[Kanchan Dahal]

“We have been living in this place for more than five years. If some emergency happens to us, nobody will be able to come for us. Despite this bitter fact, we are serving people of this region”, says Ms Radha Thapa, a senior nurse in Mother and Child Health Clinic situated in Goljung Village Development Committee of Rasuwa district. The voice of another nurse Ms. Aruna Lama and helper Ms. Dawa Yangzen is also a similar one. Having traveled to many different places like this in Nepal, this recent journey of mine has enhanced my knowledge of topographic beauty of the land and health condition of people residing there. As a student of medicine, I should consider it as another page of my learning to understand our lands and life of people. On cold morning of January 30th, 2005, in a bus going to Tangbochet of Rasuwa district through Syabru besi, I feel excited for an unknown adventure lying ahead. From six-thirty in the morning, I am engaged in seeing the landscapes of sideways. In this period, many persons become my neighbor in seat next to mine. From them, I get chance to know about their places. In this way, having pleasant chat with local passengers and enjoying natural landscapes, the bus arrives in my destination at about six in the evening. The most beautiful event for me in this journey is the rays of setting sun striking on the blades of mighty Langtang himalaya.
After I get off the bus, it is dark. I am confused whether to wait for my team (as arranged by the clinic) or to walk to the place where I had never been before. Thanks to grand arrangement of clinic management, I see three figures approaching towards me with smile on their faces. I am a new member in their team. All of them are great young ladies in their twenties, who have dedicated themselves to the challenges of this land. At this moment, I remember Mother Teresa and Florence Nightingale and path shown by them. After a walk of about forty minutes, we arrive at the clinic, where I am going to stay for coming few days. Comparing the primitive infrastructure of clinic building to modern hospital building of my university, is just being impolite to what is present in front of me. We have meals with exchanges of our introductions. I tell sisters that I am here to learn, what I have only heard but not seen. They tell many interesting things about the place. I am excited, provided there were no nights in the rule of nature; I would immediately set out to explore them. Comfortable rooms are provided for staffs of the clinic and for visitors on the upper floor of the clinic. Closing my eyes, I feel this clinic is one of the temples of Nepal and staffs here are appointed by gods of Shangri-La for the service of people here. It is my honor to be a visiting member of this team.
I wake in a new morning, where people have already started their daily lives. I am introduced to the facilities of clinic with a morning tea. With sips of refreshing tea, I am already engaged in service of one young man who has come with chest pain for about a month. After listening to his painful story and offering examinations, we suggest him to go district health facility where he can have his sputum checked for the suspicion of Tuberculosis. During our lunch ( dal, bhat, potato), we discuss about this young man. Sisters say that his community has many other people with similar history as him. I want to see his social environment. The place is above 2000 meters above sea level. The air is fresh and food so nutritious. Then why on the earth, many people have such problems? After lunch, we set out to that young man’s village. We reach his community in about two hours. “This place is Goljung village”, says sister by showing to group of crowded huts with black stones on roof-tops. Conventional imagination of some ideal country side is a scattered hut with small garden in front and somewhat beautiful figure. But when I enter this community, it is not difficult for me to understand why many people here might have tuberculosis. The typical house in this area is two storied. Ground floor is open type with place for domestic animals and upper floor has two rooms. Bigger one is used as kitchen and another one probably as a store. People are usually in the kitchen sitting around the fire. They have traditional fire place giving out more smoke puffs than heat. If you see around, the wooden walls seem cemented with carbon particles and interestingly the wall is shared by another household. It is pity that people do not know what is destroying their quality of life. They are warm hearted, so rich in hospitality and full of innocent features, but, their ignorance is troubling them. Men are seen working in the fields, women busy in weaving traditional clothes like ‘Bakkhu’. Healthy looking children are running here and there with their dirty outfits. The level of sanitation and waste management here is reflected in every aspect of life you can imagine. After this survey of social life here, we return to our base.
For the following three days, we visit to all villages where clinic has been providing its services. I find out similar life situations in all these villages as I had seen in Goljung. A village named Gatlang should be mentioned here, because this name is derived from the condition of enlarged thyroid gland. One of the locals tells me, “Once this village was full of people with enlarged thyroid gland and the word ‘Gatlang’ means enlarged thyroid gland in local language.” In 21st century, most of the people here are using uniodized traditional salt. We see many children and adults with features of iodine deficiency. Besides traveling to places, I am also busy in observing cases in clinic. One afternoon, a couple comes with a child of about two years of age. They tell me that their son has fever and breathing problem from three weeks. After failed attempts of sacrificing three chickens as per the instruction of local traditional healer, they have come to the clinic to get medicines and consultation. Luckily, this child is still normal without much complication. According sisters, these kinds of cases are very highly prevalent in this region. So many people come in the clinic with complaints of tapeworm infestations. Inadequate cooking of beef before eating and lack of sanitation might be the cause for this.
During my stay in this place, I am engaged in travel, clinical observations, communication with local people and students, understanding their culture. Here, I see hardship faced by health workers. Despite the absence of basic laboratory facilities, equipments and essential medicines, they are working to change the health conditions of people in this region. They say, “We want to upgrade our skills, so that we can provide better service.” “It would be relief to the people here, if here is one basic laboratory facility and they need not walk for hours and days to deal with emergency.” Local people say, “we feel neglected in matters of health facilities, health education etc; here we cannot find medicines and skilled health workers.” “We do not even know when to go to see health workers.” Seen from any sides, problems are really acute and there are solutions for them. Establishment of laboratory facility is crucial for the correct diagnosis of diseases prevalent in this region. Upgrading the knowledge of health care staffs is also important in enhancing their working skills. For instance, there are records of many patients who have to go to capital city for simple infectious complications which can be otherwise treated in clinic.
Since, my vacation is going to be over, I return back with memories of the place. If I were a foreigner, this would be an end of my journey. I am not. Therefore, I would prefer to continue it.
Villages of Goljung, Gatlang etc are not different than many other villages in Nepal. They are beautiful villages located on the lap of Langtang and Ganesh himalaya. These villages are situated inside the area of Langtang National Park, which is itself rich in wild flora and faunas. Rare plants of medicinal values are abundant in this region. Indigenous Tamang are this region’s ethnic tribes. They are inhabited in this region in harmony with natural habitat present there. They have their own language and follow culture somewhat similar to Tibetans; Tibet being less than twenty kilometers from this region.
People in this region are involved in agriculture, tourism industry, handicrafts for the generation of incomes and food supplies. Some young people are also employed in foreign countries. Highest level of education facility in this region is a high school. Although, many people have got degrees of further studies from cities, the standard of lifestyle has not increased as expected. The region is provided with daily bus service from capital city. But this transportation facility is seasonal and the road is very primitive. The land is mountainous. So, crop production is difficult. Potatoes and beans are the major products. Green vegetables and fruits are scarce in this region.
What makes these villages different from other villages in Nepal is their location as the nearest remote place from Capital city of Nepal from both topography and socio-economic condition.

