This was written when I spent 18 months living in my home village on the edge of the desert where I tried, mostly unsuccessfully to jump start a local NGO. You win some, you lose some. Re-reading the piece 14 or 15 years after I wrote it I feel no need to change anything. All the incidents I describe really did happen, nothing made up. It is one of my longer pieces so those of you with a short attention span may need a breather here and there. Now read on…
No, not the chemical or surgical castration of Dubya, much as it might be of benefit to the wider world, but the very imprecise practice of looking after oneself and ones fellows in remote stations, postings where there is no doctor. Or at least not one you would want to have lay hands on you.
Talk to any aid worker who has kicked around a bit and eventually there will be the ‘Did I ever tell you about…’ moment that is likely to involve fire, flood, act of god, warfare or personal accident or any combination of all; and how their impromptu intervention had saved/shortened/made even more miserable, a human life. What virtually all aid workers who work either for small organisations in poorly resourced areas, or are lone operators far from just about everything that modern medicine has to offer, will be the Bush Doctoring story to top all Bush Doctoring stories; only to be topped, after another round of drinks is got in, by something even more outrageous than the last tale of derring-do and personal inexactitude. The following pages therefore come with a health warning – there has been no attempt to sanitise or tone down anything you are about to read, on the contrary it will be talked up and embroidered (but still remaining on the side of Truth and the Angels) in an effort to brighten otherwise placid and trauma-free lives. You’ve been warned.
First and foremost – I am not a doctor, and have never pretended or aspired to be one. But force of circumstance, high-risk adventure activities like big-wall ice climbing and mountaineering generally, long-range cycle expeditions and an occasional acquaintance with things of a whizzy-bangy nature have persuaded me of the wisdom of acquiring the rudiments of first aid. So I have my Red Cross Certificates in just about anything an unlicensed person can do to themselves or others, a mountain rescue medicine course duly certificated (allowing emergency amputations, never used) and two utterly invaluable books – ‘Where there is no doctor’ and ‘Disabled village children’ both by a saintly man called David Werner, who sadly died not so long ago. David Werner was himself disabled, and wrote his original ‘Where there is no doctor’ book in Spanish almost forty years ago, when he was working in Mexico among mountain farmers (who farmed in, but did not actually grow, mountains.) It is now translated into about 43 languages, used in over 100 countries as a basic village health worker text and is regularly updated. My copy, much battered and heavily annotated over the years, was published by the Voluntary Health Association of India in 1994, and needs replacing. Anybody who would like to do me a real favour should send me a current copy. If I get more than one, no worries, I will pass them on to others who can use them even more effectively than myself. The spur for putting finger to keyboard today was a visit by a woman to the house this morning, coming to see Dosi, my sister-in-law and Keeper of the Village Condom.[1]
Dosi is an officially-recognised Treasure. Not only is she a wife and mother of surpassing quality, she has a smile of mega-wattage, a filthy sense of humour, the ability to make a decent cup of tea and, quite crucially, the training and aptitude that allows her to operate as a basic health worker. BHW’s are often the only local people with any formal medical knowledge or training, and they are the ones that give out the simple medicines, administer the vaccinations for polio and other ailments, do the health education and generally act as the community first line of defence in the eternal battle against disease.
She works for an offshoot of the French NGO, Medicins du Monde, gets 2000 rupees a month for being on day and night duty, and is very good at her job. We are now moving out of the season where respiratory ailments are the order of the day, into the season of diahorrea, heatstroke, malaria and assorted ailments of the eye. Glaucoma and trachoma are common, but by far the commonest is conjunctivitis. This is invariably caused by dust irritation, and the lady who showed up today had a nasty dose of it.
