Medical Elective Report: Shalin Abrahams and Rachel Scott

Our experiences working with Nepal Leprosy Trust at Lalgadh.

Shalin Abrahams and Rachel Scott

Partially funded by the Selwyn College Medical Elective Fund

1. Off we go!

We arrived in Kathmandu to a sea of enthusiastic taxi drivers and hotel salesmen all overjoyed to see the few lost and rather confused backpackers who had made it to Kathmandu, mid monsoon. Thankfully Kamal, our trusty guide from NLT, rescued us pretty quickly and after a scenic drive around most of Thamel delivered us to our hostel, the Elbrus Home. After unpacking and settling in we braved the streets of Thamel in search of dinner.

Thamel, the tourist hub of Kathmandu, is lined by tiny stores selling everything from fisherman’s tousers to incence to fake mountain gear. The streets are crazy with traffic and pedestrians battling it out for space without much care of which direction they are going. We soon learnt how it was done though and made our way to a lovely restaurant where we treated ourselves to some European food in preparation for the next few weeks of dal bhat we would be getting at Lalgadh.

The next day we decided to tick off some of the touristy things to do in Kathmandu.

We started with the Garden of Dreams, built by Field Marshall Kaiser Rana and restored by the Austrian government. It is a beautiful old garden filled with pagodas and elephant statues and was especially peaceful after the walk through Thamel.

Next we headed down to Durbar square in the centre of the Old Town. If you want to see temples this is the place to go - they are everywhere! We did a short circuit but being a tourist is hard work and pretty soon we were tired. We headed up to a roof top restaurant only to find that everyone else there was clutching the same lonely planet guide we had. It was a beautiful view though.

After lunch we explored the old palace and headed back into Thamel for another shopping spree. Kathmandu is notoriously expensive but we upped our haggling skills and they do have some lovely things.

The next morning we planned to fly to Janakpur and Kamal said he’d send us a driver. Unfortunately with only an hour to go before our flight no driver had come!

We managed to get a taxi but were stuck in an enormous traffic jam and gave up all hope of getting our flight. In the end we arrived 15 minutes before our flight was supposed to take off. To our surprise this didn’t bother Yeti Airlines one bit and we joined the queue where other passengers were checking in! That’s Nepal I guess…

2. Arriving at Lalgadh: After a quick 25 minute flight, on a noisy 20 seater plane (which more resembled a helicopter) we emerged into a mid-day blaze that was dusty Janakpur. It is difficult to believe that it is monsoon season here! This is the nearest main city to Lalgadh, and is an important pilgrimage site for many Hindus. Being 20km from the Nepal-India border, it has an unmistakable Indian air to it. An hour ride in a rusty Land Rover brought us to Lalgadh hospital, an emerald green oasis in the middle of povertystricken Lalgadh.

Lalgadh Leprosy Services Centre is Nepal Leprosy Trust’s largest venture. It officially opened in 1996, and since built up a reputation as the busiest, but one of the best Leprosy treatment centres in the world, seeing around 30 000 patients per year. It is remarkable that Leprosy sufferers receive treatment, drugs and food all free, and thus NLT relies on generous donations. Having developed such a good reputation has meant that even non-Leprosy patients come for opinions and treatment to the outpatient clinic. It serves a wide population, with patients even as far out as the Indian state, Bihar.

We were welcomed with overwhelming hospitality, by both the staff and patients, with every person greeting us with ‘Namaste’, while putting their hands together, a sign of respect. We were told that the patients here like to see European people, as it re-affirms their faith in the hospital, and often makes travelling far and wide worth it, in their mind. We were given a tour of the compound which includes an inpatient department for Leprosy patients, a VERY busy outpatient centre where people come for general enquiries, a maternity unit, a pharmacy, lab and an operating theatre.

The great thing about LLSC (Lalgadh Leprosy Services Centre) is that it doesn’t just try to treat the acute symptoms of leprosy. Whilst patient follow up is inevitibly difficult, prevention, long term rehabilitation and education is a key ethos here.

Therefore, there is a wound care centre, physiotherapy centre, eye care and even a community centre. There are also regular motorbike trips out to rural villages to hold leprosy focus groups to try and tackle the ingrained stigma against leprosy patients (part of which is due to intensely religious Hindu culture), which often leaves sufferers marginalised and in a cycle of chronic poverty which only exacerbates their leprosy.

We were taken to our volunteer accommodation, which is HUGE. We have 4 double bedrooms, 3 bathrooms and a kitchen between two of us. Unfortunately it comes at a price, as it is on the edge of the jungle, where there have been jaguar sightings and you can hear the cries of kyotes at night (although a quick Wikipedia search has since made us a little sceptical about the later). Our house is also resident to 5 gheckos who are always scuttling around. To make matters worse there is no real path to our door, and have to wade through long grass, where we are a terrified of seeing a snake. We are yet to see any fireflies, but there is no doubt that the nature is amazing here!

We were warned about the food here, but we are beginning to realise the implications of eating dal bhaat (a spicy lentil curry) and rice, with some fried vegetables, 3 meals per day, EVERY DAY. Whilst we are enjoying it now, I can definitely see myself having hallucination side-effects relatively soon.

3. Day One (WARNING: Don’t read this over breakfast!)

And so we woke up, nervous but excited for our first proper day in the hospital. Our day started at 9, where we caught the end of the morning handover with Dr Krishna Lama. We were immediately pulled in to see an emergency case of a man with fever, vomiting and acute abdominal pain. A quick abdominal exam revealed an enlarged liver and tender gall bladder. However, without a working X ray and only a small

ultrasound machine, there was little they could do for him at Lalgadh, which mainly sees leprosy and dermatology conditions.

After this, we shadowed Dr Yamuna as she checked on the Leprosy in-patients.

