about
Prologue
I recently disinterred a battered old ring binder, which contained about 15 rolls of black and white negatives taken when I was in Nepal from 1977-1980. It reminded me of some of the associated events, often in uncomfortable detail. I eventually decided to add some context by writing about these events, at least as I recall them .I am aware that the passage of time and my transition from a young and very inexperienced doctor to an old man no longer able to work has allowed me a certain degree of self-forgiveness and a willingness to accept that I did my best. It was accepted that doctors trained in Western medicine could deliver a top quality “Western” standard of care, without diagnostic laboratory facilities; in fact without any means of communication , other than letters, no electricity, no roads and, in my case no adult support or company for periods of months. In addition the patient population was predominantly illiterate and enculturated to the belief that disease was carried by malevolent spirits and that recovery required the intervention of a traditional healer with the skills of an exorcist.
I have tried to avoid repeating what has already appeared in Mike Gill’s book, “Himalayan Hospitals, Sir Edmund Hilary’s Everest Legacy. I would regard the following anecdotes and reflections as “appendices”, intended to supply context for the images.
Cast of characters.(for clarityI)
“Burra-Sahib”. Sir Ed Hilary. Revered by the sherpas of the Khumbu region. Relied on his sirdar, ( expedition manager, wrangler, organiser), Mingma Tsering . It was accepted that the path to Ed was via Mingma . He spoke only rudimentary English. Their relationship was warm but un-nuanced.
Lex and Nienke. Dutch couple I shared the job with in my first year. (their second year,) We became close friends.
Barry and Sue. NZ couple who helped me enormously in the final stages of handing the hospital over to the Nepali government.
Kobi, ( and Rena) Was at the hospital as one of the founding doctors. Came to relieve me while I went on leave. Returned to the hospital and rescued it with others,.(along with his remarkable wife Rena). Relieved me for three weeks while I went on leave then returned to work there for 18 months after the collapse of the hospital after the Nepali health authorities took over its management when I left.
Jim Jerram. Doctor at Kunde at the same time I was doctor at Phaphlu
Mike Gill. One of the original doctors who provided medical services when the Kunde Hospital was being established. Subsequently provided leadership to the Himalayan Trust. Wrote a history of the hospitals and a biography of Ed Hilary.
The area Phaphlu Hospital was intended to serve was the vast rolling foothills of the Solu river valley.. To attend the hospital for many villlagers required an arduous journey of one to three days or more. If they were too ill to walk they needed to hire a porter to piggyback them.
It is interesting to me to look back at what was included in my chapter of Mike’s book. I used to be acutely uncomfortable talking about my time in Nepal but I have always kept the folder of negatives, and when I saw the images, I realised the feelings they evoked were no longer predominantly guilt and shame and I can even feel some gratitude for the experience.
The included photographs correspond loosely to the text.
In 1977 I moved to Kathmandu, committed to volunteer for two years.
at the second hospital built by Ed Hilary and opened in 1975. There was a generator, only fired up for taking Xrays, a scheduled flight bringing a mail bag from Kathmandu once weekly, although there were no flights during the four months of the monsoon, no road, , no laboratory facilities, and no means of communication other than letters. The expectation of providing a Western level of tertiary care was unrealistic.
.. The “principle” impressed on all of us was to avoid deaths in the hospital, as this would be invariably interpreted as having been caused by us, i.e. that we had killed the patient rather than failed to save them The delay in presentation reduced the chances of survival, so that, we would have to turn them away if we judged them to be at risk of not recovering.
It was always tempting to try but this was an instinct to be resisted, at which I was never wholly successful.
Life and death.
I did not have to wait long to have my judgement tested, (and my eyes opened).. Before Lex and I had reached the clinic door on my first day of work we met an agitated man carrying a pale and drowsy infant on his back. . The child was struggling to breathe and was obviously exhausted with barely enough strength to hold on to his father’s neck. His cheeks were flushed and smeared with dried snot and there was a loud, honking expiratory wheeze. With only a moment’s hesitation, Lex told the father there was nothing to be done. I was stunned. Had the decision been left to me, I would have given the boy antibiotics and fluid. Small children have a remarkable capacity to recover quickly but, without any laboratory facilities to assess the severity of his condition, Lex was not prepared to risk having the infant die while in our care. The father paused briefly then trudged off down the path towards home, already, I imagined, preparing himself for the inevitable end. Sadly It was often assumed, when treatment was refused by us that we were expecting a bribe Corruption was part of everyday life and we had to be explicit that it was not the case,
Lex and Nienke flew out after just a few days for six weeks leave.