She sat on the bed in the communal sitting room while I was eating breakfast and copping my fix of BBC News that always accompanies it. We exchanged felicitations and Dosi said she had come suffering from an allergy. I looked across at her and said ‘No, not an allergy, an irritation’ and went on to explain the difference between allergy and irritation/infection, complete with drawings and my trusty volume of ‘Where there is no doctor’. I explained to the woman that wiping her eyes with a filthy dupatta was not a good idea; neither was sleeping under a pile of children who were likely to catch it as a result. We found an appropriate tube of ointment and I showed Dosi how to turn back the upper and lower eyelids to properly apply it, with me doing the demonstration on one eye, and she then repeating it on the other. Nobody had shown her how to do this procedure, and she had been giving out the medicine for conjunctivitis and telling patients to rub it on their eyelids, not to put it underneath. There followed a long discussion about basic health care generally, and the seed for this piece was sown.
The first serious piece of bush doctoring I ever did was in the Atlas Mountains, near the village of Sidi Chamarouche, in 1976. I was a member of a small group of enthusiastic mountaineers who were also social work students at the time. We were bloody miles from anywhere, it was Ramadan, and our guide Lassen was hazy about our precise whereabouts (we had no maps). We were sitting in the shade for lunch minding our own business when around the corner hove a big pickup, filled with a bunch of very unhappy looking men. With guns.
Hello, we’re the Polisario.
The Polisario were a bunch of Freedom Fighters battling the government of the day, and we had wandered slap-bang into one of their areas of control. They had an unsavoury reputation in terms of their treatment of tourists, and were not noticeably impressed by our invitation to lunch. Lassen fell over himself trying to retrieve the situation, but it seemed they wanted us to stay put. So we sat for half an hour looking glum and pondered our fate. Then one of them came over with Lassen and speaking in Arabic through him asked if any of us was a doctor. None of us were. Well what about medical kit, does anybody have medical kit? In fact we all did, of sorts, but I was the unofficial medicine man for the group, being the only one to have had any sort of training or experience, and also having an above average medical kit. So my colleagues volunteered me for the job. Job! Feeling distinctly nervous I went with Lassen and Mr. Polisario to the pickup truck, not knowing what I was going to find, and dreading it whatever it might be. And it certainly was not what I expected or feared.
On the bed of the truck lay a very old woman. She was awake and alert, and sat up when I stood at the tailgate. Mr Polisario introduced her to me and Lassen as his Mother, and could I help her? Cutting to the chase, Mum had got an infection in the middle finger of her (IIRC) left hand, a huge puce and white and red thing that was hot and hard to the touch. It looked like a torpedo attached to her finger. She was clearly in pain and running a huge fever. She had had it for a week. I said she needed to see a doctor, not me. Mr. Polisario not happy with this, and said so. I had my medical bag with me and explained it was just for very simple things, not the sort of problem his Mum had. But I did have a couple of sealed scalpels, curved needles with attached gut and several courses of my old favourite Ceporex, a good all-purpose anti-biotic. There comes a time when you have to take the occasional risk, and this was one of them. These guys were playing hardball, and wanted something done jaldi-jaldi. I asked to talk to my friends first, and went back and explained things to them. For social workers they reached a decision with commendable swiftness, and volunteered me yet again as surgeon-elect. Back at the pick up it time to shit or get off the pot. I had Mum sit on the ground, told Lassen to explain what I was going to do and that I had no anaesthetic, and that I was not a real doctor, and she just looked at me and nodded. I poured a sachet of concentrated disinfectant on her finger, wiped it with a tissue, and quickly ran the scalpel the length of the finger, from the top of the palm to the top of the pad above her fingernail. I had no idea – again – what to expect beyond lots of pus and some blood, but got neither. What I got was a splitting of the skin to reveal a solid whitish shape that I at first mistook for bone, but which turned out to be some sort of capsule of infection that popped out like a pea when I pressed the sides of the wound. It fell to the ground between her legs, looking like an unpleasant insect or giant grub. She actually smiled at me. Mr. Polisario smiled. Lassen smiled. I nearly threw up. I irrigated the wound with another sachet of disinfectant, which must have been excruciating but she never flinched, and then ran a half-dozen stitches up it drawing it as tight as I dared. Taped it over with gauze-backed Micropore and Bobs a very close relative. Out comes a course of Ceporex, instructions written out by Lassen in Arabic as to dosage, and International Friendship broke out all round. Back were slapped, hands shaken, mint tea drunk in vast quantities and we wandered off in the late afternoon, eventually finding the Toubkal base camp as night fell. We climbed Toubkal over the next couple of days, dropped down the arête to the roadhead and were in Marrakech a week later. Piece of cake. Except that I had galloping dysentery and no medication, having given it to one of my colleagues in the mistaken belief that I was immune to such things.