Leprosy is caused by a bacteria called mycobacterium leprae, cousin of the more common mycobacterium tuberculosis (minus a few genes). It is spread through nasal droplets and prolonged close contact with sufferers, but is thought that most of the population is naturally immune to it, particularly those who have had the TB BCG vaccine. The classic signs are a light coloured lesions on the skin with sensory loss in the middle and damage to the peripheral nerves. As a result patients can often present with a clawed hand and foot drop, making it difficult to carry out daily activities. If not treated early the secondary effects can be serious, including the development of ulcers due to sensory damage, eye problems and breakdown of nasal cartilage. Often patients can have leprosy reactions, where their condition will rapidly deteriorate and symptoms will become more severe. Leprosy is very simple to treat, with the WHO recommending 6-24 months of MDT (multi-drug therapy) involving 2-3 antibiotics based on the severity of the condition, and the drugs are provided for free.

Most of the inpatients have quite advanced ulcers, are post-operative patients (e.g. after amputations), or are suffering reactions and therefore need close monitoring.

We were introduced to all the patients, and Dr Yamuna and the nurses reviewed the medications. A particular case which stood out for us was a married girl who could not have been more than 13, who was admitted for severe leprosy reactions, underlying deep rooted socio-economic problems in the area.

We then watched the wound dressings being changed, and underneath the bandages were some shocking ulcers, ranging from relatively superficial ones to deep ones that had eaten through the bone and soft tissue, and the smell of rotting flesh mixed with iodine was sometimes hard to bear. To prevent septicaemia, they carry out debridement where they chip away at bone and dead tissue, but if the leg

becomes gangrenous there is no choice but to carry out amputation as with this lady.

We really saw the challenges of working with limited resources here as we discovered there is no such thing as ‘single use instruments’.

After our dal bhaat lunch, we spent the afternoon with paramedic-come genius diagnostician Ashok in the outpatient department, who only needs to glance at a skin condition to know what it is. We saw a variety of conditions from simple dermatitis and fungal infections to vitilligo and a leprosy diagnosis. The OPD resembles some of the busiest A&Es in England, with Ashok alone seeing over 100 patients a day, firing prescriptions out like a machine gun. It is strange seeing the range of conditions here: from simple acne to life-saving amputations, but I guess that’s what makes it so interesting.

4. Living at Lalgadh We have almost survived a whole week! We have seen and learnt so much at the hospital that it seems like we have been here at least a month and even living at Lalgadh is a bit of an experience in itself. A few days ago we went to visit the labs in the hospital and caught site of a rather ominous collection of bottles:

These are apparently all of the poisonous snakes and scorpions that have been captured in the grounds. Shalin and I live right next to the jungle, a setting that can seem rather too secluded sometimes. To get to the hospital or our meals we have to walk across grassy fields, sometimes in the dark, trying to dodge any potential rustles and slithers. Typically this means that every now and again I jump sky high on catching sight of a particularly lethal twig or seed pod. Inside the house itself we have some rather cute geckos, which are apparently named after the last medical students who used to live here, although they have a rather unpleasant habit of falling on you when you open the curtains in the morning!

The dhal bhaat we have for our meals is actually pretty delicious but just a bit repetitive. We have discovered that breakfast is actually the best meal as it varies each day from curry and chow chow noodles to sweet jalebi. Today we were delighted to find there was French toast for breakfast - I cannot tell you how exciting that was after a week of constant curry! Another, equally exciting culinary development (for me at least) was my first success at making my own cup of tea! Tea in Nepal is stewed with hot milk and scary amount of sugar. I have to say I’m getting to like it but I miss English tea. It turns out that making tea here is more complicated than you’d think. Having eventually managed to connect the gas to our stove (a process that filled our kitchen with gas) and lit it, using up a pack of damp matches, I had to boil the water and the unpasteurized buffalo milk. Then you have to seive the tea and de-skin the milk before finally pouring a good cuppa. It was well worth it as the tea here is fantastic and feeling proud I rewarded myself with the very last Oreo from Kathmandu.

We also recently discovered the river- well it’s been there the whole time of course but just so dry that we didn’t know it was a river until it rained. It runs parallel to the village road on the plateau below. There is a view point on the cliff edge which gives you beautiful views of the river and the foothills of the Himalayas beyond. At Lalgadh we lie at the very beginning of the Himalayas and on clear winter days you can apparently see right up into the mountain range.

Max, a podiatry student here, has been telling us about his adventures in the jungle ever since we arrived so on our first day off we decided to take a look for ourselves.

Everyone else was quite keen to join us and mid-afternoon we set off on our little expedition. Shalin and I were originally quite sceptical of the term ‘jungle’ – it sounded a bit too exotic to us! But as we found ourselves walking into denser and denser undergrowth it became much more apt. We were soon walking through grass above our heads trying to make as much noise as possible to scare off any snakes!

The terrain is torn apart daily by the monsoon rains forming an ever changing network of deep ravines and hilly ridges. We climbed up to one such hill to take a look at the view – an expanse of jungle stretching out in every direction…

5. We’re half way there We are halfway through our stay in Lalgadh and can’t quite believe how quickly it has gone! Everyday we are learning so much and are growing to love this place and everyone in it. We have now experienced nearly every department, which are all very different but play a crucial role in the running of the hospital.

The OPD is probably the most interesting place to be because you get such a variety of conditions, although we have to admit we are beginning to get bored of seeing Tinea (a fungal infection that can present all over the body). The fungus thrives in warm, moist environments and it is particularly common here because of poor hygeine, exacerbated by the climate. It is important though because tinea versicolor can be confused for a hypopigmented leprosy lesion. Other differential diagnoses for leprosy include: vitiligo, pytiriasis alba and lupus erythematosus.

