thinking fast on their feet with someone else’s life and welfare on the line—every four minutes. With the pressures of such decision assistance, it meant no one as uncomfortable as two of the six students were could be operating anywhere near patients unsupervised, and as the patient queues mounted up, they would simply freeze up in inaction. The inability that comes from the insecurity of operating way over your head in what looks like it might become an independent judgment, and may even be necessary to practice this way for the rest of a career, caused a crushing panic in at least one. It is so much easier to refer them somewhere or get an extra test or postpone taking responsibility by shunting them away to the data-generating company There were frequent complaints about the frustrations of dealing with translators—but it is a poor workman that blames his tools. The first half dozen patients I had to see in the morning and the first dozen of the patients in the afternoon session I had to see with no translator at all. This becomes pure veterinary medicine. But it works much more reliably than pulling out one’s hair over the inadequacies of international settings of poverty which you came to relieve, when saying that “I have to get out of here right now and take a deep breath outside since these people are getting to me now!”
It was a day full of more interesting patients scattered among the usual complaints of osteoarthritis of the knees and GERD APD (Gastro-Esophageal Reflux Disorder of Acid Peptic Disease) and a few kids with sore throats, fussing at their ears, and diarrhea. The most significant new findings were new cases of TB—coughing blood-streaked sputum with weight loss and night sweats. The “DOTS program” advertised here as a working unit of the public health government outreach through he “PHC’s” (Primary Health Care Centers) and opposed to the CCHC’s (Community Health Care Centers which have a few more facilities in slightly higher population villages) has the same kind of universally prescribed “Directly Observed Therapy” for sustained multi-drug treatment for TB as I had seen in Malawi last month. But, I am not sure of the integrity of the programs on paper, with few examples of people who have stayed with the full course of treatment, and whether drug resistant Tb has made it up this valley.
SOCIALOGIC DILEMMAS:
THE FIRST ONE FROM OUR OWN INTERJECTION OF A
GOLDEN GIRL INTO AN ENVIRONMENT OF
“WEST MEETS EAST”
I saw several interesting sociological problems today and heard a further detailing of one of our own making from last year. I had had with me a freshman osteopathy student from Southern California, a tall blonde and likable young woman named Sammy Gorman who is 26. She learned a lot as a protégé on the Ladakh trip and was very grateful. We left together after the Panamik excursion when I had encountered her up the mountainside with one of our handymen drivers, 21-year-old Jimmie near one of the sulfurous hot springs on the hillside overlooking the government guesthouse where we had stayed. We had found a young girl with a cardiac defect, and arranged that the child would be brought to Delhi for the All India Institute (their NIH equivalent) where I had once made rounds and seen patients. She had asked if she could fly back to India during the time the child was brought there for therapy, since her father would pay for the trip and she wanted to follow through on of our patient coups. In fact, she came back again to India and had written me emails asking if she accompany me on all of the trips I had planned for this coming year. I was a bit surprised that she had that much time to take off from her medical curriculum, but, then, what do I know of the fringe areas of osteopathy.
She will be joining in on a couple of the later trips, it seems, but not altogether because she has had a life-changing experience in discovering the wonders of international medical opportunities for service. It seems that the real reason she has made several trips back here revolves around 21 year old Jimmie, and the fact that they are now “quite serious” about an East West marriage. It would seem that their different passports would be one of the lesser differences I can see from this end, and Ravi reports that Jimmies’ father is upset, since they had other plans for him, and cannot hold u their heads to say he ran off with a tall blonde tourist, so that they could not stay in India. Jimmie has not got much future here anyway, since he started off trying a MLM (multi-level marketing) pyramid scheme, which collapsed and he lost “one lakh rupees” (i.e. $2,000.) His next means of livelihood is that he wanted to buy a bulldozer, although just what he was going to do with this was never made clear, and his father was already upset about his indecision as to how to make a living before his newest scheme of becoming dependent on an older American young woman whose medical plans for her own future would no doubt be quite radically altered if she continues to pursue her interest in spending a lot of time here in India. So, the world turns.
TREATING DISEASES:
WHAT FOR?
