From Mbale ( Eastern Uganda ) to Newport ( South Wales ) : A Case Study

The need to equip students with the theoretical knowledge and applied skills is an essential requirement for professional practice; even more in an increasingly competitive job market. The opportunity to travel to Mbale, Eastern Uganda, as part of a field course, identified areas of professional development which were then transferred and extended to students who were not able to make the travel commitment.


Introduction
The need to equip students with the theoretical knowledge and applied skills is an essential requirement for professional practice; even more in an increasingly competitive job market (Trevithick, 2012).As part of the ongoing collaboration between the University of South Wales (USW) and the registered charity Partnerships Overseas Networking Trust (PONT) community to community link between Rhondda Cynon Taf (RCT) in South Wales and Mbale, eastern Uganda (PONT, 2015), the nutrition and geography students took part in a range of community development and research projects.The area of international development provides potential employment and voluntary work for students from both disciplines.The opportunity to travel to Mbale and develop skills as part of the field course, identified areas of professional development which were then transferred and extended to students who were not able to make the travel commitment.The same approach was therefore taken and in partnership with the Communities First Health Team of Newport West Cluster, a 4-week nutrition, physical activity and cookery course was developed and delivered to community members.
The University is part of a Coalition Against Poverty (CAP), linked with the local charity PONT and a range of local governmental, educational and health-related organisations along with businesses in Pontypridd and the surrounding area (PONT Community to Community Development Centre [C2C], 2013).The PONT partnership also includes equivalent governmental, educational and health-related organisations in Mbale along with a number of Non-Governmental Organisations (NGOs) partners who deliver a range of different development projects (PONT, 2015).This provides the University with a unique opportunity to study aspects of Uganda and engage students with real projects.
Since the initial development of PONT in 2002, Pontypridd town formally twinned with Mbale town and more recently Rhondda Cynon Taf County Borough (RCT) formally twinned with the Mbale region.This direct local link has enabled the creation of partnership between established NGOs and local government in both RCT and Mbale regions.PONT works with its Ugandan partners to facilitate them in doing what they know needs to be done, but lack the resource and skills to realistically achieve.It has helped to develop projects including the training of volunteer community health workers; the linking of local hospitals with the training and mutual support of the staff; the provision of goats for orphans and vulnerable children, just to mention a few (PONT, 2015).
Another example of projects delivered through the association with PONT is the collaboration between Uganda Christian University (UCU), Mbale Campus and USW in 2009.It was envisioned that the partnership would enhance the research and teaching capacity of staff and students from both institutions, help to establish the reputation of UCU Mbale Campus for delivering high quality research services and outputs and also help towards poverty reduction and the promotion of sustainable development in the Mbale region.This helped to establish a solid foundation for professional practice through teaching and engagement on various themes, particularly climate change, food security and vulnerability developed through some of the joint field working described herein.
This paper aims to discuss the teaching-learning process and field experience.The focus will be on the nutrition projects; the lessons from the field and the meaning of internationalisation for students and staff involved will be explored.The case study will provide background information of the areas where the projects were located and describe the steps taken in the development.