Acute abdominal pain and bowel obstruction were a terrifying combination .It invariably meant that a surgical intervention was necessary but my training as a house surgeon had not extended any further than removing inflamed appendices and emergency caesarean section.
The chances of survival depended on the rapidity of response,( and the skills of the surgeon ),
Intestinal worms were endemic. It was not uncommon for the sheer bulk of the parasites to cause bowel obstruction.. Usually it was possible to get enough of a worm killer into these patients so that, in due course, they would squat over a bucket and produce impressive numbers of the revolting, now paralysed freeloaders.
On one unforgettable occasion, a youngish woman, emaciated but not unusually so, presented with abdominal distension and colicky pain, typical of bowel obstruction, which was not relieved by worm medication. I had another NZ doctor and a visiting trainee intern staying at the hospital. We somehow agreed to do a laparotomy. The bowel was under such pressure from the worms that it ballooned out through the abdominal incision. We decided to try and reduce the distension by making a linear incision in the bowel, We “milked” out two large kidney dishes of the worms through this hole. The burden of worms was such that we failed to alleviate the massive swelling of the bowel. I would like to unremember watching the incision we’d made in the bowel being sutured while a disgusting, translucent, white tendril squirmed upwards as it made its bid for freedom through this closing wound.
Inevitably she died the next day. Her bowel never started to move and we lacked any facility to adequately monitor her.
During the time that I was on my own , a man walked into the hospital complaining of the sudden onset of colicky pain and vomiting. He had been at the weekly market, the “bazaar” when the symptoms started. He lived in a village two days walk away and had come to the market with a couple of acquaintances. I was confronted with a Catch 22 scenario. If I refused to treat him he had no way of getting back to his family and would die in the hospital. If I operated without a family member to support him the family could become very upset, especially if the outcome was bad. Hence, a messenger was dispatched , and three long anxious days later the patients brother arrived. The patient, who only a few days before had left the village in rude good health was now moribund . His brother reluctantly consented and I opened him up using ketamine as an anaesthetic
He had a loop of dead bowel ,purple and grey, distended and covered in exudate stuck down in his pelvis, although I had no idea why. In any case the section of intestine was quite dead and I set to excising the 30cm of necrotic gut Although I had a reasonable idea of how to stitch the ends of the bowel back together, I did not know how to seal all the blood vessels in the mesentery. I tied off the obvious bleeders and sewed him up. We put him in the spare clinic room and I walked away with a deep sense of dread and failure. I dug a hole behind the hospital and buried my shame with the rotten length of gut. In the morning I got the inevitable news that he had died in the night and in the process had bled profusely from his abdominal wound. Potentially he had died of a clotting disorder, brought on by sepsis from his gangrenous bowel, rather than inadequate haemostasis but, in any case, he was dead and I could not bear to look at hm.
The brother left as soon as he could summon up a couple of porters, to carry the body, no doubt blaming himself for being so naïve as to trust the foreign doctor, who clearly didn’t know what he was doing. In that, at least he was absolutely correct.
Some months after that an official from Kathmandu fell ill in Salleri, with similar symptoms and managed to walk to the hospital. He had developed a large lump in his left loin. We. decided it was a stangulated hernia through a defect in the left abdominal wall which, because it was trapped there and was obstructing the normal function of the gut, would require surgery. He refused this point blank and said he would wait until he could get a flight out to Kathmandu.. Evidently the word was out regarding my surgical expertise. I assumed that the hernia was strangulated and that he would soon become very ill.. In fact he sat like Buddha for several days and got his flight out in due course.. The “hernia” if that was what it was, resolved spontaneously.
In the absence of diagnostic testing, or even a second opinion, to help with the diagnosis, it was not uncommon to find there was an underwhelming response to the chosen treatment and I was often left wondering what was really going on.
