Mountains vs. Hills

This morning I was thankful for my morning wakeup call from my husband telling me it was time to get it together and head towards the hospital where my team would rendezvous, load up, and begin our excursion. I was very excited for the opportunity to be working with such knowledgeable experts in their respective fields and I very much think the combination of expertise was fitting: infectious disease, clinical scientist, and disaster medicine. 

Terrain

This picture was actually taken from the window of the room Sudikshya and I stayed at in the hostel. The terrain in this picture illustrates the type of terrain we traveled on during our journey to Gorkha District.

It was a long ride down a very bumpy, winding road through the hills of Nepal towards Gorkha, which meant no additional sleep unless I was prepared to sleep through what would look like seizure activity as my ears continued to pop. These "hills" as the other two kept calling them, are really what I would liken to the size of the Rocky Mountains back in the States. Sudikshya and Dr. Pandit both laughed when I explained to them that when you come from a very flat place, any major increase in elevation tends to leave a person marveling at the view. Sudikshya's response was to ask if Indiana was similar to Illinois because she noticed lots of corn and flat land there--of course that was a big "Yes." 

Sudikshya lived in Ottawa, Canada for several years during undergrad and visited the States a few times. She was familiar with the idea of seeing land that was so flat you could see a horizon where the land and sky meet. To her, being originally from Nepal, she thought it was neat to see someplace to flat. Ha! You hear that Midwesterners? Someone actually has land envy. I practically wanted to invite her to come visit me in Indiana during the Fall--this gal needs to take a hayride on some of this flat land! 

A Little History

Nepal used to be a "Kingdom" up until the civil war here, which eventually led to the removal of that monarchy and the formation of the "Republic of Nepal", which only happened about ten years ago. According to Dr. Pandit, the road we took also goes to a common tourist town called Pokhara and is also the major highway used for imports and exports from India. Such a highway did not exist prior to the birth of the Republic and has been a very large component of developing Nepal's economy. While it is still an evolving nation, the cell phone towers, development of roads, and the adoption of a Parliamentary judicial system have really helped to improve quality of life for the Nepalese.

This is one of the walls of the castle in Gorkha District. This wall was at least 150 feet in the air and located near the castle's keep. 

There were many historical sights to stop and see along the way to the Gorkha District Hospital, which was going to be our first stop in our feasibility assessment. The other major stop we made while we waited on the availabillity of the physicians at the District Hospital was an old castle. This paricular structure did sustain some damage from the earthquakes, but only at what I would describe as the castle's keep. Otherwise, all 800 steps and the surrounding walls remained with good integrity. That's right--all 800 and I walked up them all. You only live once, right? Or at least that's the Chriistian theory. For scientific purposes we were just testing that theory to see what would happen if one of us croaked during the skyscraping trek up the 800 steps to what seemed like the clouds. (Sorry, maybe that was some bad humor.) Namaste!

Sudikshya was kind enough to take this photo of me as we decended from the top of the castle. It had some beautiful views!

Gorkha District Hospital

This picture was taken just outside one of the District Hospital's main building. As you can see, it has several buildings and the patient influx is near-constant from my observations.

Once we arrived at the District Hospital, we were ushered into an office area where the Medical Director would meet with us. I sat and listened to Dr. Pandit introduced us alll and explained the reason for our visit in Nepalese. As this conversation evolved, the number of people in the room began to grown from 6 to roughly 10 or 11 and we were being served hot tea. I did not speak Nepalese, but I began to get the impression that the increase in meeting attendance was a good sign.

Once this meeting was over and we were making our way towards the lab facilities, Sudikshya explained that the staff was very receptive to the idea of assisting in collecting public health data and processing lab specimens. The Lead Lab Technologist and the Medical Director invited us to tour their lab, which wouold give us an idea of what additional equipment this facility would need. This was a very large victory very early on in our journey because the hospital staff were willing to do whatever they could to hellp with the implementation of publlc health surveillance. This is the equivalency of a major hospital partnering with another university hospital to collect and process data that will eventually lead to improving the overall heallth in the Gorkha District. Hooray!

