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We woke up to a crisp, clear, blue sky morning. The early morning sun brought back warmth and great light to the pasture. After chai and chappatis at Tai Bibi’s house we donated a solar lantern to the community, said our goodbyes and started out across the snow covered, sun soaked Pamir in the direction of Shimshal. It was sad leaving these gracious, hospitable and friendly people who had generously opened up their lives and homes to us during our visit.

We left camp around 6.30am as the sun made it’s way over the surrounding peaks stretching further across the Pamir as we gained a little elevation out of camp. Shortly into our walk we were joined by the respected elder Mr Mehman Baig who joined us on our trip back to Shimshal. It was great to share the trail with him and learn more about the traditional way of life in the Pamir.

The hike back to Shimshal was a good opportunity to reflect on the health, social, economic and personal challenges the shepherds face in the Pamir.

Both summer and winter pasture residents spend many months of the year without any access to health care.

As these places will never have direct access to a resident doctor or nurse because of the remoteness and low population density, I think it is imperative that we develop better, more sustainable ways of bringing health care to them.

I think a basic health/hygiene/sanitation/nutrition community education program tailored for residents of the Pamir would be helpful. A short, basic health course for 2 or 3 interested and motivated shepherds would also be helpful. These individuals would be responsible for managing any health issues in the pasture.

I think developing an e-health program that would support the basic health worker in the pasture, link them to the Shimshal Health Centre/ Gulmit Health Centre and the specialist Health Services in Gilgit would significantly improve the health care for residents of the Pamir.

Bringing mobile/internet connectivity to the Shimshal Valley will be a good start to this plan. It was quite a change coming back to the warm temperatures, wheat/alfalfa filled fields and relative low altitude (3,000m) of Shimshal.

We met with the medical staff of the Shimshal Health Centre later that evening and discussed our visit to the Pamir, made some suggestions and plans for follow up of some of the shepherds we saw in the Pamir. We also had a long discussion re their perspective on the current TB status of the residents of Shimshal. Zulfi agreed to send me the reports from any previous TB studies in the area. We discussed the preliminary results of Imran’s mini random household study.

We later had a lovely dinner and meeting at Doulat Amin’s house with Ashraf, his family, his aunt from Gilgit (AKRSP) and religious leaders from Gulmit and Shimshal.

We finished off the day with a special meeting with Shimshal Community Leaders back at the hotel. We described our visit to the Pamir and discussed ways to improve the health of seasonal residents of the Pamir. There was many gracious words exchanged and we were presented with the gift of traditional Hunza hats, which we very much appreciated.

The next day we met with local accomplished mountaineer Mr Rajab Shah and his family at his home in Aminabad. He is a true inspiration. He is a great community leader, visionary, mountaineer, founder of the Shimshal Mountaineering Association, religious leader and family man. He has climbed all 5 of Pakistan’s 8,000m peaks including K2.He has been a great inspiration to many young mountaineers in the Shimshal Valley; a valley that has produced many great mountaineers over the years. He is humble, gracious and always so generous with his time and hospitality each time I visit Shimshal.

We met his 6 year old grandnephew who was born with hydrocephalus and had to have emergency surgery to install a shunt to relieve the pressure on his brain. He continues to have frequent seizures and is physically and mentally challenged. We discussed home physiotherapy exercises to reduce contractures, physical and emotional support strategies, safer feeding techniques, music therapy and discussed getting access to a regular supply of anticonvulsants.

We later visited our driver Sajjad’s home and met his family. He also has a 6 year old son with physical and mental challenges. He was the first twin born at term. The second twin did not survive. Both cases have significant challenges for both families, especially in a country and remote location with few medical resources.

Mr Shah agreed to do a video interview with Pat.

We met a group of gold mining families from Chilas working along the river. The children looked malnourished and did not attend school. They move back to Chilas during the winter months.

We stayed the following 2 nights in Passu.

Shimshal Pass summer pasture at 4700m.We woke up to a crisp morning with scattered clouds. At 5am women were milking their sheep/goats and yaks in the stone walled enclosures in subzero temperatures. There was a calm, focused silence among the shepherds in the animal enclosures. By 8am the milking was finished and the women headed back to their houses for chai and chappatis and start the process of making cheese and butter.

At 9am we met with community leaders who welcomed us to the summer pasture with very kind words. We started our mobile health clinic at 10am.Our aim was to complete health assessments on all of the shepherds at the summer pasture. To make this happen we extended our clinic to 10.30pm to assess the shepherds who were away from the settlement during the day. We saw a number of cases of hypertension, skin and eye infections, one case of jaundice (likely HepB), some anemia and depression.

