The rain starts innocently with scattered sprinkles—warning enough for street vendors to cover their wares and for pedestrians to seek cover. The sky darkens and the downpour begins. Rain pounding on the roof can make a telephone conversation next to impossible. And then it stops. “Must be the beginning of the monsoon,” I presume, but I learn that June is too early. Once the monsoon season (July to September) starts in earnest, the rain becomes a daily occurrence and provides relief from the heat and humidity.
Premonsoon rains herald the end of the spring trekking season, and work at the CIWEC Clinic Travel Medicine Center in Kathmandu, Nepal, slows down. CIWEC stands for Canadian International Water and Energy Consultants, the nongovernmental organization (NGO) that established the clinic in 1982. It has since become an independent center staffed by three physicians (a U.S.-trained Nepali internist, who is also the medical director, and two American doctors). CIWEC is internationally renowned for its Western standard of care and its research into the health problems of foreigners. Most patients are diplomats, staff from development agencies and NGOs, aid workers, volunteers and tourists. During busy periods the waiting room resembles a mini-United Nations, with British diplomats, Tibetan monks, Israeli backpackers and American parents and their newly adopted Nepali children awaiting consultations. Trekkers and climbers felled by altitude sickness come to the clinic as well.
I never imagined living in Nepal, a landlocked country between India and China. Apart from reading Jon Krakauer’s Into Thin Air, about the 1996 Mt. Everest climbing disaster, or listening to Bob Seger’s version of “Kathmandu,” I never thought about the place. I graduated from medical school in 1995, completed a residency in family practice at Middlesex Hospital in Connecticut, and was living in Hawaii when I received the unexpected offer to work at CIWEC. I had done medical school electives and volunteer work abroad but always preferred the tropics to the mountains. Nonetheless, the opportunity allowed me to pursue my interest in travel medicine full time. So in January 2004, I packed away my “aloha” shirts, dusted off my cold-weather clothing and moved to Nepal.
Slightly smaller than New England, Nepal has a population of approximately 25 million, with over 1.5 million people living in Kathmandu. It is best known as home to Mt. Everest, at 29,035 feet the world’s highest mountain, but its lowland tropics offer a chance to go on safari in search of rhinos and tigers. The latter part of the dry season (February to May) is a popular time to visit the country, especially for trekkers and climbers.
On that rainy day in June, my first patient was Shyam, a 4½-year-old Nepali boy adopted a week earlier by an Italian couple. His cheeks had become swollen and painful over the past few days and he refused to eat. Both of his parotid glands (salivary glands below the ears) were swollen and tender, and he was mildly dehydrated. He also had scabies and a scalp infection, conditions present in nearly all of the children that I see from orphanages. Shyam’s new parents said the orphanage had no proof of any vaccinations, thus increasing my clinical suspicion of mumps.
For a country in which the burden of infectious disease is high, diagnostic capabilities can be woefully limited. While some medical technology has reached Nepal, it does not mean that a system of modern health care delivery has come along with it. One night I had to obtain a CT scan of a patient with fever, convulsions and delirium (ultimately diagnosed as encephalopathy due to typhoid fever). After an initial noncontrast CT at the university teaching hospital, the radiologist inquired if I wanted one with contrast, which would highlight an abscess. Upon my affirmative reply, he scribbled on a scrap of paper. Sensing my confusion, he explained that I would have to take the note to the pharmacy down the street, buy the contrast agent and bring it back for him to administer.
Shyam was stoic, even as an IV was inserted to provide hydration. I wondered what was going through his mind. He had spent most of his young life in an orphanage before he was taken away by a friendly foreign couple he could not understand. Did he realize that in one week he would board an airplane for the first time and fly to his new home in Italy?
After I finished caring for Shyam, I called for the next patient. There was no answer from the waiting room. At CIWEC, that means that the patient is in the bathroom. Diarrheal illness accounts for a third of what we see, and the incidence increases between May and July. Regardless of how careful one is, the pathogens that cause diarrhea are impossible to avoid—I realized this after being stricken five times in my first two months in Nepal.