Tinea versicolor:

Vitiligo:

Leprosy lesion:

Other common conditions seen in OPD include scabies; folliculitis (pustules on the skin) and impetigo; lichen planus (multiple plaques resembling lichens); lots of acne, warts and verucas. Perhaps it will not surprise you to hear that we have both used up all our hand sanitizer!

Nevertheless, every now and then you do get to see some amazing cases. One lady presented with bullous pemphigoid, which causes you to break out in numerous painful blisters. I also saw a case of visceral leishmaniasis (or ‘kala azar’).

Leishmaniasis is caused by protozoan parasites carried by sandflies. These can spread to the organs and cause massive enlargement of the liver and spleen.

Leishmaniasis

If not treated, this is fatal. We have even seen a case of Fournier’s gangrene, necrotising fascitis of the scrotum, of which there have only been 1000 reported cases in the world! It is a terrible condition though with a high fatality rate and although it is fascinating we both came away feeling sad.

We also spent some time in Wound Care, where patients with less severe ulcers soak their feet for 20-30 minutes, before dead tissue is removed, topical medicines are applied and the wound is bandaged. We witnessed a huge abscess on the finger being emptied- luckily we stood out of the way- and minor surgery where the largest skin tags we had ever seen were removed. Rachel had to get over her squeamishness pretty quickly!

Physiotherapy helps to rehabilitate patients with nerve damage resulting from leprosy, sometimes by putting them in casts to prevent further neuropathic bone damage, other times by making them walk along bars gradually increasing their weight bearing ability. The physiotherapist also does basic motor and sensory testing, and we got to feel some fantastically thickened nerves here! Unfortunately the lack of working X Ray machine does make the physiotherapist’s work much harder, who has to have a good eye to spot where small bone cracks might lead to permanent foot deformity.

Somewhere that we really saw the challenges of working in a developing country was the lab- it’s pretty vintage, with old wooden tables and test tubes resembling more your high school chemistry classroom, but is one of the only science labs in the region. This makes Lalgadh very important as a leprosy diagnosis centre as taking a skin smear and looking to see the m. leprae bacteria helps to differentiate between the different types of leprosy. Clinically the presence of 5 or more skin lesions and any m. leprae bacteria under the microscope leads to a diagnoses of multibacillary leprosy, which requires a longer MDT regimen. However, even if there are no bacteria under the microscope but there is still a skin lesion, this could be paucibacillary leprosy- a less severe form.

Other important tests they do here are erythrocyte sedimentation rate, which is literally timing how long it takes for red blood cells to sink to the bottom of a long test tube; the vidal antigen test for typhoid; as well as blood sugar tests for diabetes (which there is a LOT of here), creatinine, bilirubin and uric acid levels. Rachel even took some blood from a patient (I was too much of a wuss), a great experience in itself. Luckily it was a leprosy patient who had limited pain sensation and big fat veins making her a perfect patient to practise on!

Lalgadh Hopsital has managed to raise enough money to buy an ultrasound machine, which is placed in one of the only rooms in the hospital with air conditioning, so of course we were pretty eager to spend our time there. The ultrasounds are done by the Australian Dr Greame, the medical director for LLSC. This room is a world away from busy OPD which is teeming with patients, with Bach playing in the background and cups of nescafe coffee for all. We mainly saw investigations of abdominal pain, seeing things from large renal cysts to uterine fibroids. Ultrasounds are quite difficult to interpret, so we are relishing getting the experience to observe some (plus it’s reminding us of all the anatomy we’ve forgotten). Being a paediatrician, Dr Greame also does ultrasounds of expectant mothers and if we are lucky enough we are hoping to see a delivery while we are here!

Last weekend we took a visit to Janakpur. Having already driven past it when we first came to Lalgadh from the airport, I was a little skeptical about how interesting it would be. It is not a top tourist destination, but its dusty charm and haphazard backstreets are somewhat hard to resist. In the heart of Janakpur there is a little jewel- Janaki Mandir- dedicated to the goddess Sita. For me the colourful marble far surpassed the numerous temples in Kathmandu, and apparently it is considered the most important model of Rajput architecture in Nepal. After dodging the holy cows in the main courtyard, we went to the ‘museum’. However, the 15 rupee entry fee was worth it to see the moving (rather creepy) doll statues playing out Sita’s life.

Unsurprisingly, it quickly became sweltering hot in the afternoon, so after a cold coke we made our way home.

While Rachel was in OPD, I made my way to the outreach clinic in Janakpur that Lalgadh does every 2 weeks, next to Janakpur General Hospital. The clinic is a tiny room with a small fan, which has to fit a doctor, paramedic, footwear specialist, pharmacist plus around 10 patients in. Whilst seeing relatively mundane things, e.g. lots more tinea and steroid follow ups, it has been one of my favourite days here so far, as I really saw how devestating Leprosy could be.

Here we heard a particularly sad story from poor Hindu priest with a bad foot ulcer.

He had dedicated his whole life to serving God and as one of the holiest of the holy at the temple, he was a very influential man. He dined with the wealthiest families and had even raised money for friends to go to Kathmandu for medical treatment.

However, after getting Leprosy he has lost everything, and was crying in despair, not understanding what he did to deserve such a fate. He has been excluded from his group of Hindu holy men and the very people he helped won’t even lend him money for some shoes. Another 20 year old girl came in with bad leprosy reactions. She burst into tears saying she had a 1 year old child, and because of her leprosy her husband will not even speak to her on the phone. I knew our lives were a million miles apart, but for some reason I identified with her more closely than any other patient I had seen.

Not all was sad though as outside the clinic was a meeting for all the leaders of the self help groups in the district, which aims to tackle the very stigma which had ruined these people’s lives. Men and women with amputed feet and clawed hands discussed income generating projects and a microcredit loan system, enabling people with leprosy could get their lives back on track. In short it empowered the Leprosy sufferers, so that they, their families and friends knew that their leprosy did not define or control them- a truly inspiring thing to watch.