Later that day while working in the sheep/goat enclosure a young 17 year old woman had a seizure. I saw her just after she collapsed. She showed signs of a non-tonic/clonic seizure. She had significant post ictal drowsiness, which lasted approximately one hour. She apparently had been having similar events over the previous month. Based on her living /work circumstances, there is a good chance that she has neurocysticercosis. This is a disease caused by the ingestion of the worm Taenia soleum, which travels to organs such as the brain, produces cysts that calcify and become the focus of seizure activity. It is a disease associated with people working in close contact with animals such as sheep and goats. Arrangements were made for this lady to travel to Gilgit for further diagnosis and treatment. I recommended a lady with jaundice and fatigue go down to the Shimshal HC for further investigations and treatment. We ended up seeing all the shepherds in the summer pasture over a 12 hour period.

My overall impression was that those people working in the pasture were generally in good health despite their harsh life and poor nutrition. The more healthy in the Shimshal community were more likely to travel to the Pamir. The diet of the shepherds consisted mainly of chappatis/cheese and chai. It lacked protein and many micronutrients. We saw no evidence of fruit or vegetable consumption. On special occasions people will eat yak/sheep or goat meat. There is too much salt + chai consumed, which likely contributes to the large amount of hypertension and heart disease seen. Common health problems included headaches, “breathing problems”, “asthma” (which often turned out to be gastroesophageal reflux), gastritis, hypertension, backpain/arthritis (knees especially), eye, skin infections, cataracts (high UV exposure with little protection), gastroenteritis, anxiety and depression. There was little discussion on menstrual or gynaecological issues because of cultural reasons. Our next visit should include a female midwife/nurse or doctor so these female related issues can be explored further. Some potential medical problems include brucellosis, tuberculosis and anthrax.

A number of recommendations were made to improve the overall health of the shepherds in the summer pasture of Shimshal Pamir.

• Increased water intake and less chai to reduce headaches and prevent dehydration…people are working hard physically at a high altitude.
• Eliminate or at least reduce salt in chai.
• Increase ventilation in the house while cooking.
• Improved attention to hand washing/personal hygiene/sanitation and disposal of human waste i.e. recommend the installation of a number of latrines in the summer pasture so human waste can be concentrated in one area away from human dwellings and water source.
• We stressed the importance of separation of livestock from human living quarters to prevent the spread of worms/parasites such as Taenia and Echinococcus.
• We discussed the construction of basic greenhouse structures to experiment with growing vegetables at a higher altitude.

I think it is worth further exploring the health benefits of local herbs/wild flowers and other plants i.e. Bozlenj (tea used to lower blood pressure) and Banafsha (used for altitude illness and blood pressure)

We did leave a solar lantern to be used by the community as needed.

We left funds to purchase sunglasses for all 35 shepherds living in the summer pasture. These sunglasses would be signed out from the community leaders each spring and returned to the community leaders in the autumn before people head back to Shimshal. The aim of this program is to reduce the incidence of premature cataracts in the community. Zulfi agreed to purchase the sunglasses in Gilgit and return them to the summer pasture.

We discussed the use of solar powered electric fences to rotate yak grazing habitat and reduce the amount of back and forth travel each day by shepherds and animals to find suitable grazing. We noted a lot of the land close to the shepherd’s summer settlement was overgrazed.

We discussed the future use of satellite supported e health connectivity between the shepherds in the pasture, Shimshal HC, Gulmit HC and Gilgit specialist health services.

During our visit, Zulfi donated one of his sheep to the community to celebrate our visit. The sheep was cooked and shared by all.

We awoke to some fresh snow and cooler temperatures. We started out a little later than originally planned (7.15am) because of the conditions. We started up a very muddy, steep incline in fresh snow. Our single poles came in handy to get some traction along the steeper muddy trail.

Fortunately the snow stopped about 90 minutes into our travel. Shortly after this the clouds lifted and we were gifted with warm sunshine and no wind. It gave us the opportunity to dry out some of our gear and improved the trail conditions.

We continued the long hike along the banks of an extensive river drainage.

Further up the drainage, we met Susan, an OT from Calgary with a guide and porters. They had come down from Shimshal Pass after a few days of trekking. She had been bicycling with her friend Liam from Calgary and had taken a little time to visit Shimshal Pass. We stopped and had a tea break and nice visit in the warm sunshine. We continued along the river drainage, with a gradual ascent through a yak pasture, crossed a small bridge and had a chai break at a larger shepherd settlement. It was a beautiful setting, close to the river with great views down valley. We then started the ascent to a small pass above the huts and valley. At the top of the pass we marvelled at the great views down valley and the open meadow towards the Pamir pasture.

