In 2003 Canadian Rob Viereck set up a clinic in one of the most remote and impoverished regions of northeast Nepal. The challenges and rewards are ongoing but for the people of the surrounding communities a corner has been turned. Rob Viereck lets us in on how it all began and the challenges that lye ahead.

Brief history of the clinic

In 2003, while on a trek through the Everest region, blissfully unaware of the conflict in the “hilly areas” and ignorant of the dire situation the inhabitants faced there, I accidentally walked into one of its most impoverished and troubled regions.  My trekking partner had fallen ill and decided to take the direct route back to the closest trailhead while I chose a seldom travelled route which passes through the Hongu river valley, homeland of the Kiranti Kulung Rai people.  Simple enough, I thought, to follow a river south, however I soon found myself off my map, in territory seemingly without trekking facilities.

A chance meeting with a young porter led to me staying a week at his family’s house in a small village where I shortly became aware of their economic, social and health problems.  One night, after urinating in the family garden, I realized that I had just desecrated the grave of one of my host’s dead children, an innocent mistake, but one which made me think deeply about how great the divide was between my privileged Canadian lifestyle and the reality that these villagers survive in.

Upon leaving the village, I asked my hosts what I could give them to compensate for their hospitality.  They simply requested that I send them some “Cetemol”, considered locally to be a panacea for all afflictions and perhaps some form of snakebite treatment.  However, I suspected that a simple pain reliever like Paracetemol would not even begin to address their needs and that I knew nothing of snakebite treatments.

On leaving the village, I gave my word that I would do something to help them and promised to meet Kirti, the young porter, at a different trailhead in two weeks time.  When I arrived safely back in the urban chaos of Kathmandu, I soon realized that I was almost completely ignorant of medicine, having not even had occasion to visit a doctor in the past 20 years.  I needed to educate myself… fast.

I discovered that Kathmandu bookstores had a wealth of books about wilderness medicine and that it would require only a modest amount of money to set up a rural health post; this encouraged me.  However, being at the end of my travels, I was hopelessly short of cash.  Another chance meeting with a wealthy young Chinese entrepreneur playgirl and notoriously bad gambler enabled me to work for a week as her translator.  My pay and a lucky bet at a local casino enabled me to buy enough health training manuals, equipment and medicine to start up a health post.

I hopped  a bus and, despite three days of window-smashing riots, roadside firefights, landmines planted on the highway and our driver’s insane night-time driving because of a curfew and road closure protests in the areas we passed through, along with the usual  mechanical breakdowns, somehow made it back just in time to meet Kirti.

I told him that, being the only person in his village to have a school leaving certificate and the ability to read Nepali, it was up to him to use the materials to teach himself and others medicine and start taking care of the health problems of his village and, by extension, the rest of the Hongu valley.  Yes – one medical worker for a valley of 10,000 tribal people, most of who had lifelong chronic illnesses and had not had access to medical care in over 10 years!

What other alternatives did they have?  It seemed to be that or nothing.   However, although they were used to having no medical treatment, my personal opinion is that it is a tragedy when a child does not at least grow up healthy and have a chance to lead a happy and fulfilling life and celebrate his culture.

Kulung Rai Culture and Community Development

The Kiranti Kulung Rai, an ancient wandering Mongolian tribe who speak a number of mutually unintelligible Sino-Tibetan dialects, migrated north from the Terai area of southern Nepal to settle in the Hongu river valley thousands of years ago.  Their geographic, political, cultural, linguistic and religious isolation has resulted in them remaining cut off from the country at large and also from accessing aid initiatives available to other, more integrated, Buddhist and Hindu tribes.

In the six years since we initiated this project I have come to realize through trial and error some of what works and what doesn’t and the reasons why, which are often economic or cultural.

To begin with, high altitude sedentary subsistence farmers are cash poor; they often prefer to barter their nutrient-poor high altitude millet and maize with the lowland Rai for supplemental foods such as rice and fruit.  This system has worked well for thousands of years.  The only way to obtain money to buy anything that they do not grow or manufacture locally or to amass enough money to pay for their children’s schooling and medical treatment is for men to go out of the valley to work as trekking porters or construction workers, leaving women to deal with raising children and farming.

