JUL-B-9
THE
THREE DAYS OF MEDICAL CAMPS AT TANGSTE,
WITH ONE MORNING EXCURSION TO PANGONG LAKE
BEFORE THE RETURN TRIP THROUGH CHANGLA PASS
BACK
TO LEH, FOR REGROUPING,
AND
PACKING UP FOR THE NEXT FULL DAY’S ROAD TRIP
TO EVEN MORE REMOTE KARZOK,
FOR TWO DAYS OF MEDICAL CAMPS AT TSO MORARI
LAKE
July
23—26, 2002
I can summarize the five sessions of the three days in our medical camp at Tangste in one chapter of the “Ladakh-02” story, since the events were in the pattern they had taken last year, with our streamside camp in the valley within walking distance of the Tangste PHC (Primary Health Care) center, which we had used last year. We had only one excursion out of our camp (except for a single cause celebre’ on the part of one of our number which almost got her sent back out of the team) and that was as a group to Tso (+ “Lake”) Pangong, the border with China through the three fourths of the lake that once was Tibet.
When we had arrived, with all of our number successfully transiting the Chungla Pass at 17,350 feet officially, making it the third highest road on earth through which we have transited, we were met with the official reception as we had been last year. Like last year, we were late and the entire Women’s Association of the Valley around Tangste waited patiently for our arrival in full costume with their turquoise marital dowry headdresses, passed from generation to generation with each adding some semi-precious stones, and their official “Kati Ceremony” in which we were given the silk scarf of welcome and tea. We toured the facilities, and set up for the next morning. We were eager to put the pharmacy stocks in, but we were also told not to come to early, since if we were there before 8:30 AM if would set a bad precedent for the government civil servants that are the medical staff. These were introduced. We had with us, Dr. Sam, who was the chief of this station last year when we were here, but now is posted, on a two-year rotation in Leh, but he returned with us as a “homecoming” to his former district. There is a 27-year-old Kashmiri dentist named Hanif who is posted here and it is killing him. He had come from the bright lights of the city of Kashmir, and now is isolated in this cold lonely powerless place, and on his busiest day, he might have two patients to see. It is not because of the expense that they fail to come, it is all free. But they are hard-pressed to get out of their dung-fire heated huts where the whole family is crowded and brave the –50* C temperatures in winter, when there is not much sun, little heat, no electricity, transport and still less social things to do. So, he is doing what most any ambitious Indian is doing: he is studying to take a qualifying examination for a specialty ---any specialty will do—to get him qualified to get out of India---as he has applied to new Zealand, Canada, Australia, and—in his dreams—the US. Almost all other Indians I had met who were professionals or high up in the Army command, all had elder brothers who had been more successful and had studied computer engineering and were currently living in Los Angeles or New York State. One of the majors from the nearby Army post (they all make social calls on me as a dignitary from the outside world, and perhaps since it is the only thing of note that happens in Tangste---and this summer season is as good as it gets) had all four brothers scattered in the US, and regretted only that he had so little ability left over by the time it came to him in the family, that the most he could do was to try to rise through the ranks by exercising the “whom do you know” principle, and that had so far only got him promoted to this forsaken post for two years of marking time.
There is a new replacement for Dr. Sam and that was Dr. Mansoor, who was quiet, and generally put upon, since his post here should be a happy one just now, since his sons are visiting from Leh for the break in the school holidays. His family, typically, is not accompanying him on this extreme frontier assignment, which also gets an extra bonus for combat, hazardous or extreme conditions service, so that they can move up to a more desirable assignment. There is a young woman doctor, who, like all the women doctors essentially is given the role of Maternal and Child Health, whether they had wanted such an assignment or not, along with general practice. Last year, I had scores of patients in uniform from the nearby several companies strong military posts along this road from Tibet guarded by the ITBP (Indo Tibetan Border Patrol). The military population is about double the scattered civilian population, most of whom are nomads of the 4,600 people in this borderland of high arid mountains, and narrow valleys, which can hardly sustain a flock of grazing sheep—and that is only during the best of the year—now. But, the commanding General, Brigadier General I. Mohindar Singh whom I had met last year, had ordered that the military doctors take care of the military patients in the better staffed and supplied clinics they have rather than attending the civilian clinics—though he supported them by delivering patients from remote areas. Gen. I M Singh is a very “commanding figure” being a stiff as starch Sikh Army General, is on leave, bringing his on to graduate school in Bangalore in Management Science, and returned as we were leaving so that we had a “Hail fellow well met” rendezvous on the road with his convoy.
We returned from the opening ceremonies to our camp site on the stream bank, where our group had set up a volley ball net and played with the locals, who were much better adapted to the 13,500 feet altitude. We had frequent chai breaks and also began the evening didactic sessions in which each of the students would present a patient they had seen and we would discuss the case and the pathophysiology and the care they received.
