“Helping with Glasses”: Eye Clinics in Khumbu

/ LED

In recent years, LED has started to carry out basic eye checks in the remote communities Val visits when distributing LED solar lights and medical/school supplies, and while on trek. This has been down to the invaluable guidance and support from “Eye Doctor” Pat Booth who has provided instructions and charts and glasses carefully labelled and packaged.

In November 2022, Pat headed out to Khumbu with Val and a small trekking group. Here’s her write up of the trip.

It was with some trepidation that I agreed to go back to Nepal in November 2022, after missing three years with COVID restrictions. But it turned out to be the best trip ever!

We started off at Chhahari Eco Resort, just outside Kathmandu, as a group of nine trekkers. I got a box of glasses out and showed them all how it works – as most Nepalis and Peruvians have really good distance vision you can give them reading glasses based on their age. The next day four of us went up to Nagi Gompa to check some of the nuns and screen the schoolgirls staying there.

Pat preparing to start eye checks at Nagi Gompa

Then up to ‘Remote Khumbu’ via Lukla. One of our first visits was to the hospital at Kunde. They had some donated reading glasses there already but unfortunately mainly too strong; +1.00 and +1.50 suits most people, if you would ever like to bring some along with you. They had an ophthalmoscope (for looking in people’s eyes) that we borrowed as I had had to leave mine behind because of the weight restrictions on the flight to Lukla. The best thing was the news that they had an Eye Camp coming in the Spring to do cataract surgery, so we were able to advise people to come back then.

Dr Kami, Kunde Hospital

We then went on to Thame where we were treated to a display of Nepali dancing by the pupils at the school. We were then able to screen all the children who were boarding at the school, using an alphabet poster as a chart. Even the youngest children could do this easily – they all had fantastic vision. We had so many helpers we were able to work in two teams.

Dancing, Thame School

In the afternoon we were booked to do eye checks at the Thame Health Post. Again, we were able to work in two teams as we had a retired GP with us who was also able to use the ophthalmoscope. That turned into a long session, and it was getting too dark to see by the end. My scribe was side-tracked by the guides’ and porters’ tales of how many times they had summited Everest and Ama Dablam etc. They would all have been world famous if they had been westerners.

When we were in the more remote areas of the trip, we pretty much did eye checks in every place we stayed. As ever, the people were incredibly grateful for our services. We were all laden down with prayer scarves by the end.

I was re-acquainted with Tsering from my Manaslu trip, when he was a very helpful primary teacher in Sama. Here in Khumbu as one of Val’s team, Tsering did most of my optical translation for me, as well as being my personal porter. From his point of view, he became recipient of my Most Improved Optical Assistant award and graduated to Fully Trained Sight Tester!

The sun is very strong in the mountains and can cause eye damage; Tsering embraced the need for change and we took every opportunity to get people to wear a hat or cap with a brim, and sunglasses if possible, especially for the guides and porters who spent time on snow and ice.

We were in an area near Everest which had a lot of infrastructure supported by The Hillary Foundation, which means there is lots of Wi-Fi – and so lots of mobile phones. There unfortunately seemed to be an associated increase in distance vision problems. So we also encouraged youngsters to follow the 20/20/20 Rule: for every 20 minutes on a screen or device, spend 20 seconds looking at something 20 metres away.

In total we saw over 300 patients, mainly for reading glasses but also some distance, conducted vision screening in youngsters and a basic eye health check. We also distributed some safety glasses (it was alarming to see stone masons at work unprotected) and gave advice to two families whose very young children had squints (not previously diagnosed).

Three of the trekkers also spent a couple of enjoyable hours repairing and servicing some non-functioning solar lights that LED distributes, and we all were amazed by the solar reflecting panels used to boil our tea kettles!

It was such a rewarding and satisfying trip, I had forgotten how much it meant to me to be able to give something back. My heartfelt thanks go to all my helpers, especially the doctor and another trekker who helped me with my Diplomacy Course, as I can be a bit blunt at times!

“Eye Doctor Pat” conducting an eye check

And, of course thanks go to Val and all her team without whose help nothing would be possible…and for all the extra work ‘Helping With Glasses’ has created. In the end, we had run out of glasses, but were able to keep records and hopefully we will be able to send out what is needed next time.

And thanks to my husband who puts up with all the brainache this creates!

George Thomas – Medical Elective in Quishuar, Peru – LED Report

/ LED

In summer 2022, Leeds medics George Thomas and James Peaty undertook their medical elective at the  health post LED supports in Quisuar, in Peru’s Cordillera Blanca. Here’s the report George prepared for us:

We really enjoyed our time at the clinic and want to thank the LED charity for giving us the opportunity to go and the local people around the clinic for being very welcoming. We went to the clinic in Quishaur near Huaraz for around a month. This clinic supports the health of the people in the area surrounding Quishaur.