Compared to this international assignation, it would seem that the problem patients I saw today have much simpler and far more insurmountable problems. They are faced with difficulties for which there simply is no realistic way they can get any treatment at all, let alone the highly expensive state of the art that would b e a necessary “standard of care” in another part of the world. For example, the doctors here do not feel it is worthwhile to treat worms, since everyone is still going to b e present in the same environment and get reinfested almost immediately after treatment. So, our deworming of children particularly seems one specific and beneficial thing we can do for them that probably makes very marginal sense. We have been treating GERD, for example, with antacids and H-2 blockers, only to the degree it relieves the symptoms for a short time. But, this kind of APD is based in an infectious agent that has to b e treated by a three drug combination of antimicrobials that have to be sustained for some time, and after the patient is feeling better there would be very little likelihood that they would complete the treatment course, even if they could find and afford the drugs in the first place. And, of course, the same question pertains to them as to the children with worms, why bother to treat at all, if they are going to get reinfected almost as soon as the treatment is completed?
There are several purposes for “screening clinics” of the kind that these medical camps are purported to be. One should look for serious and life-threatening diseases for which there is a marker well in advance of when the disease is incurable, and also find the patients into treatment at the earliest stages so that the highest assurance of a curative treatment outcome is possible. Yeah, right. What purpose is there in finding something that you cannot fix? And why find it early, lengthening morbidity without changing mortality? And that is even assuming that there is a treatment for the disease, let alone an effective treatment!
We made a spectacular case-finding pick up in one patient today who was questioned by the students who had never seen before nor guessed the nature of his abnormality. He had a weight loss of “over one stone” recently, had been weak, had slight bleeding from his rectum and gums, and had just acquired a most unusual skin condition, which had appeared only two months before and now had blossomed all over his skin of the chest and trunk. I was called over to look at him, since they were completely non-plussed about what it might be and how serious it could potentially be. In one glance, I recognized a condition with the redundant name of a skin fungus, which is in no way a fungus, and, more importantly, not a benign condition. He had a classic “mycosis fungoides”—which is the cutaneous manifestation of a rather unpleasant hematologic malignancy, a not very treatable or curable from of Hodgkin’s Disease. I fell what must be the great triumph of the classic internist “fleas” the neurologist: “Eureka! I know exactly what is wrong with you and even all the fancy names in Latin and French that describe your impairment; but, it is lethal and unfixable. So, on to the next patient for another clinical ‘tour de force’ diagnostic triumph!”
There were several of these. Some of them had been brought to us who had already been seen and treated by some physicians or clinics elsewhere, yet they came with the blind faith that we would give them some medicine that “would cure their paralysis.” This may be partly naiveté on their part and perhaps a good deal of Western Medicine “overselling.”
The reverse is also true. We had seen some patients who had clean curable conditions—the kind of acute and fixable problems for which such medical camps might be ideally designed—the “bragging cases” of cures brought to the poor by junior clinicians from America for free! But, no thanks. These conditions were already under treatment by Ayurvedic medicines and herbs and would not be needing the antibiotics for the specific acute condition which would be very limited by curative intervention, and would stay chronic being “managed” by Ayurvedic nostrums. But, the patient was satisfied with the “attention” if not “intervention” in their disease process, so I am not here to make them dis-satisfied with what they have considered a therapeutic relationship. Our presence here must be positive for the patients, health care staff and the community, so I collaborate with the “alternative” healing branches of the medical arts---a whole lot of it represented by what we ourselves are doing here as an alternative to what they usually have available. I have done this with the curanderos of South America and the witch doctors of Africa, and I don to place the Ayurvedic sages to far ahead on that scale of development of the medical science, but they are ahead of us on some parts of the medical arts—hey, we are here to all feel better, right?
ALTERNATIVE MEDICINE:
“ALTERN ATIVE” TO WHAT?