Because of this trend, husbands, wives and children are separated for long periods of time which leads to serious social problems in the community.  Exposure to the wealth, materialism, consumerism and morals of urban society and trekking groups also has a negative effect on their culture.

Community development initiatives, even the most well-intentioned, if not carefully thought out, can have devastating results.  For example, high child mortality rates, though tragic, are the established norm. If even minimal health care is provided, more children survive, which means more mouths to feed, which necessitates growing more food, which means using more firewood, which requires clearing more land, which results in deforestation, which leads to landslides, which can destroy the village.

One solution is birth control, but men refuse to wear condoms or submit to sterilization, so it is the women who must be proactive.  Depo-Provera shots and birth control pills are expensive and need to be taken regularly and IUDs, contraceptive sponges, cervical caps and diaphragms, impractical because of a lack of basic hygiene, can lead to serious infections or death.  The only real alternatives are natural methods such as rhythm or standard-days which have failure rates of 25%, but require education and strict discipline as well as the cooperation of men.

Traditionally, the Kulung people have relied on local “dhami and jhakri” (shamans) to provide health and counselling services.  Initially, I was hopeful that they could act as outreach workers and that their traditional healing methods and knowledge of herbal treatments could be incorporated into our services.  However, this idea was rejected by both the shamans themselves and the villagers who, while still having faith in the fabled weather-changing, shape-shifting, spirit possession and anti-landslide powers of shamans, as well as their ability to recount the oral histories of the tribe, no longer believe in the effectiveness of their traditional ceremonies to heal critically ill children.

As well, there are few shamanist apprentices, these days, as the shamans, by and large, have fallen into disrepute due to an image of chronic alcoholism and a dominant and pervasive belief in the seemingly more powerful “magic” of western medicine.  However, their ceremonies and chanting do provide   psychological comfort and familiarity to frightened and critically ill patients which I believe is very beneficial to them in their healing process.

Shamanistic séances involve drumming and drinking herb-infused alcohol.  A shaman will invite the spirit of an animal to enter his body and begin rhythmically chanting and shaking.  When he enters a trance state he begins dancing around an altar of freshly cut bamboo and flowers.  Then the animal spirit sings and speaks to the audience to recount the history and legends of their ancestors.

Respiratory diseases are endemic in Kulung Rai areas because their houses have a centrally located, open fire pit without a chimney to direct the smoke and gases outside.  The fire serves a number of purposes in the home besides keeping it warm.  It dries out firewood placed on a platform just above the fire and the smoke dries and preserves food hanging from the rafters and the greasy soot serves to seal and protect the thatched roof from rain as well as drive out insects and vermin.

Even though villagers try to minimize exposure to smoke by sitting on floor mats just below the smoke level, because windows are closed against the dust, wind and cold, there is little ventilation and the smoke stays inside, causing eye and lung damage which significantly reduces quality of life and life expectancy.  And these are just a few examples of a myriad of problems.

Currently, we are receiving and treating 20 – 30 patients per day.  On village market days that number can rise to 100 or more.  We are seeing more and more patients arriving from outside the valley.  This is the inevitable consequence of offering cheap medical treatment in an area which has none. We have outgrown the small, simple house that was donated to us and have begun construction on a more modern, hygienic facility where we can keep seriously ill people for short-term observation and treatment.  We are installing a solar panel for lighting during night-time emergencies, but without an open pit fire or thatched roof, we have still not worked out how to keep our patients warm in the winter.

Without donations of money, equipment and medicine to keep things going, we no longer know how we will improve and expand on our services here, let alone continue to offer the barely adequate levels of service we have provided for the last six years in this remote and impoverished area of the Himalayas.  It seems that now we must concentrate efforts on two new income-generating projects – establishing women’s weaving co-operatives around the valley and marketing their traditional clothing in Kathmandu and abroad and encouraging the development of Bung Valley’s tourist infrastructure and use as an alternative trekking route to Everest/Sagarmatha National Park area.

This would include reviving and preserving Kulung Rai song and dance and other forms of their culture which have already began to disappear due to the cultural influence of more dominant Nepalese ethnic groups. With a little effort, luck and outside help, I believe that we will accomplish this in the next few years.