6. FEET! If I had to use one word that described the last few days it would have to be – feet! I have never been very good with feet; they are ugly, they smell like French cheese and are always getting dirty. However, you can’t really avoid them in a hospital like this. Most patients have peripheral neuropathy and can no longer feel their feet.

This means they don’t notice the cuts, burns or calluses on them that can develop into ulcers. This is tragic really as large infections often lead to the amputations of toes causing permanent disability. We see ulcers in the wards, in out patients, in wound care, in septic surgery and even out in the field – they have to be pretty gory now to shock me.

To add to this onslaught of feet Shalin and I have been doing a study on leprosy patients to assess how the progression of their neuropathy increases their risk of falls. So far we have tested 20 leprosy patients and 20 controls. We check the foot for anaesthesia, ulcers, amputations and test their muscle strength before asking them to do a timed get up and go test. This means that in total I have held 80 feet in the last 4 days! Bearing in mind that many these are oozing ulcer goo I am feeling rather proud that I have managed to get through it so far!

We even had a visit from a rather eminent podiatrist, Hugh Cross, who now works for the American Leprosy Mission but was at Lalgadh when it was first starting up. It turns out that he is a total hero! He has the best stories I have ever heard from unknowingly drinking opium-drugged tea in China to mistakenly ordering a dog he though was cute for dinner in Thailand. He also told us he once saw a jaguar attack a group of wild foxes in the back garden of the house we are living in!

Hugh’s work has drifted away from feet (lucky him!) to public health and he is now the regional director for Asia at ALM. He is responsible for the Reclaim projects running in the local villages around Lalgadh. These projects establish self-help groups and give them a sum of money, which they are then able to loan out, at low interest, to individual members with a sound business idea. The interest collected can then be used to give out more loans. These groups develop economically but also socially as they gather frequently to discuss village matters. The self-help groups are generally born out of self-care leprosy groups, the disabled and oppressed women. In groups that have been established for several years Hugh describes how both stigma and women’s rights have really improved. He also told us of the significance of women being able to come to the meeting. Most were quiet and covered their heads, but their presence hinted at vast improvements in gender equality in these villages.

Hugh was kind enough to take us with him so that we could see for ourselves. We travelled for about an hour to a remote and rather idyllic looking village south of Lalgadh. This group was fairly new, only about 6 months old, and still had some progress to make socially but had already raised a significant amount of money from their endeavours. The group meeting lasted around 3-4 hours, and the discussion ranged from petty quarrels (with one lady accusing a man of keeping his buffalo in front of her house) to important public health education, such as how to wash hands properly. Afterwards the group leader, a man with leprosy, invited us for tea at his house. This turned out to be full dhal baht sat in the middle of the village with a quite a crowd watching us. The food was delicious but we had already eaten and I had to work hard to finish it – only to find that before I could say anything I had been helped a generous second portion! I was painfully aware that this was their best food and they have very little to spare.

Hugh Cross stayed for a few days before driving back to Kathmandu with Max – making us the very last students left here. Germain and Alena, the other students, left last week , an occasion we marked by taking a trip to Bardibas (the nearest thing to civilization) to get henna. This was great fun as we all squeezed into a tiny beauty parlour down a dark corridor of shops. We all got mehndi and the woman who did it was great. I was a bit upset when I peeled mine off to see that it had gone bright orange – making it look more like I’d had a fight with a bottle of fake tan – but luckily it darkened overnight.

Bardibas itself is a dusty row of tailors and grocery shops crowding the main road.

Apparently it has a cinema but we were warned not to go because it frequently has large fights when a film is playing – luckily this isn’t often as most of the time it is broken. Personally I think I rather like Bardibas; it has its own charm and it sells luxuries such as fruit juice and chocolate, which are not to be scoffed at.

Back in the compound we have moved house so that we are a little less isolated.

Actually it is the complete opposite as we now live in a square of houses all occupied by workers at the hospital. It has a real feel of community with kids playing football and everyone knows exactly what everyone else is doing…there is no hiding! I’m not sure I feel much safer on the snake front though – as we were moving our bags we passed Samuel, the physiotherapist, proudly brandishing a snake he had just killed.

We have discovered an absolute haven in Lalgadh – the water tower. By far the tallest building in the compound we often climb up onto the roof to watch the sunset over the grounds, the river and the jungle. It is the most peaceful place I have ever been and we have taken to dragging all our stuff up there every evening. It also helps that it is the best place in the compound for wifi!

7. Namaste/ Goodbye Lalgadh!

Our last days in Lalgadh were a mixture of excitement, lots of sad goodbyes, some new arrivals and, of course, more dal bhat. Whilst only having been there a few weeks, it became a home away from home and has been fantastic learning environment. However, we are leaving with lasting friendships and the knowledge of a devastating disease, which we have discovered is an ever growing problem needing much more public awareness.

We tried to pack in as much as possible into our last week. Our main focus was finishing data collection for our study, looking at the link between peripheral neuropathy caused by leprosy and the risk of falls. After inspecting 120 feet and buying at least 400 incentivising sweets (half of which we actually ate), we finally finished gathering data for the 30 cases and 30 controls we needed. Although it has been stressful at times, we have really enjoyed getting to know the leprosy inpatients and their remarkable stories. There is one particularly cheeky patientMozahin- who always tried to steal our sweets. Though it was aimed to just be pilot research, it has made us realise how much planning actually goes into doing a casecontrol study (and that it is near impossible to plan and do one in 2 weeks!)

Rachel examining her favourite body part‌

Mozahin

We spent some more time in IPD, following Dr Yamuna as she did the ward round.

This mostly involves reviewing ulcers and medications. Two wards are dedicated to leprosy reactions, which occurs when the immune system reacts against bacilli in the

body causing inflammation. These are really serious as they can result in rapid peripheral nerve damage and occur before, during or even after MDT treatment.

