Saturday, July 16, 2011

Begin at the beginning and go on till you come to the end: then stop.

Before I begin, a disclaimer. Most of these photos are mine, but there are some that were taken by Danielle Davies, a medical student at Robert Wood Johnson in New Jersey and a colleague on HHE. She has graciously given me permission to use her work, and it is labeled as such. Please see more of her work here.

Not exactly how I had expected to start my life-changing trip to India. As the pilot came over the intercom once more to say that we would be delayed leaving Raleigh, I started to question whether or not I really needed to go on the trip at all. Sitting on the tarmac at 7:15, on a plane that was meant to takeoff at 2, I began to doubt what I was doing. At this point, there was no way we would arrive in time for our 8:30 direct flight to Delhi out of Newark, and, letting my anxiety run away, I had no idea how we would meet up with the rest of the medical team once we finally arrived in India. I looked back to try to catch a sympathetic look from Emily Hughes (another UNC student); we'd been commiserating over our continued delays since we'd arrived at the airport shortly after 1.

We ended up arriving in Newark 10 minutes after our original plane had left and were resigned to staying the night. We arranged for a plane the next afternoon and got ourselves a hotel room (pictured above), fortunately meeting a third UNC student (Josh Thompson, who had been delayed on a different flight) outside and hopping the shuttle to the hotel for some much deserved rest. It wasn't the most auspicious beginning, but it was good practice for the coming adventure that would be challenging in so many ways.

In the morning, we woke up and headed to the airport for our afternoon flights, spending most of the day in the airport, before boarding our planes and finally getting on our way again. We had spoken with the main office of Himalayan Health Exchange, and they had assured us we would be able to meet up with the team once we reached India. So it was in a much more relaxed mood that we made the 14 hour journey.

From Newark we headed to London, and then from there to Delhi on a flight that was no more than 1/3 full, before we arrived in India, exhausted and excited. We were picked up at the airport and whisked to the nearby hotel, through the craziest traffic I've ever seen at 1 AM. We had to be up again at 4:30, so I took a long and deserved shower before jumping into bed for a few hours' sleep.

In the morning, I felt like our real trip began. We drove through the quiet early morning traffic back to the airport for our flight to Chandigarh, in the state of Punjab, the nearest airport to our destination in Himachal Pradesh, one of the northernmost states in India. We were greeted there by Rakeesh, our driver for the day, who told us we would be in the car for "a few hours." Unfortunately, we hadn't been briefed that on this trip, a few hours could mean anything from 2 to 12. But we were in a good spirits as we made our way through Chandigarh and began climbing towards the capital of Himachal, Shimla. We passed cows in the markets, rickshaws in the streets and trucks around blind curves that made all of us grab our seats. And all the time we continued climbing up into the mountains. After 4 hours (and a call from our trip leader, Ravi, letting us know he would see us "tonight"), we finally passed through Shimla, the capital. The rest of the team had stayed the night here, but we were trying to make up our lost day, and so had to speed through, but it looked fascinating: crowded, congested and perched atop its hill. We only had a brief look before we were off again into the hills and continuing to climb over passes and drop back into valleys over the main highway, which was only sometimes recognizable as such. After a brief stop for lunch at 2, we got slowly back in the car, wondering when our travels would be done. At 6, we stopped for tea, thinking we were close. Rakeesh was hesitant to say how much longer we would drive, but we finally got him to commit to another 4 hours as we all looked at him with surprise. The next four hours consisted of some of the scariest driving of my life. There aren't any pictures because I needed both hands to hang on to the handles of the jeep while we flew around blind curves on a single lane road, honking or flashing our lights at trucks coming the opposite way and squeezing past them with our wheels on the edge of steep drops. We dodged donkeys and dogs as we passed through villages and then we crossed a river below a dam and began to climb into the dark. After another half hour, we were finally told to get out, and walked 200 m down into a canyon, following two guides as we did. We were greeted at the bottom by the staff of our camp, bearing oil and scarves of welcome for us, and we breathed sighs of relief as we accepted the gifts, before meeting our fellow travelers and eating an incredible dinner of chicken and vegetables before bed.

