Final clinic days

4^th clinic

The fourth clinic day was at the same site as the 3^rd because we had so many patients that day, and the village was bigger than most of the others.  I was in pediatrics again this day.  One of our more interesting child cases was an 8 year old boy who had lower leg pain for the last 2 years.  He said it hurts the most at a scar he showed us, and hurt the most with cold water and with running.  The biggest concern was that he could have osteomyelitis (bone infection) resulting from the dog bite.  However, it was also possible that it was leftover nerve pain from damage caused by the bite. 

This day at the clinic was a little less busy since we’d been there the previous day.  While we were standing around waiting to go back to camp, we were talking with a few teenage girls through our interpreter Shaellie.  We asked them if they felt we were more ‘masculine’ based on our dress (pants) and our career choice.  However, they said that they thought it was pretty great.  They didn’t feel that we were masculine, just different then what they experience in their culture.  They said they were also very happy with their lifestyle and the ‘norms’ associated with it.  This interaction was interesting because of the pretty extreme restrictions for women in these cultures.  However, they seemed very open minded in understanding our culture and situation as well.  My cynical side was also in the back of my mind, wondering if these girls had really experienced the restrictiveness and oftentimes disrespect that comes with being a woman in India.  Hopefully they will never experience it, but it’s fairly common.

The evening of the fourth day, we held a ‘road-side’ clinic back at our campsite.  Since a lot of the people living where we were staying work all day, they were unable to make it to the day-time clinics.  So around 4:30, we set up a few tables across from our campsite and saw patients, with goats walking around amongst us and on top of the roofs of the village.  The most memorable and thought provoking woman from this clinic was a 22 year old woman who came in with her 3 children ages 5, 3, and 1.  Each child was there with a pretty severe scabies rash, molluscum contagiosum (a skin virus that usually clears on its own), worms, and malnourishment.  The youngest child also displayed strabismus, a condition where the eyes are not aligned together.  It seemed the child could see with both eyes, as he would sometimes watch you with one eye, and sometimes switch to the other eye.  Besides treating for parasites (which can sometimes cause this) we could only refer her to another more specialized physician.  We gave the rest of the children vitamins in hopes of helping with malnourishment (the 5 year old child weighed only 22lbs).  As the mother finished up with her children, she also had a few concerns of her own.  She said she hadn’t had her period in 4 months, and she thought she might be pregnant.  She had gone to the doctor after having her youngest child a year ago, and was given oral contraceptives to take for 5 months.  The physician hadn’t told her that she would need to get a refill to continue taking after she ran out of those, and so she ended up pregnant again.  She wasn’t very happy about the pregnancy, as she already had 3 children and she was so young.  She mentioned that both she and her husband had been open and considering receiving surgery to prevent having further children, but they didn’t know where they could go to have it done.  This was the most depressing part of it for me because she was educated and had an open enough relationship with her husband that they had tried to make the right choices for their family, but because of a lack of resources were in this position of having another child they were unprepared to take care of.  These are the realities of living in a place like Himachal Pradesh.

The fifth clinic day was relatively uneventful.  It was really slow, but we had a sciatic pain and a carpal tunnel patient.  These were interesting for me since we had learned the physical exam skills to diagnose these kinds of issues, but I had never been able to see them on a real patient.  Luckily, we were able to provide a splint for the carpal tunnel patient, and some physical therapy for both of them to improve their symptoms.  These are the types of problems that arise from such hard manual labor though, and I expect many people live day to day with these types of pain.

On our sixth clinic day, we set up another roadside clinic.  I was at the pharmacy this day, so I didn’t get to see any patients.  However, at the end of the day I heard about another really sad and complicated case.  A man and woman had come in together, for each of their own problems.  The man went the adult medicine tent and explained that he and his wife were having trouble getting pregnant.  He said they had had a child 8 years ago and he had died of a heart defect.  They had taken him to a hospital when they realized something was wrong, and the surgery would have cost them 10,000INR (Indian Rupees), equivalent to $200.00.  They were unable to afford the surgery, so they took their son home to die.  They’d been trying to conceive for the past 8 years without success.  He also mentioned that he had some burning with urination, and some other symptoms that indicated a sexually transmitted infection.  We later found out that he was married to the woman who had gone to the gynecological tent for complaints of infertility as well.  She told them that her and her husband had had 2 children, one girl, and one boy, and the boy had died of a heart defect.  Her husband was upset with her for ‘her’ inability to get pregnant and produce a son.  He was threatening to remarry.  She begged the doctors to tell her husband that it was his own fault they could not conceive, as they had been to many doctors before who had determined it was a problem with him that meant they could not conceive.  Her physical exam was normal.  The delicacy of this social situation meant that the doctors treated the man for sexually transmitted infections, and explained that they didn’t have the necessary testing to determine the cause of the infertility.  This was another example of how women are restricted disrespected, and the difference in social norms and expectations.

