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The Accidental Ambassador

Paul Charlton went to Pakistan to spend time in the mountains. He returned to spend time with the people.

By Paul Charlton ('14)

Tink, tink, tink. A pebble bounced across the gravel road.

We stopped walking and listened. There was no sound, no movement, no wind. Nothing.

Thirty seconds later, again: tink, tink, tink. A second pebble bounced across the road.

"We can't go on," Khalil said. "We should drop our backpacks in case we have to run."

Paul Charlton is a third-year medical student at Geisel, as is his wife, Jessie Bay.

Run from what? The two pebbles?

I was traveling along an isolated road in far northeastern Pakistan with Ibrahim Khalil, who was a friend of a friend and lived in the area. Khalil had just been telling me why he didn't intend to send his daughter Shaazi to school: "It's too expensive. If she has more education than boys it will be tough for her to get married. Plus, she's too small to run fast enough."

I was skeptical. I asked what running had to do with education.

"The school is a mile walk from our house," Khalil replied. "Some days rocks fall. She can't run away if she needs to. It is too dangerous for her."

The road Khalil's daughter would have to take to school was the same road we were walking. From where we stood along the banks of the Hushe River, scree slopes rose 3,000 feet to peaks that loomed over the area's small villages. At one end of the valley was Masherbrum Peak, which stands more than 25,000 feet high.

If we had been at a table, Jessie would have kicked me. But we were sitting out in the open, so she just kicked me.

It was a harsh place, dominated by rock and ice and with only a small strip of life at the bottom of the valley, but it posed no obvious threat. I was unconvinced by Khalil's reasons for keeping Shaazi from school, just as I was unconvinced that we should be worried about two pebbles.

"Let's go," I said.

That's when the rocks began to fall. First they were the size of golf balls. Then baseballs. Then softballs. I dropped my pack.

Seconds later, rocks were raining down the slopes all around us, 100 feet, 50 feet, 20 feet away from us. With nowhere to hide on the road, we sprinted up the scree slope to try to reach a small rock overhang that might offer protection.

"KABOOM!"

A rock the size of a small building cut loose 2,000 feet above us. Time slowed. I could barely move. My heart had long since redlined from the sprinting. I was completely spent. And I was nowhere close to reaching that overhang.

Jessie Bay and Paul Charlton pause on a 2005 trip to the Hushe Valley of Pakistan. Charlton was initially drawn to Pakistan for the chance to explore lightly traveled areas. On this expedition, he and Bay achieved a first ascent of Karpo Brakpo, a remote peak in northeast Pakistan.

The enormous rock continued to tumble toward us. This is it for me, I thought. But at the last moment, as we were about to become pancakes, the rock smacked the slope above the overhang, took flight, and hurtled past us. It landed on the road, creating a huge crater, then bounced into the river.

I never again questioned the importance of schoolchildren's running ability.

The Most Dangerous Nation?
That was my first trip to Pakistan, in 2001. In the years since, I have returned there six times, spending a total of two and a half years working and living in different regions of Pakistan.

At first I went for the climbing. I started climbing when I was 17. By sheer luck, the people who introduced me to the sport had been members of the first wave of Americans to climb in the Himalayas, in the 1960s and 1970s. Their accounts of their adventures made a deep impression on me. One story that stuck with me was the disastrous 1975 American expedition to K2, the world's second-highest mountain, which lies in Pakistan's Karakoram Mountains. The climbers hired hundreds of local Balti porters to carry their equipment along the Baltoro Glacier to the K2 basecamp. Noting the opportunity, all the porters went on strike halfway to basecamp and refused to carry the loads any farther unless their pay was increased. It was a debacle that nearly came to violence. This incident began decades of opportunistic striking, earning Balti porters a reputation for being hard to work with.

"Pakistan would be a great place," one of my climbing mentors remarked, "if it weren't for the people."

A primary school in the Kaghan Valley of the Khyber-Pakhtunkhwa Province that collapsed during an earthquake in 2005. Almost all of the students were trapped inside when the roof fell in, but everyone survived.

That mistrust at first colored my own views of the people of Pakistan. And in the years since my first trip there, the attitude toward Pakistan in the United States seems to have grown even darker. A 2007 Newsweek cover captures what seems to have become the prevailing sentiment: "The most dangerous nation in the world isn't Iraq. It's Pakistan."