It was to be ten years before I was called upon to try a similar trick, and in not dissimilar circumstances, but this time in Nepal. I was climbing and trekking in the Everest region with a group of mates from the Old Dungeon Ghyll pub in Langdale, a famous climbers haunt in the English Lake District. We’d had a bit of a muck-about on Everest, getting up to Camp II before discretion got the better part of valour, knocked off Island Peak and been knocked off by Pumori. Quietly satisfied, we were doing a long high circuit back to the roadhead at Jiri when one of our Sherpas came down with something nasty. Sherpas are the local tribespeople who have made a decent living out of the mountaineering fraternity for a hundred years or more, and are themselves formidable mountaineers, with Tensing Norgay being the first Sherpa to climb Everest with Ed Hilary in 1953. We had an excellent bunch of Sherpas, male and female, who had looked after us for a month, and to whom we had got very close. Norbu was not the sharpest Sherpa in the box, but he was always cheerful, and it was a surprise when, one morning, he was not on duty as per usual and lay in his tent, inert. We thought he might have died in the night of mountain sickness, that can even kill experienced Sherpas, but Tony, an ex-soldier got in and had a look and declared him alive but ill. Again, no sign of doctor and the nearest was at Kundon, where there was a tiny hospital manned by volunteers, two days away. This time we did have maps and knew where we were, but our yaks had gone round by another route to meet us below Namche Bazaar, and we were with just what we carried, all the heavy kit and equipment having gone with the yaks.
Norbu had a version of what the Polisario Mum had, but infinitely worse. He had either cut himself or got an infected wound at some point, and one of his arms was a weeping heaving mess of infection, pus, caked muck and – and this was a good thing – maggots. The maggots were probably keeping things at bay, munching on this and that and generally doing the maggoty business. It needed debriding, a job that fell to Tony and I, and a bit of a clean up but not too much, followed by a Serious Conference. We snipped away the rotten flesh with the nail scissors on a Swiss Army knife. (Which I still have with me.) He could not walk, we had no stretcher and it was improvisation time. Between us we had six amps of morphine, a couple of field dressings and assorted painkillers and various treatments for the shits. In the end, we lashed three frame sacs together, tied Norbu to them, and carried him for 36 hours to the Kundon hospital. Sadly, he lost his arm, but we did our best for him. I saw him a couple of years later, with a Heath Robinson prosthetic, showing tourists around the remains of the Rongbuk monastery, that had burnt down on the very day that the electricity supply was turned on for the first time. Ho hum. The price of progress.
Messy business, birth. Very messy. Not made any easier when the delivery in question is a breech, arm out first, mother is a first-timer, likewise Doctor, and I am holding the aforementioned ‘Where there is no doctor’ which the Doc is consulting at regular intervals. The scene is illuminated by my Petzl head-torch. All this is going on in the back of a jeep on the side of a mountain at two in the morning. A tribal had awaked Dr. Zahid and me in our separate residences. He was from one of the valleys in Nagar, deep in the Karakorams of northern Pakistan in late summer 1996. Dr. Zahid was the only Doc for 100kms in any direction, and I was his boss. Ayoub, my driver had taken both of us to the point where the woman had been brought down to a place close to the road by her family members, a move that was later to cost all of us dear. Zahid was a properly qualified and practising doctor, but what he knew about medicine and women you could get on the back of a packet of tampons. He had never delivered a baby in his life, but had seen a film of it once. He had no idea what might be involved in a caesarean section and was deeply worried about the whole business. My role in this imminent disaster was to hold his bag of spanners, provide encouraging advice along the lines of ‘Hmmm…that looks about right, Zahid’ keep my headlight on the area of operation and stop Ayoub the driver from fainting. I later learned that he had never seen a woman’s genitals for real and was suffering from almost terminal embarrassment. The husband had drifted off into the rocks somewhere and Dr. Zahid and I were quite literally on a voyage of discovery. WTIND is pretty good on most things, but when it comes to birth of a complicated variety, and very specifically where there is an arm where there should not be an arm, it says in big caps ‘TAKE PATIENT TO NEAREST HOSPITAL IMMEDIATELY.’ Gilgit was the nearest, four hours to the south, and we didn’t have four hours.