District Health Office 

The next stop was the District Health Office in Gorkha, which would be the U.S. equivalence of a county-level department of health. The aim of this meeting was to speak with the Gorkha District health officials and gain their perspective of how feasible a publlic health surveillance system would be in this region of the country. Keep in mind, there are lots of components to consider:

    -Geography: Gorkha District contains some of the most mountainous areas in the world.

    -Transportation: The terrain only allows for motorcylces or 4-wheel drive ATVs in many areas, so transporting samples will be a challenge.

    -Communication: There is an app that will help with the reporting of epidemiological data and is perhaps one of the lesser challenges because despite elevation, the cell coverage is pretty decent. 

(Note: I still have yet to figure out how there is such good cellular coverage in the mountains of Nepal, but in flat, rural Indiana near where my dad lives is a notorious dead zone. That figures.)

     -Specimen processing turnaround: The first two components I listed above are really the limiting factors on decreasing the turnaround time for results. The idea is to shorten turnaround time on processing the cultures so that treatment is less delayed. 

     -Establishing a unified reporting system: This somewhat ties back into communication, however as with anyting for study purposes, there are going to be forms that need filled out. And before they are filled out, they need to be developed (Yawn!).

As luck would have it, the visit to the District Health Office did not greet us with as much enthusiasm. The good news is, the officialls we spoke with  and expressed their reservations on the feasibility of specimen collection and processing. The bad news is they were asking what "incentive" there was to motivate such actions. Great. That was the type of response I was mentally anticipating and mulling over during most of the trip from Kathmandu. I was reallly unsure of what exact "carrot" to dangle on this one especiallly because of the cultural differences. The most obvious motivator in a poor economy would be money, but is that it? I'm still brainstorming and came up with another few ideas that may be helpful in providing some incentive. 

Unity

However, the one thing on our side is that Nepal is still in a post-disaster/recovery state. Many of the locals encountered on our trip so far have all been quick to offer their stories of the "Bhūkampa", which is Nepali for "earthquake", and is an indicator [to me] of how largely this impacted the people. It has been well-documented in the field of disaster management that anytime there is a large-scale incident, a sense of unity becomes commonly felt among the population affected. In some cases that could be the people in a small village, in others, an entire nation. (Examples: USA 9/11/2001, Haitian Earthquake 2010, Japan Tsunami 2011, Boston Marathon Bombing 2013, London Subway Bombing 2005, etc.)

This sense of unity oftentimes promotes a sense of duty among individuals to become more involved in recovery and to help where they are able. It is because of this post-disaster state that I hypothesize other officials in the outlying Heath Posts in the Village District Committees (VDCs) will not require a large incentive, and will help implement a public health surveillance system knowing that it will promote a healthier Nepali population. 

Just a side note:

Unfortunately, many times post-dsaster scenarios give birth to implementing concepts that would never have gained stakeholder buy-in before the disaster. It's because of post-incident findings and lessons learned that many stakeholders begin to "see the vision" behind necesssary adjustments and are less reisstant as a result. I'm channeling my inner Steve Irwin here: This conundrum is commonly found in a more "traditional" setting where people are not accustomed to--ahem--change. In many cases, this can leave more proactive emergency managers feeling as though they are banging their head against a wall and tap dancing in an empty auditorium. Who knew that such a small, one-syllable word could cause such headaches?!

Sleeping Accommodations

After we made a few other stops we traveled back to the City of Gorkha and made a discovery after a little more recon: The place was not leveled. 

This is another picture taken from the window of my room at the hostel in Gorkha. As you can see, many of the buildings are still standing and appear to be in good condition as they are still being used. I am told by several locals that civil engineers came by each building to do an inspection shortly after the second earthquake.

