Eight year old boy with malnutrition

We leave camp this morning at our usual time of 7:30 AM. We descend for three hours through more rhododendron and alpine forests, passing an increasing number of villagers as we near Tipling. At mid-morning we take a long break, resting at the outermost edge of the terraced fields of wheat, rye, millet and oats--that like an offering of goodwill--marks the entrance to the village of Tipling. An addition hour walk through these green, lush fields brings us to the Tipling health post at 8,000 feet elevation. The clinic lies 1,000 feet above the town on the south side of the valley. The valley's bottom, 4,000 feet below, has a river that we will follow westward when we leave Tipling.

The medical clinic consists of two long buildings, built one above the other on consecutive terraces. The exam rooms, all rather rudimentary but adequate, have a wood examining bed without a mattress. The room's light comes from a sheet of translucent fiberglass that has been placed among the tin slats that comprise the roof. A bowel of water tinged blue with potassium permanganate is the disinfectant we will use to sanitize our hands.

We are supposed to have the afternoon off, but word of our medical team spread down the valley and into the village of Tipling, arriving a day before we did. When we enter the Tipling Medical Clinic we are greeted by approximately fifty villagers waiting to be seen. We quickly unload the half-ton of medical supplies into the clinic's pharmacy, eat a hurried lunch and start seeing patients. The patients come fast, my first two being so sick that I would have admitted them to an ICU if I were in the United States.

The first patient is a distraught woman who is carried in by her husband. She is three weeks post-partum and her legs and lungs have filled with water, making walking painful and breathing difficult. In addition, she has a fever and a heart murmur. I consult the other three doctors and we surmise that she either has dilated cardiomyopathy or endometritis. Dilated cardiomyopathy is a rare condition when the heart expands making it inefficient and increasing the potential of heart failure. Endometritis is an infection of the lining of the uterus and not as serious if treated with antibiotics. We did not have an echocardiogram to help confirm our suspicion of the life-threatening dilated cardiomyopathy and are left trusting our clinical skills. We give her Lasix to help draw the fluid off her lungs and legs and a course of antibiotics to treat the possible infection in her uterus. We instruct her to come back the following day for a re-check.

The second patient I see is also carried in by her husband. She is an elderly woman who had been prescribed a number of cardiac medications by a cardiologist in Kathmandu some years earlier. She informs me that she had run out of her medications three weeks ago and has not urinated in three days. She too would have been admitted to a hospital in the United States. I refill her medication and instruct her also to come back in the morning for a recheck if she has not urinated; knowing full well that there is a good chance that she had walked two days to get to the clinic and was now going to start her return trip home, putting complete faith in the western medicines that I had just put into her hands.