Nepali Times
Himalayan health hazards


Fifty years ago when Tenzing Norgay and Edmund Hillary attained the summit of Sagarmatha they made mountaineering history. Yet unknown to most, their feat also secured a medical coup.

In 1952, one year prior to the first successful assent of the world's highest peak, a Swiss attempt by Raymond Lambert and none other than Norgay himself had to turn away nearly 300m from the top. Later, two Welsh doctors, Griffith Pew and Michael Ward, assessed the principle reasons for the duo's shortcoming: their stove used to melt ice for drinking water had ceased to function and the technology available at the time allowed oxygen inhalation only while resting-the mountaineers were defeated by total dehydration and insufficient oxygen.

Learning from the experience the doctors assembled a contraption that enabled climbers to inhale oxygen while on the move. A year later, plenty of hot lemon in hand and lungs full of oxygen, Norgay and Hillary accomplished what so many dreamed of doing and so many died trying. Half a century since that celebrated climb many advances in high altitude medical research and rescue has minimised the risks of humans who are determined to conquer, climb or just experience the Himalaya.

With years of professional experience as an adventure travel operator, Tashi Jangbu Sherpa reckons Acute Mountain Sickness (AMS) can be avoided and fatality from AMS prevented all together. "Whether rooted in ego or ignorance, we continue to lose lives to altitude related illnesses," regrets Sherpa. "We have to be attentive to our body and be very honest about it. Walk slowly and the body will automatically adjust. Walking slowly is the safest way to walk in the Himalaya."

A climber himself, Sherpa was trained as a mountain guide in France. He has climbed in Europe and Nepal and takes safety on the mountain very seriously. At Everest Trekking, his two-decade-old agency, he insists on sitting his clients down for a ritual briefing prior to departure. And the mantra of the day can be a life-saver: not too high too fast. Problems usually occur when symptoms of AMS are ignored.

A clinical review recently published in the British Medical Journal by doctors PW Barry and AJ Polland describes altitude illness for most as a self-limiting syndrome characterised by fatigue and weakness, dizziness and lightheadedness, headache, anorexia, nausea or difficulty sleeping. It is common in travellers above 2,500 m, particularly if the ascent is rapid. The illness can be fatal if it progresses to more severe forms such as High Altitude Cerebral Oedema (HACE) or High Altitude Pulmonary Oedema (HAPE), accounting for 0.0036 percent of trekkers' deaths in Nepal.

The misconception that physical fitness and youth are shields against this indiscriminate illness is a popular and dangerous one. Young and feeble, old and fit, all are susceptible to altitude related illnesses. A previous healthy experience at high altitude can mean little, while preexisting ailments and illnesses do not preclude mountain sickness. To be sure, there are risk factors involved: rapid ascent, the actual altitude gained, altitude at which you sleep and individual susceptibility.

Though the precise causes of mountain sickness continue to elude us, simple treatment is often critical: cease and stop climbing, and descend if symptoms do not ease or rather exacerbate after 24 hours. If resorting to medication, acetazolamide, known to us as Diamox, effectively reduces symptoms of AMS.

Prevention is certainly better than cure. Acclimatisation is the natural and gradual regulation by the body to cope with altitude but is a random process varying from person to person. To get the required amount of oxygen at higher altitude our heart and lungs must work harder. At 5000m they are working twice as hard as they would at sea level. Allowing the body to acclimatise over the first 1-3 days at a particular altitude requires a flexible itinerary and is worth the while. Diamox is also used to prevent mountain sickness.

A study recently completed by Nepal's foremost high-altitude medicine specialist, Buddha Basnyat, found that 125mg twice daily of Diamox is sufficient for the prevention of AMS. This is particularly important as allergies and other side effects can result from using Diamox. Some smaller trials suggest extracts from the Gingko bilbao tree and asprin are also effective in preventing symptoms.

While hiking through the hills, inquiring about traditional remedies used to nip the illness in the bud could prove interesting. Hot fresh garlic soup and sprinkles of Chinese black pepper (timoor) are touted on many village menus as surefire natural means to help mountaineers cope.

