(Above) Ladakhi women in their traditional turquoise headdresses

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1 Introduction The Himalayan Health Exchange (HHE) offers the incredible opportunity to travel to one of northern India s highest, least-populated, and most inaccessible regions of the Himalayas. Situated on the Tibetan borderlands, and at over 11,000 feet, Ladakh and the Chang Thang Plateau regions are where most of this 6 week expedition was spent. Two separate programs are offered by HHE, including an anthropology field expedition and a medical/dental expedition to provide health care and education to villages throughout the medically underserved area. By combining the two programs, unique insight is offered into Indo-Tibetan culture prior to offering medical services to the region. Organized by the departments of Anthropology and History of Himachal Pradesh University, located in the north Indian state of Himachal Pradesh, the anthropology field expedition involved visiting a number of highly remote Himalayan villages to experience the rich cultures of the Indian and Tibetan people. During this part of the journey, the team became immersed within the communities visited, experiencing many aspects of daily life and gaining exposure to the religion, society, and indigenous medical philosophies and practices of the Himalayan/Tibetan people. There were extraordinary opportunities to visit monasteries and temples, meet monks and traditional Tibetan healers, visit Tibetan Children s Villages, and experience the Tibetan nomad daily life. In addition to directly experiencing the culture of this highly unique region of the world, HHE also provided several courses during the expedition, through which American professors lectured on topics such as Hinduism and Buddhism, family dynamics and gender roles, effects of high altitude living, traditional Tibetan and Indian medicine, and cultural and ecological effects of tourism and globalization. (Above) Ladakhi women in their traditional turquoise headdresses Since communist China s occupation of Tibet in 1959, the area surrounding Chang Thang has been highly restricted to outsiders, allowing few

2 people to enter the region for several decades, including physicians. Traveling from village to village in this very region, the HHE medical/dental team set up make-shift clinics in tents, schools, temples, or government buildings. During the clinical portion of the expedition, there was a valuable opportunity to experience health care delivery systems very different from modern Westernized medicine, and to learn skills of how to practice medicine with limited resources and technology. Exposure to the health care needs of these particular people and the various illnesses and diseases of the region was also encountered. Nomadic Tibetan tribals, known as Changpas, and Tibetan refugees were the primary target population to be provided care. The anthropological experience continued throughout this journey as well, as more of the societal, economical, medical, and other daily concerns of the Indian and Tibetan population were revealed through patient contact. This portion of the expedition was organized jointly by HHE and the office of Health Care Program For Tibetans In Ladakh, with assistance by the National Commission for Scheduled Tribes, New Delhi. (Above) Changpas in their homes made of Yak hair Program Description Himalayan Health Exchange is an organization founded in 1996 that was started with the vision of providing much needed modern health care to remote regions of the northern Indian states of Jammu and Kashmir and Himachel Pradesh. Based out of Decatur, Georgia, HHE is run by a native to Himachel Pradesh and his American wife who have a sincere passion for what they do, and who have very good relationships with the local government in those states which allows them to enter this highly restricted area several times a year. The organization is run extremely well, and the main concern of HHE is for each person s well-being and safety throughout the experience. Once an applicant is accepted onto a team and pays the final costs for their particular expedition, Himalayan Health takes care of practically every detail

3 from the time you arrive off the plane in India, until the day you leave to go back to the United States. Though it may seem a bit high at first glance, the cost of each expedition is all inclusive, accounting for all international and domestic flights, accommodations, meals, ground transportation, medical supplies, and support staff, including local team coordinators, professors, translators, cooks, and lab technicians. Most students choose to participate in only one type of program offered by HHE, choosing to do either the anthropology or the medical expedition. These programs are each approximately 2 ½ weeks long and would cost close to $3500 for either. By combining the anthropology and medical expeditions together, the price falls just under $5000 for the full 5 weeks. These prices do not include necessary immunization requirements, passport and visa fees, or the required travel insurance that must be purchased. Students should also bring extra money for using the international phones or internet, souvenirs, or extra activities such as visiting the Taj Mahal or white water rafting. No more than $ would be necessary to carry with you on the trip. The basic travel plan of both the anthropology and medical expeditions began by arriving in Delhi and then taking a short domestic flight to Leh, the capitol of Ladakh. Participants were allowed to acclimate to the altitude for 2 days in Leh before the actual program began. The teams traveled several hundred kilometers from then on entirely by jeep. Only a couple of days were spent at each site before moving to the next location, so there was the opportunity to see many different villages, cities, and types of landscape throughout the duration of the trip. Almost the entire trip was spent at altitudes between 11,000-16,000 ft, so symptoms of altitude sickness were experienced by some team members including headache, nausea, shortness of breath and trouble sleeping. It is recommended that each person be in very good health before going on these expeditions. (Above) Sleeping conditions for much of the expedition

4 An important aspect of these expeditions that a person interested in participating should be aware of is that the quality of accommodations that is common in the US is not what will be offered during the majority of these expeditions. About half of the time was spent in hotels, which are not the cleanest or most comfortable places in the world, but did offer such luxuries as a bed, toilet, shower (that occasionally had hot water), and sometimes even a television. The other half of the expedition was spent camping in weather dome 5-person tents without the availability of electricity or running water. Though it sounds rugged, the camping was actually quite comfortable for most people, and adaptation to the bathroom situation was reached fairly quickly. One of the most enjoyable aspects of traveling with HHE was the dining experience. Each meal was prepared from scratch by a professional team of cooks that traveled to each location with the team. There was so much delicious, and safe, food offered that there was very little worry of ever getting hungry or sick. Northern Indian and Chinese food were the most common types of cuisine, though many American dishes were also served. Plenty of bottled water was provided as well. Lectures were offered once or twice daily by various professors and were an excellent source of information about the geology and history of the region, the culture of the indigenous people, and the medical cases and conditions that were encountered. The instructors were fellow team members from universities across the US with backgrounds in a wide range of specialties. (Above) The Himalayas of Ladakh, India