We were pleasantly surprised with our tents, as we were throughout the trip. They were permanent, covered with tarps and very well-appointed, including a sit-down toilet and running water (most of the time). Josh and I settled in quickly for our first full night in India.

The next morning provided the first shock of the trip. As I woke early to get ready for a planned hike at 9, I stepped out the front flap of the tent, with a cloud of my breath in front of me, and my mouth nearly hit the ground. The view was absolutely stunning, and having driven in the dark the previous night, I had never expected it. I woke Josh, who popped his head out of the tent to equal amazement. We got ready quickly and went down to the mess tent for tea and breakfast, excited to meet the students and attendings on the trip. I had more than ample opportunity to do so once we left for the hike, as we climbed through an incredible, picturesque valley, crossing waterfalls and stopping every kilometer for photo opportunities.

The UNC Crew (not pictured: May Doan)
Here I have to make a decision about whether or not to go into detail about the other folks on the trip. I don't think I can do all 30-odd of them justice however, and so I won't talk about anyone in particular. Suffice it to say that they were all like-minded individuals, inspiring in their own ways. Nearly everyone was a pleasure to talk to and a wonderful travel partner, and I have no doubt that the other Himalayan Health Exchange trips are the same.

The goal of our hike was a small town called Chitkuil, not a significant distance from the Chinese border. It was the definition of picturesque, with traditional houses, prayer flags and a monastery against the backdrop of the outer range of the Himalayas. From there, we returned partway down the trail for a "picnic" lunch of cooked okra, fresh naan and beans. It was absolutely fabulous, as dinner had been, and was a good example of the type of food we'd be eating for the rest of the trip. We returned to camp after lunch and had the rest of the afternoon and evening off to rest and take a "bucket shower," before dinner. The next day, we would be leaving for our first clinic site at Nako, so we packed up and went to bed early, still tired from traveling.

Another few hours away, Nako would be the highest village in which we would stay throughout the trip, at over 12,000 feet. After a quick stop in Rekong peo to get permits to travel to the Inner Line of the Himalayas, we rejoined the convoy of jeeps and followed them over the winding, bumping road. About halfway to Nako, we were stopped on the road for blasting - a man-made rockslide had blocked the way, forcing us to stop for a half hour until the rocks were cleared. Once we got moving again, we drove for the confluence of the Sutluj and Spiti rivers. We had been following the Sutluj since reaching the area, and now would be crossing into the territory of Spiti herself.

We crossed a bridge festooned with prayer flags and then headed UP, around 20 switchbacks as we climbed 2000 vertical feet to reach Nako. There we were greeted with more beautiful views as we passed through terraced snow pea farms and into the village, which sits surrounding Nako Lake. At the campsite, we found more tents like those we had stayed in the previous night at Sangla, and unpacked before eating dinner in the nearby teahouse. The additional altitude definitely made it colder; I started pulling out layers I hadn't thought I would need and the temperature dropped into the lower 50s. At dinner, we discussed the logistics of the next day's clinic and heard student-delivered talks on TB and osteoarthritis. By the end of the talks, everyone was ready for their warm beds and I fell asleep quickly, excited to get to work.

I was awake by 5 or 5:30 the next day, pulling the sleeping bag up around my chin and trying to avoid the thought of getting up. But the cot was doing terrible things to my back, so I decided to change quickly for clinic and then meet up with some others for some exploring before breakfast. We took the short climb above the campsite and came to a line of stupas (literally "collections" which are often erected for the death of an important person in the community) and, a little farther on, a prayer mound covered in stones scrawled with writing in Bhoti, the local language and a descendant  of Sanskrit. More gorgeous views from this spot made me start wondering when I would get tired of looking at these mountains (the answer turned out to be never).