One of my students, who verges on the status of an uncritical “true believer” of anything mystically Oriental, asked what my opinion of the “alternative medicines” might be. I told her that as a straight laced academic surgeon I had more patience than most of my colleagues could ever muster for a lot of what passes for therapy, even if it is cant and tripe huckstered by the yogis of the world—and I include those who graduated from Harvard with a “full line” of dietary supplements, meditation prescriptions, dietary laws that would make an orthodox Jew blush. I find, for example, the moderate tones of a fellow who advises a more carefully considered diet and exercise plan a good thing---and I hear the Mark Ornish’s and Andrew Weil’s of the developed world making almost the same kind of sounds that I make—until they start doing “cranial suture adjustments” and sacro-coccygeal (tailbone) realignments, or chelation therapy, and then pop up with a full and patented line of “Echinacea, Kava, Ginseng, St John’s Wort, borrage, Vitamins E, mega-C, all packaged under my own label for added confidence.” This is a “confidence game” and is the chicanery of charlatanism of quacks, whether in India or Arizona. If anyone considers that I am anti-“alternative” since I am part of a jealous establishment, let them consider how many rock-ribbed folk have written a book entitled “Natural Health Secrets from Around the World.” If they think that any of their bee pollen or brass bracelets are so god that they are above the requirement for evidence, think again. Every one of the therapies, from coronary bypass to royal jelly and shark cartilage must be subject to the most rigorous proof of patient outcome.
Further, let it be said that there are some conditions for which the treatment is so well established that there is an enormous burden of proof required before we would ever agree to consider any options: when I was in medical school, acute leukemia in kids was 90% lethal in six months, and now with combination chemotherapy (acknowledged as toxic) the survival for a normal life is 90%, so we do not want anyone coming in and suggesting that an Indian prayer dance with chants and feathers is going to be welcome if it suggests it is a substitute for anything that provably therapeutic. Now, how about cancer of the esophagus, or pancreatic carcinoma, or lung cancer? Well, what do you have, since we have a lot or treatments, but no one of them works, so we will listen. WE don to have any curative drugs for Alzheimer’s or schizophrenia or ten dozen other illnesses that are of the kind that are prey of the alternative gang, sometimes before legitimate therapy has a chance to get there to prove that it is not working—arthritis, other inflammatory conditions and a whole lot of functional and psychiatric conditions. Any newcomer is welcomed in the absence of an overwhelmingly efficacious treatment, or after such treatments have failed. But they, too, must stand up under the same kinds of neutral observer proof of efficacy based in evidence and not in testimonials of a “typical case” anecdote.
What do the people here think of our medical camp and the therapy provided? After all, they are seeing a lot of very young people, all but one of them “girls” by their definitions, and several are foreign nationals, and one senior American doctor (the only one with a license to practice) who is not treating anyone but is only supervising and consulting the junior doctors, most of whom have never written a prescription, let alone one from the very limited stock which we carry along, which has to support all 1,000+ patients we will be seeing, since none feel they have been treated unless they walked away with something in their hand from the magic stock we have brought..
One patient summarized his thoughts in relating this through Ravi. He said “Yes, we are grateful for being seen and examined today and getting this free medicine for the rest of the this week. But, what then? We will need more of this same medicine and will need to be seen again frequently, so why are you leaving?”
This is the same response I have received in Africa, where the most ambitious ones seek to become full-time dependents of mine, and want to be assured of a “residual income” that will always be reliable there to support them. If I insist that all treatment comes through the hands of the indigenous people who will be empowered to deliver this care sustainably after we are gone, it is often devalued---“Why, that is the same fellow we had here before you came—so what is different and better?” When I insist that the local health care workers will be carrying on the same health efforts when we are gone since they were doing it under supervision when we were there, the African response is “You cannot fool us! You are white men, and you walk one the moon! You can accomplish miracles and we expect you to, but these folk we have known all our lives!
“Can any good come out of Nazareth?” has been said many ways in many places and over many times. That may be why I have such an impact coming in to such an environment as this! In Africa, after all, I am an extra-terrestrial, having not just walked on the moon (the name “Glenn” has always impressed Africans from the first time I was there—when they knew that I had gone around in space, to the second to last trip when they knew that I had been back up there as the oldest man ever to do so!)
My favorite chief complaint from an agitated young woman I had seen last year in Dharamsala was “I have too many thoughts!” She was treated with a minor tranquilizer for a short period to help her sleep better. If any of you out there were thinking of assigning this chief complaint to me, I should warn you, I have had a few more! I am able to sleep quite well except here on the wrong side of the world, when I have “too many thoughts” about 2:00 AM, and spend a drowsy afternoon staring into space.