5 Ladakh The region of Ladakh is located in the Indian state of Jammu and Kashmir. Most people associate the state of Kashmir with the conflict between India and Pakistan; however the region of Ladakh is quite peaceful and free from the turmoil. The climate is characterized as a high altitude desert. The largest city, Leh, is at an altitude of 11,500 feet. Our travels through Ladakh took us over the Chang-la pass which is at 17,800 feet and had us camping as high as 15,200 feet. We were given adequate time upon arrival in Leh to acclimate to the altitude, however strenuous activity was discouraged throughout the trip. The temperature was quite warm during the daytime when the sun was out, but would drop to a very cool temperature once the sun set. The night time temperature at our higher altitude camp sites dropped as low as upper 30 s. (Above) A map of the region of Ladakh, India The majority of Ladakhi people practice Buddhism. There are a few Muslim people that live in Ladakh and even fewer Hindus. Most people speak Ladakhi which is a dialect of the Tibetan language. Many people speak additional languages including Hindi and rudimentary English. Ladakh was isolated from the rest of the world until 1974 when India opened 2 roads to promote trade and tourism. During the long winter months, many of the roads are closed and the only access into Ladakh is by air into Leh. Ladakh is thus a region undergoing a radical transformation as a result of the entry of Western ideas, practices, and tourists. The effects of the changes in Ladakh are still being evaluated and much work is being done to preserve the local culture and landscape in the face of increasing globalization.

6 (Above) Young monks at Lamayuru Monestary The Himalayan region is rich in traditional medicinal systems. Many people rely on Tibetan medical practices known as Amchi medicine. Amchi healers use a combination of Buddhist behavioral change principles and herbal medicines to treat conditions. The ancient Indian medical systems known as ayurveda as well as traditional Chinese medical practices are also utilized in the region. Many Ladakhi people visit traditional Shamanistic healers called oracle healers that use rituals to call on local Buddhist deities to heal the ill. Most Ladakhi people use these alternative medical practices in combination with allopathic medicine when they are sick. Because of difficult means of communication, the distance to hospitals, and the lack of transportation, many Ladakhi people do not receive adequate allopathic medical care. (Above) A view from the Shanti Stupa in Leh, Ladakh

7 Medical Clinics The medical team consisted of 6 doctors and residents that supervised the staff and wrote final diagnoses and prescriptions. There were about 24 medical students from the U.S., Canada, and England. The dental team consisted of a senior dentist as well as 5 students from England and Scotland. The group also included a local lab team, cooks, and drivers. We set up temporary clinics in community centers, schools, and primary health centers. Students were divided into groups of 5 or 6 and assigned to a supervising doctor or resident. 3 of the groups saw general medicine patients, one group saw pediatric patients, and the final group saw Ob/Gyn patients. All students were given a chance to rotate through all of the groups. In addition, 2 students were assigned to take vitals for all of the incoming patients and 2 students were assigned to the pharmacy and fill prescriptions. The medical clinics offered students a unique experience as agents of health care delivery in a very remote setting. We did not have fancy imagining or radiological equipment, thus the history and physical exam that we all learn as first years took on a new level of importance. We had a lab team from a local hospital that could perform basic lab tests including blood tests such as electrolyte profiles and liver function tests, urinalysis, pregnancy tests, sputum tests for tuberculosis, and cultures from cervical smears. As students, we took a history, performed physical exams, and towards the end of the clinics had gained enough experience to develop a preliminary plan of action. We then presented patient information to the supervising physician who would order tests, confirm the diagnosis, and write prescriptions if necessary. We were also encouraged to educate patients about behavior modifications such as cutting tobacco and alcohol use. The students working in the dental clinics educated patients on dental hygiene and distributed toothbrushes to children. (Above)- Us performing an abdominal exam on a patient in clinic

8 Some of the major conditions that we encountered were arthritis, GERD, upper respiratory infections, skin infections, tuberculosis, and rheumatic heart disease. Himalayan Health exchange also sponsors a surgical clinic staffed by Indian physicians to perform mainly valve replacements for patients suffering from rheumatic heart disease. During our clinics, we registered those patients who were candidates for the surgeries. We had a substantial supply of medications donated by various sources. One of the more frustrating aspects of the clinics was our inability to care adequately for chronic conditions such as arthritis which require a constant supply of medications. We were able to provide such patients with a few days supply of the medications they needed and advised them to visit the nearest physicians regularly. The language barrier was also a negative aspect of the medical clinic. We had translators at most clinic sites, but there were never enough translators. There was also the constant worry that important information was being lost in translation. At some of our clinic sites, there were very few people who could translate and we had to utilize some of our drivers, cooks, lab staff, and even other patients to translate for us. Overall, the clinical experiences provided us an opportunity to hone our history taking and physical exam skills while developing a knowledge base to determine a diagnosis and plan of action. During the evenings, the physicians and residents each lectured on a particular disease common to the area or about local medical practices. The diversity of students on the expedition also gave us the opportunity to learn about medical education in other countries such as Canada and England.