After breakfast, we made our way through the village of Nako towards our clinic, which was set up on the monastery grounds. It must have been quite a scene: Thirty people stomping loudly and excitedly through the middle of town carrying backpacks, stools and stethescopes, but everyone greeted us with warm Namastes. We arrived to find our clinic already set up by the staff and drivers. Eight tents were pitched, one for each of the tent leaders and each with a specific focus: three general med tents, one peds tent, one gyn tent, one dentistry tent, one pharmacy tent and one tent for triage. Patients registered with translators by the front gate and then were shown to the proper tent to to be seen. Once they received a "prescription" for their treatment, they made their way to the pharmacy tent to be checked out and instructed on how to proceed.

My first day would be spent in the pharmacy, which I was at first disappointed about, since there would be very little patient contact. However, it turned out to be one of the most instructive days of the trip, as I quickly learned what medicines and treatments we could prescribe and which we could not. It also became clear exactly how limited our resources would be, as we had to run an entire pharmacy meant to treat nearly 1500 people out of 15 bins no larger than 1'X3'X1'. Patients trickled in to our tent slowly as our leader, Hem, instructed us on how to count and label pills. The morning picked up quickly once the medical teams started to finish patients, and we were working furiously to fill prescriptions and annotate the sprawling HHE notebook to reflect the number of patients treated and their ailments. Most received what seemed to us to be everyday treatments: tylenol, hydrocortisone cream, sunglasses, but everyone was thankful and smiling. Once work got going, the day passed in a blur of writing and clawing through bins looking for medicine. And it seemed the more rushed we became, the more the wind picked up. It blew hard off of the mountains, cooling down what had been a surprisingly sunny morning into a chilly afternoon as we had to weight down the tents to keep them from blowing away. Eventually the wind died down and the patient flow slowed to a crawl, so we packed up by 3:30 and made our way back to camp for the evening. Everyone was exhausted, but had enough energy to celebrate one of the team member's birthdays with two giant cakes, some Zingaro and a sip of Rakshi before tucking in for the night at the very late hour of 10:30.

Clinic day two started out a little warmer than the first, with the fastest bucket shower I could possibly take. Otherwise, it was a similar story, but this time I would be working with one of the residents in the third medical tent. Two other medical students would be joining us for the day. Before we started, I was nervous about being rusty with my interviewing and physical exam skills, and I started off slowly, letting the other students take the first two patients who came to us. But then it was my turn to work through a patient with the help of the interperter, and though I felt I started shakily, my confidence grew with each patient. The resident had us perform a full history and start the phsyical exam before we presented to her with our thoughts about the patient and our differential diagnosis. While none of us had worked on differentials before, we learned quickly through the experience of seeing patients largely ourselves and through the process of talking through patients with our resident. By the end of the day, I felt like I had already learned more about the mechanics of the interview and the building of a differential than I had in my entire first year of school. I had to practice narrowing my focus without losing important details, or cutting out possible pathologies too early in the process and I would continue to work on this throughout the trip. We closed up clinic around 4 and headed back to camp after playing frisbee and cricket with the monks and children who we had been our patients that day.

Our third day of clinic would be in a nearby village called Leo. Again, we set up shop outside a school in a dirt lot. Leo lies a few hundred meters below Nako, and the morning was sunny and quiet as we watched the kids at the school give their morning prayers and waited for patients to arrive. I was excited to be working in the peds tent with one of the trip leaders, a pediatrician at CHOP. Our most interesting patient of the day though, was our first, and she was certainly no kid. She was an elderly woman who came complaining of a number of things, but the one that bothered her most were the vesicular bumps on her tongue that had lasted for the last six months. They looked viral, but the amount of time they had been there essentially ruled our an infectious etiology. We called in the other team leader, who felt strongly that they were not neoplastic either. Eventually the physicians settled on a vitamin deficiency (could have been multiple B vitamins), which can present this way. A later consult with the dentists on the trip revealed that it could also have been caused by dental infection which had been transferred continuously to her tongue. Either way, giving her a multivitamin certainly was not going to hurt and beyond that there was little treatment or further diagnostic testing (given that our "labs" were limited to urinalysis dipsticks, pregnancy tests and HemOccult tests) we could offer. The rest of the day FLEW by as all of the kids from the school began coming to our tent for their general physicals. We checked their hearts, lungs, cranial nerves and abdomens before moving on to the next patient. We also had some sicker children I saw five headaches, each with a different cause, before lunch and some interesting cases, like the boy who had passed out in his bathroom and lacerated his chin. Exhausted from running around with the kids, we all hopped back in the cars and drove the 40 minutes back to Nako for dinner and a restful evening.