In fact, most of the buildings there were still standing tall and appeared to remain in decent integrity. (Of course this was just a basic windshield assessment, but it counts if the buildings are still being used!)

We made our way to a hostel that Dr. Arjyal set up for us and proceeded to drop our belongings off and head to dinner. This trip just dramatically improved: No tent necessary AND we get a hot meal.

Nighttime view of the City of Gorkha from the hostel I stayed at during my tour in Gorkha District.

Field Trip Planning

I was unable to post the last several days because some plans developed later in the day on Wednesday that subsequently resulted in my rushing around that night.

I got a call from Dr. Arjyal around 4:30 p.m. Wednesday to come to his office and meet with members of his team. I was over near Patan Square at the time, so my walk was only about 10 minutes to the hospital.

Once I arrived, I noticed the hallways were nearly empty whereas the day before at around 2:30 p.m. the place was practically packed. In some ways this brought me back to my hospital days where it seemed everyting was on overload during the day hours and everyone working day shift rotation seemed to be on a never-ending patient care treadmill, but that's another story...

I made my way back to Dr. Arjyal's office where I met with Dr. Sarbagya Pandit and another associate to discuss our future endeavors. As it turns out, Dr. Arjyal was hard at work organizing a mission for myself and two others to head out to Gorkha District and gather information and assess the feasibility of implementing a public health surveillance system. This team would be led by Dr. Pandit since he is working for Oxford University here in Nepal at the research center with Dr. Arjyal. Myself, Dr. Pandit, and Sudikshya Acharya, who studies infectious disease, will be heading out on our mission in Gorkha District at 5:30 in the morning. (Ugh! I am much more productive in the mornings, but this was a tad ambitious for my taste. Oh well.)

Now, keep in mind that to this point there really is not a very well-supported communications infrastructure here besides cellular service. Nor is there any one way to coordinate a message of the overall condition of the District, uness it comes from the three political officials in that area. Many of the Nepalese who do not reside in the Gorkha District are under the impression that most of the area is a crumbled mess with very primitive living conditions. Dr. Arjyal was kind enough to provide us with a large box of bottled water, sleeping bags, tent, a driver, and an armored vehicle (I kept calling it "the tank"). It was a situation where we all were thinking worst-case scenario, but hoping for the best. We all knew what we saw in the media coverage of that particular Nepal area and we were hoping it was a bit sensationalized.

This picture was taken during one of the stops on our journey from Kathmandu to 

Gorkha District, which was the epicenter of the last two major earthquakes in Nepal.

I quickly left the meeting excited to get back to Serita's and pack in preparation for the next day's journey. It would be a four hour ride over to the City of Gorkha, which is within the Gorkha District and I was hoping to get a little sleep along the way. 

I called my husband to let him know what the plans were for the next three days and that I would be back Saturday. In that time I did not know if I would have any access to WiFi at all, but I could at least text him from my Nepal number and let him know I was okay. Whew! I passed out early so that I could be sure and get up at 4:00 a.m.

This is a picture of me taken at one of the stops we made during our journey in Gorkha District.

XXL

'Remember in my last post when I told everyone that the workout capris were not going to cut it for a meeting? As it turns out, I'm apparently a size XXL in Nepal sizes which literally translates inito: Good luck because the next size up is a set of drapes.

**Sigh**

On a happier note, I did manage to find a nice pair of sandals in my size that I was able to barter on and get for cheap. That's right: Made in the USA, but my feet have a Nepalese exchange rate. 

I'm waiting on Dr. Arjyal to get in touch with me after his meeting today and for Toby to get back with me on the whole mat issue. I can get what Toby wants, but I need to know how to get in touch with the other physician and get them loaded before he goes out on his medical mission.

Wandering

This picture is of a small worship temple near a monastary in Patan, Nepal. It's very beautiful structure still remains intact after both earthquakes earlier this Spring.