Getting the critically ill on a plane to the only,, “western” style of treatment facility, “Shanta Bhawan Hospital” in Kathmandu was not always a solution. I recall with searing clarity a tall, good-looking Sherpa gentleman whom I started on treatment for TB with no positive diagnosis. After a few days of IM Streptomycin, he began complaining of tinnitus, then it became apparent that he was in renal failure. He flew to KTM but no treatment or diagnosis was forthcoming. I was at the airstrip when he arrived back in Phaphlu, .Before he got off the plane I could see he was desperately short of breath. The flight in the thin mountain air had aggravated his fluid overload and he was in acute cardiac failure. We rushed him up to the hospital on a stretcher and he died within minutes of our getting him into the clinic. We had all become fond of him. The senior sherpa nurse, Pemma cried buckets of bitter tears and I felt wretched, blamed and inadequate.
Trauma cases, fractures, burns ,lacerations were the most easily treated because the treatment was generally self-evident. I had done three months in a plastic surgery unit as my first run as a newly qualified house surgeon so knew how to skin graft.
The biggest challenge I faced was a young man who had been attacked by a bear. He must have tried to protect himself by curling up but the bear had flipped him over causing deep gashes in his arm and then bitten off the left half of his face. Most of his lips were gone, as well as most of his nose, his left cheek and jaw muscles and salivary gland leaving his jaw bone exposed . He had walked to the hospital and lay quietly as I pulled together the remains of his lips. The defect where his nose should have been remained . By extraordinary good fortune we were shortly thereafter visited by Paul Sylvester who was an advanced surgical trainee in NZ and an ex-Kunde volunteer. He spent several hours dissecting a flap of skin from the poor mans forehead and rotating the flap round 90 degrees , creating a cover for the raw area,, that was the remains of his nose . I was able to get skin grafts to “take” eventually by draining the saliva from the remains of his parotid gland through a plastic “butterfly” and he recovered . There was no “manual” to consult about situations like this. We did our best and relied on the extremely hardy nature of ( particularly ) the hill tribesmen to do the rest. ( The British Army identified their toughness which is why they were recruited for the Gorkha Regiment))
There is an ancient, Buddhist art form called the thanka. Creating these paintings is considered a form of religious devotion. The content of the paintings is proscribed but the finer points of the finished picture are open to the artist’s interpretation. A couple of hours away from the hospital there lived an especially brilliant thanka painter with a particular delicacy of touch. . The price he charged was appropriately high, but it was slow and painstaking work.
The completion of one painting took months as he worked with extremely fine brushes. Sitting cross-legged several hours a day and working by the washed out light from a small, smoke -blackened window, he was the driving economic force in the family.. He also had chronic bronchitis and had completed a course of Tb triple therapy already. He presented, complaining of weight loss and fatigue.
He was pale and thin to the point of cachexia and the skin on his face was stretched tight over his cheekbones and orbits .
The monsoon was about to begin, after which there would be no flights for four months. As a “ last resort” I urged him to go to KTM to, at least, get a firm diagnosis and treatment if it was deemed possible. We flew him down, and at Shanta Bhawan they did a minor operation called a gastrostomy which allows food to be deposited directly in the stomach, bypassing the apparent obstruction He was discharged and checked into some lodging in the area of Bodhinath where there was a huge buddhist stupa and a large sherpa diaspora. I don’t know if a definitive diagnosis was made and what further treatment was planned but he died in the night, on the same day he was discharged.
This was a catastrophe of epic proportion for the family. His wife was outraged. Her financial status was dependent on his production of paintings, with nothing else to generate income. She placed blame entirely on me and could not accept that he was seriously ill .She believed his death was the result of my sending him to KTM..
In addition I had a three -quarters finished thanka with no faces on the figures and none of the fancy filigreed gilt that was to be added at the end. I was obliged to steer my way through this grief -sodden swamp of blame and indignation ,negotiate buying the gold paint from her and persuading another renowned thanka painter to finish the painting. The second painter had an entirely different style, lacking in any restraint or subtlety, resulting in an entirely novel end result that resembled a restrained and demure depiction of, say, Michelangelo’s Last Supper but with Jesus and the disciples wearing garish clown masks like gatecrashers, who’ve made an ill-considered choice of fancydress to wear for the occasion.
There was however one unexpected bonus in this sorry affair. The painter’s father lived in an adjacent house. He was a carpenter who produced intricately chiselled patterns on low tables which were essential furniture for welltodo Sherpas. On a visit there I found he had developed a painful swollen foot. He had a deep infection and I managed to persuade him to come to the hospital,. I opened drained and debrided the abscess, curetted out all the necrotic tissue. and even managed to put a split skin graft on the big crater he had in the sole of his foot.