Type 1 reactions result in large red, erythematous patches. Type 2 reactions cause small, very painful nodules to appear on the body. These are both treated with steroids and the wards are a great place to see the long term effects of steroid use such as adrenal atrophy, osteomyelitis, redistribution of body fat, stunted growth, etc. As steroids impede the immune system, some people die during a reaction episode due to secondary diseases like pneumonia.

Another important aspect of inpatient care is surgery. Although sensory impairment cannot be corrected, motor function can be somewhat restored. A common problem is foot drop due to damage of the common fibular nerve, where the sufferer cannot raise the foot. To correct this they do a tibialis posterior transfer (TPT)- taking a muscle which pushes the foot down, splitting the tendon and attaching it elsewhere so that it can now pull the foot up. Although we didn’t get to see the surgery, we became experts at spotting who had had one done.

A foot which has had TPT surgery

Clawing of the hands can also be repaired by re-routing tendons, but the intricate functions of the palm and fingers are harder to recover. However, in a patient with chronic foot ulceration the only option is amputation. As Lalgadh can only offer a spinal block and no GA, they can only do below knee amputations. This means part of post-surgical management is dealing with neurological problems like phantom limb, a fascinating phenomenon where the patient feels like their missing limb is still attached to the body and is moving appropriately with other body parts.

Below knee amputation

Some leprosy patients in Lalgadh are involved in a large randomised double blind control trial called TENLEP (treatment of early neuropathy in leprosy), covering India and Nepal. I went to the TENLEP office (one of two rooms in the hospital with AC) on a particularly sweltering Tuesday morning, obviously to ask about the trial‌ Apparently they test for subclinical neuropathy using nerve conduction equipment and put patients on different steroid regimens to see which outcomes are better.

The results should be out in 2015, and it will be interesting to see if using such equipment helps prevent permenant disability.

We also decided to do a few interviews with the patients. We particularly wanted to talk to a married 14 year old girl with advanced leprosy. It is always heartbreaking to see children with leprosy, particularly those with deformities, as you immediately know that their prospects in life are very low. It was a difficult interview as marriage and being away from family are sensitive topics, and at one point she starting crying when we asked about her parents.

She was diagnosed with leprosy when she was very young. Her parents, recognising that she would need someone to care for her after they die have decided to marry her off early. Her husband is also very young- just 19- and we understand that he has some kind of deformity too, as it is unlikely that someone like Shova, who has badly clawed fingers and chronic ulcers, could get married so easily. Even so, her parents had to pay a huge dowry- around 30 000 rupees and some farm animals. Her husband is working in Delhi and she is staying with her mother in-law and sister inlaws. Because she is the youngest, she has to cook for all 12 people in the family, and cannot even try telling her in-laws that she can’t do all the work they ask of her. As a result it is difficult for her to practice self care, and her ulcers and clawing will gradually worsen. On a positive note, her husband is supportive of her, wanting her to go to school and he has paid for her travel to Lalgadh. Nevertheless, it is a tragic story, almost made worse by her blissful ignorance and naivety.

It is also interesting hearing about the patient’s beliefs about why they have leprosy.

One man had a black tattoo around a leprosy lesion on his arm, believing that this stopped the lesion spreading.

He said that if he had done the same with lesions on his foot, his leprosy would not have progressed. Another man thought his leprosy originated from his days of working in the paddy fields, where his feet were constantly submerged in dirty water. It is difficult to educate these people about the true causes of leprosy and how it is transmitted (especially since the scientific community are not entirely

certain themselves), but LLSC organises street plays around the district which attempts to do this, often attended by around 20 000 people!

To get an idea of the sheer number of leprosy patients, we went to the records room where there are 30 000 red files, each one representing someone who is being/ has been treated for leprosy.

Out of the 50000 patients LLSC saw last year, around 1200 were new leprosy cases, up 300 from the year before. This paints a very different picture to WHO’s claims that Nepal has reached leprosy ‘elimination’ (prevelance 1/10000). Just being here for a few weeks has made it clear that there are certain leprosy hotspots- an issue which cannot just be brushed under the carpet if leprosy is to be eventually eradicated.

It is not just leprosy sufferers who stay in the IPD. The hospital also admits people who are partcularly sick and need hospitalisation. For example, one 10 year old girl came with the complaint of a stiff neck and fever- probably meningitis.

Unfortunately, as soon as she started improving following treatment with IV antibiotics, her parents decided that the aetiology of the illness was an evil spirit and took her to the temple to be exorcised. Though the doctors highly advised them to take her to another hospital, it is possible that the girl may not have survived. We were particularly interested in the Fournier’s gangrene case (necrotising fascitis of the perineum)- he had been admitted and following strong IV antibiotics, he was looking a lot better. We saw his debridement (removal of dead/ infected tissue), which essentially involved cutting off half of his scrotum with what looked like fabric scissors- not pleasant! I sincerely hope he had finished having all of his children….

OPD was, as usual, equally interesting. As well as your run of the mill tinea and dermatitis, there was a rare case of xeroderma pigmentosum. This is a autosomal recessive genetic disease in which the ability to repair DNA damage caused by UV light is deficient. Therefore, these children often develop basal and squamous cell carcinomas and malignant melanomas from an early age, which will kill them if the cancer metastasises. They have to be ‘children of the night’ avoiding the sunlight at all costs- it really is a matter of life or death for them.

Xeroderma pigmentosum

Other cases included herpes zoster (shingles), which occurs due to some leftover chickenpox virus which hides out in nerve cell bodies. This is quite easy to spot as the rash follows the area of sensation supply of that particular nerve.