The 7^th clinic day took place inside the hospital.  We saw a young woman this day who had just been married 11 months earlier, and was 6 weeks pregnant, but feeling a lot of pelvic pain.  After determining that she had Pelvic Inflammatory Disease (which can sometimes be caused by STI’s), we decided to treat her with an intramuscular shot of ceftriaxone (which is quite painful), and oral azithromycin.  We also asked her if she could have her husband come in later on for treatment, as these kinds of things can be passed back and forth and may put the baby at risk.  We were uncertain about whether or not they would actually return, due to the delicate dynamics of husband-wife interactions in such cases.  However, later that evening after dinner, she arrived with her husband.  He asked why he needed to be treated too even though he wasn’t having any problems.  We tried to explain without placing blame that infections can cuase these problems, and can be passed back and forth between husband and wife, and it is for the safety of the baby that he is also treated.  Fortunately this was an acceptable explanation for him, and he willingly accepted the painful shot.  The interaction between the young husband and wife was sort of refreshing given the other things we’d seen to make us more cynical of this kind of situation.

The 7^th day there was also a 17 year old girl named Amshita who came into clinic with her father who was presenting with diabetes (which is fairly uncommon for the group of people we had been seeing).  She spoke surprisingly good English, and it turned out that she was studying pre-medicine in Chandigarh and was home on break.  She was interested in staying and helping us with interpretation for the rest of the day and she was very helpful. She also took us on a tour to see the local Buddhist monastery and the rest of the town.

Another example of the difficulty we encountered treating people in this situation was a story told by one of the students that evening.  She said that a patient had come in complaining of foot pain and swelling.  However, in the middle of his interview his aunt came in and pulled up his shirt to show the physician the man’s back, which had a large open ulceration that looked infected.  The bone was just about visible, and they said he had received a skin graft from the local hospital, but that it hadn’t taken very well and he was still having problems.  After sending him home with antibiotics and some advice to keep pressure off his ulcer, and to return to the hospital for another graft, Katherine saw him walking up the pathway on our way to visit the village.  He was carrying a large basket of rocks on his back, and it was pressing directly against the ulcer.  It was incredibly distressing to her, and is another example of the difference in priorities one has living in such circumstances.  It was not an option for him to take time off to rest and heal his problem.  The priorities seem to be more day to day, such as dealing with the pain, and making money, rather than having the luxury to use foresight and expenses to retry the skin graft, and allowing the proper healing time. 

The eighth clinic day had many of the same encounters.  There was a very cute puppy however that everyone wanted to play with.  Our infectious disease attending was very clear that we should NOT touch the dog, because the rabies treatments were only in Delhi, and it would be a real bummer to get airlifted out on one of the last days. 

After the clinic days were over, we began our long journey back over the Rohtang pass to Manali, then driving to Bilaspur.  The final day in India we drove 5 hours from Bilaspur to take a flight from Chandigarh to Delhi.  We waited in the airport for another 5 hours because our flight was delayed.  Once I reached Delhi, I had to pick up my bags and re-check in to my flight from Delhi to Newark.  I waited a few more hours in the Delhi airport (thankfully it was very comfortable and provided all amenities needed) before getting on a 15 hour direct flight back to the US.  Gina picked me up at the airport at 4:30AM (although my internal clock was WAY off).  I went  with her back to NYC and hung out for a few hours before driving back to Massachusetts.  All in all, a very successful trip.   

If anyone has any specific questions, please post them and I will try to answer them as best I can!  Sorry the rest of this blog ended up being so late.  Thanks.

First few clinics with HHE

On our way back from the clinic the first day, we decided to walk.  Hem (our leader/organizer) told us to walk down the road and then take a right down by the fields, but not to walk through fields.  Needless to say we got a bit lost, and Shaellie our interpreter had to ask some locals for directions.  They took us down a little path through a village and some fields.  It was pretty silly to see 30 or so Westerners wandering around amongst these fields.  We crossed a rickety bridge while a bunch of locals watched us with interest.  On our way back up to the campsite we passed quite a large group of goats and sheep.