I did some wandering today, although I still need to stop by the pharmacy here before I head to Gorkha District whenever that happens. I did get some laundry done, which was quite satisfying since it seems I've sweated through every ounce of clothing I brought. Okay, that's an exageration, but it is very HOT and I'm definitely looking forward to July 4th weekend with friends back home by some water. Lots of water. And not the flood water that is apparently becoming a constant nuissance back home.

I made it through many of the downtown shopping areas in Patan, which was really like playing some type of "Ultimate Frogger" every time I attempted to cross the street. I'm starting to adjust to my surroundings and to the flow of traffic a bit, but seeing its disorganization and chaos makes me cringe. I mean, really, must we honk the horn so often to indicate that you are driving through? Some people would like to leave Nepal without hearing loss or wetting themselves because some bus decided to abruptly turn and blare the horn. I will say that even as chaotic as it all looks, there must be some sense of order that native drivers here are all taught because I have seen no car accidents. Zero. I'm really not sure how that's even possible beccause I can only describe the scene as some type of cross between bumper cars and a kamikazee pilot with road rage.

I was actually pretty proud of myself because I used the map that Serita gave me when I went out. I was able to recognize enough places (I've only been out twice and it's quite crowded with shops here) that I even made it over to the hospital before I came back to Sanu's House (see the pictures below). Keep in mind, the two earquakes happened roughly 2.5 months ago and I am still seeing Red Cross tents all over the place from China to Germany to Japan. I was also told by Bernie (paramedic from England) that the Swiss and the Russians did an incredible initial response and helped to get things stabilized.

Heading Back

I really only stopped a couple of times to ask and make sure that I was headed the right way--and I was, so that was comforting. In all honesty, from the moment I left the hospital to return I was watching the looming clouds overhead and noticed a breeze developinig. I was sure the rain was going to start pouring full force since monsoon season in this area is just beginning. Luckily, I made it without getting caught in the rain.

Field  hospital tents set up outside Patan Hospital. There is a nurse standing on the right side of the picture and those other vehicles are for patient transport. 

Pictured above is a Unicef field hospital tent setup outside Patan Hospital. There was a line waiting to enter the tan tent on the left side and all of the tents appeared to be pretty full of patients.

Good Successes

Yesterday I posted pretty early on in the day before I had several good things happen aside from the sightseeing and last night I got in a tad later than usual and I needed to use what daylight hours were left for other things.

 

I found this guy trying to climb the steps of a temple while I was taking my tour around Patan Square. I could not resist taking a picture and showing everyone. He represents the opposite of how traffic is in Nepal.

Firstly I wanted to start off by saying that I'm unsure which is more terrifying: 

-Tarzan swinging off a ledge in Costa Rica

-The traffic in Nepal

Holy cow. Pedestrians pretty much just have to take the right away here and weave between motorbikes and cars as they go through the downtown areas. I have never wanted to wear a helmet and survive in a bubble more in my life than when I was trying to navigate through the busy downtown area here. After my meeting yesterday at Patan Hospital (I'll get to that next), I was given a ride on a motorbike and dropped off near the place I'm staying--which was nearly just as scary because of the close proximity all of the motorized vehicles have when traveling near one another. The one positive thing is that the traffic is typically so dense, the motorbikes reallly only get up so about 20-25 kilometers per hour. Motorbikes and small Volkswagon Rabbit-sized cars are the typical mode of transportation here. There are just a few pickup trucks that I see in passing every now and again, but they really are not too common. (Surrprisingly, I did see a newer, silver Ford Ranger the other day.)

Above: One of the monastaries in Patan, Nepal. 

 

I'm unsure of what exactly this is called above, but I wanted to showcase the intricate detail on this statue that survived the earthquake. Verry beautiful.

Meeting

This picture was taken just outside of the ER in Patan Hospital in Nepal. Dr. Arjyal told me that after the earthquake there was such a large volume of patients that the predetermined waiting areas were not sufficient. For example, they were so crowded with patients who were triaged "Red", the "Yellow" and "Green" patients were actually outside of the hospital waiting for care. The designated "Green" area actually became the hospital's front lawn.

