The truth is that even as the plane landed on the tarmac in Leh, I had no idea where we were. We had spent 8 hours on an overnight plane to Delhi, 6 hours lying on the Domestic Airport floor and 2 hours experiencing turbulence flying over the Great Himalayas. Our only worry as the plane hatch opened was: landing at an altitude of 3,000m above sea level, would 250mg of prophylatic acetazolmide taken the night before save us from getting sick? Unfortunately, some of us would discover the answer was ‘no’ later on. As I stumbled out of the plane, sleep-deprived and airsick, I realized the view was breath-taking. Which literally meant I was gasping to take several breaths of the dry, propeller-exhaust filled, oxygen-deprived air. Contrary to my pre-conceived images of ‘Little Tibet’, I found myself standing in the middle of an old military airfield, surrounded by sparse lands of dirt and sand, jagged rocks, and slate-grey mountains. Amidst the dusty plains, I counted a total of two trees, one bush and a wandering goat in the distance.
‘I thought you said we were coming to work in a beautiful place…’ I mumbled under my breath as I trudged past Myra*. Thankfully she did not hear my moment of indiscretion (which I blame on the hypoxia at altitude). We were received by Bill^, who wasted no time in loading us up on a bright yellow Ladakhi school bus, while the medical equipment were loaded swiftly into a truck.
Our first task on this mission: to rest and acclimatize. As I thought to myself, ‘how hard can that be?’, we had our first casualty within the hour. ‘Nausea, vomiting, giddiness, headaches are early signs of altitude sickness….’, read the Altitude for Dummies Handbook, ‘breathlessness from pulmonary edema and cerebral edema are severe complications.’ Before my own giddiness and nausea could set in, I found myself watching over my buddy as he received oxygen, and eventually intravenous dexamethasone. The rest of us nervously lined up for our pulse-oximetry, and comparing the team’s average of 80% to my 72% was not reassuring at all. The good news was that my buddy was recovering rapidly after steroid therapy; the bad news was that we were to ascend to 6,500m above seas level in less than 12 hours time. I nervously popped another gritty pill of acetazolamide, and went to the roof of our guesthouse for air.*Dr Myra Elliott is the leader of the Ladakh medical team who coordinated the team effort, medical logistics and supplies. She has had years of experience in medical missions and had persuaded me to give up my holiday and head to the beautiful land of Ladakh instead. ^Mr Bill Kite runs a trekking company in Nepal and Ladakh, organizing community service and exploratory trips for groups and schools from Singapore such as UWC and Tanglin Trust. He has been the logistical backbone of several missions, and provides the bridge between the mission teams and people of Ladakh.
Halfway up the rickety ladder, I regret my decision. I discovered that before I adapted to my newfound level of oxygen tension, any activity other than walking on level ground would render me dyspneic. When I finally negotiated all 10 rungs between asthmatic wheezes, I found Bill already on the roof. “The mountains and its people will enchant you, Marcus”, he said to me as we watched the sun descend wearily behind the mountain range in front of us, imparting an orange glow that diffused through the pinnacles and crests like a deliberate bushfire. The frosty tightness in my chest, woozy sensations in my head and tingling in my fingers and toes# did not help to relieve my secret skepticism. “We are bound by Pakistan, Tibet and China within the Himalayan and Karakoram ranges.” Still, I had no idea where I was. I took in another drag of the bitter air and listened intently to the background of the place in which I was about to spend my next 7 days.
Apparently, we were in Ladakh, the highest plateau in India located in the Kashmiri state of India. Centuries of conflict and territorial dispute meant that these lands had Tibetan, Bhutanese, Indian and Pakistani influence. Dispute, that was as recent as 1999, where Pakistani and Indian troops clashed in ‘the highest battleground in the world’. It explained the occasional camouflage pillbox and barbwire fence scattered over the mountainous landscape. In fact, Taliban forces had recently retreated to the range further north into Pakistan, pointed Bill to a bunch of rocks that did not seem distant enough. I suddenly wondered if the Taliban recognized the Geneva Convention, should they decide to turn up for a health screen. The desert-like terrain from being in the rain shadow of the Great Himalayas, long harsh winters at high-altitude and war-torn history makes Ladakh a very remote part of India, untouched by the industrial globalization that has consumed most parts of the world.
Dinner was a simple yet scrumptious meal comprising rice, dhal and yak cheese. It was the first time our 16-strong team sat down together– and the diversity in our experience, expertise and personalities were immediately evident to me. Yet, camaraderie and unity were cemented before the end of the meal. Bouts of laughter amidst the ‘get-to-know-you’ chats indicated that no formal introductions were needed. We were dentists, nurses, doctors, surgeons, anesthetists – and everyone knew their role and place in the team. We filled our tummies, and popped more pills like junkies who enjoyed the ‘tingles’, and turned in. An early night’s rest and plenty of water were needed to prepare us for the next day.
The next morning at 0500H, a convoy of jeeps and trucks carried our team and medical supplies over Khardung La, the ‘highest motorable road in the world’ at 18,380 ft. It is a snaking, gravel road that was so narrow at most places – every time we met head to head with trucks coming in the opposite direction, someone had to slam the brakes and reverse to a wider section where both could pass. Looking over the cliffs and rocky edges of the paths, it did not help to see occasional burnt-up vehicle carcasses that were heaped up amongst the rocks. So anyway, there I was fighting my nausea from the rocky roads, brake slamming and altitude sickness; Myra had to share her comforting story on how she had watched a program called ‘World’s most perilous journeys’ and remembering how Khardung La was featured in it! I was beginning to wonder if I would make it alive to see any patients at all.