On the second clinic day, we were supposed to set up in the bottom floor of a school house.  However, they were unable to do so because of some kind of event going on, so instead the woman across the street offered to let us use her partially built house.  This day I was assigned to be in one of the adult rooms.  We saw a lot of people with non-specific abdominal pain.  After ruling things out like GERD or diarrheal diseases, we de-wormed a lot of people.  This was also the first day that I got to look at some good eardrums. It seems that a lot of people in this region get recurrent ear infections and then lose their hearing over time.  Many adult ear drums showed significant scarring and previous trauma.  Unfortunately, at that point there is nothing we could do unless there was evidence of current infection.  One of the most memorable patients from this day was an 85 year old man who had signs of Parkinsons Disease.  He had a visible pill-rolling tremor in both hands, as well as shuffling when he walked.  He also had a pretty stooped posture, limited facial expression, and shuffling when he walked.  One of his main complaints was his inability to swallow, and therefore continual drooling.  We had to explain to this man and his son that the process of aging and the disease was irreversible, and just to continue helping him try to cope.  Most of the saddest cases were ones like this, where people came to seek medical attention, but it was too late, and the resources too poor to help them much, or at all.  Another woman we saw this day came in for some debridement of a previous frostbite injury that had not regenerated healthy living tissue.  They were able to do some of it there, but it required more extensive work and we needed to refer her to a hospital.

By the third day, we were becoming very familiar with the clinic process.  I was placed in one of the pediatric tents, and we were given enough freedom to do the full interview and physical exam before consulting the doctor.  We were then asked to give a “SOAP” patient presentation (Subjective, Objective, Assessment, Plan).  The doctor would then consider what we had determined, ask a few more questions, do more physical exam, and then use it as a teaching moment if we weren’t correct.  This style quickly got us comfortable asking questions of our preceptors, but also taking the reigns and doing the majority of the patient interaction ourselves.  

            My favorite patient from this day was an older woman of about 65 who came in complaining of shortness of breath and joint pain.  She was my favorite mostly because she was really pleasant and nice.  She was so grateful for our attention to her problems.  She had about 8 piercings with rings in each ear, so heavy that they were weighing her ears down.  She also had some home-done tattoos on her hands and I showed her my ‘Om Mani Padme Hum’ tattoo which she liked.  The Tibetan prayer I have tattooed on my foot was very prevalent in this region, and I saw more than a few people with the same thing, or only the ‘Om’ tattooed on them.  She also had a cleft lip and palate.  She allowed me to look in her mouth, and I could see the hole into her nasal cavity.  She said she never had any problems with it.  I was wondering about how it might affect her marriagability, but she said she had kids, and grandkids, so her winning personality (or dowry…) must have made up for any stigma associated with the defect.  The other memorable patient we had that day was a boy of about 14.  He came in for abdominal pain, but I noticed that one of his eyes was smaller than the other.  On inspection, we realized he had no pupil in that eye, it was all iris.  He said he’d been born that way and never been able to see out of that eye.  Both of his eyes moved together so it seemed like the ocular control nerves were all intact.  I’m not sure how something like that could happen, but I assume it’s a congenital defect.  There was another boy we’d seen who had a multitude of warts on his hands and enlarged lymph nodes.  He was there for eye pain and difficulty seeing up close.  Our infectious disease doctor sent him to the hospital to follow up because it makes a pretty good case for HIV infection.

After the 2^nd clinic, we had a little time to sit down and reflect on the patients we had seen.  Although I was in one of the pediatrics tent, we heard a bit about what went on in the gynecological tent that day.  A woman had come in complaining of pelvic pain.  On exam, and given the history, it was determined she had an STD that was contracted from her husband after he had ‘been away’ and clearly cheating on her.  She told our female interpreter that he came back wanting her to do all kinds of things she was uncomfortable with, and she was too scared to disrespect him by asking him to wear a condom so she was forced to get this infection.  After we treated her and sent her home with medication for her husband, she called a bunch of her friends who all came with the same story.  It was pretty depressing that these women are in such a situation where their health is at risk, and they’re unable to stand up for themselves.  And I don’t really believe it’s a ‘cultural difference’ because none of the women were really OK with it.  It’s just a shauvanistic belief that it’s an acceptable thing to do, and that’s only half the population.  So I’m not willing to call that a ‘cultural nuance’.