I was able to get to Patan Hospital, which is about a 20 minute walk from Sanu House, and meet with Dr. Amit Arjyal. Meeting with him was hands-down the best experience of the trip so far. As it turns out he does clinical research for the hospital and is working with a small team to try and establish some type of public health surveillance system in the Gorkha District of Nepal. The biggest challenge for that team is that they have never had to establish anything of this nature from the ground up before, and when I told him of my background, experience, and my occupation, he became pretty excited.

To give everyone some idea of what we are talking about, Gorkha (Pronounced: Gor-Kah) District is where the epicenter of the earthquake was located and as a result, was the most impacted. As Dr. Arjyal explained to me yesterday this area is on the cusp of monsoon season and there are already public health concerns with water-born and food born illnesses in addition to febrile illnesses. There is no pre-established public health surveillance system here and what I would be working on with this team is to develop one specifically for this district and then hopefully be able to adapt it to other districts here as well. Needless to say, I am ECSTATIC!!

I will be meeting today with Dr. Arjyal and other members of this team to hopefully gain approval of other Patan Hospital officials and to colaborate over what the next 5-6 days will look like in terms of our activity. Dr. Arjyal says that if everything goes accordingly we will be heading to Gorkha District tomorrow to begin meeting with members of the Health Ministry there and seeking their support and we may be there for up to 5 or 6 days. (Toby, I hope you're reading this.) With the information I was given yesterday, I believe this will be a fairly well-recieved concept because other officials with the Health Ministry here see the need for implementation of a system like this. 

During our meeting I wrote down several things and asked Dr. Arjyal to see if he could find out where I could locate some informaiton that will help me determine the terrain (there are mountains on the northern region of Gorkha District), the cellular coverage, and some other various details that will help us determine some of the more logistical planning that will go into implementation. 

Now, keep in mind that when I packed for this trip I was planninng to be out in a more remote area so I packed a lot of quick-dry clothing that was really for more summer-ish climates that I would experience in the United States. I really was not super concerned with impressing anyone. Towards the end of the meeting, I really got a good chuckle when Dr. Arjyal gently tried to tell me that I would need some, "....trousers that go to your ankles." Basically, the workout capris were not going to cut it for the meeting that I have today. (Haha!) I really had not planned on a business casual-type dress code, but I will see what the market throws my way when I go out today to pick up some other items. (I still have to get the 5 sleeping mats that Toby asked me to pick up for Dr. Ranjeet.)  

SIM Card

Just before Serita's brother took me on my tour yesterday, he helped me get a cheap mobile phone here because the SIM card reader in the phone I brought from home was not reading the one I bought here. Never in my llife have I had so many issues with a SIM card. Once I finallly got my phone, I was still having issues so Serita took me to the place we bought the SIM card (Remember, this place was like going to the BMV) and the man behind the counter must have some type of infinite SIM card wisdom because he was able to get it to work with the phone I just bought. I practically wanted to shout, "Freeeedooom!!" in the store because this was the first time I would be able to contact the folks I needed to connect with out here. (I hope you Braveheart fans got the joke.) Anyhow, so in one day I was able to secure a medical mission and have cellular service. **Sigh** I felt like a rockstar.

Before Bed

To celebrate my good day I went into a convenience store and bought a 20 oz. COLD Mountain Dew and a small bag of potato chips. The emphasis is on the temperature of the soda because it is not often you find cold drinks here; almost everything is served at room temperature. Hey, it's not my norm, but I haven't really felt like consuming alcohol here, so I figured the soda and chips would be a good substitute. Once I got back I "celebrated" and then took a shower, which felt amazing after the 100+ degrees Fahrenheit that I was out in most of the day. I'm pretty sure the water sizzled when it hit me and steam began rolling. If someone would have handed me a wok over the door to begin cooking at that moment, I would not have been surprised.