Nubra Valley was our destination. With Khardang La and the infrequent military flight into a nearby base as the only links to the outside world, Nubra has been dubbed as one of the ‘most remote places on earth’. We arrived mid-afternoon, to set up camp at the Lamdon school. Lamdon School started as a small school with seven students, but has grown to be the gold standard school in the Himalayas with 1,400 students at the main campus in Leh and nine satellite campuses scattered throughout the region. Within the hour, we would set up our clinics and begin receiving patients. Bill and his team had already laid the groundwork, set up generators and designated areas for the clinics within the school compound. The efficiency of the medical team, and the willingness of the local volunteers to accommodate us, made the process easier than it might have been. We cleared the school hall to set up rows of dental chair and beds for the dental team and surgical areas; private rooms for the O&G consults, medical teams and an eye consult room; and the outhouse pharmacy and a sheltered waiting area. A ‘dry run’ was carried out, as we received our first few patients in the late evening, and it seemed that we were all set for the next 5 days.
The next morning, we would wake up at 0600, have a simple breakfast and walk to Lamdon School, from the lodge we were put up in. The view in the morning was always a surprise to me – it took me a while to get used to the fact that no matter where I turned, there was always a clear blue sky and majestic mountain range in the background. The air was cold but crisp. And the walk to the school was always met with friendly shouts of ‘Julley!’ from anyone we met.
‘Julley’ meant ‘hello’ or ‘goodbye’ or ‘thank you’, or represented any form of greeting you wished. An ‘all in one’ greeting of sorts if you like. It was always said with respect, honesty, and good will. I have never heard a more genuine word, spoken with more sincerity.
I stood from the entrance of my makeshift eye clinic, which overlooked the school, and took a long deep breath of the cool, brittle air. I watched as queues at the triage station extended into long files of people. It was time to get to work. Over the next few days, the dental team found a staggeringly high incidence of tooth decay. We learnt that the culprit was the recent introduction of refined sugar into their diets, which was brought to Ladakh by the Indian army sent there forty years ago to fortify the international borders with China and Pakistan. Other than cleaning, scaling, pulling decayed teeth and doing simple dental X-rays, our dental team also distributed toothbrushes and toothpaste to all the patients, teaching dental and oral hygiene. More importantly, a local dental nurse was taught basic dental cleaning and scaling techniques to continue with the work through the year, until the next volunteer dental team arrived next.
I also quickly discovered, from the overwhelming crowds outside my clinic door everyday, a vast majority of patients had also come to the medical camp for an eye consult. The harsh, dry conditions and strong ultraviolet rays from the sun at high altitude meant higher and premature incidence of pinginculae, pterygia, and cataracts. The lack of an optician within miles of Nubra, meant that prescribing appropriate reading glasses to the elderly ladies suddenly enabled them to sew or weed again; and that men could mend their nets or Lamas could now read their scriptures. After screening 300 children from Lamdon School and nearby government schools, we found 80 children who would be sent over the pass to Leh to have spectacles made for them – so that they could read the writing on the class blackboard again. Most of these children have never left Nubra, let alone know what myopia means. We also carefully selected 50 elderly patients who would benefit from cataract surgery, which will be carried out by the volunteer surgeons from other parts of India towards the end of the year.
Meanwhile, our team gynecologist found that the women of Ladakh suffer a very high rate of cervical cancer, which is primarily due to a total lack of even the most basic gynecological screening and education. Cultural and religious factors did not allow our team to examine and screen as many women as we liked; however we learnt of villages where infant mortality rates were high due to lack of contraception, multiple births and poor delivery conditions. With that knowledge, we would plan to bring a team to reach out to those people at the next available opportunity; and set up a basic cervical screening program for the women in Ladakh.
The medical doctors, assisted by a local volunteer Dr Nordeen, saw every other patient that walked through the door. From tick and mite bites, to diagnosing hypertension and diabetes mellitus, to rare conditions like neurofibromatosis. The meantime, our makeshift pharmacy was over-run every single day with hundreds of orders from every clinic, which they had to cope by managing the limited supply of medications. I was amazed at the snaking long lines of patients that waited patiently outside the pharmacy, every day.
The next five days went by faster than I could imagine, during which we triaged, examined, treated and managed a total of 1,600 local children and people from Nubra. Some families had walked for days to come to seek medical attention. Most of the patients needed primary dental or health care, which was not even available to them as a basic human right. Over these five days, I had unexpectedly grown fond of the mountains and morning walks; and the star-filled night skies that we gazed at in the nights.
I was touched by the sincerity and gratitude of the people, everywhere we went. I was amazed by the strength in Ladakhis, some of whom carried their young and walked their old from villages afar, to seek our help. I felt the passion in our translators, who worked tirelessly to explain our diagnoses, simplify our advice and convey our empathy. I met inspirational men such as Dr Nordeen, a local doctor who had returned to his homeland to serve, after his medical education outside of the valley; or Morup Namgyal who started Lamdon School on meager funds he raised through musical performances and drama shows – and became the first teacher with only seven students. And of course, selfless individuals such as Bill and his team who worked behind the scenes, providing continual logistical support to the medical team, from food and potable water, to transport and electricity. Our medical team, who had travelled miles from a distant Singapore, made up a cog in the wheel of the whole process that made the mission a success.
As I stood on the departure platform looking out towards the barren but beautiful landscape of ice-capped peaks and sand dunes, I recalled the words of Bill when I had first arrived, and realized what he had meant.