Challenges
The problems encountered when working in the field of international development are typically broad and holistic, involving issues of health, nutrition and relationships with people, culture and environment.This has provided the opportunity for nutrition and geography staff to work together on developing the field course.Holistic project work for both student groups included the assessment of water sources with impacts on community health and working through interpreters to gather data within communities for the assessment of nutrition and for vulnerability to climate change.The enthusiasm for considering development issues has provided an interesting and enjoyable motivational factor for the teaching staff involved.
Nutrition education is vital in preventing malnutrition, which is particularly important in situations where families have limited resources.It can also help to address cultural and tradition-based misconceptions and improve general knowledge (Sunguya et al., 2013).Improved nutrition requires access to knowledge regarding how to prepare a balanced diet to sustain life and health (Benson, 2004).It has been established that having sufficient economic means to purchase or access food is not solely enough and it is vital to know how to use the available resources to achieve a nutritious diet (Oldewage-Theron & Egal, 2012).Lack of education plays a major role in the endless cycle of poverty; meeting this challenge is essential in order to reach the Millennium Development Goals (United Nations [UN], 2015).
Additionally, alongside acquiring workable skills, another aim was to provide students with a hands-on experience in developing public health programmes, holistic and multidisciplinary in their approach.Although obesity is considered today's greatest public health challenge that affects virtually all ages and socioeconomic groups (WHO, 2015), it is accompanied by hunger and malnutrition which are considered the number one health risks worldwide -greater than AIDS, malaria and tuberculosis combined (Word Food Programme [WFP], 2015).We are witnessing an escalating global epidemic of overweight and obesity ironically coexisting with malnutrition (specifically under-nutrition) in both developing and industrialized countries.Furthermore, data shows that inequalities between the world's rich and poor countries and the vulnerability of the poorest members of developing countries are growing dramatically (WFP, 2015).Consequently, the greatest challenge to health promoters will be to develop programmes to address both the issues of under-and over-nutrition, where inequalities in health within the country and between rich and poor countries are substantial and increasing.It is seen to be essential that graduates are provided with the academic knowledge and skills to tackle such complex and challenging task.Therefore, learning in both contexts offered the students an experience of other cultures and a diversity that influenced their learning and their development.Students' perceptions of such experiences can be positive and negative and this will be reflected upon (Jones, 2010).As well as the subject specific knowledge development these experiences have significant potential to develop intercultural competence.The ability to draw upon the knowledge and skills developed of other cultures, along with changes in attitude that occur as a consequence of working and learning through such experiences.Such intercultural competences promote a person's ability to understand the other person, to learn and to work with people from diverse cultures and backgrounds (Higher Education Academy [HEA], 2015).

Case study
This case study presents an overview of the field work developed each year from 2011 onwards and augmented by the reflections of the academics who facilitated the work and the students themselves.These reflections are considered from both the practical, workbased learning and the theoretical perspectives of internationalisation of the curriculum and the development of culturally competent practice of both academic teaching staff and students.Intercultural competence is defined as 'the personal ability needed to communicate and work efficiently in intercultural every day and business situations with members of different cultural groups or in a foreign cultural environment (Hatzer & Layes, 2003cited by Behrnd & Porzelt 2012, p. 214).
Today's world is one of unprecedented change that results in a sense of interconnectedness understood as globalisation.As a consequence, higher education providers are seeking to internationalise the curriculum and the student experience so as to promote a sense of global citizenship and professionalism in their alumni.One of the ways in which this is being facilitated is by short-term stays abroad (Jackson, 2008).The field work trips afford such an opportunity and the potential support of such learning and development was identified early on by the academic staff.
In relation to the underlying pedagogy the reality of the field work trips ensured active, participatory, adult learning that challenged the students to work in ways that were underpinned by cycles of reflection and action, that engagement challenged uncritical subjectivity and promoted skills to manage uncertainty, unpredictability and promote team working (McGill & Beaty, 2001).This can only be achieved if the experience itself allows the student to immerse themselves in the host culture, make meaningful relationships with the local people and have some opportunity to reflect on those experiences (Behrnd & Porzelt, 2012).