The plan was to know your limits and not stray outside them but the complexity of any task was not always apparent to begin with and you don’t know what you don’t know.
Doctor-sahib, you must come.. Baby not coming
Even though I had just done six months training in O.and G, so was reasonably up to date, the thought of trying to manage an obstetric emergency in a dark little hut with a dirt floor and the light provided by a sputtering smoky oil lamp, filled me with horror.
In my view there was only two kinds of obstetric events. Normal delivery, (which as many a taxi driver has demonstrated), does not require a trained interventionist, and the abnormal delivery, which is a medical emergency, too dangerous to attempt to treat hours away from the hospital.
i will never forget one dreadful example of adhering to the principle of insisting that women in trouble in labour be transported to the hospital. A young man appeared at the clinic , around the middle of the week pleading that we come to help his wife, who had been in labour for two-three days. We gave him a stretcher and he went to fetch her. By the time she arrived she had been in labour for five days and the baby was dead . I was at the bazaar and Lex was left to try and deliver the baby. He divided the pelvis through the midline which is a well -known emergency procedure but the woman haemorrhaged uncontrollably and died. Presumably she had developed disseminated intrvascular coagulopathy, a recognised complication of intra-uterine death. Lex and Nienke and all the hospital staff were devastated.
A week or two later I passed through the village where she had lived. The bereft young man was sitting cross-legged out in a small paddy refusing food, drink or consolation. He sat immobile, a mute, accusatory presence in the middle of the village, a monument to our assumed incompetence. I felt guilty for having avoided this event but felt even more guilty on behalf of Lex .One bad outcome had more influence on our reputation than ten happy endings.
I only once succumbed to the request to attend a home delivery, . The man who came to fetch me was the patient’s father, an old Sherpa gent , of considerable local status. I knew him because he was the one who had been despatched to fetch me when the much revered re-incarnate lama had fallen from his horse.*
________________________________________________________*covered in the book by Michael Gill. “Himalayan Hospitals….”
I packed a few random dressings and a pair of obstetric forceps and trudged reluctantly after the expectant grandfather-to-be, sure I was walking into a disaster, in which I was going to play a starring role.
There was no-one available to go with me and remarkably there was no-one at the house supporting her. It transpired she had come home from Kathmandu to have the baby, her first. Her husband was away working in India.
There were two older women huddled together in the main room of the house. The expectant grandfather ushered me through to a separate room and gestured by way of introduction the young woman kneeling on the floor. She was obviously in active labour. She was fully focussed on the waves of pain and barely acknowledged my presence . I tentatively tried a few reassuring remarks attempting to mask my own anxieties .The father withdrew and left the two of us alone. I checked her pulse and blood pressure but I sensed that it would not be appropriate for me to do an internal check on progress.
We kneeled and squatted together. She was restless, struggling to manage the contractions. I was fervently hoping that Nature was going to run the show and that She held the key to a successful outcome somewhere in her earthly breast.
There were no functional concessions to the special nature of the day’s expected event. She was wearing a long, black, typical felted woollen Sherpa dress , the same thing she would be wearing if waiting for a bus in Kathmandu, which added to the feeling of surreality.. She was also wearing a digital watch, the first I had ever seen and I distracted myself fiddling with that . After about an hour she started making small whimpering sounds at the height of her contractions and as she became steadily more restless and flushed. I noticed she was starting to push .Eventually , she rocked forward onto her knees and there was a long, wet gurgling sound like the eviscerated guts of a butchered sheep dropping into an abbatoir offal pit and she suddenly relaxed. I tentatively bunched up her dress and to my delight established there was a baby between her knees. Eventually she passed the placenta with a final grunt. I must have cut the cord but all I remember was helping her wrap the baby in a long grubby blanket and drinking lukewarm greasy tea with the grateful new grandfather. I never found out why there was no other attendants at the birth but I suspect it was because the old man had an entrenched belief that the Western model of medical care was superior and the women who sat impassively in the next room maybe were intimidated by my presence. I never saw nor heard anything about her after that but I do remember her look of disappointment when I gave her back the watch, flashing 00:00..I didn’t know the date and there was no other time-keeping devices to reset the watch against but that small setback did not dent the euphoria I felt as I walked back to the hospital with a spring in my stride, feeling as light as air.