Today’s winner was “I have a heavy body.” That might seem appropriate for three fourths of the American patients seen, but they don’t seem to feel that way even if it were appropriate. This had to do with weakness and weariness of an asthenic Indian woman who was tired, merely because she was carrying heavy rocks uphill as part of a road constructions crew. Equal opportunity is hard-hitting in India!
The African equivalent global chief complaint has always been “My whole body pains me!” And probably it does. I always had to resist on the fiftieth patient of the day with that complaint that threatened to hold me in clinic by candlelight, responding: “yes, and it is beginning to pain me also!”
One patient who cleared the queue with an excited rush as an emergency was carried in past the waiting crowd and delivered to the examining table, since he was “paralyzed.” “Could I drop what I am doing,” said both the accompanying family, and also the hyperexcited junior staff of my charges, “and come and see this ‘serious case.’”
It was serious, all right, and—in this case, at least—he was even partly paralyzed. With one glance and one question “How long has he been this way?” he became less urgent.
“Since birth.” He is a serious case of cerebral palsy, the seriousness being the lack of social services and special education and other facilities that the developed world might afford, and even urban centers in the developing world. He is a long way away from either, and the wonder is that he has been rather well cared for by the informal family net of social services. I saw several such children, who were either impaired by an unattended birth process that took rather long, or more commonly, who were normal at birth, and had developed a contagious disease at about age three, which left them sightless or deaf or spastic. Two such patients had carried hardened neurological deficits since being untreated or late treated for meningitis, and another with significant contractures already developed along with choreoathetotitic movements had had some from of encephalitis.
For the very first time in any of the Indian or African camps I saw patients who had varicose veins (three) and I had two complain of “piles.” The extreme rarity of these common complaints in the Western World was the source of an editorial I had written with the late great Denis Burkitt, so I should now revise my estimate to “rare” from “unknown” unless I can use these dubious markers as indicators of progress in development.
One of my complaints against the flightier of the students on my earlier trips to India was that everyone must have at hand the personal equipment needed, and never snitch it from a working team at a station to pursue their own purposes and paralyzing the working station. Never leave your station! I will bring to you interesting findings from the other spots, and I don not want a rush of all personnel to one room abandoning the others and instilling panic in the long queue that the patients who have been waiting will not be seen, so they surge forward to get to the desk first. My pet peeves are such vital equipment parts as a ballpoint pen. I said at the outset of our clinics that I wanted to be sure each person had a working pen, and if they did not, I would furnish them one right now, and then, never snitch one away from someone working! This little piracy can shut down a whole station that has been efficiently seeing patients at a rate of one every four minutes, and now cannot write a history or findings or prescription. The same holds for a penlight, a stethoscope, otoscope, BP monitor, thermometer, but—above all—a translator! The biggest rate limiting steps in the whole process is finding and then retaining a translator, and we have often interviewed a patient who then turns out to know even rudimentary English and impressed such a patient immediately into service as a translator. I do not know why they should mind, since the crowd is always pushing in to get close to the table to overhear and make editorial comments on their neighbors’ complaints. Periodically, I have to send Anuj as the heavy cop to push back more than 50 interlopers who is pressing in on the action area, since we are the only game in town and highly entertaining to all comers.
A thirty five year old woman came in with complaint of pain in her foot. As she sat there, I saw a series of lumps in her neck along the posterior cervical triangle. I palpated them, and there were three large fixed lymph nodes that were nontender and doughy in consistency along the muscle. She had brushed off my inquiries, saying that this area did not hurt, only her foot did. We treated her foot with some analgesics, but she has a much more significant lesion in her neck, which I would have needle aspirated if she were in any place where a cytologist or pathologist could be found. She has metastatic cancer in the nodes with a large burden of disease up there for an unknown origin. OI checked her thyroid and her breast (not easy to do in any degree of privacy since the room filled up with a rush of patients when the door had opened to let the next patient to be seen in so that we would at least have a chief complaint before getting the next one. She had nothing there so that it would be unlikely to be from one of the better prognosis cancers, but would require chest X-Ray and a visceral study. So we referred her to Mandi, the closest town—but so far away as the patient had never ever been there. Our workup was perhaps all she would get, in telling her that the more urgent problem she had that needed fixing within the month was more serious than the pain in her foot which should get better with the medicines with which we treated her symptoms while she had a serious problem that would shorten her life if not attended to immediately. “A lot you know,” she seemed to be letting us know with here smile as this news was however imperfectly translated in the instructions to send her on her way with a note to the local “doctor” to follow up on her.