Mbale, Eastern Uganda
The journey started in the Republic of Uganda which is located in the Eastern part of Africa and known as the 'Pearl of Africa'.The country seemed at the time of independence in 1962 a nation with a great future ahead.However, more than 20 years of civil war, economic mismanagement, social inequalities, poor governance, corruption, just to mention a few, led the country to a degenerative path (SeJJaaka, 2004).The population, projected to increase to 35 million in 2015 (Uganda Bureau Of Statistics [UBOS], 2014), is expected to double in the next 22 years with a fertility rate of more than 6 percent and half of the population below the age of fifteen (United Nations Population Fund [UNFPA], 2014).
In 2006, one third of the Ugandans were unable to access adequate calories; malnutrition is a major health concern in Uganda and 38 per cent of children under five suffer from chronic malnutrition, 16 per cent from being underweight and 6 per cent being acutely malnourished (FANTA-2, 2010).Additionally, life expectancy for an adult is 54 years (UBOS, 2006).
The average prevalence of malnutrition within Uganda hides important variations related to differences in socioeconomic and regional characteristics.Children living in rural areas face a greater risk of becoming malnourished and 40 percent of these children under five are stunted, compared with 26 percent in urban areas (Shively & Hao, 2012).This is partly due to the uneven distribution of food, seasonal and climatic factors, education level, access to clean water and proper sanitation, gender, health and wealth inequalities (Shively & Hao, 2012).
Mbale district is found in the Eastern region and it is named after the largest city in the district, Mbale (Green, 2008).According to the 2014 census in Mbale district the population was 492,804 of which almost 80 percent lived in rural areas (UBOS, 2014).The prevalence of stunting in the Mbale district was 45 percent (Mbale District Local Government, 2003), much higher than the country's average and according to the World Health Organisation standards, Mbale district's nutrition situation is classified as critical (WHO, 2010).
As part of the field course, students were involved in a range of projects engaging with local communities in the Mbale district.The nutrition students were involved in the development and delivery and evaluation of new training courses on nutrition and public health and in the diagnosis, monitoring and treatment of malnutrition.The geography students were involved in the development of new disaster risk reduction strategies for areas plagued by landslides, the use of agroforestry and sustainable land management practices and the assessment of alternative energy potential.
Project work, which jointly engaged both nutrition and geography student groups included the assessment of water sources and the impact on community health and the collection of data within communities for the assessment of nutrition and vulnerability to climate change.The latter also included students and staff from Uganda Christian University, Mbale Campus, giving students further cross-cultural experience as well as one-to-one experience of working through interpreters.Data collected was in relation to dietary intake and vulnerability to climate change.Different participatory data collection techniques were used, from 24-hour dietary recall; food frequency, agricultural and livelihood questionnaires; wider-community and gender-specific focus group discussion and the production of seasonal calendars, used to explore seasonal changes in food production, health, income, etc. (Voluntary Service Overseas [VSO], 2009).
The data collected in the first two years helped, along with the review of the literature and the PONT Mbale Livelihood Coordinator's input, to draw a profile of the area and to identify projects that were developed in the subsequent years of field work.
The weekly lectures, along with regular meetings with PONT Rhondda Cynon Taf members, allowed the students, guided by the lecturer, to plan the food combining course which aimed to engage participants in understanding the value of food combining in order to increase nutritional value of meals.The role of the lecturer as a facilitator was key; the international context of the field trip, the multicultural diversity of the experience and the maturity of the students themselves influenced the facilitative style of the lecturer (Clarke, O 'Neal & Burke, 2008).It was essential that the group negotiated and agreed ground rules that clearly outlined the expectations of both lecturers, students and group process.This gave structure and therefore a degree of a sense of safety to both, the students and the academic team, in what was a very active, student centred learning process.
The course was planned, the evaluation questionnaire prepared and a booklet produced to be handed out with the certificate of attendance to all the participants.The students worked as a team, carrying out the weekly assignments, not only in preparing the course but also in the other tasks required: preparing the information sheet and consent form for the participants, the questionnaire required for the water and sanitation project and so on.Additionally, the involvement of the group in planning and carrying out the activities is an essential part of the learning process.It promoted discussion and motivated students through developing their confidence, self-esteem and ability to work within a team (Boud, Cohen, & Sampson, 2001).
The participants had attended nutrition training as part of their role; therefore, the objectives were to reinforce the knowledge in nutrition, to introduce the idea of food combining as a way to increase the nutritional value of food and to reinforce the message of increased nutritional requirements at different life-stages e.g.children, pregnancy and breastfeeding.
The course was aimed at Community Health Workers (CHW) like Operational Level Health volunteers (OPL), Community Health Promoters (CHPs), Traditional Birth Referral Attendants (TBRA) and other community volunteer workers based in the rural villages of the Mbale district.It was delivered over two days by academic staff and students to 62 female and male health workers in Bududa and 25 in Wanale, both areas in the Mbale district.The training and the group discussions were conducted in Lugisu (local dialect), therefore a local interpreter was engaged to help deliver the course.Working with interpreters proved to be a very positive enriching experience providing students with additional employability skills.
The role of our gatekeeper, the PONT Livelihood Coordinator, proved vital for a successful outcome.As previously stated, PONT's partnership with Mbale enabled the field trips to happen; however, we were welcomed into the communities and families as friends and treated with respect and care.This was due to the recognition for PONT's role and appreciation of the Livelihood Coordinator's work.Furthermore, we learnt that in order to be invited into a village, the community's chief has to formally acknowledge your presence which gives licence for you, as visitors and guests, to carry out the work.