From the health point of view, these villages have sub-health posts within the reach of all household. But the medical facilities are negligible in these centers. Lack of adequate medications and manpower is the major problem. Though efforts are done to improve this situation, they are inadequate and not reaching the targets.
With the help of community people and distinguished foreigners, the community clinic is being run targeting three villages namely Goljung, Gatlang and Chilime. This clinic, despite the absence of basic laboratory facility and other equipments has been providing primary health care service to the region. But, this is not enough. Health staffs of clinic are not able to assure the people for the quality of service they are providing. This might be due to lack of essential skills or language barrier. Besides, staffs in the clinic have not been able to provide primary health education to the community people. Knowledge upgrading tools like health journals, guidelines in simple native languages are rarely found. Due to this, staffs are not being able to explain why people of this region need their service and why people should first go to clinic rather than going to traditional healers.
Due the scarcity of green vegetables and fruits, they might have deficiency of minerals and vitamins, which could be predisposing them to many disorders of eyes, skin, nerves etc. Until now no studies have been done regarding these conditions and neither sample testing from this region have been done to determine to what extent these deficiencies have contributed to the illness in people of this region.
There is possibility of multi-disciplinary research in this region because of its unique natural resources, ethnic tribal population dominance, and presence of variety of diseases patterns. Many works can be done in improving the health conditions of the people of this region, enhancing their quality of life and ultimately using the resource of this land to add to the economic development of Nepal. Priority should be given to assess the impact of topographic features, socioeconomic condition, etc on health conditions of people of this region.

(Travel diary based on visit to Rasuwa, Nepal from January 2005 to February 2005, maintained by Kanchan Dahal)


My sincere acknowledgements:
1. Mr Gyanendra Ghale, Project Manager of KFK-Nepal, for providing me opportunity to participate in the team work of KFK-Nepal.
2. Mr.Scott (KFK's International Director) and George Martin (everestnews.com),for arrangement of facilities in the clinic and making my trip possible.
3. Ms. Radha Thapa, Ms Aruna Lama, Ms. Dawa Yangzen, staffs of clinic, for providing me guidance and supports while my stay in the clinic.
4. All people from Goljung, Gatlang and Chilime VDC of Rasuwa district who provided me warm welcome to their abode and supported my work heartily.
5. Professors, Dr. Cai Feng (P.R. China) and Dr. Wang Yang (School of Public Health, Chongqing Medical University, P.R. China) and Ms. Chen Qing ( Chongqing medical university) for providing me support and guidance to participate in this project.
6. My father, Mr. Rudra Pd Dahal, Agricultural Development Bank-Nepal, for providing me valuable suggestions to focus on sociological aspects determining the disease processes of the region.
7. My friends, Ms Jaika Ojha (Arizona State University, USA) and Mr. Upendra Man Shrestha, Mr. Sunil Thakali (Chongqing University of medical Sciences, P.R. China) for the clinical books provided to the clinic.
8. My native(nepalese) friends (2001 batch-CQUMS) and Chinese friends of Chongqing Medical University, P.R. China for providing support of medicines and simple medical equipments to add to the service of clinic.