Over the decade that I have been traveling to Pakistan, I have developed a very different perspective on this fascinating country, one shaped by firsthand experiences working with Pakistanis on disaster relief and other health-related efforts. I have been disabused of some of my assumptions about Pakistan and, I hope, able to give the people I've met in Pakistan a different perspective on the United States.

Aftermath of an Earthquake
Nearly being crushed by a chunk of granite creates a certain bond, and after our close call Khalil and I became good friends. Khalil, like the porters I had heard disparaged, is Balti. The Baltis are of Tibetan heritage and live in the valleys of the Karakoram, in a region of Pakistan called Baltistan. Through Khalil I met many other Baltis who work as porters. To my surprise, they weren't the conniving fire-breathers I had read about in books. They seemed like good people. In fact, after a couple of trips to Pakistan on mountaineering expeditions, I started to be more interested in spending time with the Baltis than I was in mountaineering.

Balti porters are an essential part of mountaineering expeditions in Pakistan. The porters typically sleep on the glacial debris, huddled behind rock walls with whatever clothes, blankets, and sleeping bags they have among them. Gasherbrum IV, a 26,000-foot peak, looms in the distance.

In 2005, my girlfriend and I planned to go to Baltistan to take part in a grant-funded effort to build latrines at mountaineering basecamps. But first she took me to meet her parents.

"Why do you like Pakistan?" her parents asked.

"Because life there is always on the edge!" I responded. "Avalanches, rock slides, glacial outburst floods, vehicles tumbling off cliffs—everyday life is so hard, so dangerous, people never know what is going to happen."

Jessie, my girlfriend, looked at me as if I had a neon sign on my forehead that was flashing "Stupid! Stupid! Stupid!" Her parents' eyes bulged. But I just kept talking. "And then there is all of the political unrest. Different groups of people fighting over this and that. Whole villages wiped out by—"

If we had been at a table, Jessie would have kicked me under the table. But we were sitting out in the open, so she just kicked me.

I stopped talking.

That was the start of my relationship with my future in-laws.

Despite that incident, Jessie and I made it to Pakistan. Our time there both changed our perspectives on the country and helped set us on the path to medical school. We spent a few months working with Khalil on the latrine project, and we also found time to climb.

One morning, having completed the project, we awoke to the ground shaking. We ran out of the house where we were staying and saw the poplar trees swaying so violently that their tops almost touched the ground.

There was little damage where we were, so we didn't think much about it until we started hearing reports on our shortwave radio. What had been a rumble in Baltistan was a 7.6-magnitude earthquake centered 60 miles from Islamabad, the capital of Pakistan. More than 75,000 people died in the earthquake, and hundreds of thousands of others were affected. We called friends in Islamabad to ask what we could do to help.

"This was massive," they said. "We're working with the relief teams. You should come down." We went to offer whatever help we could.

We asked our contacts in the Pakistan military what to expect. "We don't know," they said, "because we've never had a presence in these valleys."

The days following a major natural disaster are inevitably chaotic, and this earthquake struck remote mountainous areas as winter was approaching, adding another layer of difficulty to the response. So in the first few days, it was primarily people already on the ground who were in place to offer help. Jessie and I were connected to a small team of nurses and EMTs that had been loosely coordinated by the nongovernmental organization Save the Children. Almost everyone on the team was either Pakistani or an Urdu-speaking foreigner already living in the county. I was trained as an EMT and had worked for several seasons as a mountaineering ranger for the U.S. National Park Service at Mount Rainier in Washington State. Although I had been on helicopters a number of times and conducted many mountain rescues in my work at Mount Rainier, what we saw in the aftermath of the earthquake was far beyond what we had expected.

The Pakistan Army flew our team to remote mountain valleys to stabilize, triage, and evacuate the seriously wounded. I was glad to have had training in mountain rescue. From where the helicopters dropped us off we hiked with our basic medical supplies to isolated villages. As the sole female member of the team, Jessie was often the only person able to tend to the injured women and girls because of cultural taboos about interactions between men and women. After treating those we could, and occasionally consulting with physicians via satellite phone, we would prepare patients who needed it for evacuation. We would then contact the military by satellite phone with the number of people to be evacuated and our location. After we identified and cordoned off suitable landing zones, the military would send helicopters to shuttle the injured to hospitals in the region. Then we'd move on to the next village.

In 2011, after his first year of medical school, Charlton returned to Pakistan to work with Khurpa Care, an organization dedicated to training porters in mountaineering skills. Here, Charlton and Zahid Hussain Rajput (left), the president of Khurpa Care, attend a religious festival honoring deceased relatives.