Herpes zoster

We also saw a case of painless obstructive jaundice, apparently bad news as it could be pancreatic cancer. He was scheduled for an ultrasound which would have been interesting to see, but even after sending out a motorbike search party for him, he was nowhere to be found. Other cases included sciatica (pain down the back of the leg) and plantar fascitis, a painful inflammation of the connective tissue in the sole.

On average, there are also around 5-6 new leprosy cases diagnosed from the OPD clinic every day. Some lesions are the faintest patches of slightly lighter skin and I understood just how skilled the doctors and paramedics have to be to diagnose leprosy.

A very faint lesion- I can’t see it either…

In the meantime, Rachel’s infatuation with Nepali Nepali chai was growing (worryingly) stronger. No longer were the two creamy glasses of tea at breakfast sufficient.

Consequently, we discovered a little tea shop, just 5m away from the hospital, which served small shots of tea to satiate her cravings while I had a cold Mountain Dew. It is a rustic little place, with planks of wood for seats and hindi tunes blaring from the radio, but the doctors often come here for some down time after a hard day’s work. When we were first invited it felt like we had finally become part of the family at Lalgadh!

Although A&E doesn’t really exist in Nepal, Lalgadh Hospital does get the occasional emergency case which the on call night doctor/ paramedic has to deal with. As we had moved house in our final week to one nearer the hospital, we now had to walk through the hospital to get to the canteen for dinner. Every now and then we stumbled across a poor soul in the emergency room, either being treated, but more often waiting to be referred on to a bigger hospital. A man who had been bitten by a poisononous snake had to be sent on to Janakpur General as Lalgadh Hosptital does not store anti-venom venom (another small reason we were terrified of snakes, especially since Janakpur General is scarier than any karit). Other cases involved involved a man with very bad nose bleeds due to high blood pressure and was losing blood very quickly, as well as a women who had exploded into hives after reacting badly to a drug. We also saw an assault case- a women who had been strangled after some inebriated youths came to her shop, demanding alcohol. These incidences certainly made our daily walk to dinner far more exciting.

With the prospect of leaving soon, we tried to get as much practical experience as possible in the last week, mostly in wound care. My ‘gruesome wound’ tolerance level has been significantly raised, as we saw countless more abscesses. For example, there was a girl who presented with tinea capitis (a fungal infection of the head),

with large infected sores all over her scalp and a man with a huge retro-auricular abscess, where I’m pretty sure you could almost see the middle ear!

I got to test out my suturing skills as a guy who had lacerated his fingers with a wood cutter needed to be stitched up, and also gave a person with keloids (excessive scar tissue) a steroid injection.

Despite not getting the opportunity to see any surgery, we did assist in septic surgery. After scrubbing up (and shamelessly pretending we were in Grey’s Anatomy), we helped Dr Lama inject local anaesthetic, suture wounds, and scrape out infected tissue and dead bone from bad ulcers.

I finally got to take my first bloods, and possibly had an even better patient than Rachel- a female leprosy sufferer who had brilliantly palpable veins and was mute, so shee couldn’t scream out in painpain but all was fine.

Every tuesday Lalgadh runs an eyecare clinic, where the effects that leprosy has on the eye are managed. As the facial nerve can be damaged, the eye can be affected by lagopthalmos, where the sufferer cannot canno shut the eyelid.

Lagopthalmos

As a result of corneal exposure, the eye is prone to infection, exacerbated by the lack of lacrimation that blinking usually supplies. Exposure keratitis can develop where the eye’s cornea becomes inflamed, as well as chronic iridocyclitis (inflammation of the iris). As corneal sensation is lost, corneal ulcers can also develop. To make things worse, having leprosy can complicate cataracts and cause secondary secondary glaucoma and if things get really bad, the eye must be removed.

Advanced cataracts

However, the prophylactic approach of the eyecare clinic means that the number of these conditions is falling. Mostly the clinic checks people’s eyesight, seeing general patients too, and prescribes them glasses- pretty standard. I did see a pterygium- a benign growth of the conjunctiva- caused by excessive sun/ wind exposure.

Pterygium

The X ray machine was revived mid-week, and so we ventured into the radiology room to see some X rays being done, such as one of a lady presenting with left sided chest pain and history of trauma. Much more exciting was seeing the X ray B&W dark room, where the films are developed. Here the radiographer passes the film alternately through different fixing agents and water, and voilĂ , you have an X ray.

When we thought we had finally seen every part of the hospital, we discovered the footwear department after following the scent of fresh rubber emanating from the workshop. Here they make shoes for leprosy sufferers to prevent them developing ulcers. With 4 men working in there, they can make 8 pairs a day, and the shoes are

simply rubber soles made to fit with straps. They put different pads in place for different ulcer types: a malleolus ring pad for an ankle ulcer; a plantar metatarsal pad for a sole ulcer; a heel cop for a heel ulcer; and a cobra pad to give a flat foot an arch again. The shoes were originally free, but now patients have to pay 50 rupees, a small price for ulcer prevention.

Dr Yamuna left for Kathmandu on the Tuesday of our last week, so we said an early goodbye to her. Before this, it was her birthday, and we were invited round to her house for food, along with Dr Graeme, his wife Meena and their loquacious parrot (also called Meena). We had momos, a type of delicious dumpling stuffed with meat and veg followed by apple pie. Rachel who was originally a momo skeptic, consequently became a die-hard fan; they were that good .

Flowers we picked from around the compound for Dr Yamuna

That week, we also took a visit to Bardibas, our favourite road-side haunt to buy some leaving presents (and more dirt cheap oreos for us). Although we had to say

goodbye to many people, we also made a new friend- James, a final year medical student from Texas who arrived in our last week.