Another set of cervical lymph nodes was of interest for historic reasons. Walking the roads of Barot as well as all the rest of India are the sacred cows that are there to produce fuel (not a tidy job, but someone has to do it) and milk and in some instances drayage. You can be sure that this milk is not carted down to Delhi and run through the dairy processing where its temperature is raised to short of boiling (which would denature all the milk proteins in it if it boiled) in a process described by Louis Pasteur, so it is known as “Pasteurization.” This kills the microbe peculiar to the cow—which may be sacred, but does not have any immunity to the same kinds of diseases we find all too commonly in the people walking around it—Mycobacterium bovis. When the non-pasteurized milk is drunk and the lymphoid tissue in Waldeyer’s Ring (the tonsils, adenoids, and paratonsillar lymphatic tissue in the mucosa that ring the upper gut as a sentinel of what is ingested,) these mycobacteria can set up shop in the cervical lymph nodes. They may fester and drain in their granulomatous process, producing giant cell reactions to the foreign mycobacterial proteins and this can drain spontaneously. This condition, classically known as “scrofula”, was said to be able to be healed by the touch of the ruling monarch, for which reason mothers brought their scrofulous children to court to be touched by His Majesty’s hand, so it was called the “King’s Evil.”
None of these people knew any of this medical history (based on the sheer poppycock that creeps in if uncritically accepted over time as received wisdom), but then again, neither did any of my medical students here. That did not keep them from nicely exhibiting tuberculous cervical lymphadenitis in a textbook way, even if those textbooks were unavailable to them and apparently unread by my prime USA medical students.
The students were also unaware of the significance of a large tender jugulodigastric lymph node as the sentinel node for the drainage of the tonsil in younger kids, so missed the chance to diagnose acute tonsillitis even before the mouth was opened. In a generation raised on high techery, the simpler findings exhibited here were the kind of antidote that every USA medical student should have before going into practice to know what they can do with eyes and ears and hands and head, before they go out and commit extravagant waste for no particular therapeutic purpose.
We have had no holiday break since arrival and have bee3n saving any touristic tour for the end, since getting over the long road trips cannot be said to embody “getting there is half the fun.” If we could get the clinic finished by four, we might be able to hurry through the student case presentations and the tutorials from their single faculty—mois—and still ride up the road to the village of Lahori to see what the villagers who live after the end of the road in this district we have been treating look like when in their home setting.
The case presentations and the tutorials which had been feared before now seem to be the most welcome part of the medical experience, and they actually prolonged them in longer Q and A’s to learn more. We therefore got out a little later than planned, but rode up the road, now high above the Uhal River into the mountains at the end of the road. There is a village of Lahori at 2500 meters altitude, and 32* 04. 34 N, 76* 51.27 E (LAHO) hanging from the side of the slope as water gushed down diversion troughs into small stone gristmills. The terraces that held the ripening wheat in small paddies was almost ready for the plugs to be removed from the millraces, and ground between the small but perfectly formed millstones that seemed to be delivered to them for this purpose by the rapid runoff of the spring thaw. I saw a number of these scavenged from the river rocks at the rapids and stacked up along the chutes, where baffles caused the water to squirt up and out in a balloon that looked like most mall decorative fountains.
I watched shepherds following their small flocks while spinning the shepherd’s drop spinner to make yarn of the fleece under their arm as they went. They wore heavy brown virgin wool coats that seemed rich in lanolin that shed the water that sprinkled occasionally. As I had once seen on the Tibetan village at the end of the road above Sangla in Spiti, I came upon this village off the road, where tourists are an unknown event and the village was bustling in the fall rain to gather in as much fodder as possible for the long winter ahead. The animals of the size of cows and donkeys were in the lower stable of the stacked rock hut, with sheep and goats and a few chickens at the next floor, and the much smaller quarters for the human residents was the next floor up, covered in a very large thatch of the stored fodder. The heat source was below, and the insulation was above, and they could live here through the long winter—but not without crowding and coughing at each other—which I found in evidence of their endemic disease pattern as well. Here was a duplicate of that experience.