TANGSTE
CLINICS AND THE PATIENTS WE TREATED:
There is a shop here in Leh with the intriguing title over the door, “Same Same, But Different.” I could say that about this year’s clinic in comparison with the last. Of our first day’s patients, I saw a monk who had food sticking in his throat, and I suggested we see if he could have a barium swallow and endoscopies since that represented to me almost certainly an esophageal cancer, since he had no antecedent acid reflux disease, as almost all other patients did. After all of this was gone through thoroughly, he asked again for the medicine that would make this go away, since as a lama, he could not be cut upon. I suggested that he could have some temporary relief from a “bougie” to dilate the esophageal obstruction, and that did not involve him being “cut on” but it did represent an operation and only an operation would help him. Finally the translation returned: “That is just what they had told me in Leh when they had done the X-Ray and the scooping that found the cancer you suggested, and all they wanted to do was to operate also, but you Americans have medicines that work.” Not for this disease---here, or there, and the operations also are simply palliative very expensive and not very life prolonging from a disease which we should honestly say out loud is incurable.
Later I found a woman with a right supraclavicular “Virchow’s Node”. This is a sign of an intrabdominal malignancy, and in this area that would almost surely be gastric cancer. Finding such a problem, it is by definition, too late. When I discussed this case with Dr. Sam, he pointed out that ALL of the patients he had seen presented very late, and the amazing numbers are as follows: There are 4,600 people in the entire district of vast remote mountains. In the two years of his posting here, fifteen new patients were found to have late gastric carcinoma as well as a couple more who were known to have it and died of it when he was already here. Only one woman came in with an umbilical nodule (the “classic Sister Mary Joseph’s node”) and with no other disease evident on the ultrasound that they can do when the late night occasional electricity comes on as a special favor from the nearby military base generator. So, they took her down to Leh, whereupon opening her abdomen, her entire omentum was stuck full of the tumor and liver mets not seen on the ultrasound were also present. So, here is the laboratory to study this disease, and one other.
That disease is GERD (GastroEsophageal Reflux Disease). It may be due to an organism identified only during my residency era, called Helicobacter pylori, which may be carried here by the slaughter of a yak or a sheep, which is then cut into more or less thin strips and dried as jerky. Dr. Sam thinks the thicker slices may be loaded with the organism. We had tried to get the H. pylori “breatholyzer test kits” for both here and the Spiti Valley to look into the prevalence of this organism, since the epidemic is recent. The GERD that every other patient here has seems to have entered even since I have been doing these medical camps in the Himalayas, and it would be a vary good clinical investigation to find out why they have such a high rate of acid peptic diseases as well as the killer incidence of gastric cancer.
One woman came in reeking of urine. Immediately I suggested that she might probably have a VVF (vesico-vaginal fistula, a complication of unattended childbirth.) I had gone through the differential of other possibilities (uterine decensus, or prolapse, etc) and then said that it is most likely that she has a VVF, and asked the Doctora to come over to examine her, suggesting that she should have an exam and a referral for a Simm’s repair if the VVF is what she has, since such patients are almost always outcasts from their families and what ever society they could possibly find in an area so remote of social resources. It took a while to free up the female doctor. During that time, Bina got involved. Bina is not medical, and in fact is a Bombay –born immigrant Indian who went to Chicago where she stayed and now does corporate law there. She speaks Hindi, which I had tried to convince here in Leh was an unlikely language to help in the remote areas of Ladakh. “Absurd! Everyone here speaks Hindi,” she said. I reminded her that this is Leh, the Ladakh capital, and that most of the people where we are going speak only Ladakhi. This turned out to be the case, so that there was a game going on like “telephone.” The student---in this case a naive freshman who would not know what she was supposed to ask or what the significance of the answer might be---after all, this was the very first day of her life she was ever seeing patients, and now she was confronting them across a huge gulf of culture, economics, language---and let us be very frank, profound ignorance, and not just on one side---and this questioning is going on under my observation and prompting. Then Bina would translate this to Hindi to have one of our drivers or cooks who had come along with us to help in the clinic when they were not setting up the camp or making dinner. The helpers would then translate the Hindi into Ladakhi—often a different Ladakhi from the town of Leh than is spoken in the remote rural isolated communities---and even then across the huge cultural barrier of a male asking a female patient something about her genitalia.