After a short break, we continued the long walk across the grassy meadow towards Shimshal Pamir. We watched many yaks happily grazing on both sides of us. The lush green of the Pamir meadow was in stark contrast to the arid rocky slopes of the approach. On our way we met a shepherd friend of Zulfi as he herded the yaks back to the shepherd settlement. A little later we got some more snow and the temperature dropped. The conditions confirmed we were close to 4700m at this point.

We passed 2 beautiful lakes to our left and continued along a muddy, yak trodden path towards a small

Zarat leading to the summer pasture settlement of the Shimshal community at 4700m. It is an idyllic setting with a wide open meadow, lakes and high snow-capped surrounding peaks. It is located very close to the China border.

We were greeted enthusiastically by Ashraf’s mother, Tai Bibi outside her stone pasture home. She prepared a lovely meal of yak cheese, chapatti and chai for us. We appreciated very much her giving up some of her valuable time away from her animals. Her great hospitality during our stay was very much appreciated.

We started out the day gaining good elevation along the side creek and then started a long traverse high above the river. There were spectacular mountain and river views along the traverse. The footing was more forgiving as things started to dry out. We stopped for a break at an old shepherd’s hut with an old dried out yak pelt outside. This would be the site of our last camp on the way out.

We then dropped down to the river, crossed a long suspension bridge and ascended a muddy, narrow, steep trail on the left side of the river. We then dropped down to a shepherd’s hut on the banks of the river where we stopped for lunch.

We then crossed a small bridge and headed up a steep, slippery, narrow incline above the river. This took us to a prominent point with spectacular views. Above this was a very cool wooden ladder made out of juniper and other local woods. This took us through a narrow section through pillars of mixed rock and clay and on to a open doorway to another high point with spectacular views down valley.

At this point the terrain flattened out and we reached another shepherd’s hut where we had some chai.

In light rain, we traversed across clay like terrain with spectacular views of snow capped peaks towards Shimshal Pass and yaks grazing in their summer pasture high on the upper slopes on the far side of the river.

A little later we saw a herd of 7 Ibex grazing above us but conscious of our presence.

We later dropped down to a side creek drainage to 2 shepherd’s huts and our campsite in a beautiful, green area. The newer hut was constructed by Hussain and his brother in honour of their mother. We were joined a little later by 3 local donkeys grazing happily nearby and content at finding some new grass in this dry landscape.

On July 3^rd around 6am with low cloud we headed out of Shimshal village on foot towards the Pamir.

Our group included Zulfiqar (Zulfi/HC administrator + guide), porters Saieed and Hussain, Pat and Dr. Bill.

Our gear comprised of medicines/ medical equipment (including blood pressure machine, stethoscope, auroscope, opthalmoscope etc.)/dressings/ clothing for kids + LED lantern + food and fuel, camping gear etc.

A trip like this had not been done before in this area so we were not sure what to expect. We started out with mixed feelings of excitement and apprehension.

I was interested in traveling the same route that the shepherds seasonally have travelled for decades with their sheep/goats and yaks.

Travelling the same route gave us a much better understanding of the many challenges they face and the impact such challenges have on their health. Traditionally mainly women live in the Pamir (4700m) during the summer months(May to October) tending to their animals and a smaller number of men spend the winter months looking after their animals in the winter pasture at a slightly lower elevation. The winter shepherds usually rotate between families. Children from the villages usually join their mothers in the summer pasture once school holidays begin. The fathers usually look after the households, tend to the gardens and fields during the summer months.

Shortly after we started out eastward along the Shimshal river drainage we encountered rain and cooler temperatures. We crossed the river a number of times and then headed northwards towards Shimshal Pass. We rapidly gained altitude shortly after we turned northward. We traversed a very narrow, exposed, muddy trail above the river. There were beautiful views back towards Shimshal and across to a glacier across the valley. We dropped altitude to cross the second of many suspension bridges we would encounter along the way. We took shelter in an old shepherd’s hut close to the river for a welcome break for chai and chapatti.

We then gained further elevation above the valley and passed a new shepherd’s house almost fully completed.

After we gained further elevation, we started a long, narrow traverse high above the river. Some of the wet, slippery rocks added to the challenge along with the elevation gain. As the day went on the clouds started to break up and the rain eventually stopped. We saw ibex/blue sheep /yak and shepherd tracks high up on the opposite side of the river.