Everywhere I turned, I was invited to come in and sit by the small smoky fire to have “chai”. It seemed they know who I am (I guess word spreads fast, from the evidence of our crescendoing clinic size, and they all smiled and wanted to show me their babies or their prize livestock. There were a group of kids playing volleyball—as we had once seen in Kibber, the highest year-round human habitation on earth over the Spiti valley beyond Ki Monastery. This time in Lahori, since the altitude was only a piddling 9,000 feet, thereof our group got in and played volleyball with them—although not lasting as long as they did.
Behind the village was the spectacular sight of the snowcapped mountain range with the Mount Lolol and Dinosol and other very Alpine features begging for a climb. Three men sat around a hooka water pipe—a safer way of smoking and one of the few examples of smoking I encountered up here.
I saw a young girl and her even smaller brother making what I had assumed were chappatis (the small pancakes that are grilled) and took their picture as they were making the small pies of a wet clay-colored mud. It turned out to be clay that they were patting in place to put on the slates that they would use for their schoolwork. I asked to see the finished product, and the young boy was dispatched to get the slate so that I could see his homework of the day, son to be “whitewashed off” with a fresh layer of clay to begin tomorrow’s lessons. His family was very excited to see him in conversation with a westerner, even if his pre-pubertal sister was shrinking in shy smiles; they invited me in to tea, and I begged off, gesturing toward the waiting Tata over by the road’s end.
While Marita and Lena were walking the streets passing the looms and tailors and the hot coals ironing that was being done which I pointed out to them after my first pass through the muddy streets, they were returning to the group just next to the volleyball game. One young man who was in the manic phase of a coming bad headache came up to each of us, and wanted to have his picture taken in all his florid glory, brushing his coat (since he had recently stumbled and was lying down in the mud the first time I had passed him by.) He was eager to have his picture taken with some Western women, and I told him his lucky day had arrived since two were on the way to him. Lucky them.
A woman we had seen coming up the road had been carrying a small yoke over her shoulders while driving a group of small heifers before her. She may have been breaking in these inexperienced small cows to break them for the yoke to convince them they would have work to do in their lives. We unfortunately met them again on the way down in a “mini-tragedy” of the kind that must happen daily around here. Ahead on the road lay one of the brown small cows, dead, surrounded by rocks that had rolled out with him in a small avalanche it had probably started by trying to run up the slope to get out of reach of the woman who was trying to put the yoke on it. There must be a hard lesson ready to be derived in their somewhere.
When we walked out of the Guest House after a too late dinner, there were a lot of gnashing gears as a big Ashok-Leyland Indian Army truck was pulling around, having dropped off its tow senior army officers who planned to stay in the Guest Quarters as their men were preparing to roll up in wool blankets in or under the truck. The head officer knew a little English and anted to talk to me, since he had heard that the Guest House had some prior guests and there were some American doctor(s) here. He came to ask questions, but mostly to show off his limited vocabulary. The mission they were on was a police and Indian Army commission from a wealthy British family with an only son who had come to India to try his hand at hang gliding, which he had just begun with some enthusiasm. It was said that he had been blown off course somewhere over Billings (which we had visited last year in a drive and climb up the rhododendron forested mountain) This, I later learned, was two weeks ago and he had not been found since. The army was here in this remote forested place to go over every area on foot after aerial surveys had found nothing. “The family is very concerned since he is an only son,” explained the captain “And they have given One Lakh Dollars for the continuation of the search. I do not think we will find very much.”
The added story I got was that if he landed anywhere in the forests here, a leopard would have most probably carried him off if he were wounded or dead. What I still later learned, was that this kid is in his third disappearing act, having gone hang gliding before and turned up missing only to be found six weeks later, and again a few weeks later disappeared again. The British family is upset, the tabloids are having a field day, and the army is happy to take their money, so they will search along a bit longer until he shows up with a new girl friend somewhere.
By the time we drove back down for a very late dinner, I was too drowsy upon return to type up this day’s events, as well as too chilled. I wrapped myself in several layers and tired to start, but when I noticed about ten lines of commas, or whatever letter my finger had landed on as I fell asleep, I elected to try another time. There was neither heat nor hot water, of course, in our room in the Guest Hose of the “Head Man Works”—the supervisor of the hydrel project, so I am just good for nothing more than crashing under as many covers as I can pile on.