Another woman had come to the clinic on the second day, and had what Abraham Verghese terms “the head and the heart disease”.  It basically a physiological manisfestation of depression, where a person’s head, heart, and many other things may actually feel pain due to their extreme situation and their ineffective coping mechanisms.  It reminded me of the woman who Dr. Kamat had seen at his office in Lonavla (during my previous program), except this woman did not have access to such a physician.  She said she had tried to attend our clinic the previous day, but had missed it.  So between then and the 2^nd clinic she walked for 8 hours between the clinics.  She was unable to catch a ride, so she walked to whole way.  She sat and talked with our interpreter for a while, about general life things.  Her husband, parents, and siblings had all passed away, and her children had abandoned her.  She had no where to sleep that night, so she was planning to sleep in the shed by the school.  It was pretty sad to hear about the interaction, and it brought our interpreter to tears to recount the story.

The next day we took for travelling to our second campsite.  We woke up bright and early to leave because although it was only supposed to be a 3 hour drive, they had taken 7 hours the previous year because they got stuck in a river.  The roads in these mountains are just barely cut out of the mountain side.  There is just barely room for one car to pass another, and definitely not while both cars are moving.  About halfway to our next campsite we went through the river they had talked about.  It was about a foot deep and just pouring down over the rocks and all down the road before continuing over the edge and down into the valley where it joined up with the larger river.  Once we got to our new campsite we saw that it was much more open and flat.  There was a heli-pad that is used in the winter to fly in supplies to the villages.  However, since it wasn’t in use, the drivers and the girls from the UK decided that we should play a game of cricket.  So they taught us the rules and we all had a practice hit before we began playing a game.  It’s pretty complicated, but it was fun.

New Delhi, Taj Mahal, and beginning of HHE

After meeting up with Brian at the hotel, we signed up online for something called the 'city walk' with these guys who work for a company that helps slum children.  The guides themselves are kids that used to live in the slums.  During the tour we learned that most street children spend any money they get on things like video games.  Because they sleep on the street, they can’t afford to have any money on them because it will just get stolen overnight.  One of our guides Iqbal told us that his parents used to beat him and put pepper in his eyes, and one day his father just left him at a market.  A couple found him there and told him they were his aunt and uncle.  They took him home and used him for slave labor, and they used to beat him too.  So one night when he was six he ran away and took a train to Delhi.  He actually doesn’t even remember where he’s from, because he was so young when he left.  He used to work as a pickpocket on the streets of Delhi, and then he was part of a gang for safety.  When a woman from the Salam Balaak Trust asked him if he wanted to go to school and live somewhere nicer.  Initially he didn't trust her, given his previous experience with strangers offering him things.  Now he works for this company and they provide money for schooling, and they have places for children to stay and everything.  It's pretty great.  It's called Salaam Baalak Trust, which means salute the children.  They’re also able to get documents for the children so that eventually they can open bank accounts and become a productive part of society.

Later in the day we went to the Red Fort later today and the Jama Masjid.

TAJ MAHAL- Mathura, Fatehpur Sikri

The next day, we had hired a car to pick us up early in front of the hotel.  The train tickets were sold out, and confusing to figure out.  So we decided to pay a bit of extra money to hire our own driver with an air conditioned car.  This way, we could also stop in Matheran, and in Fethepur Sikri during our Taj Mahal trip.  In Matheran, there was a beautiful temple where Krishna is said to have been born.  The security at this place was very tight.  We weren’t allowed to bring anything but money into the place.  Being a temple, we had to remove our shoes.  This sometimes posed a challenge because the ground is so hot.  In a lot of places they had rugs down for people to walk on so they wouldn’t burn their feet. 

Within the temple compound, there were a few buildings.  In one of them, there was a group of men singing and playing drums while some people danced, and some people sat.  The women were on one side, and the men were on the other.  One of the other buildings had more of an artistic feel, with a lot of painted pictures of various gods hung on the wall.  An Indian woman and her family took us around and told us which god was which, although she didn’t speak any English.