We camped close to a side stream and shepherds hut high above the river. We had some rain on and off during the night but the weather cleared by morning.

Our first morning in Shimshal involved a number of meetings and organising food and gear for our upcoming hike to the summer pastures of Shimshal Pass.

We visited the Shimshal Health Centre early in the morning. We met the staff and then joined Mr Farman Ullah at his clinic, seeing patients together. We discussed current health issues in the Shimshal Valley including hypertension, bronchitis, pneumonia, anemia, urtis, maternal, child care/nutrition issues and had a long discussion with all the staff about their current perception of TB prevalence in the Shimshal Valley.

We discussed previous government/Aga Khan and privately funded studies on the TB issue and the absence of an active DOTs program in the area.

We indicated that BHI would be willing to act as consultant in setting up and completing a comprehensive TB surveillance program in partnership with the Government of Pakistan ,Aga Khan Health Services and any other interested parties. Mr Zulfiqar agreed to access and provide copies of previous TB studies to BHI so we can look at the best approach for a comprehensive community TB assessment, treatment and prevention plan.

We discussed future e health possibilities once mobile phone and internet services open up in the Shimshal Valley. We discussed training of medical staff in e health possibly through the KADO IT centres.

Apparently there has been some discussions with S- Com recently re future mobile/internet connectivity in the Shimshal Valley.

We later met with local Sam (IT trainer) and his new wife Nazarine (dental hygienist from Afghanistan)

We discussed multiple medical issues including the dental health of the people of Shimshal Valley.

Nazarine and I discussed the possibility of doing a joint dental health improvement seminar in the community at a future visit.

We then had a lunch meeting with Ashraf’s father Doulat Amin at his beautiful home in central Shimshal.

It was so nice to visit with him again. He is a great educator and spiritual leader in his community and always so hospitable and generous with his knowledge and time.

He provided a beautiful lunch for us all and agreed to have Pat record a video interview.

We then visited Nambardar Baig Doulat and family at their beautiful home in Khizarabad overlooking the Shimshal Valley. He is an amazing 95 year old farmer, father, grandfather and great grandfather, community and spiritual leader living with four generations in the same house. When we arrived, he had just come back from working in his beautiful garden.

He is in great physical and mental shape and a true example of the old Hunza traditional life with long life expectancy. He attributes his good health to regular physical and mental exercise, good diet (grows a lot of herbs in his garden/ low salt intake) and reduced stress. He grows lots of vegetables, herbs, apricots, mulberries, cherries and apples and has a large yak herd currently in the Pamir. He apparently rarely has to visit the Health Centre. He is a great example of what can be achieved in areas such as Shimshal and what can be learned from the elders and past generations. He agreed to do a video interview with Pat.

Imran agreed to do a simple random household TB surveillance study in all communities in the Shimshal Valley while we were travelling in the Pamir. He went from house to house collecting data and interviewing residents. He did a wonderful job and was received well by the community. The results will hopefully give us some guidance in regards to setting up a more comprehensive household TB surveillance study in the Shimshal Valley.

With the help of Imran, Zulfi, Hasil (hotel owner)and hotel staff we prepared food and gear for our hike up into the Pamir.

The following day we headed up the adventurous 55km Shimshal Road from the KKH and Passu. This road has a long and interesting history. It was built with a lot of local villager voluntary work over a 20 year period with some financial support from the Government of Pakistan and the Aga Khan Foundation.

It opened in 2003 and turned a 3-7 day journey on foot into a 3 hour drive. See history of the Shimshal road by David Butz, Brock University, Canada.

The road had been blocked by a rockslide 10 days earlier so we were not sure if we could get through to Shimshal that day. After one hour of driving the windy, narrow and exposed gravel road we came to the blocked area. There were at least 10 men working on repairing the road under the supervision of a government engineer. We were told that it would be at least another day before the road would reopen. It certainly did not look like the road was close to being finished. They were using dynamite to break up some overhanging rock to use as a base for the road and reduce the chances of further rockfall in the area.

We waited a couple of hours in the mid day sun to see if any opportunities opened up to get a ride to Shimshal from the far side of the blockage.

Fortunately a driver showed up from the Pasu side but had keys for a jeep on the Shimshal side of the blockage. All 8 of us loaded up the vehicle and headed happily to Shimshal. It was a great relief to get through the blockage because a big part of this trip’s objective was to spend some time with the shepherds at Shimshal Pass (4700m).We were concerned that we would not have enough time to make it there and back by foot.