The decision to actually cut the woman was Zahids. She was screaming and thrashing about, we had no painkillers and in the end Ayoub had to sit on her chest and hold her arms. I sat to one side holding the book, which had a picture of a traditional caesarean and a brief ‘how to if you have to’ and wearing a brave smile that I hoped suffused Dr. Zahid with overweening confidence. He cleaned her with fluid from an IV drip, said a prayer and got on with the carving. And not a bad job, in my humble opinion. It was a bit ragged, but he managed to extract the infant, deliver the placenta, cut this and that, clean up the woman and do the necessary embroidery and at the end of 45 minutes the world had another citizen, the woman was alive and we were quite pleased with ourselves. A decision was taken to try and get her to an unmanned BHU in Hunza, a couple of hours away, that whilst it had nothing beyond a few pills and a clean bed, was at least better than the bloodied jeep she was in. Husband returned to drive jeep, Zahid and I followed. We broke the lock on the door to the BHU at about 5 a.m. and found an Aga Khan LHV who lived close by, who agreed to look after the woman. Then our problems really started.
You’d think there would be pats on the back all round for that little epic, but not so. Local conservative religious persons took strong exception to the breach of purdah that had occurred, in that I had been present at the birth, as had Ayoub and Dr. Zahid. Nobody in the religious fraternity were in the slightest concerned for the poor woman or child, only for the cultural Nazi-ism that occasionally prevailed in Nagar. Slogans appeared on rocks close to my house and office, calling me a Zionist spy, my wife Rose ‘a leader of prostitutes’ (she was a women’s development worker at the time) and threatening us all with death. This was serious stuff, and required immediate action on the part of various members of my management committee to calm things down. Matters were not helped when the Crazies dynamited a jeep at the BHU where we had taken the woman and child, and poured burning kerosene down the chimney when the Lady Health Visitors were in residence a week later. The woman herself was evacuated to Islamabad, as there was a real risk that she would be killed, along with the child, for having ‘dishonoured’ her tribe. Her husband bravely stood out against the Crazies, later going on to be elected as a member of the local Union Council, the bottom tier of local government. It all blew over after a month or so, but it was a bit tricky for a while.
Dr. Zahid was party to another little escapade the following year, when we decided to have a crack at getting some health care into the most remote part of my operating area, the Hispar valley. Hispar really is about as far out on the edge as you would ever want to live. It is the most remote part of a remote area, only accessible for three or four months of the year, and lived in by quite the oddest bunch of humans I have ever encountered in my life. Hispar was (some say still is) the area used by the Mir of Nagar as an open prison, where he banished subjects who had fallen out of favour. There they lived scratching a living at the bottom of the glacier in the most marginal of environments. In recent years there had been attempts to improve their lot. There were about a thousand of them, all living in a single large village. The Aga Khan Rural Support Programme had built a mini-hydel for them, a pocket size hydroelectric generator, which they had promptly pillaged and sold off for scrap. A government tax collector had made the serious mistake of getting in in 1995. They killed him and left the body in the middle of Hura Bridge, the last place where you can cross the river with a vehicle below their village. Beyond the bridge there is a track that is blasted with stonefall, or drops occasionally into a washout. The last time any health service had got in, according to the director of Aga Khan Health Services in Gilgit, was fifteen years before. And they were not about to use valuable helicopter time and fuel by trying again. Perhaps not the most promising of populations to try a little outreach operation with.