As we managed to finally scrub up for septic surgery on our last day, against all odds as most of the doctors were on leave, we felt luck in the air on our last night. James was not the only new arrival that week- after 3 weeks of desperately waiting and hoping for someone to go into labour, we finally got the chance to see our first delivery. While having our last meal of dal baht, we got the funniest little ‘telegram’ from Anita, the head nurse, and we rushed to the tiny delivery room where the expectant mother was at stage 2 delivery.

We learnt from Dr Hugh Cross that many poorer Maithili women give birth in a cow’s shed, as they are considered too ‘impure’ to enter the house. Here they stand upright with their hands tied to a bar, just waiting for gravity to do its job. The baby’s cord is often cut with large scissors used for the buffalo, making them prone to tetanus infections. Accordingly, Lalgadh Hospital has expanded to provide basic obstretic care, whose income also helps support leprosy work. This includes having weekly antenatal clinics, where the pregnant mother’s progress is tracked and ultrasounds are done, and around 1-2 deliveries are performed every week.

However, complicated deliveries must be referred on.

The delivery room was a recent build and has a bed and a small incubator. The birth we saw was not the easiest as the baby’s head was slightly too large, and after many futile contractions, Anita decided to prescribe intravenous Syntocinon (oxytocin), which promotes uterine contraction. However, still there was no success and we were all getting worried about the baby’s precarious position. Finally a deep episiotomy (surgically planned incision of the perineum) had to be done and the baby was born. Expecting a bright pink, crying child, we were shocked when an ashen white, completely silent baby boy was born. I don’t think I breathed for 10 minutes as the doctors tried to oxygenate and rescuscitate the baby, but eventually there was a small cry and a pinkish hue developed over his wrinkly skin. We all breathed a sigh of relief, and I don’t think either of us will forget the moment we saw the almost-baby open his eyes, entering a strange, new world with his whole life ahead of him: it was wonderful.

8. On the road‌ exploring Nepal one terrifying bus journey after the next Our last morning at Lalgadh was hard for both of us; although we’d only been there 3 weeks we had made it our home and we would miss everything and everyone in it.

Despite the overwhelming events of the night before we decided to wake up and see the sunrise from the water tower. We had spent so much time up there during our stay that it seemed the perfect way to say our final goodbye. We were not disappointed - watching the sky turn pink over our steaming cups of chai was magical.

The rest of the morning was slightly less relaxed. There are no tourist buses from Janakpur to Chitwan so we had to flag down a local bus on the highway. James, another student from Texas, had decided to join us and we were a bit relieved to have a guy travelling with us. As we waited we became apprehensive watching the garishly painted, horn blaring trucks speed by (apparently not caring which side of

the road they were on). Eventually our bus arrived and we were rushed on to it and squeezed into our seats. Actually, it wasn’t bad. Sure it was dusty and the Bollywood music was deafening but it added to the atmosphere as we drove past villages and bright green forest. As for the driving, I made the decision just to never look out the front window.

Waiting for the bus…

Classic Nepali garage…

After 5 very bumpy hours (we were delayed for an hour as the army decided to use the main road for a relay race – seriously???) we made it to Chitwan and were transferred into an even bumpier ‘safari truck’ to take us to the hotel. This turned out to be an oasis of manicured tropical gardens and endless tea (the later of which James and I appreciated fully). Over the next few days we were sent off on all sorts of trips and activities from canoeing to elephant back safaris.

The canoe was fairly scary for when we had all clambered into it the sides only cleared the surface by an inch – bear in mind we passed 10 crocodiles down the river! Thankfully we arrived safely downstream, from where headed straight into the jungle to try and see some animals ‘up close and personal’. Unfortunately, we made so much noise, what with breaking twigs and my very squeaky shoes, that we scared most of the game away. In hindsight this was probably a good thing as I am not sure a close encounter with a rhino would have ended all that well. We did see some bushbuck and a wild boar though. By the end of the walk we were all feeling rather hot and very itchy (all those mosquitoes!) and were pleased to hear our next stop would be elephant bathing. This was great fun as we got to ride the elephants as they wallowed in the river and sprayed trunk fulls of cool water in our faces. Our elephant had been trained to throw us off her back – a trick that she clearly enjoyed and did 4 times! The mahout made us wear life jackets, which I was initially very skeptical about, but as we fell into the river I had to swim hard not to be dragged away by the fierce current…

We also made a trip to the elephant orphanage and government sanctuary. Here we were introduced to the only elephant to have survived giving birth to twins and to a cheeky young calf. It was easy to forget that this sweet little elephant still weighed in at several 100kg and after it nearly crushed James’ foot and tried to head but me into the enclosure I decided that baby elephants would, after all, not make good pets. Later in the evening we returned to the riverbank to watch the sun setting over the jungle, still humming with sound of cicadas and chattering monkeys.

We were all very excited for our last afternoon in Chitwan, during which we were scheduled to go on an elephant safari. As it hit four o’clock we gathered our cameras and made our way to the truck just as a torrential monsoon rain was released. We were soaked! It settled to a gentle downpour by the time we climbed the 10ft stand to mount our elephant. There were about fifteen soggy looking elephants each bearing a colourfully painted box and munching bananas, sold at three times the price to gullible tourists. The three of us shared one box each sitting in a corner with our legs dangling over the sides into the trees. The ride was not exactly comfortable, Shalin did look vaguely sea sick by the end, but it was definitely exciting. Our mahout was an intrepid sort and almost immediately turned our elephant off the path and into dense branches. Under the shelter of the trees we were much dryer but had other pests to fight off including leeches and exotic red-stripped insects. Shalin and I escaped leech free but James was less lucky! From the height of our elephant we could easily spot the wild dear, peacocks and wild boar hiding in the undergrowth (although taking photos on a lumbering 5 tonne animal is less easy).

However, 2 hours in and there was tension in the air – everyone knew that a safari without seeing a rhino was not the true experience. We scanned the planes, the riverbank and the forest and finally came across a one a few hundred meters from the gate. It was obligingly photogenic and did not care at all about us being so close.