Our last day of clinic in the area would be at Leo once again. I was a little skeptical of my assignment for the day: the dental tent. I wasn't completely interested in the idea and wasn't sure what I would learn. But right away I saw that I would learn a ton, as the young dentists took a good deal of time before the first patient even came in to explain the very basics of tooth health and dentistry. For the rest of the day, I assisted by cleaning and passing tools to the dentists and dental student as they did extractions. They were incredibly impressive, bending over their patients in the sweltering tent and working hard to give them the best possible care in truly primitive conditions. Unfortunately that care consisted of three main options: do nothing, have a temporary filling or an extraction. They removed multiple teeth from many of the patients, even young children, who were all stoic as they had their extractions done with little more than local anesthetic. I can just imagine kids here having that work done: they would be screaming bloody murder and their parents would undoubtedly take them away. The expectations are clearly different.

That evening, we met with an amchi, a healer trained in Tibetan medicine who talked with us about his practice and how he felt health was maintained and lost. He read the 12 pulses of a number of people in the room, placing both his hands on each wrist and closing his eyes. He spoke about the thousands of herbs he has cataloged in his mind, ordered by their effects and where to find them. And interestingly, he spoke about his thoughts on Western medicine coming into the towns, which he had no problem with. He thought there were some things that Tibetan medicine treated better than Western medicine, but felt that sometimes people needed to see an allopathic physician. Of course, this all took a long time to get across, as his speaking had to be translated from Bhoti to Hindi, then from Hindi to English, a problem we often encountered with our older patients.

The next day, we would move on to our next site at Tabo, by way of a "half-day" clinic at the nunnery at Chango. We left early and reached the more affluent town of Chango around 9, where there was already a line of people waiting for us. While we had expected to treat about 150 of the nuns, it turned out that many people from the town had also come up to the clinic. By the end of the day, we had seen more patients than we would on any other clinic day: 240. I worked in a medical room with another of the residents, whose style of teaching I really liked. I felt extremely independent, but also like I had a lot of back up and learned a number of good physical exam tips and tricks. We saw a couple of interesting cases, including something I would expect to see more in the US: a relatively wealthy man who came in complaining of a huge number of symptoms, including urinary trouble over the last 10 years. The more questions I asked, the more he came up with and none of his symptoms pointed to anything specific. In the end, it turned out he was really looking just for a second opinion about something his Indian doctors had told him.

The chorden at Tabo Gompa
We finally wrapped up around 4 and jumped back in the cars to make our way to the monastery at Tabo, the oldest on our trip (built in 996). We arrived around 7 and were welcomed by the packs of dogs that we had been warned about. Overall, the town appeared to be much poorer than many of the places we had been so far, and also bigger, with an internet cafe and "German Bakery." We ate a late dinner, checked out the view from the roof of the monastery, and then went to bed even earlier than usual, exhausted from a long day. Unfortunately, the dogs were just waking up, and they fought and howled all night, which made it difficult to get much sleep. Still, it was the first time on the trip I had truly slept poorly, so I couldn't complain.

Day 6 of clinic would be in a small village a few kilometers back down the road we had driven to get to Tabo. We crossed the river and found ourselves in the poorest of the villages we had yet seen on the trip. Our clinic was set up in the small schoolyard, and though we didn't expect to see many people, my triage station was busy from the beginning of the morning. Medically, triage isn't the most interesting station, but it is a good place to keep an eye on the clinic and have a good sense of how things are flowing and what interesting cases have come through. For the most part, the patients were children waiting for physicals and the patients came more and more slowly towards lunchtime, to the point that we closed up shop early after having seen only 80 patients (which made up for our hectic day during the previous clinic). We headed back to Tabo, where I took my first actual shower since leaving Delhi, then met the rest of the team on the helipad to play cricket with the drivers, which was an absolute blast despite the overly complicated rules. By the time we got through dinner and our talks, it was well after dark, so we played cards for an hour or so before bed.