After a few days, the military sent us to the Allai Valley in the North-West Frontier Province (since renamed the Khyber-Pakhtunkhwa Province). On the one hand, I was excited about the assignment, because the military had selected our team to go to this difficult area because of our mobility, Urdu-language skills, and cultural awareness. On the other hand, I was concerned because this was a Pashtun area.

Prior to this trip I had divided Pakistan into two spheres in my mind. "Good Pakistan" meant the people I had interacted with in northern Pakistan. "Bad Pakistan" was everyone else. Pashtuns fell decisively into the "bad Pakistan" category. Many non-Pashtuns spoke derisively of Pashtuns, describing the women as oppressed and the men as uneducated, backward, and universally supportive of the Taliban. To date, my limited exposure to Pashtuns had been uncomfortable experiences with aggressive individuals. I had no desire to work with Pashtuns, but there we were in the helicopter on our way to "bad Pakistan." We asked our contacts in the Pakistan military what to expect. "We don't know," they said, "because we've never had a presence in these valleys."

In those first few days, it seemed that my preconceived notions were correct. For instance, in one village the Pakistan Army stationed a small group of soldiers in a rice field to establish a helicopter landing zone. Their job was to make sure the landing zone was clear of people. But the local Pashtuns turned it into a game. Hundreds of men from the village stood along the perimeter of the landing zone. Soon they realized that if they breached the perimeter of the landing zone the soldiers would come chasing after them, swinging long nightsticks. Men in one area would cross the perimeter, drawing the attention of the soldiers. When the soldiers ran towards one group, men at another spot would push across the perimeter. The soldiers frantically zigzagged across the landing zone as the crowd cheered. The game would go on and on until the soldiers threw up their hands and gave up. Usually the helicopters landed anyway.

Charlton has become very familiar with many regions and people of Pakistan.

These Pashtuns were traditional but not militant. Because of the remoteness of these valleys, people were independent and relatively unperturbed by the politics of the region. At the same time, there was quite a bit of feuding between villages, and there were a lot of guns. People frequently showed me bullet holes in the walls of their houses, which were often the result of a visit from someone in a neighboring village to settle a dispute. In one village I was told not to walk anywhere near the ridgeline because villagers from the next valley over would shoot at anyone they saw. Despite all this, we never felt threatened.

To the contrary, Jessie and I found the Pashtuns to be some of the most hospitable people we had ever met. And it wasn't just Pashtuns from this area. We ended up helping in a medical role for a month after the earthquake and then remained in the area for the next seven months to work with Save the Children as it transitioned from humanitarian relief to long-term development programs. Through Save the Children we worked with hundreds of Pashtuns from all over Pakistan. Without exception they were gracious and kind. They were nothing like I had expected.

One of the surprises about the Pashtuns we met was their sense of humor. The members of the team I was on were constantly playing practical jokes on each other. As conservative Muslims, the Pashtuns did not drink alcohol, but one day even a senior religious leader on our team played along as everyone tried to convince a gullible team member that the juice they were drinking had alcohol in it (it didn't) and that he should join in the drinking. On other days local men held spontaneous marksmanships contests that degenerated into exuberant circus games (albeit circus games with guns).

On one occasion, I accompanied a group of local men on a hunting trek over a series of high passes that connected their pastures with valleys controlled by non-Pashtun groups. Every time we approached encampments of non-Pashtun neighbors (who were all pretty tough as well), the Pashtun hunters would look over at me, smile mischievously, and fire deafening blasts from their Kalashnikovs into the air. "Someone has to uphold our reputation," they told me with a wink.

Balti porters learn climbing and wilderness rescue skills as part of Khurpa Care training programs. Courses includes sessions on topics such as safe glacier travel, ice climbing, first aid, and high-altitude sickness.

Return to the Mountains
Our work with Save the Children was satisfying and successful, but both Jessie and I noted that during the first month after the earthquake we had been asked to do things well beyond our limited medical training. I decided that I was either going to stop doing emergency medical work or get more training. I chose medical school. Jessie came to a similar conclusion through a different route. With Save the Children she had managed a large needs assessment and nutrition survey, participated in investigations of cholera outbreaks in the Allai Valley, and even contracted typhoid herself during the course of her work. Those experiences set her on the path to becoming an infectious disease physician. Like me, Jessie is now a third-year medical student at Geisel.