But they had come to us, apparently because they felt we were somehow ‘OK’, in the person of quite the smelliest visitor I ever had in my office. This man, who turned up one day in late spring looking like he had dropped from the set of Planet of the Apes, stunk like a pile of corpses. He was even considered smelly by the Nagrocis, who collectively are the smelliest people on the face of the Earth. It was the kind of smell that instantly contracts the throat and engages the gag reaction. He was stooped, spoke a form of Burushiski that even Rose found difficult, and it was some time before we actually found out what he wanted and where he was from. When I told my management committee a day later that there had been a request for a health camp from the Hispar people there was a stunned silence, followed by the Nagar version of ROFLMAO. Serious debate followed, as there was real concern that this might be a ploy to lure us in, kill us and take our jeep. Despite the somewhat ‘jokey’ feel the idea of an open prison might have, there were some VERY serious criminals in Hispar – killers, robbers and bandits. So we sent a dak-wallah with a letter on a stick (no, I didn’t make that up) that he left on their message point on the Hura Bridge. We wanted to have safe passage assurances, and for a couple of their people to come down and stay in Lower Nagar at Askurdas until we were safely returned. They astonished us by agreeing, and the dak-wallah brought back a couple of their reps four days later.
It was to be me, Rose, Zahid, Ayoub the driver and the doctors assistant at the time whose name now escapes me. We crammed the Daihatsu Rocky with everything we could think of inside and out, put extra fuel tanks on top, and water, said our goodbyes and off we went at dawn. I have to admit to having Blackie under my arm, and Rose her old Webley revolver on her belt. Ayoub had his sawn-off PA under the seat and a couple of grenades. We made it to Hura by about 11 in the morning, the road being reasonably good that far, and had a close recce by field glass before going on. All quiet. We could see something white on the dak-stick they used for messages on the bridge, and it turned out to be another surprise. It was in English, from a man who had agreed to go and set up a school for the Hisparis, saying that he had arrived two days before, they were peaceable and cooperative, and we would be OK. Rose vaguely knew the author of the letter, a Hunzakut from Karimabad, and said he was a good egg.
Beyond Hura, it got interesting. Ayoub is one of the very finest mountain drivers in the whole of Pakistan, and the track even taxed his skills. There was negative camber on the track above the river; rocks falling from the thaw above hit us, the armoured windscreen starred, our poor Rocky even more battered than ever before. At one point I thought Ayoub had lost it and was about to give the ‘bale out’ order when he did something fiddly with his fingers on the dashboard. Like he was playing an instrument of some sort. I shouted ‘What the fuck are you doing Ayoub?’ and he immediately shouted back ‘Turning jeep into heli Mister Chris’. A comforting man to have around, Ayoub. He later told me that he was sure we would be OK because I was wearing my Jadoo Topee, or Magic Hat. Ayoub had been convinced that my most disreputable hat, the filthy cricketing number I still wear, was bulletproof,[2] and that as long as I wore it no harm could come to us. I make sure I have it close by me always, just in case he was right. After a couple of hours of this we emerged on to the little plateau where Hispar village sits, driving past a very un-encouraging graveyard and the ruins of the hydel.
And there in the middle of the road was the teacher who had left the message on the bridge and with him the Simian Wotsit who had made the first contact with Naunehal Development Organisation, of which I was Director.
There followed two days of non-stop doctoring and grassroots development work. To their credit, the Hisparis had decided it was time to come in from the cold, both literally and metaphorically, and wanted to join the rest of humanity. There is a tool that I use with emerging communities called PRA, or Participatory Rural Appraisal, which is designed to allow those of us doing the developing to respond appropriately to those who want the development, using a timetable and agenda that they are comfortable with. I had a confab with the teacher and got Plan A together. Zahid and his oppo set up surgery in the ruins of an ancient government building (which a couple of years later was revived as the first VRRHC -Very Remote Rural Health Centre – in Pakistan. See…I DO win some!) and I tried to work out with a consortium of local people just what they were hoping to get out of the exercise. PRA involves quite a bit of sitting around with stones that get moved about to represent different situations. This can go on for hours. Days. Rose interpreted the crude Burushiski (she speaks eight languages at the last count and is currently working on her Spanish) and eventually took over from me as Zahid had asked for my assistance at the med camp. It was not so much assistance that he needed, as moral support and a second witness as to what he was seeing in case nobody believed him later.