Around the middle of my second year I sank very low and the Trust despatched Kobi Karalus, one of the founding doctors at the hospital to come over and give me the chance to have a holiday. The night before his arrival I had, what felt like the worst experience of my medical career. I had recently treated a young boy for pneumonia from which he had rapidly recovered. The father approached me and told me his wife had had two premature labours and that both babies had died, he asked that his wife be able to live in the hospital so that, if she went into premature labour again they would be close by to access help. I agreed to this and she arrived with all the essentials of everyday life including her attentive husband. The mother presumably had gross cervical incompetence and the baby was virtually falling out. It was duly delivered, a tiny girl, about 1500g, and about 16 weeks premature. This was a baby that could have been saved by the most up-to-date neonatal medicine. In an unheated clinic room, by the light of a flickering kerosene lantern she stood no chance. I tried to keep her warm and dripped some glucose solution into her mouth but her breathing became increasingly laboured and I was reduced to blowing down a breathing tube, feeling increasingly guilty and inadequate. Presumably she had not had sufficient time to mature her lungs and as the night faded so, too did the tiny baby until six hours after birth all breathing effort ceased. I was shattered.
Kobi later described the impression he had of me on arrival the next day was reminiscent of “Apocqlypse Now” .. with me in the Marlon Brando role of Kurtz.. sitting in the dark, muttering, “The horror, the horror”
My most memorable triumph, where my intervention truly made a difference was quite early in the first year when I was sharing the job with Lex. An anxious Sherpa appeared at the kitchen door in the late afternoon beseeching us to come and attend to his cow which had been in labour for 24 hours but was now weakening, unable to stand, and still there was no sign of the calf arriving. We followed him up a path behind the hospital an arrived eventually at an untidy cluster of stone buildings, surrounding a small dirt courtyard, in the middle of which a young cow was sitting on its haunches, with its head outstretched and its eyes drooping and dull. The atmosphere amongst the gathered onlookers was pessimistic. Lex nominated me interventionist-in-chief on the strength of two years In Veterinary School. . With some trepidation I put my hand up her vagina and was greatly disheartened to feel a wall of furry skin blocking the delivery .I was about to announce there was nothing I could do, when I suddenly realised that the calf’s head was bent double on itself, as if looking back over its shoulder and what I was feeling was the curve of the middle of the neck
. I reached in again forcing my hand into the uterus and feeling past the front legs until I could identify the head and the face of the calf. I worked my way down to the calf’s nose and, with a finger in each nostril I was able to gradually pull the head around and then, with conventional anatomy restored the rest of the animal was extracted, flaccid and showing no signs of life.. However the cow was much improved. Within thirty minutes of delivery she stood up, to the delight of the audience who had gathered to witness the drama.
The umpire strikes back.
The CDO, was the King’s most senior representative in Solu-Khumbu He was a punctilious little man, well educated and a determined nationalist bureaucrat.. I attended two meetings between him and Ed Hilary, which led the Trust to agree to hand the hospital over to the Nepali government. Given that this same government agency proposing they run the hospital, had failed to provide any service other than the construction of the Health Post building in Salleri, without medical supplies or medical staff, I did not have any hope that this plan would succeed. There had been no doctor there since I had arrived, the previous incumbent, trained in Moscow, having departed about the same time.
I had observed first-hand the administering of local justice, usually delivered by supporters of the injured party . I was visiting Kunde when a sheepish red-eyed villager arrived in the early morning requesting we attend a victim of this justice. A night of heavy drinking and a lingering desire for revenge had led to his prolonged humiliation. He was tied to a post, was urinated on and had his leg broken with rocks thrown on him. The CDO took the opportunity to make an example of the village headman as the nominal ringleader. Some weeks later he was force marched to prison in Salleri, obliged to undertake the four day journey on bare feet. He was brought to the hospital en route to prison. His feet were swollen with multiple infected lacerations and he could barely walk.
The relationship between the CDO and his team , a small legion of lesser functionaries, and the Sherpas was one of mutual distrust. The Solu valley was the furthest extent south that the Sherpas had originally moved and they were in no doubt as to their rights to the land.. The valley was dotted with large Sherpa houses and interspersed between them were the much more basic dwellings of the hill tribes,
They were hardened by their environment to be stoical , open and extremely strong. The bureaucrats of Salleri were from the Kathmandu valley or further south and were quite different. They were Hindu and fully invested in the caste system which reliably placed them within the top two rungs of their social classification, from whence their sense of superiority and self-worth originated. It was a galling anachronism for them that the hospital was built by a person who had a well-known affection for the Sherpas In addition, as the mountaineering and trekking industry continued to grow, a disproportionate amount of wealth was directed towards them.