This was not ideal. But Bina got involved, overly involved, as an “advocate”, especially when this poor 78-year old woman began to cry. “Something must be done to help her! Said Bina and looked around for someone to plead her case to, right after I explained to the medical student who had never heard the term, what a VVF is, how difficult it is to treat, how they often recur, and how they require operation that breaks down in infected tissue, and the patient goes back to being an outcast. I was called over to consult on a young girl with a heart murmur at that point, as Bina found Ravi to tell him that we must make the payment to get this patient to a hospital for an operation—as I shrugged, and said that would be necessary, but not sufficient.
I went to see the young girl, a 7-year-old who seemed normal except stunted in her growth, and with a roaring holosystolic murmur of a cardiac interventricular septal defect. I suggested that it sounded like a simple defect, and that she might get an echocardiogram at Leh on the machine I had seen them use there, and that would conform the diagnosis, and it should be an imminently repairable defect with a normal life to follow, if she is given some prophylactic antibiotics to guard against the possibility of an intercurrent infection giving her endocarditis at the jet defect.
As I was finishing this consultation with the other team that Dr. Monsoor was checking as I had shuttled among six stations manned with the students and two nurses, Bina came rushing over. “You are absolutely right! This woman has a daughter who refuses to have anything to do with her, and she has no friends or family that can stand to have here live with them because of the smell, and we must make that operation you suggest available to her right now!” She had already got Ravi to say that there were limited funds, but they could solicit other help to try to see if she could be fixed—just as I came up with the story of a young girl with a normal life ahead of her if a simple cardiac defect were repaired—a better allocation of limited funds. While we were standing there, we finally got the local doctors over to see her and Dr. Sam said: “Oh, her! She has a VVF, and was sent to Srinagar where she had an operation that failed, and when she went back there they suggested another repeat of the procedure without much chance of success and she refused it.”
Well, spot on, I guess, for the experience that leads me to recognize with some precision the diagnosis and prognosis of certain human conditions, but no luck in assuaging the angst in the team members, who have been brought up in a society where everything MUST be done for EVERY patient no matter how marginal the benefit may be, and now there were advocacy groups starting to contend. It also seemed that the patients themselves were playing the “American card” coming with high expectations that they did not get from me, that we were packing a bunch of free medicines, that fixed everything they had with a few pills, and they could forgo the less appetizing suggestions of treatments mentioned here—with which I would have entirely concurred.
DIVERGENT
OPINIONS IN THE TEAM ABOUT THE PURPOSE
AND VALUE
OF THIS EXPERIENCE,
FOR US AS
A VERY JUNIOR MEDICAL TEAM,
AND FOR
THE PATIENTS WITH HIGH HOPES AND EXPECTIATIONS
Medical missions of the kind that I engage in are intensive learning experiences. They also take place at a time in a student’s career when nothing they see will ever be forgotten, and they have to confront in their “first day in the office” the realization that people come to them with problems, not all of which (or many) can be solved. If one then compounds this scenario with abject poverty, and the marginal benefit of even heroic therapies that are more expensive to carry out than the entire economy of this valley can bear for even one such patient---take any of the three I just described---esophageal cancer, VVF, or the VSD---only the latter with any hope of a “return on that investment.”
So, the young student on her first-ever clinical experience this morning under my supervision, burst away from the clinic and went to her tent in tears and skipped lunch confiding in her diary. But that was not all. It took until the next day, but she was very angry with me, and for a cause that she had predetermined with answers to problems for which even the questions are unknown. She came to me with the following statements:
“I am so unsatisfied with the way you are running this—all you are doing is fixing problems and encouraging these poor patients with all their respect and adulation for American and Western medicine to believe there is a quick fix for their problems which they bring to you, and you prescribe antacids to relieve their GERD, but you do not eradicate the root cause, and here I thought I would be coming away from that American practice. WE must change their life style and PREVENT their problems, telling them how to avoid any of their diseases, which are so common here rather than trying to treat them. For example, we should give them all sunglasses to prevent pterygium (which she had just learned about minute before) and cataracts. We should be holistic, empowering and enhancing these people’s lives and not coming to them with treatments that they expect will relieve them, just like Americans do!”
Well, it takes a bit of guts and even more profound ignorance to tell the leader of the team with three tenured professorships and 38 years of international medical missions, the first of which were carried out at her stage but over a decade before she was born, that she has the right way to go about this. Especially since in a single sentence she got in all the cant of some overheard unoriginal ideas, scattered with the postmodernism of the “holistic” empowerment and enhancement. It is she who has the quick fix!---It is simple—just PREVENTION! OK, tell me what you know for sure that you can effectively prevent—for example, POVERTY?