When we got to the Taj Mahal, we hired a guide to take us around and tell us the history.  The Taj was built under the Mughal emperor Shah Jahan.  He built it for his 3^rd wife Mumtaz, who died giving birth the their 14^th child.  She was his only love marriage, and his favorite wife.  So he built the Taj Mahal as her Mausoleum and buried her beneath it.  It took 12 years to complete, so she was actually buried somewhere else first and then dug up and put under the Taj.  There is also a Mosque in the grounds, so the Taj Mahal is closed on Friday except to those who go there for prayers.  There are three different entrances to the Taj Mahal, depending on what standing you had.  Most of the Taj Mahal is made of White Marble which was somehow shipped in from Rajasthan.  There is also some red sandstone which comes from Fatehpur Sikri.  One of the most impressive things about the Taj Mahal is the marble inlay work.  There are countless numbers of precious stones inlayed into the marble in various shapes of flowers and vines.  The stones used are Jade, Crystal, Turquoise, Jasper, Lapis Lazulie, Sapphire and Carenelian.  In a lot of places where they haven’t walled it off, you can see how deeply inlayed these are because people have popped them out to sell.  There is also a lot of lattice work that was pretty intricate, and incredible because large chunks of lattice are carved out of one piece of marble.  There is a myth that after the Taj Mahal was built, Shah Jahan had the workers’ hands and tongues cut off so they could never tell or build another one like it.  The guide book said there was no evidence supporting that.  After Mumtaz was buried in the Taj, Shah Jahan’s son ended up taking over the empire and imprisoning his father.  When Shah Jahan died, however, he buried him next to Mumtaz under the Taj Mahal.

After the Taj Mahal we went to Fatehpur Sikri.  This place had 3 palaces and a holy area that were built by another Mughal emperor named Akbar.  He had 3 wives, one Christian, one Muslim, and one Hindu.  He built each of them a palace, and then at the holy place he integrated all religions into the construction.  It was pretty cool to see all the different architecture mixed together.  Our guide told us that Akbar believed there was only really one religion, since most religions ultimately believe in one god.

After this very long day, we drove back to Delhi and brought our stuff to the hotel down the street where we met up with the Himalayan Health Exchange program to begin our journey into the Himalayas.

HHE

The first day with HHE we woke up at 4AM to go to the airport.  We flew from New Delhi to Chandigarh, and then found our cars and drivers waiting for us at the Chandigarh airport.  They packed our bags up on top of the cars and we got in and began our first 5 hour drive to Bilaspur.  We had a quick meeting on the first night in Bilaspur, and got all of our air conditionings working before eating dinner and going to bed.  We met the other ~25 medical students, and attendings, residents, and a few family members.  There was a group of people from various places in Canada, a couple of girls from the UK, a group traveling together from Ohio, a group from Texas, and a sprinkling of other people, with a good amount from the New England area.

The next morning we woke up and had a nice breakfast before heading out for another 5 hour drive to Manali.  They had us driving only short distances each day so that we could acclimatize to the altitude.  The 5 hour drives were not covering as much distance as one would expect in the U.S. because the roads are so much worse.  From Manali we traveled for a very long day over the Rohtang pass to Udaipur in Himachal Pradesh India.  Google maps estimates that this drive will take 2.5 hours.  However, with the stand-still traffic, and tiny road only big enough for one-way traffic at a time, the drive took us 14 hours in total.  In my car was the two girls from the UK, Clair and Shruti, as well as one of the girls from Ohio, Linda, and Nick from Oregon.  Our driver’s name was Prem, which we learned means ‘love’ in Hindi.  He became my favorite driver.  We were spending some time trying to learn Hindi that would be helpful for the clinic and we made up a Hindi version of “head, shoulders, knees and toes” (sar, kandha, ghunte, panw, onk and kaan, and muh and nonk).  We even got Prem singing along.  We got to know each other very well that day, and the girls went on many outings to find rocks large enough to pee behind.  We also hadn’t been prepared for these circumstances and didn’t really have enough food.  Shruti and I split a chick-pea salad/burger thing and also some sweet corn that they had grilled with lemon and salt.  It was all really tasty, although a bit scary (travelers diarrhea, worms…).  We arrived at our first campsite around 8:30pm, ate some dinner and went to bed.  The crew had already arrived there before us and set up all the sleeping tents, dining tents, bathroom tents, shower tents etc. 

In the morning they had Chai ready for us at 6am, and breakfast ready at 8am.  They continually had hot water for those who wanted to shower in the morning (and in the evening after clinic).  Breakfast was often pancakes, eggs, toast, and things like that.  After breakfast, they had a dish cleaning set up where we could wash our own dishes.  We then packed up our day bags with our gloves, stethoscopes, TB masks, hand sanitizer etc. and headed off to the first clinic.  Some of the crew drove the pharmacy boxes, and some drove us.

Before clinic, we arrived and there were a bunch of children playing a game that looks a bit like duck-duck-goose, only they are all in a line and it has something to do with which direction you’re looking.  They were also playing volleyball in the flat area next to the clinic.  There was also a pretty famous temple in Triloknath where they had a white marble idol of Lord Shiva.  However, because it is so far north in India, there is also a huge Tibetan influence.  At this temple there were prayer wheels, prayer flags, and a lot of other Tibetan Buddhist contributions in and around the temple. We entered the temple and rang the bell (a Hindu ritual), passed through the ‘sin columns’ and were given a white fabric tie around our wrists.