It’s not every day you see somebody with three legs, or several people born with a single eye, admittedly not in the centre of their forehead. Or a range of such grotesque physical deformities that it could only point to very long-term inbreeding by this group of people. There were simply far too many oddities for it to be anything other than genetic malfunction. Statistically in this size of population there might be two or three, here there were dozens, of different forms and severity. And so it proved to be. There were not only cousin marriages, but also relationships that had produced offspring in pairings that traduced natures laws.
Not only were they having trouble on the genetic front, there was an alarming incidence of goitre, pointing to them not using iodised salt in cooking. Children with hugely distended thyroids were presented to us, as were children who had been imperfectly circumcised with predictable grisly results. In health terms it was an absolute disaster area. There was a very high incidence of respiratory illness in young children because of the practice of covering their faces with a gauze mesh until they were five or so, to prevent their eyes being invaded by evil spirits. I took picture after picture, and held patient after patient for Zahid, who was heroic on those two days. He did knife-and-fork tidy-ups on the worst of the botched circumcisions, excised growths, freed webbed fingers and toes and generally did all that could be asked of him and more. The people had cleared a house for us to stay in, and we all bedded down together on that first night, exhausted and wondering at what we were seeing and had got ourselves into. The next day was much the same, except that we were now infested with lice ourselves, having picked them up from the house we slept in.
Plan A turned out pretty well in the end. The community was clearly in crisis and urgent need of every kind of help. Fortunately, the teacher who had volunteered to stay with them was also a competent social organiser, and he was the base on which a development programme eventually grew over the next year. The government agreed to fund medicines if we would take them in, and we scrounged educational materials, health education stuff from an NGO in Lahore and generally pulled out the stops for the Hisparis. It wasn’t all plain sailing, but our efforts – and theirs- bore edible fruit remarkably quickly. The last I heard, a year ago, was that they had established a small guest house to serve trekkers coming over the Hispar glacier and had got themselves on the tourist map. A local woman had started to train as an LHV courtesy of the Aga Khan Health Service in Karimabad. Dr. Zahid and myself had long moved on, but those two days in Hispar will be with me for a very long time.
These days, its all a lot less adventurous. The worst I am likely to encounter is a vehicle breakdown in somewhere remote, but somebody always knows where I am, and I am never that far from help. And the population is not armed, a big plus on the development side; but the problems of providing a health service to a diverse and dispersed population remain. As do the difficulties of working with a corrupt bureaucracy, bloody minded local officials and the downright dim-witted. Some days it feels completely pointless, as you confront yet another case of a woman who has twelve live children, assorted still births and whose husband is beating her for not producing more sons. Or the Xtian priests who try to cure deafness and diabetes by casting out devils (it happened in my own family here in the recent past) or the kids suffering from vitamin A deficiency because the goodness has been boiled out of their meagre diets by ‘cultural’ cooking methods. And on other days, when shy ladies turn up to scuttle off with a handful of condoms, or a man asks for a vasectomy referral, or a family builds a latrine, you think the other way. My actual bush-doctoring is limited to a little gentle advice to men and women who are far better trained and skilled than myself for the most part, and who are beginning to provide primary services at a recognisably satisfactory level. The TB and hepatitis problems are intractable, and we have a severe malaria problem in the village right now, and there are rumours of a fresh rabies wave on its way in from the desert. I had to shoot a mad dog the last time this happened, and frightened myself half to death in the process. But that’s a tale for another day.
Chris Cork
Chak 74-A Fatimapur
27th
March 2004, 20.00hrs PST
[1] There is actually more than one, but re-rolls are not uncommon here and are sold as such in some bazaars.
[2] This was based on the fact that we had both, on one occasion, run through gunfire to gain the shelter of the underside of the Rocky. I was wearing The Hat at the time. Of such stuff are legends born.
Thunksforthinkers 