But we didn't go straight to medical school. After we finished working for Save the Children I returned to Baltistan to help establish a training program for Khurpa Care, an organization dedicated to improving the health and welfare of porters in Pakistan. More than 4,000 Balti men work as porters or guides during the three-month summer climbing season. They carry heavy loads long distances over high passes and glaciers strewn with crevasses, all while using poor equipment. Balti porters are tough and strong, but most know someone who has died in an unroped crevasse fall, drowned in a river crossing, or been killed by falling rocks.

Many of these accidents are preventable. This is why in 2007 a group of Baltis formed Khurpa Care. The organization's primary goal is to ensure that porters gain the knowledge, skills, and equipment to work safely. I worked with Khurpa Care's trainers to design and pilot their trainings in wilderness and high altitude medicine, environmental awareness, sanitation and hygiene, safe glacier travel, and climbing skills.

A second goal was to help porters find constructive ways to address their grievances. Thirty years after members of the 1975 American K2 expedition nearly came to blows with Balti porters, strikes on the Baltoro Glacier were still a regular occurrence. Yet by listening to porters' grievances, the Baltis working with Khurpa Care were able to identify the issues at the root of the strikes. Khurpa Care gave porters a voice on these issues, helping them to find workable solutions.

Thanks to funding from Ohiyesa—a Dartmouth organization founded by Jack Lyons, M.D., and Dean Seibert, M.D., that supports medical students working in underserved areas—I spent the summer after my first year of medical school back in Pakistan continuing this work with Khurpa Care. It has come a long way, but there is still much to be done. One of the next steps is to get the organization's master trainers additional formal training. My hope before I leave Dartmouth is to secure funding to bring two Baltis to the U.S. to train in wilderness medicine in New Hampshire and to take part in mountain rescue training programs at Mount Rainier and Alaska's Denali National Park, home to the highest mountain in North America.

As part of his work with Khurpa Care, Charlton has helped lead training sessions for mountaineering porters, including on this 2006 visit to Pakistan. More information on Khurpa Care is available at www.khurpacare.org.

Doctors and Diplomats
Contrary to my initial expectations, I have returned to Pakistan over and over again not despite its people but because of them. I overcame my distrust of the Baltis and Pashtuns by actually spending time with these people. And over the years, I have seen changes among some Pakistanis as well. My friend Khalil, who once hesitated to educate his daughters, now sends all three of his girls to school and has become an ardent supporter of education for all children in Baltistan. The strikes that gave Balti porters such a bad reputation have essentially disappeared, largely through the work of Khurpa Care, which has helped resolve disputes and improve conditions for porters.

I have also seen the role that health care can play in overcoming cultural and political barriers, and I look forward to continuing my medical training and adding to my ability to provide care to those in need. I have realized that Pakistan is home to difficult but fascinating health-care issues. It is one of three countries where polio is still endemic, and the campaign to eradicate it has been complicated by a sham hepatitis B vaccination campaign carried out by the U.S. Central Intelligence Agency in an attempt to obtain DNA from Osama bin Laden's family, an effort that may have diminished public faith in vaccination. Pakistan—like the U.S.—faces health-care delivery challenges as well. It is home to many excellently trained physicians, but the health-care system still struggles to meet the needs of its population.

When I talk to people about my experiences in Pakistan, they often ask what they can do to help improve relations between Pakistan and the U.S. Most of us have little direct influence on the policies of the U.S. or Pakistani governments, but we can have an influence through individual interactions with Pakistanis and Pakistani-Americans. Physicians and other health-care workers may be especially well positioned for this outreach, as there are more than 10,000 Pakistan-trained physicians practicing in the U.S. Every year hundreds more begin residencies at U.S. hospitals.

Many times I have been in remote regions of Pakistan only to run across someone whose cousin lives in Utah or New Jersey or Florida.

Many times I have been in remote regions of Pakistan only to run across someone whose cousin lives in Utah or New Jersey or Florida and loves it there. The Pakistanis I've met who have had positive personal contact with Americans tend to hold more tolerant and nuanced views of Americans. Efforts here to reach out, to learn, and to listen can make a difference. In this sense, we are all ambassadors. If there was ever a time for improving the relationships between Americans and Pakistanis, it is now.

After all, misunderstandings can run both ways. When I was in Islamabad in 2011, a large, bearded man approached me on the street.

"Where are you from?" he asked sternly.

Oh, boy, I thought. I'm about to get an earful. "The U.S.," I replied.

He shook his head in resignation as he made a "tsk, tsk" sound.

"I watch The Wire on television," he said. "I would never visit your country. It is too dangerous. Welcome to Pakistan."


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