Bacteria are responsible for most of the diarrhea among foreigners in Nepal. However, the premonsoon season ushers in the seasonal parasite Cyclospora cayetanensis, which causes cyclosporiasis, a debilitating diarrheal disease characterized by marked fatigue and anorexia and first identified in Nepal in 1989 by a CIWEC lab technician.
The patient emerged from the bathroom with a big sigh and recounted how he had had intermittent diarrhea for two weeks. Every time he thought he was recovering, the diarrhea would return. He had no energy or appetite and was losing weight. His stool examination confirmed Cyclospora. He was treated with trimethoprim/sulfamethoxazole and reassured that his appetite should improve within a few days. Untreated, cyclosporiasis is self-limiting, but it can last up to several weeks.
After lunch Mr. Sherpa, a 40-year-old Nepali, presented with four days of fever and headache. His symptoms put typhoid at the top of the list of possible diagnoses. However, Sherpa had recently returned from the West Bengal region of India, an area endemic for malaria. A blood smear revealed severe Plasmodium falciparum malaria, the most dangerous of the disease’s four forms. I started an IV, administered an antimalarial and transferred him to the hospital for closer monitoring. In Kathmandu one can lose valuable time while waiting for an ambulance, so Sherpa was sent to the hospital by the quickest means available—a taxi.
As it turned out, Sherpa’s ride to the hospital was held up by political demonstrations in the streets. What should have been a 15-minute ride took nearly an hour. Nepal has become increasingly plagued by political problems: an eight-year-old Maoist insurgency and a Maoist-imposed blockade of the Kathmandu valley in August 2004 made international headlines. Political parties calling for a return to a democratically elected government (dissolved by the king in 2002) frequently stage demonstrations and call for strikes. In addition to delaying patient transport, the protests can directly affect a patient’s health as well—on one occasion police threw tear gas into a hospital because political agitators had fled there.
Later in the afternoon a frantic call came from Mrs. Paddington, whose husband worked for a British development agency. Her 4-year-old daughter Daisy had stuck a bead deep into her right nostril. Daisy was more preoccupied with the toys in the waiting room than the commotion that her action had caused. After a few unsuccessful attempts at blowing the bead out (by pinching off the opposite nostril and exhaling into the child’s mouth, a task assigned to Daisy’s mother), I used forceps to retrieve a bean, rather than a bead. Mom had no idea where the bean came from, and Daisy denied putting anything up her nose. After a scolding from mom and a sticker from the nurse, she skipped happily out of the clinic. I then headed home on my bicycle.
It takes me about 15 minutes to ride home. I live in a quiet residential neighborhood a few blocks from the prime minister’s residence. On the rare days when the air is unpolluted and the skies are crystal clear, I can see the Himalayas from the second floor of my house. The traffic in Kathmandu is a tangle of bicycles, motorcycles, tempos (local three-wheeled transport), cars and buses, all negotiating the congested streets. Vehicles swerve and stop without warning to avoid oblivious pedestrians, crater-like potholes and sacred cows (literally—Nepal is a predominantly Hindu country). The chaotic traffic combined with the noxious pollution frequently tests my patience, and one day I found myself laughing after I realized I had “road rage” from riding my bicycle.
As I reached my doorstep, the telephone rang. A British volunteer called to say she had been attacked by several monkeys while walking near a temple. The attack was unprovoked and, interestingly, the woman’s two friends were unmolested. She had several scratches on her legs and was frightened about contracting rabies. Rabies is endemic in Nepal and monkeys are potential reservoirs. Because she had not been immunized, she required human rabies immune globulin along with a series of five vaccinations over four weeks.
“Not your typical day back home,” I mused. However, as I thought about what I had seen that day, something was bothering me. Most of the problems were preventable—mumps is rare in the United States due to routine immunizations; better sanitation and a safe water supply would prevent much of the diarrhea in Nepal; Sherpa would not have contracted malaria had he taken prophylaxis; and the volunteer’s risk of rabies and her anxiety about it would have been alleviated had she been vaccinated prior to coming to Nepal. As for the bean in the nose … well, I’ve seen that back home and I suppose there’s no way to curb a child’s curiosity. YM