For our 7th straight day of clinic, we would be using the primary health center in Tabo and I was assigned to the gyn station. We walked the short distance to the clinic, a two story cinder-block building that looked relatively new. Inside, it was dark and cool and we could see that there was a woeful lack of resources. The entire "hospital" was run by a single physician without labs or even beds. Each of the "wards" were just empty rooms and the surgical suite had nothing more than a set of stirrups sitting on the floor. Our physician for the day was also a Hindi speaker, which was a nice change from my previous experience. Because she was precepting our histories and physicals as well as translating, the entire interview much more smoothly, although we could do fewer patients at a time. We had another busy day, seeing 200 people and bringing the total for one week's work to 1150. For me, one stood out. She was a 22 yo woman, who was G4P1 (pregnant 4 times, with 1 child living). Her living child was from her first pregnancy and he was 1.5 years old. Since then, she had had a miscarriage at 4 months and a stillbirth and was now pregnant again. In the US, she would have been worked up to check to see whether Rh compatibility was causing the problem, but all we could do was ask her to keep seeing her doctor regularly. I couldn't help but wonder what was going on at home if she had been pregnant 4 times in the last year and a half.

The abbott in the center
After clinic was finished, we returned to the monastery to speak with the abbott, who ran that particular institution as well as a couple of others in the area. He talked with us about Tibetan Buddhism and its positions on health, life and about his relationship with the Dalai Lama. After a fascinating and exhausting hour, we broke for dinner and a few hours of relaxation before bed.

That Tuesday we didn't have clinic for the first time in a week as we moved to our next monastery at Kungri. On the way, we stopped for lunch at Dhangkar monastery, built on a ridiculous outcropping of rock overlooking a valley. The story goes that people had been trying to build there for years with little luck before the local religious leaders ordered them to build a monastery on the spot. The resulting building looks like it grows right out from the rock, like it's always been there. Inside, the rooms are small, low and dark, but they are also cool and serene. We ate quickly before getting in the cars to finish the drive, arriving at the monastery in Kungri in the late afternoon to find a few tents pitched on the lawn - Ravi told us some of us would be sleeping out for the 2 or 3 nights we'd be there, while others would stay in the guesthouse. The differences were minimal, honestly. I stayed in a guest house room with Josh which had two cots on a concrete floor and one small window. We checked out our rooms and explored the grounds, finding some beautiful views from just above the monastery before dinner.

The next morning, we woke to the sounds of the monastery: young monks yelling at one another and gongs and horns sounding in the sanctuary. After breakfast, we drove the 5 km down the valley to Sagnam, our clinic site for the day. Here, we worked out of another health center, which looked like it was cut from the same mold as the one in Tabo (only with fewer working toilets, and those only when we poured buckets of water down into them). The day was expected to be slow, and it was, but started off with a very interesting patient. Many years before, Ravi (the man who basically IS HHE) had sponsored a valve replacement for a young monk with rheumatic heart disease. He came to see us to make sure his treatment was going as planned and we got a chance to listen to his heart, which had a normal rate/rhythm, but a very loud holosystolic murmer over the mitral area. Classic mitral regurgitation and very interesting, especially since the monk was doing so well. He thanked us profusely and went to speak with Ravi and it was nice to see some of the lasting effects that HHE has had on the region. We finished clinic before lunch and headed back to the monastery to eat quickly before getting in the cars for an excursion to what was described to us as "The Highest Motorable Permanent Settlement in the World" at Kibber. It was another beautiful drive as we just continued climbing towards the peaks above before finally reaching Kibber, at 14, 200 feet. There wasn't much to see in the town itself, but it was incredible to see how truly remote it was. On the way back, we stopped at yet another monastery, called Kye, which was also located overlooking the valley, atop its own little peak. By that point, it had been a long day, so we didn't spend long before getting back into the cars and heading for home.

After a late dinner, we heard from Ravi that we would probably not be able to cross Rohtang Pass as planned, making our trip significantly longer. We would have to leave after clinic the next day and go back the way we had come in order to reach Manali, the last stop on the itinerary, on schedule. Everyone was disappointed but understood that not even Ravi could move the glaciers blocking our path.

