In response to the article on medical tourism in the Annapurnas ('Trekkers bring medical care to the Annapurnas', #193) I would like to offer a few comments based on my own experience in Nepal as a visiting western trained physician. I have been working with a village in the Annapurna region for three years helping them identify and implement a health care plan that moves beyond the 'bandaid concept' of stocking supplies. The village committee, mothers' group and health care workers identified key components to a plan designed to improve the health of the villagers while preserving cultural heritage and respecting the environment. The plan included the renovation of a building for use as a clinic, introduction of composting toilets, improvement of the water delivery system, student health education, preservation of traditional shaman teachings and net-working of the health care workers with Nepali physicians in Pokhara via telemedicine for advice and continuing medical education. The basic design is building a health program run by the local health care workers and supported by the village. The program self adapts to the culture, regional resources and skills available for the area, thereby decreasing dependence on foreign aid. Dependence on foreign aid in the form of supplies, skills or money comes with a high price. Lose of self-respect, dependence on a foreign system that can collapse, misunderstanding due to cultural ignorance and blind acceptance of a system that may seem superior but in actuality performs poorly in the home country are a few of the pitfalls. If an individual, village or even a country does not pay for a product or service, but merely accepts handouts, then the process is devalued. If you do not value something you can not respect it or 'own' it.

Debra Stoner,
Himanchal Educational Foundation