Kulung Rai people, despite their pristine natural environment, suffer from a wide range of the same maladies city people suffer from – migraines, brain cancer, ulcers, stomach cancer, pneumonia, eye and ear infections, deep cuts, crushed fingers and toes, dislocations, broken necks, snakebite, respiratory diseases, animal bites, rabies, skin rashes, insect bites, virulent warts, tooth abscesses, and lately SARS, H1N1 and STDs.  They often die if untreated.

The Shit Pig

In Kulung culture, nothing goes to waste, not even one’s own excrement.  My first night in the village, I asked where the toilet was.  I was given a flashlight and directed to the back of the house.  I found a rickety outhouse perched on stilts above a rock enclosure.  As soon as I sat down I began to hear a strange grunting noise from nearby.  They became louder and closer.  I shone the flashlight between my legs and to my horror I saw the huge jaws of an animal with a long protruding tongue and tusks, its hot breath steaming up through the hole.

I yelled in fright and ran back to the house where I excitedly mimed that there was a terrible monster under the outhouse.  The family laughed for an hour about it, making grunting noises.

So, embarrassed and not wanting to appear cowardly, I went back out and defecated directly into the monster’s mouth, allowing it to lick my ass clean as it squealed with delight.  The next morning they took me back to show me the biggest wild boar that I had ever seen.  Later, they killed it the traditional way by stabbing it in the heart with bamboo skewers so that its blood, which they consider to be sacred, did not touch the ground.  The boar slowly stopped moving and turned white.

The whole village came to share the meat.  It was the best-tasting pork that I have ever eaten.

A Wild Bear Attack

Bung Valley is right on the edge of Sagarmatha National Park, a protected refuge for many wild Himalayan animals.  As I came over a mountain pass and entered Bung Valley for the first time, I noticed a group of men walking fast up the trail toward us.  One of them was carrying a large basket.  As we came upon them I saw that there was coagulated blood dripping from the bottom of the basket.  I assumed that they had been hunting, but when Kirti asked them what was in the basket, they lifted the lid to expose a man covered in blood, smelling horribly and bleeding profusely from many deep gashes on his arms, legs and body.

He was a woodsman and had been chopping firewood for his family, illegally, in the park at night when a Himalayan bear had come up behind him and attacked.  These bears are small, but intensely territorial and will viciously attack any other animal on sight.  The bear clamped its jaws around the man’s head and began mauling him to death with its long claws.  The man took his kukri (machete) and slashed at the bear’s head, finally managing to fight it off.  He staggered back to his village and collapsed.  When his neighbours found him the next morning they decided to carry him to the nearest hospital – a five-day walk away.

They asked me what to do.  Seeing how serious his condition was and how much blood he was losing from his wounds, I told them that he would probably not make it to the hospital because of heavy blood loss and infection.  We took him back to his house and cleaned his wounds as best we could with a clean handkerchief and some disinfectant.  The man was unconscious.  I suggested they get a shaman to come and perform a healing ceremony and that they should all pray for him to survive.

I thought that if he died at least it would be with his family at his side comforting him.  One week later, as I was leaving the valley, I saw him again.  He was striding up the trail toward the forest to chop more wood, his wounds having healed completely.   That’s how resilient these people are with only minimal medical treatment.

Nepal’s political background

In 2008, the Nepalese Maoist People’s Army, a diverse group composed of intellectuals, university students, trade unions, urban radicals and Indian advisors commanding an army of forcibly conscripted rural soldiers, many of them teenage girls, finally won an ugly ten-year guerrilla war and bombing campaign against the King and ruling Congress Party for the ironic honour of both proclaiming the world’s newest republic and forming the government of the world’s latest failed state.

Despite the obvious drawbacks of fiscal bankruptcy, lack and withdrawal of outside investment money and the generally sorry state of the country’s infrastructure, the new-found political stability has allowed some teachers and health workers among the approximately150,000 internally displaced refugees to return to their jobs in rural areas, allowing local populations some limited access to government and NGO education and health programs.

However, many of the more isolated mountainous tribal areas still remain almost completely without education and medical services because of continuing school and health post closures where, even before the war, services were tragically inadequate.  Nepal has a higher prevalence of disease, malnutrition and infant mortality than any other South Asian country, coming in at 140 out of 177 countries monitored by the UN.  To lend some perspective, this figure represents quite an improvement on their former position.