The Himlayan Rescue Association (HRA) has been working on high altitude medicine with aid posts in Manang and Pheriche (see box). This year it will also be present at Base Camp (5,000m) with a temporary clinic run by four American doctors to aid trekkers, climbers, Nepali support staff and porters. The first aid-post at this altitude, HRA will be available to the 32 expeditions already planned for this month. A cameraman with the French expeiditon died last month of a heart attack, and could not be saved.

There are many risks that face the mountaineer besides illnesses common at high altitudes. Trail hazards range from avalanches and rock slides to accidental death or injury while seeking that perfect photograph-especially while adjusting gadgets on a manual camera-or getting pushed off the trail by a beast of burden.

Helicopter rescues are now possible, but retrieval has been affected by phones been knocked out in remote areas by Maoists. Lack of information by trekkers about their itinerary also makes rescue difficult.

Nepali porters have an even more difficult time with rescue. Adhikari of HRA estimates that 60 percent of well-established agencies, particularly members of the Trekking Agents' Association of Nepal (TAAN), comply with the law stating all porters must have death and dismemberment insurance. But hiking in the hills and mountains is not included in the insurance. "In many cases it is a matter of ethics. The agency is liable for the porter, paying all expenses in case of medical treatment or hospitalisation. Agencies can now buy a medical policy for porters, which solves another problem, but they are not bound by law to do so."

At Porters Progress, Arjun Dharel says there are other provisions like above 3,500-4,000m the maximum weight is set at 20kg and 30kg below this height, which, if followed, significantly reduce risks to porters. Whoever is at risk, mountain rescue is always complicated. Bad weather can impede a successful operation. If the rescue is accident related, proper transportation is critical. Panic and mishandling can cause further damage, complicating injuries. Says Sherpa, "Search and rescue is necessary, especially given Nepal's terrain. This country does not have one well-trained standby unit dedicated to rescue."

Buddha Basnyat says high altitude medical research is an open field and needs more Nepali doctors. "There is 'do-able research' in Nepal," says Basnyat. "We cannot do cutting edge research on the coronary artery, but we certainly can investigate altitude sickness and become a world centre for high altitude medicine research."
If medical input by the Welsh doctors partly enabled the ascent of Sagarmatha, it seems entirely possible that some homegrown high altitude research could bring us closer to help understanding this deadly disease.

To the rescue

Then prevention must give way to intervention, the team at Himalayan Rescue Association (HRA) has led the way since 1973. The non-profit organisation was established to reduce fatalities in the mountains related to AMS, various altitude-related complications like snow blindness or frostbite and other accidents. At the HRA information centre in Dhobichaur, prevention through various awareness campaigns is going on.

For those already out on the mountain, HRA operates two high altitude aid-posts at Manang (3500m) in the Annapurna region and Pheriche (4200m) in the Everest region. During spring and fall foreign and Nepali volunteer doctors aided by HRA staff hold fort. Foreign patients are requested to pay a service charge or leave a donation. Nepalis are treated free of cost, though those who can afford to pay a Rs 50 consultation charge.

On average 3,000 patients including many Nepalis are treated annually while over 100 emergency evacuations are made. HRA's Prakash Adhikari says, "We've saved a lot of lives in the past years." HRA is considering another aid post along the Langtang route for which the government has contributed Rs 300,000. HRA chairman Ang Kaji Sherpa, "It is easy to build a hospital. Running it is the challenge. We are accessing where the need is." Then there are sustainability issues with tourism in a slump, but once tourism picks up HRA wants to set up health posts in Makalu and Kanchenjunga.

HRA coordinates helicopter rescue once informed of a case requiring evacuation. For foreign trekkers, the agency will usually have insurance information or an agreement in the event of an emergency evacuation. The HRA coordinates with the agency, insurance company and the relevant embassy ensuring a guarantee prior to dispatching the helicopter. This is time consuming in emergency situations, but over the years, with practice the crew has devised a fairly efficient system. The HRA is on 24-hour radio call with helicopter companies such as Fishtail, Karnali, Dynasty and the Royal Nepali Army.

Tel: 977-1-4440292, 4440293,

(11 JAN 2013 - 17 JAN 2013)