It did cross our minds that it was rather conveniently placed but at that stage no one was going to be picky…

That night we were taken out to see a Tharu cultural show, in which women and men spun to loud drumbeats and performed complicated stick dances that made our attempts at ceilidh dancing in Cambridge laughable. I have to admit cultural shows aren’t really my thing as they always seem terribly artificial – we’d seen half the performers working in the shops outside wearing jeans during the day – but they were pretty good. James, however, disagreed and promptly fell asleep! On the third day we parted ways with James, who was taking the local bus back to Lalgadh (a trip that turned out to be a 12 hour disaster), and caught our slightly fancier tourist bus up to Pokhara. The road west was beautiful as we weaved though the mountains and crossed paddy field lined rivers. However, the passing scenery soon faded out as our eyes were locked on the incoming traffic that frequently threatened to force us off the road and over the (all too close) cliff edge. Deciding that this was making her blood pressure rise too high Shalin coped with the situation by a tactical nap. I, on the other hand, was left wincing every time a truck passed by.

Pokhara, it is universally agreed, is by far the wettest region of Nepal and we were forced to accept that the monsoon had finally caught up with us. The Annapurna range remained stubbornly hidden in mist, except for a few brief hours, the entire time we were there. Luckily most of the rain occurred at night so it didn’t interfere too much with our plans and when it did rain we only had the hardship of retreating into delicious coffee houses and shops filled with tempting pashminas and scarves.

The shopping was fantastic, much cheaper than Thamel, and we got a little over excited.

What we saw…

What we wanted to see…

Pokhara itself lies on the northern banks of Phewa Tal , the second largest lake in Nepal. The water is remarkably still and reflects the forested hills and snow-capped mountains (our misty foothills in our case) of the untouched Northern bank across its surface. It has become a tourist haven for trekkers fresh off the Annapurna circuit, dying for a pizza and ice cream and after our long abstinence in Lalgadh we also felt entitled to enjoy these western luxuries. One of our favourite places to go was Busy Bees café, a cosy courtyard around a fire, where live music played all night (I should say that in Nepal most places close at 10 – busy bees is open till a rebellious 11.30). We met lots of friendly travellers (and some rather odd ones too) and swapped stories of our time in Nepal.

On our last afternoon in Pokhara we wanted to trek up to the World Peace Pagoda, which is perched on the hills overlooking the lake. First we had to take a one of the small brightly painted rowboats across to the southern shore. This takes you past a

tiny island where the Taal Barahi pagoda lies covered in pigeons. Tourist and pilgrims alike gather on this tranquil island to ring prayer bells and light incense sticks to the Hindu goddess Shakti. At the opposite shore a steep hour-long walk takes you up through the forest on a rocky pathway. It was pretty hard going and at first we were relieved to feel the pitter patter of light rain to cool us down. We were less pleased when, reaching the top, it started chucking it down so that in a few minutes we couldn’t see the view at all!

On the island‌

Feeling soggy at the world peace pagoda…

We didn’t hang around long but by the time we found the path again it had turned into a stream and we had to take care not to fall on the slippery rocks. Fifteen minutes into the descent we came across a group huddled in the rain – a woman had fallen and badly hurt her ankle. She wasn’t able to walk and they had to call mountain rescue services to get her down. In the mean time we felt a bit useless as all we were able to do was offer our bottle of water and pass on a message to her boatman.

After another long bus journey we returned to Kathmandu and checked into our new hotel only to find that Dr Greamme and Meena were staying next door. They filled us in on all the Lalgadh news and recommended we visit the monkey temple, which we did the next morning. The temple, known formally as Swayambhunath, is built on the hill overlooking Katmandu. We were beginning to notice a pattern as we struggled up the 365 stairs to the stupa. Our visit coincided with the Hindu festival Teej, in which married women pray for their husband and children. Dressed in splendid red saris they visit the holy temples in groups with offerings of flowers and coins. Interestingly, the monkey temple is sacred to both Buddhists and Hindus and therefore the main square was filled with women as well as several musical groups that had come to join the celebration.

The central stupa, a vast white dome above which four pairs of Buddha’s eyes look out into each point of the compass, dominates the square with prayer flags flying between it and each corner. The rest of the courtyard is dotted with shrines (even one dedicated to the goddess of small pox) and lined by small stores selling miniature Buddha’s and prayer bowls. In the northwest corner the sacred monkeys torment tourists stealing their food and sunglasses - all to the great amusement of the locals.

Descending the hill on western side will take you to a smaller white stupa surrounded by thousands of prayer flags. Here lies the shrine dedicated to the goddess of learning where many an anxious student flocks during exams (we paid our own visit for good luck). Pushing through the crowds we found ourselves beside a fountain with a golden statue of Buddha standing on a lotus leaf in the centre. At the statue’s feet is a bowl into which onlookers aim brass coins to pray for world peace. We had a go and missed horrendously (the woman next to me tried to teach me - apparently you have to throw under arm - but soon realised it was hopeless).

Our last afternoon in Thamel was a mixture of sadness to leave and excitement to be going home again. We used up the last of our Rupees on useless knick knacks (that we reasoned to ourselves would make good presents or be a good investment). I desperately tried to haggle for Pokhara prices but there is a Thamel conspiracy

between vendors to rip off tourists and I soon gave in. Worn out we went for dinner at a really cool Israeli restaurant where we stuffed ourselves with hummus and naans lying on cushions by low tables.

As we drove to the airport in the dim morning light, just after sunrise, we mentally waved goodbye to Nepal and all the friends we had made there. We have had a fantastic journey, beyond anything that we could have imagined. I am really looking forward to seeing my family and friends back home and like most travelers I long for personal space, hot showers and decent wifi - but watch out Nepal, we’ll definitely be back!