Our last clinic day was conveniently located at the monastery in Kungri, and I would be repeating the gyn station (just by random draw). We were located outside, on the patio of the monastery (with a backup room for more personal physicals). It was quiet and we didn't see any gyn complaints, just a number of cases that largely summed up what we had seen over the course of the trip: eye complaints, URTIs and skin infections. We saw 120 patients, bringing our final count for the trip to 1350, which was right on target.

We closed up clinic and packed quickly so that we could be in Tabo once again before dinner, which we were. Everyone was feeling relaxed having finished clinic, and we stayed up and relaxed in the dining hall in the monsastery until much later than usual, before heading to bed in order to wake up for a very long drive in the morning (expected to be close to 12 hours).

We woke in the grey light of morning to eat a quick breakfast and then start a drive that was expected to take us 20 hours over the next two days; we were to stop at a campsite just short of Manali this evening and then make our way into the mountain resort the next day. We drove back the way we came, in Rakeesh's car, revisiting all of the places we had been. We rolled along for 7  hours, through lunch, before seeing Ravi's car coming back down the road in the other direction. Never a good sign. He let us know that there had been a landslide ahead, and that it would be at least 3-4 hours before we could go on. It was hard news to hear after such a long drive, but everyone remained in good spirits.

We started to worry when we saw the HHE staff dig a hole and pitch "potty tents" over it. We busied ourselves checking out the landslide, which had wiped out a few hundred feet of road ahead. Yet people still crossed it on foot, reaching the buses that had stopped on either side and continuing on their way - just part of life in the Himalaya.

As 3-4 hours turned into 5, then 6, then 7, the crew set up tents for cooking and we knew we would be there for some time. We played trivia and card games, ate dinner and kept hoping that we would get the word to leave. Around 10, Ravi came in and told us that work on the road had stopped for the night and that we would be camping exactly where we were. We were fortunate that we had stopped in a spot with enough room to pitch tents, and everyone grabbed sleeping bags to bed down for our expected night of camping, although not in our predicted spot. 

IF I wasn't sure already that this was the most posh camping trip I had ever been on, waking to the smell of a hot breakfast convinced me. In the night, a second landslide had occurred just a few hundred yards down the road from our campsite. Luckily it was much smaller and no one sleeping on the road was hurt, but it certainly was scary news to hear. Work had already begun on the road when we woke up and we walked up to the site after breakfast to find the debris about half cleared. It would still be a few more hours, so we entertained ourselves, creating a new game that was a cross between tennis, handball and ping-pong and having a tournament, which took up most of the morning. At the end of lunch, Ravi came in to let us know that work on the road was nearing completion and that we should be ready to go at any time. This put a charge through the entire camp, as we cleaned up quickly, struck the tents and went to stand by the cars so that we would be ready the moment we go the news. We jumped in the cars shortly thereafter, only to sit in traffic for another 45 minutues before finally crossing the newly created road and speeding off towards Manali. It had been 24 hours since we stopped.

We drove through more varied terrain now. It was much greener and we passed up and down through multiple valleys. As dinner time approached, we climbed up the steepest roads of the trip (saying a lot!) and weaved in and out of the clouds underneath trees thicker than any we had seen so far. At sunset, we arrived at the campsite we had originally planned to stay in the night before. The advance staff had made it through before the landslide and had set up camp and dinner for us in a beautiful spot. We had a birthday celebration for a couple of members of the trip, signed our tent and then had to stop enjoying the beautiful spot to get back in the cars. The sun was already long gone, and we twisted and turned our way all the way to Manali, arriving just a little before 12. The streets were still full - this was by the largest city we had been in since we left Delhi and it was a little overwhelming. Dogs and tourists were everywhere in the streets, even as the businesses began closing. But we were exhausted and would have time to explore the next day. After going out to grab a mango juice (sweet, sweet mango juice), I climbed into my bed, happy to enjoy the comforts of air conditioning and a western bathroom once again.