We were very happy to arrive in Shimshal in the late afternoon after a number of challenging river crossings. Shimshal (3,000m) has a population of approximately 2,000 people living in 3 villages (Aminabad, Shimshal and Khizarabad) at the far end of the valley. These three villages consist of Wakhi speaking residents that support herds of sheep, goats and yaks that are moved up and down valley with the seasons.

Shimshal residents have hydroelectricity for approximately 5 months/year. There are current efforts being made to extend the hydroelectricity availability using a natural spring further down valley that does not freeze in the winter. Shimshal currently does not have any access to landline/ mobile or internet connectivity. The community has a satellite phone that is only used for emergencies.

The equivalent Local Support Organisation (LSO) for Shimshal is the Shimshal Nature Trust (SNT).

The previous government run dispensary in Shimshal was replaced in 2011 by a privately (German) funded and supported Shimshal Health Care Centre. This new Health Care Centre was built by the community with external funding from Misereor, Germany, Gesundheit fur Shimshal e.v Germany (Lisa and Horst Buschmann) with the support and advice from Nawbhar Education and Welfare Development Organisation(NEWDO),Shimshal.

The new Health Care Centre is bright, cheerful, quite spacious with running water, a birthing suite, consultation room, pharmacy area, and administration room. It is supported by a staff of 5 people i.e. Dispenser, LHV, Midwife, Assistant Nurse and Administrator. The Dispenser, Mr Farman Ullah has been providing medical care to his community for the past 36 years. He has and continues to be a real asset to his community. The administrator Mr Zulfiqar is very competent, motivated and also very active as a community leader including SNT.

The following morning we drove the 23 km north and west to Misgar. The approach to Misgar village is especially beautiful this time of the year. The fields were vibrant with wheat/barley and alfalfa crops with snow capped peaks towards Mintaka and Kilik Passes in the background. The water in Misgar is very pure. It looks so clear as it runs through the human made channels throughout the village.

We had a breakfast meeting with Mr Abdullah and the LSO coordinator and board member at his home in Misgar. He has a beautiful garden, full of vegetables and fruit trees.

Misgar is an oasis in a very dry mountain landscape. In many ways it is a model village in their agricultural practices and community support/engagement.

We visited the Misgar Dispensary with Mr Abdullah. He now has a medical technician working with him.

He appeared to have quite a good supply of medicines and dressings.

There is currently no LHV/midwife working in Misgar. All pregnant women have to travel to Sost to deliver their babies.

Intermittently, the 16km gravel road from Misgar to the KKH gets blocked by mud/rock slides and occasionally snow in the winter months.

BHI has agreed to spend up to 480,000 rupees (20,000 rupees/month x 2yrs) towards the training of one selected candidate from the Misgar Valley to complete the combined LHV/Midwife 2 year program at the Aga Khan University in Karachi. The selected candidate will need to commit to working in the Misgar Valley for a minimum of 3 years after completing the program.

We met with some LSO representatives and 4 potential candidates for the LHV/midwife training program.

We explained that the position would be open to all candidates from the Misgar Valley. The selection of the candidate should be fair and transparent and go to the best qualified applicant. The selection should come from the LSO and confirmed by KADO and BHI.

Misgar village has landline phone access but no mobile phone or internet connectivity yet. We discussed e-health possibilities once there is connectivity in the future. We did discuss the possibility of e-health training for health workers from Misgar at the KADO IT Centre in the future.

We also met with two Basic Health Workers, one works in a room attached to her home in the main village(where we met) and the other is assigned at the lower end of the village. They help with vaccinations and mother/child care in their community.

We then visited a Female Youth Vocational Training Centre. The program has been operational for 6 months and is run by a very enthusiastic female teacher. They have a number of sewing machines that help produce their clothing products. With Imran’s help, we discussed developing a marketing plan once the products are made. Imran indicated that KADO could help with a marketing program and training.

We then visited a Women’s Carpet Making Centre and viewed some of their fine products. They would also benefit from more education in the marketing area.

We visited the old British built Post Office. It was built in 1915 and is still operational today as a post office. Misgar was historically part of the old Silk Route for caravans of human and animal movement over Mintaka and Kilik Passes into Central Asia.

We tried to arrange a visit with shepherds at Mintaka(4827m) and Kilik Passes(4726m) prior to our arrival.

Unfortunately both areas are closed to westerners for polital/security reasons.

We returned to Sost later that day.