Viewed from that facet of the prism it was easy to understand why the CDO was displaying such enthusiasm for taking over the hospital.
The first I was aware of this plan was a letter from the Trust proposing that I stay on for six months, to transfer responsibility to a Nepali doctor who would be responsible for the clinic work and run the hospital as well
I was in no condition to undertake this. Jim Jerram wrote to the Trust expressing his doubts that I could cope, which they responded to by arranging for a young couple Barry Lowe and Sue Pearl to come and support me with the handover.
I should never have agreed to undertake this but I did not have the courage to refuse. In due course the news got out that there was new young Nepali doctor in Salleri.
Dr. Pathak an urban Nepali, trained partly in India, duly arrived. He had no motivation or even a passing interest in living in this remote rural environment but refusing to comply with the posting would have had serious consequences for his career. He was guarded and aloof and we never managed any civil interaction which might have led to a co-operative working relationship.. He never confided in me and appeared bored and distracted when I tried to explain the accounts that needed paying, the records to be kept etc.
He did not accept my offer of seeing patients with me, and instead moved into the Govt. health post in Salleri. The health post had had no doctor for at least the last 18 months. The obvious practical solution was for this newly arrived doctor to work from the hospital,. But he did not respond to my invitation to start seeing patients at the hospital. Instead, we were operating in atmosphere of mutual suspicion. I decided the only solution would be to entice him to move to the hospital by removing myself so that he would not feel scrutinised.I don’t remember his seeing evSn one patient. He simply did not arrive on the dates we agreed on. seeing patients at both places with no communication risked duplication or worse,
Goodbye to all that.
As I distanced myself from the day to day management, I felt increasingly marginalised. The number of patients was dropping and Barry and Sue were helping with the clinic
A new social phenomenon was evolving. A number of young men began frequenting the hospital staff living area. This was unheard of previously., but it was apparent that they had assumed they had a right to be there, since it had become apparent that I was no longer the person in charge,, or, at least, that I would soon be gone. The table tennis table was in high demand and the solar heated shower provided them with an experience that was entirely novel. I did not feel i had the authority anymore to control this influx and the young men rapidly grew in confidence. They gathered in the communal kitchen and would fall silent and stare at me if I walked in. The staff were livid but seemed to be as impotent as I was, sintimidated by these relatively sophisticated young men. These bored interlopers were all similar; somewhat better educated, (often courtesy of support from Ed Hilary) and more widely travelled, then the norm, (they had visited Kathmandu at least) , ‘they were distinguished by their “uniform” , a version of Western fashion that they preferred; generally comprised of a tight-fitting paisley shirt, a turtle neck sweater,(or puffer jacket, if they had connections in a trekking company), flared polyester pants, tailored by one of the old men who sat cross=legged, in the dust at the bazaar, grinding away on a hand-driven Singer , and platform shoes with faux-leather uppers. They were bored and feckless, stuck in a hiatus between adolescence and leaving home to seek work, mostly in the trekking industry.
The hospital kitchen radio, labouring bravely at full volume, not quite tuned to a Hindi radio station, was grinding out Bollywood music at maximum distortion and the ping pong table was continuously in demand .
From the day of the nominal handover of responsibility these young men ignored me studiously. Otherwise nothing changed. There was no sign of Dr. Pathak and inpatients and outpatients in the hospital clinic dwindled markedly . The Salleri bureaucrats seemed to be enjoying the free service close to home and seeing a Nepali doctor. of a compatible caste which dealt with some irksome social issues
The loyal hardworking staff were confused and unsettled by the breakdown of “normal service”. We were close and had endured long months of intense highs and lows together. Village health workers ,who were aware there was going to be no further outreach ,felt rejected and let down by the Trust. My sense of failure and desolation reached an anti-climactic peak and I decided the most useful thing I could do was leave and hope that Dr Pathak would then feel able to move in.