Reflections
The students became very active learners, embracing the responsibility of the project, learning with and supporting one another.The principles of active learning suggest that students learn by doing things and then thinking about what they have done (Bonwell & Eison, 1991).The whole experience facilitated this.
Although in preparation for the trip there were conversations regarding the different cultural norms and expectations such as what would be acceptable to wear, especially for women, in the remote rural villages in the region, how to greet people and shake hands and so on, the reality of cultural diversity and a growing cultural competence was realised through the field work experience.Through their experience they became culturally aware.The students developed a sensitivity, an appreciation, a greater tolerance and an ability to accommodate what was perceived as 'different' in their personal and professional lives.For example, the training materials were prepared centred on the local context and included information and food samples based on the Ugandans' values, tradition and culture.
The training was divided into two parts: theory and practice.Both groups of participants partook in a nutrition exercise which involved pairing food items into the correct nutrient group (e.g.cassava in the carbohydrates, beans in the protein, etc.) to refresh the knowledge acquired through their previous training.The importance of GO foods (carbohydrates, fat), GROW foods (protein) and GLOW foods (vitamins, minerals) were demonstrated and nutrients and energy needs at different stages in life were discussed.
It was also decided that visual aids (such as pictures and real food) would be used.These visual aids proved to be powerful tools for education and communication; furthermore, visual education is a simple form of learning which also helps to increase clarity, retention and interest (Linney, 2012).The importance of food combining was introduced using real food and food cards demonstrating a 'complete meal'.Both groups were involved in the discussion in which questions regarding nutrition were answered.
Group discussions enabled free exchange of knowledge, opinions and ideas among the trainees and trainers.The learning methodologies employed by the team were very positively received.The trainees' educational experiences to date had been passive, a didactic transmission model of teaching had been employed.This course was different in that it promoted active participation and engagement, this caused obvious enjoyment and enthusiasm.The trainees participated and their many further questions challenged the students to provide responses which also assessed their own learning.
The practical element saw the students (males and females), the lecturer, the PONT coordinator and some of the female participants cooking a variety of recipes aimed at demonstrating the principles of food combining.Nutritionally balanced dishes made using locally sourced products were tasted and rated by all the participants.The demonstrations showed the volunteers new ideas which aided learning by combining theory with practical examples (Burgess, Bijsma, & Ismael, 2009).This proved to be culturally quite significant.On the one hand, witnessing men making food was a new experience for the Ugandan participants as this is a chore that men are not accustomed to and is potentially socially unacceptable in this rural part of Africa; while, on the other hand, watching 'mzungu' (white person in Lugisu) cooking in their kitchens with their tools, was a unique experience for everyone.

Evaluation
The evaluation, questionnaire and focus group and the distribution of booklets and certificates were carried out on completion of the training.Although, evaluation is important to identify if learning outcomes have been met, to review the approaches taken and possibly assess how information will be used by trainees (Oshaug, 1997); it was also identified that some of the potential impact could not be so easily quantified.
Engaging male students in cooking created interest, curiosity and debate among locals.The same can be said in relation to the impact on our students, some of the skills learned can be measured and listed in their Curriculum Vitae; however, the life skills and the impact on one's life are more difficult to measure.Without exception students' reflections highlighted a sense of pride for having taken part in a project that they felt was meaningful and potentially useful.Another common feeling was the need to reassess one's life in relation to what is important and what is not and to review one's priorities.
However, full immersion in a different culture raised questions in relation to how far would anyone go to embrace what is different and potentially controversial.This is a question that academic staff and students had to consider and discussions were carried out to explore the different viewpoints.The students described their pre-concepts especially in relation to poverty and quality of life which did not respond to their observations and interactions with the community members.The importance of understanding the host community and accepting what may seem different were identified as important issues by both, lecturers and students.
Again the role of the facilitator is key, the processes of planning, action and reflection need to be managed.In a study by Arkoudis et al. (2013) that looked at promoting interaction between domestic and international students in a higher education setting six key themes outlining the work of the facilitator emerged: Though a different context, there is a congruence with the role of the lecturer in facilitating the activities of the students during the field trip and the approaches taken proved to be successful.Furthermore, the interdisciplinary approach taken meant that students (geography and nutrition) with different specialities were working together on a task; this helped, on the one hand, to understand that in order to address an issue, the holistic approach that critically focuses on all the aspects may be required; while, on the other hand, it allowed students to experience the meaning of partnership working.Furthermore, the lecturers also felt the benefit of this approach as they learned from each other; enriching their teaching practices.
Personal and social transformation has been facilitated through the field trips and the experience of the field work itself reflected what academic attempts to 'internationalise' the curriculum are trying to achieve (Hanson, 2010).Student self-evaluation identified change in personal outlook and a greater ability to see and understand the other, it broadened the minds of the students.Through discussion and reflection on the experience it became clear that they were much more open to the other culture and had a greater understanding.This allowed them to clarify their thinking and adopt more empathic, positive attitudes.Similar findings were reported by Bomna et al. (2015) in a study using email facilitating American and Korean student interaction.
The outcome of the evaluation of the Mbale experience highlighted the value of providing hands-on projects that enabled students to work in a team, learn from each other and apply acquired theoretical and practical skills to real-life situations.However, because of the cost implications and differences in inclination, not all students were able or interested enough to take part in field work in Uganda.Therefore, the same opportunity was offered to students and the Communities First Newport West Cluster is where a parallel project was developed.