At the health post: George and James with Claus and Lary

The clinical part of the elective was very varied. Primarily it consisted of us working at the clinic. We would see people with the permanent nurse, Lary, for consultations in the clinic and go on home visits. Often it could be difficult for local people to get access to glasses, so on one occasion we also went to a neighbouring village to do an eye clinic. Furthermore we did lessons in English with the local school where we tried to incorporate teaching about health.

Eye Clinic

Often there was different health problems to what would be normal in the United Kingdom where both of us are currently at medical school. People would more likely to have late presentations of diseases which could make them more severe. Different medical conditions were also more prevalent for instance parasites were more common. At the clinic we had less access to the resources that would be expected in the UK for instance investigations such as bloods or scans therefore it was very important to work as a team doing the medical fundamentals of history taking and exam well. It was very useful for our training to be able to see conditions which would be less common in the UK and focus in on the core fundamentals of medicine.

The Clinic, Quishuar

The language barrier could also pose a challenge as both our Spanish is not the best. We have to thank both Claus, a local mountain guide, and Lary, the nurse, who we couldn’t have done without who helped with translation from Quechua to Spanish. Though by the end our Spanish had improved a lot and we also have to thank them for that!

It can be difficult for local people to get access to healthcare in the area around Quishuar therefore throughout my time there we realised the importance of clinics such as the one we were at to give medical support. It was a very humbling experience going to such a remote clinic and getting to help treat the local people. I was continually surprised; especially by some of the older people there, by how tough they were and their ability to carry on living quite physical lives with sometimes severe medical problems. Even so the local people were always very generous to me and James. One memorable experience was after a consultation one of the patients very kindly gave us some Guinea Pig which we had never tried before.

Home visit

After the clinic we also had the opportunity to do some mountaineering in the region with Claus, a local mountain guide who also helped translate at the clinic. This was my first chance to do mountaineering and I really enjoyed it. It was challenging at times, for me especially so when I was trying to sleep at altitude. I was a bit out of breath and only managed to fall to sleep what felt like just before I had to wake up. We ended up going up Mount Urus and Mount Ishinca. It was a really great experience and has made me keen to do more in the future.

Mountaineering with Claus

We both want to again thank Val and everyone at LED for what was a great experience at the clinic and we really appreciate the help from everyone who made it possible for us to go!

An Elective Volunteering in a Rural Peruvian Health Clinic

/ LED

In summer 2022, Leeds medics James Peaty and George Thomas spent their medical elective period at the health post LED supports in Quisuar, in Peru’s Cordillera Blanca. As well as providing healthcare from the clinic in Quishuar and undertaking home visits for local elderly people who weren’t able to come to the clinic, James and George also ran a mobile eye clinic to distribute reading and distance glasses away from Quishuar and provided English lessons for local children in Quishuar. Here’s James’ report.

Aims and objectives

The key aims of the elective were to:

  • Experience healthcare provision in a developing country.
  • Experience healthcare provision by an international charity.
  • Contribute to healthcare provision in an area of need by fundraising for and purchasing a laptop as well as transporting glasses donated in the UK to be handed out on arrival.
  • Learn a new language using audiobooks and Duolingo.
  • Conduct English lessons for local school children.
Quishuar
James Peaty at the Healthpost, Quishuar
Quishuar

Background and Organisation

I first heard about the elective form a friend, Hugh Harris, 3 years above me on the MBChB program at Leeds. He along with 3 other University of Leeds Medical Students had volunteered at the clinic based in the village of Quishuar in 2019. Through Hugh I was able to contact Val Pitkethly, the founder of the charity, Light, Education, Development (LED), that supports the clinic. After a short application process that involved submitting a CV and meeting with Val to discuss practicalities and get more information my elective partner, George Thomas, and I were accepted onto the elective.

The clinic itself is based in a mountain village on the eastern side of the Cordillera Blanca range in central Peru. It serves the people who live at the highest elevation at the western end of the province of Lucma who are furthest from the government run clinics that sit on either side of the range.

Satellite map showing the location of the health clinic in the whole of Peru
Focused satellite map of the Peru showing the location of the clinic (red pin) and the key features of the local area including the mountains (white) and nearest large town Huaraz
Satellite map of the Lucma district

The main activity undertaken by the population served by the clinic appeared to be small scale farming and labouring jobs and the main form of housing was mud brick houses.

The local shop and a mud brick house in Quishuar

The clinic building consists of 4 rooms; the kitchen and nurse’s quarters, a waiting room, the consulting room and the bedroom. Running of the clinic is funded by the charitable donations mainly form the UK but also worldwide thanks, in part, to an international network built through Val’s mountain guiding clients.

There is a permanent Peruvian nurse stationed there throughout the year but all other medical staff are volunteers. Volunteers were mainly doctors and 5th year medical students from the UK but doctors from other developed nations had also staffed the clinic on a temporary basis in the past.