So I named a day, put the last of my belongings in my pack, said our awkward goodbyes and walked out of the hospital. Barry , Sue and I, turned east towards the road end, four days walk away,.As we retreated, I remember the sound of the wind in the pine trees, gradually overwhelming the tortured whining of a another lovelorn heroine on the radio,not quite tuned, accompanied by the staccato syncopation of an endless game of ping pong..
I only have episodic memories of that walk out. I was lean and acclimatised, a different physique and different person emotionally than when i had walked in two years and a lifetime ago . But there was no sense of elation or even relief.
On the third day I did something indescribably stupid, for which I felt a sickening chill whenever I thought about it.. We were passing through a small hamlet built close to the path. There was a group of adults and small children sitting in front of a house. A large dishevelled-looking Tibetan mastiff challenged me, advancing warily, barking at full noise.
I disliked this type of dog. They were territorial and aggressive and were highly valued for their guard-dog qualities. I had poisoned a stray at the hospital , for which I always felt bad.
in blind fury I picked up a rock and hurled it at the dog without thinking what was behind it. The rock bounced and whizzed over the head of a woman nursing a small baby. The group. erupted in a howl of indignation and I apologised profusely and rapidly escaped . I hate to think what would’ve happened to the three of us if the rock had hit the baby or mother. that rock was full of hate and resentment: which I had supressed for so long. It was sadly appropriate that my last interaction with the people of Nepal was to flee from an angry mob pursued by a chorus of threats and insults, gradually fading from earshot as we stumbled down the last section of the track to the road end to meet the bus,, to take us back to Kathmandu
The End.
Reading through the anecdotes above, I have to own the fact that they are not notable for their happy endings. One reason for that is that the stories chose themselves. I decided to add some text after I’d looked at the photos and some of the images had evoked feelings that I had locked up forty five years ago.
One unexpected bonus of this project is that I was, for the first time able to feel some gratitude and even an appreciation of the whole experience. There were many positive experiences and some lifelong friendships forged. They deserve a more thorough consideration , particularly of the influence they have had on the decisions I’ve made since returning from Nepal. That chapter , for the time being, remains in gestation and if it reaches maturity may eventually hatch. I am afraid that the egg if allowed to hatch, might prove to be addled and unfit for consumption.
Notes:
· Medical foreign aid conventionally focuses on providing public health programs, ( clean water, vaccinations etc) and we did try and offer these but there is no doubt that without the interventions with acutely ill individuals, there would be no incentive for the population to get involved with the service we were offering.
· The problem with trying to provide emergency interventions, as a single 27 year old, two years post graduation, with no means of communication or consultation with the outside world, no electricity or laboratory tests, was that I was randomly and quite frequently out of my depth.
· The final act of passing management of the hospital to the Nepali government and walking away was a challenging way for the nearly two and half years to end but its reassuring and comforting to look back on it and feel that it wasn’t, after all, a pointless waste of time.
Epilogue
As expected Dr Pathak left to attend a family wedding and did not return or respond to the Trust’s attempts to contact him.
The hospital was rescued by two NZ ex-volunteers who returned to the hospital as emergency cover and re-established the facility
A young Sherpa doctor who came from the Solu area asked to take on running the hospital and was there with his wife and family for twenty years. The Trust were careful to nurture him and listen to his requests and he proved to be, not only a very good doctor but also a skilled administrator and negotiator, rising eventually to a senior position in the Nepali government.
Salleri became briefly famous as the site of a gun battle between Maoist insurgents, ( communist rebels who lived in the hills, extorting money from trekkers and wealthy sherpas), who aimed to overthrow the government,) and soldiers stationed in Salleri. The guerillas attacked the town and the airfield, killing the CDO and many other bureaucrats. The region was in the control of the Maoist rebels for several years until eventually a compromise was reached . There was a period of considerable instability when the Crown Prince shot dead his father the King and his mother and seven other members of the royal family. He also died of a self-inflicted wound, the King’s brother was the next in succession but he was unpopular and also suspected of having some complicity in his nephew, the prince’s actions.
After a short unpopular tenure he abdicated, the monarchy was abolished and he withdrew into obscurity in Kathmandu as plain Mr. Shah. There was no evidence made public to support this theory.
Hydro electricity has been supplied to the Solu valley and there has been road access for the last twentyfive years
The hospital continued to function through all this upheaval and has been held up as an example of a successful institution, the best rural hospital in Nepal.