Newport, South Wales
Newport, found in South East Wales, is the third largest city in Wales with a population of 145,700 (Office for National Statistics [ONS], 2011).According to the Welsh Index of Multiple Deprivation (WIMD) which ranks zones in terms of deprivation across various domains such as health and employment (Welsh Government, 2015), 11% of Newport's areas are the most deprived and around half of its areas are more deprived than the Welsh average (National Assembly for Wales, 2008).
Newport West Cluster, where the project was based, has a population of 9,885.One zone is in the top 10 per cent most deprived, while two areas are in the top 20 per cent according to the WIMD 2011 (Welsh Government, 2014).Though, life expectancy and the overall health profile of the residents are similar to the Welsh average, the gap in health status and the Healthy Life Expectancy (HLE) between the wealthier and the poorer has increased; this is a reflection of the existing inequalities in Newport (One Newport, 2015).Furthermore, rates of overweight and obesity are above the Welsh average while consumption of fruit and vegetables and the physical activity level, both key factors in maintaining a healthy lifestyle and weight, are below the Welsh average (One Newport, 2015).
Therefore, in partnership with the Communities First Health Team of Newport West Cluster, a 4-week nutrition, physical activity and cookery course was developed.As for the other projects, teaching was dynamic with elements discussed in the class environment and others experienced in the field.The same approach was used; students met weekly, worked as a team and were involved in all the aspects of the project.The needs assessment as well as the meetings with the Communities First Health Coordinator and her team helped to shape the course which aims were to provide basic nutrition knowledge in relation to healthy eating and mental health; to introduce quick, easy to make, healthy for the body and the mind meals on a budget and to provide simple activities that people could carry out daily in their homes.As discussed previously, the gatekeeper, the Communities First Health Coordinator, was key to ensuring the projects were delivered efficiently.
Eight participants, males and females, from Pillgwenlly, Newport took part in the course.Students planned each session which included three parts: theory on nutrition, physical activity, followed by a cookery session in which the dishes made were taken home by the participants.Questionnaires were completed and a focus group was held at the end of the last class to evaluate the project.Food hampers which provide short term emergency food to an individual or family in crisis in the area were also evaluated using a questionnaire which was piloted and amended.

Reflections & Evaluation
Though English was the spoken language, students experienced a reality far from their everyday lives.The same discussions in relation to understanding and acceptance of a way of living which is different and potentially controversial took place with the students.The same feedback was provided; the students felt that working in this environment broadened their understanding and felt that they were doing something useful, something that had a meaning.This can be perceived as a positive outcome of the experience and potentially one that would have been harder to realise in teaching in a more traditional classroom setting, however innovative the approach of the lecturer.Furthermore, the value in developing such cultural competence has been acknowledged as a positive attribute and within healthcare the improved cultural competence of healthcare providers has been highlighted as significant in terms of improving patient outcomes (Mantzourani et al., 2015).
The students who travelled to Mbale or opted for the Welsh option had to take part in all the stages of the projects; though they were assessed on a chosen theme which was developed in a dissertation.