I spoke with my friend from England, Bernie, who let me know that his teaching workshop was taking a more successful turn. He also mentioned that when I get back from Gorkha if I want to come to one of the workshops where they are teaching the taxi drivers first aid, I should attend. Hopefully that is still an opportunity that is still in the cards for me--we shall see. I know that this trip has not went as anticipated, but nothing ever does and I'm just happy to be here and lend a hand to those who need it.

I was lucky enough to be able to speak with my husband this evening and tell him what a experience I had that day. It felt so good to talk to him. We planned last night to Skype when I got up this morning, which went well.

I then attempted to speak with my staff back home, which was cut short due to WiFi problems but it sounded like a very busy week for my department. Again, I'm very fortunate to have the staff that I do and that they are able to handle things in my absence.

Lastly, do not be afraid to leave comments for me on this blog. I really enjoy any commentary or any questions that my friends/colleagues back home have about my trip and the culture here. I'm aware that it is quite different here and I encourage any comments or questions.

Another one of the surviving ancient sculptures in Patan.

Beautiful temple with ornate detail that glistens in gold. 

In the background here you can see some of the mountains.

This is inside one of the temples where people are gathered for a service. The man sitting down on the right-hand side appeared to be conducting some type of spiritual teaching.

This character in yellow stopped and asked Serita's brother (at the top of the steps) if I wanted to take a picture of him. He is hauling these to vessels to go collect water near the river shown in the first video I posted. This is very characteristic of the activity seen in the downtown areas of Patan, Nepal.

Patan Square Video

https://youtu.be/T9k8m1_hQys

Patan Tour 1

https://youtu.be/CobfLptXn6s

Touring Patan

For those of you who are interested, Patan is a small town that buds right up against Kathmandu, Nepal.

Phone

This morning I received a message from Toby that I need to get some yoga mats for sleeping purposes, so naturally I just added that to the list of ointment for the mosquito bites (don't get me started), and a phone that actually likes the Nepalese SIM card I bought yesterday. By the way, purchasing a sim card here is nothing short of a process I would liken to going to the BMV. You have to have a photo to attach to the form, which is similar to a passport photo. Then they need your passport information and your length of stay. FINALLY, they need my husband's full name and his grandfather's full name--whether they are alive or not. I thought Sarita was joking until she pointed to it on the form. Soooo....after running that drill, I have a SIM card that my American phone (that probably has Chinese parts) does not want to read. Luckily, a new phone here is a matter of a few American dollars.

Sarita's (I think I finally got that spelling right) brother took me all through the town of Patan and to get my phone this morning. It was about a 2 hour excursion on foot, but it was very beneficial to see the existing infrastructure and what was already underway for relief and recovery after the two earthquakes. Of course I had to stop and take pictures of the various temples we encountered along the way.

During that tour I spotted a shop selling fruit. I guess the word "banana" must be universal because Sarita's brother doesn't know a lot of English, but he knew what I meant when I said I wanted a banana. (Ha!) By the time it was all said and done, I had 12 bananas and I only paid 100 Rubles, which is literally pocket change in U.S. currency. I now have breakfast for the next few days if I do not return back to my room at Sanu House.

Damage

As you can see in some of the pictures below, there are a lot of crumbled dwellings--sadly this is just a glimpse and does not do the full extent of the damage justice. I also hope to post some videos later.

As we toured Patan, there were many locals out working to do manual cleanup. It gave me goosebumps to see these people doing much of the same labor I remember seeing depicted in photographs of the 9/11/2001 aftermath in New York City. I say this as an observation only, and not to liken the impact of this natural disaster to a terrorist attack. They are two totally different scenarios and I respect them both individually.

I just received an email from one of the physicains (Amit) that I am to meet up with later this afternoon. I will be walking to Patan Hospital to meet him so that we can discuss plans for the rest of the week. I also need to get those yoga mats to another one of the physicians I will encounter later on my journey.