Even the example she used, give them all sunglasses—presumably starting at age two throughout life. Notwithstanding the objection that they might not want to use them, and if given them, would almost surely sell them for something go of much more immediate value—like food, of example, what is the evidence that lifelong sunglasses (as she preaches to me from behind a set of designer shades loaned to her since she lost hers on the first day) prevents the “pterygium” she just learned about when I told her that was what she was looking at? There are good data that people who wear glasses—any glasses—are more prone to injury from the swirling sands of the desert environment in which we are standing by the eddy currents of the blowing sand behind the glasses which is the irritant that gives the granulation tissue that slowly grows over the eye—giving abundant time to find and fix it (with a very quick and simple procedure) if it should be interfering with vision. And, just how many cataracts did she see in clinic, and just how many of those would be prevented by lifelong use of the unaffordable sunglasses given in wholesale quantity (witness her own loss of two pair in the week) and how sure is she of this mass prescription in her own “quick fix?”
She is going to come to this valley on her first day in clinical medicine, never having been to India or anywhere abroad other than a Club Med-type vacation, and she is going to instruct these people in a change in their diet, to which they have presumably had to become adapted to survive over the ten millennia of history that originated here along the Indus River in the earliest recorded settled agronomy? And if she were going to advise a dietary change to prevent their disease, to what would she advise they switch? Big Macs? Isn’t that what she was parroting to me about American Lifestyle, that we should be reverting to a vegetarian mixed variety of food sources—essentially what these people have now? And does she recommend that I tell them as they come to me with a problem. That they should go somewhere else, since I am only interested in preventing such problems and whatever they are doing –presumably just like me---is all wrong?
I
asked her for one incontrovertible preventive practice she might name. We cam up with “Stop Smoking.” I might even agree with that. However, does that mean I refuse to treat
smokers? And would I like to take the
totalitarian orders of a medical school freshman to interdict whatever these
people are doing in their own adaptive responses to the kinds of life stresses
they must be under, since she does not believe it is good for them, and “I know
what is best for you?” She is adamant—I
have it all wrong, and I am not showing these people any respect. Now which of us has the degree in Health
Promotion/Disease Prevention, and which of us might come closer—if by no other
reason than the time I have invested in learning about their anthropology,
history, religion and their culture, and having listened to over a third of a
century more impoverished people than she had just encountered, I have a quick
diagnosis of my own: The Princess is
mandating major changes in another peoples’ lives in a categorical naïve
“preventive prescription” based in profound ignorance.
She has her own summary description: I find the way you practice medicine in this population very unsatisfying and disappointing. How might the patients seen today been differently approached in the USA, eliminating the constraints of their remoteness from facilities and their poverty? “We should instruct them in how to better their lives, and not just fix their problems.”
True, I am not even close to fixing the problems of the esophageal cancer nor the recurrent VVF, and neither of them would be fixed in the USA either. I DO hope to practice prevention for the young girl—she will have a normal life with about 99.8% medical certainty (discounting the profound social constraints she may have as a burden from this environment) and THAT is a “fix” I find better and more certain than her cartloads of sunglasses for unknown results except in making these people look more like her. And, I have one more summary statement: She will find the practice of medicine in the USA profoundly unsatisfying.
ACCENTUATING
THE POSITIVE:
THE
MAJORITY OF THE TEAM FOUND THE EXPERIENCE IN TANGSTE UNIQUE AND REWARDING
I have not dilated unnecessarily on the one negative experience of a single individual, since I have many more encounters and much more positive features in many aspects to describe. But, I found her dislocation from the fantasy world in which she lives a means for her to lash out against anyone who tries to help, however imperfectly, in her frustration from her own impotence to do anything to help anyone—especially not with fatuous blanket condemnations. In her very fastidious MTV world, I agree, there is not room for an elderly smelly woman reeking of infected urine. So, this sort of thing should not happen. But, I find it cruel to dismiss patients who come to me with a problem to tell them, “If only you lived a healthier life, you would not be so sick just now!” And, of course, if you did not insist on being so poor, you could be a lot more like me. I found her response instructive in how I might confront my own frustrations at limitations, even though they seem less boundless than hers. But, one feature I hope I will not carry from this Post-Modern parroting of the subaltern autonomy is to blame the patient for their disease—even if it could be conceivably partly self-inflicted, it will be treated according to their request for help, since most of us are aware of health only after the fact---and that ignorance may not be a property of only the uneducated.
We saw and treated (and I have no idea how many problems potentially prevented!) about three hundred patients in Tangste. I could log in many more perhaps mundane examples, countless patients with osteoarthritis who cannot be cautioned to avoid stress on their joints as they are trying to cultivate small terraces on steep mountain flanks. (That item did come up in which I suggested that a widespread USA “preventive practice” for osteoporosis universally prescribed has just had to be recalled on evaluation of the data showing more harm than good coming from HRT—Hormone Replacement Therapy—so be careful with universal prescriptions for prevention!)