Conclusion
The relationship between PONT and the University has provided a unique way in which higher education students from Rhondda Cynon Taff and from across the UK were able to engage in the development of projects, environmental education and increase their understanding of sustainability and global citizenship.
The interdisciplinary approach that enhanced the learning experience for the students had also an impact on the teaching practices for the academic staff.Additionally, the values experienced through the development of the Mbale project were translated into changes in the module which enabled more students to benefit from different teaching/learning approaches.However, effective interventions require a 'facilitator' and a 'gatekeeper'.Without the key role of the coordinators, in both realities, it would have been impossible to enter into the communities.The role of the facilitator provided guidance, enabled discussion, leadership and ownership of the projects.
The engagement of students in the activities helped to improve employment prospects.The new skills developed and practised have provided work opportunities in the UK; students have had employment prospects enhanced for example in using interpreters for working with ethnic minority communities in housing projects.These developments have been realised through engagement with the host community in meaningful and significant ways.
Furthermore, the journey helped the students to mature and to develop a greater understanding and acceptance of different realities, broaden their views in life which enabled a critical introspective review translating, for some of them, in life change actions.It was realised that the greater impact may not be evaluated as it could be compared to throwing seeds and look forward to the harvest; though, this may take an unknown period of time to produce the products.
It has been realised that students thrive with high expectations made of them while they are supported to work with clear guidance and direction.As acknowledged, the role of the facilitator is key and it is wrong to assume that intercultural competence automatically develops by being in a foreign land.A well perceived environment is in relation to its potential to support students' learning and benefit from managed facilitation processes.This includes the establishment of clear ground rules and expectations, the opportunity to share and reflect in anticipation, during and on experiences with the opportunity to explore and apply the underpinning theory.Action learning and other forms of participative enquiry allow this to happen.
The chosen pedagogies reveal that, calculated risk taking, high expectations and the faith to give students real responsibility, facilitates personal and professional growth through the authentic experience of learning in practice.The underpinning theories were understood and appreciated in ways that classroom teaching arguably cannot.
Finally, collaborations, such as those described, benefit everyone.The students are able to practise and learn skills in a 'real' environment while the agencies are able to offer a quality service at no cost.This is what could be described as a 'win-win' experience.
Internationalisation is of increasing relevance in today's globalised world.This could potentially mean a mind-set change for the academic sector; internationalisation should be driven by global perspectives and the understanding that we live and work in rapidly changing, globally connected realities.Everyone agrees on the importance of equipping students with the essential tools and skills to deal with this fast changing environment; however, novel teaching approaches and an up-to-date attitude that reflect these needs, may be required.

Recommendations
Academics should be supported in their consideration of the concept of internationalisation and what that means in their practice as teachers.Arguably, if there is a genuine desire to embrace and accommodate cultural differences change will occur as is reflected in the case study presented.Those values must be held by the academic in order to promote such learning opportunities.
We as academics must develop more critically considered approaches to supporting teaching and learning that utilise real world experiences to promote learning and culturally competent professional development of students.Teaching staff themselves need to be supported in developing the necessary skills of facilitation and active learning methods.
Higher Education Institutions need to 'open their doors' to facilitate the development of relationships with external organisations to develop mutually supporting collaborative networks such as is described in this case study.
Students must be encouraged to become more actively engaged with the learning process and be supported in their practice.

Biography
Teresa Filipponi is a Senior Lecturer in Human Nutrition, currently based at the University of South Wales.Qualifying originally as a dietitian in Rome, Teresa worked as a dietitian and moved to Britain to continue her studies.She completed a Master's degree in Nutrition and worked in the education field until she discovered health promotion and public health.Since 2004 Teresa has had the opportunity to develop her skills in public health; she has completed a Master's in Public Health and worked at strategic and local level with a range of partners with the objective of planning, implementing and evaluating a range of programmes as a response to local need.Teresa was then appointed as National Food in Schools Coordinator leading the implementation of the Welsh Assembly Government's strategy 'Appetite for Life'.Teresa's main remits were to provide practical support to local authorities, caterers and schools on implementing the nutritional standards recommended and to develop and implement a marketing and communication strategy.
Her present position as Senior Lecturer in Human Nutrition at the University of South Wales is allowing Teresa to further develop research and teaching in the disciplines of nutrition and public health and to apply knowledge and skills in practice.Teresa is completing her PhD thesis on the role of modifiable risk factors on individuals that genetically or environmentally carry an increased risk of cardiovascular diseases e.g.older adult or specific ethnic groups; specifically chronic mountain sickness or 'Monge's disease' patients from the Andean countries.