New Manali in all its glory
We had a full day in Manali the next day and, to be honest, it was too much for me. The day started off perfectly, as I woke up early to a clean bathroom and took a long shower, feeling clean for the first time in at least a week. Then we had breakfast at the hotel, which was also nice. But as soon as I walked out into New Manali, I was overwhelmed. It was much more tourist-y than any of the places we had been so far, with hundreds of stores selling trinkets and knock-off clothing and the streets filled with both Indian and European tourists. It was hot and dirty and just kind of uninspiring. I still needed souvenirs though, and I was determined to get them, so I spent the morning looking around unsuccessfully before heading back to the hotel for lunch. Afterwards, I hopped an autorickshaw up to Old Manali and it's small bazaar, which was still filled with tourists, but much quieter, and I quickly found everything that I had been looking for. We stopped in the "Drifter's Inn" in Old Manali for a snack and beer, as everyone relished some of the "American" comforts the cafe had to offer, like free Wi-Fi and decadent desserts. It was the first time on the trip I had really felt travel-weary at all, and I was happy when we headed back to the hotel for a nap before dinner. I felt restored afterwards, which was good because we spent the night giving out awards for the trip, then saying goodbye to our drivers with a party in the hotel's bar - dancing to Indian music until later than I had stayed up most of the trip. It was the last night we would all be together, as a few groups would be separating in the morning, and I was already genuinely nostalgic over the experiences we had shared. I wouldn't have expected this out of a three-week trip, but the challenges were unique in the special way that makes travel such a bonding experience.

I woke in time for breakfast and goodbyes in the morning. It felt like the end of the trip, though we still had two more days before we left India. We would be driving to reach Chandigarh the rest of the time, a fitting way to end a trip that taught me the real meaning of a trek. We had until lunch time to spend in Manali before leaving, but I think many people simply stayed in the hotel, ready to get on the road for the day, ready to be moving once again. When we finally did, I realized how culturally varied India is. Even within Himachal, the more populous southern and western areas we were driving through seemed like a completely different country than the stark terrain we had left not two days before. We arrived at the hotel in Bilaspur uneventfully and spent the night eating and watching movies.

Our last day in India was spent covering ground. We left after breakfast for the Chandigarh airport, making it in plenty of time for our evening flights to Delhi. After a quick (and pretty nasty) lunch at the airport, we said goodbyes to those who would be going other directions, and those who were on later flights and then got into travel-mode, that weird state where you just kind of drift along with the flow of people around and do what you are told. The flight to Delhi on Kingfisher Airlines was short and pleasant, and we were mostly surrounded by Indian businessmen. A few of us would be traveling back to the States on the same flight at 10, so we had a little American team for our 6 hour layover. The last order of business was to get a Maharaja Mac from the airport McDonald's. Two buns, two chicken patties, a slew of vegetables, all topped with a curry sauce sounded like the ideal way to make the transition back to American culture without forgetting where we were. It was one of the most satisfying meals of my life, as I polished off a whole sandwich and danced my way up to the counter for more.  Feeling fat and happy, we sat and waited for our direct flight back to Newark. Everything went smoothly on this trip, and seeing the Newark airport again didn't even trigger any PTSD. Exhausted, I made my way back to RDU, where my girlfriend picked me up.

Three days later, this happened:
Now she's my fiancee.

I wish I had something profound to say at this point. I don't. This was no doubt a life-changing experience, but I'm still too close to it to know how it will change my path. It was my first exposure to global health work, and I have to say, it was even more than I expected in terms of the things that I learned and the ways that it made me question my own assumptions about how to deliver health care most effectively.

It should be noted that from top to bottom, this trip was beautifully organized and that is almost entirely due to the work of Ravi Singh, who runs HHE. If you are considering this trip, but worried about being properly taken care of, don't hesitate any more. Ravi is a master and has been doing this for 17 years now. Who else could put up a feast in an alley by the side of the road? The people and the place are welcoming and beautiful.

And when else will this be the view from your clinic?

And if there is one way to sum up the right approach to med school...

-Evan Zeitler

Questions about HHE? Feel free to contact me any time at