Poo, puddles and parasites

Jane Wilson-Howarth (or Jane Wilson as she was then) graduated in biological sciences from Plymouth in 1975. Her books include accounts of zoological expeditions, a memoir looking at attitudes to disability and death in Nepal and England, and children’s adventure stories. She has also written three travel health guides and her updated bestselling How to Shit Around the World was republished in October 2020.

I’ve been passionate about the natural world forever, so perhaps it was inevitable that I would study in Plymouth where it is so easy to get up close and friendly with the inhabitants of marine, freshwater and terrestrial ecosystems. 

Here I indulged in every possible adventurous activity, including caving. I even served as a cave rescue warden and in my third year, researched how microclimate within caves controls what animals can live where. Post graduation, with three others from Plymouth, I put together a plan to explore South Asian caves and their wildlife. During our six months away we discovered scientifically unknown invertebrate species, but more importantly, I met people ravaged by infectious disease. 

High up in hidden valleys beneath the Hindu Kush I inadvertently began a hygiene promotion campaign, communicating the importance of wound care with locals who did not know about microbes. I was astonished at how sharing information could improve villagers’ health so dramatically. I resolved to continue such work and, to cut a long story short, managed – through spinning travellers’ yarns at the interview – to secure a place at medical school.

Further expeditions punctuated my studies and early medical career but it wasn’t until I married an irrigation engineer that I went to live in Asia. Here I worked on preventing disease through talking about poo: promoting good hygiene practices as part of water supply and sanitation projects. My ecological education that began in Plymouth proved useful: cutting disease transmission is a lot about life cycles, and like any good zoologist I ended up looking in puddles (for mosquito larvae) and at poo (for parasites and pathogens). 

In parts of rural Indonesia people live in houses on stilts; cattle are kept underneath. Well-meaning health promoters aiming to reduce diarrhoea, advised corralling cows away from living accommodation. This bit of ‘health education’ increased malaria cases locally. Health advisors hadn’t considered the whole picture. Local mosquitoes tend to hunt at ground level and bite the first blood-containing creature they find, be it cow, goat, rat or gecko. If there are no animals beneath the house though, mosquitoes will search up and feed on people: not ideal. 

Such cases made me realise how important it is to understand the physical and cultural environment before offering advice.

I’ve lived in Asia for 14 years, nine of which have been in Nepal. 

During much of the last three years I’ve volunteered with the charity PHASE who employ paramedics to work alongside government health staff in remote Himalayan villages.

My first trip to meet PHASE clinicians involved an 80-mile, eight-hour, rough drive from Kathmandu, followed by a sweaty four-hour climb. Sometime after dark, the PHASE paramedic was called to see a young man who had slipped off the path and cracked the back of his head on a boulder. The skull felt boggysoft and, from what we could see with flickering torchlight, cerebrospinal fluid was leaking from an ear. This was serious. He needed to be evacuated.

The injured man was filled up with antibiotics and pain relief and strapped onto a stretcher. Eight friends, four carrying and four resting, manoeuvred the casualty through the jungle in the dark. At one point only two could carry the stretcher. The path narrowed to a notch carved out of the vertical mountainside less than two boot lengths wide. There was a sheer 1,000-metre drop to the river below which sparkled silver in the moonlight. Once the men reached the dirt road running alongside the river, they flagged down a truck. Eventually the casualty reached the main hospital in Kathmandu where a neurosurgeon operated. The patient recovered completely. 

In the mountains, I found myself making some of the scariest clinical decisions of my life working with minimal resources where evacuation is difficult or impossible (depending on the season). Not evacuating could result in death but if we did advise a patient to go to hospital unnecessarily we could throw the family into debt for years. A trip to the capital costs. Accommodation and food is expensive and there is always the danger that the evacuee would end up having private care and paying dearly for this.
At another clinic, I awoke around dawn to someone hammering on the door. Night crickets were still calling. I made out the word birami – an ill person. Saraswati, the senior Auxiliary Nurse Midwife gathered information from the man who’d woken us. His daughter-in-law had been in labour for a long time. He was vague about how long.

It was not for men to know about such ‘women’s stuff’. We put heads under taps and gathered together our medical kit and set off. Ahead the Langtang Himalayan ranges glistened with pristine snow. The air was crisp and the pace of our walking made me pant. Beneath the rutted, pot-holed ‘road’, lush terraces led steeply down to the sapphire snake that was the Indrawati River perhaps 800 metres below. After half an hour our guide led us up through the terraces to a two storey, mud-plastered house surrounded by verdant maize and growing potatoes. There was an inviting smell of wood smoke. I was nervous. I hadn’t delivered a baby for decades and obstetric problems have a habit of going horribly wrong terribly fast. As I took off my shoes and ducked inside, I registered moans coming from a dark corner of the big communal downstairs room. She sounded bad. Older female relatives cooking rice on a central open fire were repeatedly saying, ‘Why isn’t the baby coming out?’ Saraswati took charge, ordering all the males to leave while we assessed the situation. The young woman – she was probably in her early teens – had been in labour for two nights. It was her first pregnancy. She was exhausted. The neck of the womb was still closed tight. The girl needed to be evacuated. One of the menfolk was dispatched ahead to stall the only bus of the day which was due to leave at 8am. After some fettling, the mum-to-be, Saraswati and I walked back to the road-head pausing each time the girl had a contraction. We were in time though. She climbed aboard the bus, which rattled and bumped for four hours along the dirt road to the nearest birthing centre. That night, with some assistance from an oxytocin drip, she delivered a healthy daughter.

It has been great to see the improvements there have been in access to healthcare over the years I’ve been back and forward to Nepal. Traditionally people feared that if a baby died inside the house, the spirit of the dead baby would kill future unborn children. Now though it is rare for women to labour alone in a cowshed. Increasingly women give birth with an attendant Auxiliary Nurse Midwife or in a birthing centre. And although it is still seen as an unclean time, fewer women are confined with the animals while they are menstruating. Happily, such unhelpful ideas have largely been put to bed by health education efforts. Progress is being made, but in Nepal as well as Britain, we continue the battle to get patients thinking about avoiding disease rather than looking for tonics and potions to mitigate it.