At the clinic, they had assigned each student to a tent.  After the patient saw the intake for weights and ‘chief concern’, they came to our triage tent where 2 students would take blood pressures and heart rate of each patient coming through.  They would also monitor the flow of patients and point them in the direction of whichever tent they ought to go.  Beyond triage, there were two adult medicine tents (with adult or family doctors), two pediatric tents (with pediatric or family doctors), and one Gynecological/OB tent with a family doctor or our OB/family doctor.  After a patient was seen and diagnosed, they were given the sheet with the notes and doctors signatures to take to the pharmacy.  They were given whatever medications they needed, and then they took the sheet with them.  Frequently patients are seen by many different doctors, so it is good for them to hold onto their own records so they can bring it with them to whichever practitioner. 

Around 1 o’clock, the clinic would break for the lunch our cooks made for us fresh at the site.  We then would start up again in the afternoon until everyone had been seen that day.

The first day, Shruti and I were assigned to triaje.  It was kind of interesting because we were able to see every patient who went through that day.  Even if not in detail, it was a good overview before beginning the patient interviews at the next clinics.  One of the most interesting patients was the first patient we saw that day.  He was a 9 year old boy with an ‘eye issue’.  His eyelid looked deformed on one side, and he was unable to close his eye all the way.  We learned after he had gone to the pediatrics tent that it was the result of a post-natal chlamydia infection.  In the developed world we typically screen expectant mothers for chlamydia and gonnorhea, and may or may not also prophylactically treat a baby’s eyes with antibiotic to prevent this (depending on the country/hospital etc.)  This boy fortunately did not have any loss of sight, but was at increased risk for trauma and damage due to drying.  He didn’t have any sign of current infection though, so they just tried to explain to him the importance of keeping his eyes moist and clean.

Another memorable patient was a little girl who was 8 years old.  She came in because her mother said she wasn’t growing (she looked like she was about 4 years old), and because there was something visibly wrong with her chest.  Although I didn’t get to hear it, they found an incredibly loud murmur indicative of a Ventricular Septal Defect (the heart has four chambers that are meant to be separate, and with this defect the two largest and strongest chambers are connected, which really messes up the oxygenation and pumping of the body’s blood).  They referred her for surgery, so hopefully she will be able to get that soon.  Without it she will die.

A few other general things we noticed was that almost every patient had low blood pressure.  I think the average was probably somewhere around 110/70.  The highest ones we saw were 140-160/90-110.  It must be the diet and lifestyle that makes this true across the board.  There were also a lot of eye problems.  It seemed like a lot of people had allergies, and general sensitivity to the sun.  Most of our patients were farmers, so that makes sense.  We didn’t bring nearly enough eye drops or sunglasses though unfortunately.  There was also one woman who described to us that she had ‘angina pectoris’, which is the typical squeezing chest pain and shortness of breath that one gets with cornonary artery disease.  However, she didn’t speak English.  So instead she huffed and puffed and then demonstrated a squeezing motion over her chest.  It was quite easy to figure it out.  Seems to be a universal sign. 

That evening, Shruti and I had been assigned to do a discussion of Ayurvedic Medicine in India and Traditional Tibetan medicine.  We had talked a bit about them so we decided to combine our topics, since Tibetan medicine has a huge Ayurvedic component, and because I had just spent the previous 2 weeks learning a lot about Ayurvedic medicine.   One of the most interesting things I think was the prevalence of Ayurvedic medicine in Himachal.  In every town we went to, there was a local Ayurvedic health office.  However, the only two hospitals (and therefore allopathic medicine) were in Kullu or in Udaipur.  The other thing about Ayurvedic and Tibetan medicine is that they both take a very holistic view of the patient.  They spend a lot of time listening to the history and daily habits of a patient to determine exactly what the problem is and what the best solution for that patient is.  I think the process of these types of medicine could definitely be something we strive towards in allopathic medicine, but the treatments are pretty different.  In a lot of cases, the patients trust Ayurveda more than they trusted the allopathic medicine, because it is what they grew up with.  We tried to use whatever we knew about it to build repore and even to help treat the patients.  For example, a lot of the first-line treatments in Ayurveda and Tibetan medicine are lifestyle and dietary changes.  These are things that our patients could get on board with, with an obvious difficulty in some lifestyle changes due to the physically very difficult nature of their work.