The consultation room of the clinic, Quishuar

Type of work performed

The clinic functioned as a basic source of primary care. To fulfil this function the clinic was equipped with basic examination equipment including all the equipment necessary to perform observations, a few books including the BNF and Oxford handbook of clinical medicine and a large stock of various basic medications ranging from antimicrobial agents to proton pump inhibitors.

In the clinic our history taking, and examination skills were well practiced. Diagnosis based exclusively on these was essential as the only tests we had access to were urine dipsticks. Communication skills were also tested as none of the patients spoke English and many did not speak Spanish but instead only the Incan language of Quechua. Thus, all communication had to go through the translator working with us.

Other functions that were performed by the clinic included: distribution of glasses, English lessons for local children and home visits for local elderly people who weren’t able to come to the clinic. My elective partner and I were involved in all these functions. For example, one weekend we packed up enough for an overnight camping trip and drove across to an adjacent valley, hiked up to a village with no road access and set up a field clinic distributing glasses to the anyone who required them.

My elective partner George using a Snellen chart at the mobile glasses clinic.

I had bought the glasses, which included both reading and distance prescriptions labelled as various strengths, in a shoe box from the UK. In the box there was also included a Snellen chart and reading materials of different sizes to help us determine, using a bit of trial and error, what strength of glasses each patient required. Over thirty people turned up to this mobile glasses clinic in both the evening and the morning of the next day. In the end we ran out of distance glasses.

English lessons were conducted after the children had finished school 3 days a week. We taught a small group of keen, primary school age, students basic things like the colours, animals, how to say their name and types of food in English. We also included games, songs (such as head, shoulders, knees and toes) and education about basic hygiene, sun safety and healthy eating. We tried to use as many visual aids as possible and to work form a rough plan.

Lesson materials and plan used for English lesson.

Other tasks we performed while at the clinic included taking stock of and helping order medications, alphabetising medications, taking stock of equipment and helping purchase or replace equipment. We also helped purchase and set a laptop for the clinic that we had fundraised for by running the Leeds Half marathon.

George and I at the finish line of the Leeds half marathon
Using the laptop in the clinic

Case report

During the elective I was fortunate enough to be exposed to clinical cases that were fundamentally different from cases I commonly saw in general practice in the UK. An example of this was a 5-year-old child bought in by his mother due to a month-long history of gradually worsening diarrhea and epigastric pain particularly after eating. He had also developed a chronic cough in the last month. On further questioning it was noted that because of the stomach pain the child wasn’t eating as much as normal. The key positive finding on examination was that the boy was underweight for his height and age measuring at the 50th centile in height for his age but only at the 2nd centile for weight.

On discussing my findings, I was told that this was a classic presentation of worms. One study done on the prevalence of parasites in rural Peru found that half of the participants (aged 3 and above) had at least one intestinal helminth or protozoan detected by microscopy. The most common parasite detected was Strongyloides stercoralis which infected 24.5% of the population studied. This nematode can produce symptoms of pneumonitis, chronic malabsorption, diarrhea and abdominal pain thus accounting for the child’s presentation.

I was informed that the standard treatment for this infection was Albendazole. Although the Oxford handbook of clinical medicine recommended Ivermectin as the first line treatment of Strongyloides stercoralis without access to stool microscopy or blood tests it was impossible to be sure of the causative organism. Albendazole has been shown to have good efficacy against a range of roundworms including others common to rural Peruvian populations like hookworm. So, using this broad-spectrum drug was more likely to be effective in treating this child.

In addition to pharmaceutical management, I learnt that it is important to educate patients on basic hygiene and protective measures to avoid re-infection. Many parasites are picked up by the faecal oral route but hookworms and Strongyloides stercoralis can also burrow through the skin. Studies have shown that those who do not wear shoes when leaving the house, and particularly when defecating are more likely to become infected with Strongyloides stercoralis. Therefore, education about regular handwashing is highly important but shoe wearing is also likely to reduce rates of nematode infection. However, this is easier said than done in an area where houses have dirt floors and there is poor access to proper sanitary facilities. Living in close proximity to parasite carrying livestock may also increase risk of infection.

Extra curricula activities

During my elective I was able to significantly improve my Spanish through a combination of immersion, Paul Noble audiobooks and the Duolingo app which I had been using to practice daily since January 2022.

Conclusion

Overall, I believe the elective met almost all of my aims. I was able to fully experience what it is like to work in an international charity and to contribute to healthcare provision in an area of need by: fundraising for, helping purchase and set up a laptop for the clinic; taking and handing out glasses donated in the UK to those who cannot afford them; and helping with the day to day running of the clinic. Furthermore, I significantly improved my understanding of Spanish and taught English to local primary school aged children.

I would have liked to experience the Government run hospitals and clinics to get a full experience of how their health system works. Although this was originally planned it did not end up coming to fruition.

Additionally, this elective had many learning points. These included: learning about diseases, like parasitic worms, that I hadn’t come across in the UK; learning what it means to live in a developing nation and how health needs in a developing nation are different from those of developed nations such as the UK; and the practicalities of healthcare provision in a resource poor environment.