Anaemia in Ladakh

We often hear the word ‘highest’ being used in relation to Ladakh. The world’s highest motorable road, the highest dosa point in the world, and the highest ATM in the world are a few examples. Recently, Ladakh featured in the national news for having the ‘highest’ prevalence of anaemia in children in India at a whopping 92.5%. Well, many might have recorded it as a fact, but this got me thinking. Who collected the data? Who compiled it? And, who interpreted the data? Was it interpreted correctly? Was this another case of armchair research?

According to the National Family Health Survey (NFHS) data, over 50% of the Indian population is anaemic. As in other parts of India, anaemia is a public health issue in Ladakh too. However, when is said to be prevalent in 92 % of children, the data needs to be scrutinised more closely. The reasons cited in the news article I read for this prevalence were plausible. It argued that Ladakhi children do not have access to green leafy vegetables and fruits for a major part of the year. It also mentioned that crops are grown in the summer and that in the winter people do not have a regular supply of fresh produce.

On the contrary, I think that most Ladakhi children at present enjoy a good meal even if they do not always have access to different varieties of fruits and vegetables as enjoyed by other Indian children. Anaemia was also cited as a reason for Ladakhi children being stunted. Well, this has to be interpreted in the context of genetics, which play an important role in the height of a person. Most high landers are shorter than the average human. This is said to be a part of their adaptation to life in a high altitude area. In fact, I rarely see a severely malnourished child in my practice. Maybe we are not doing justice to this issue as we are using the standard chart developed by Indian Academy of Paediatrics, which adapted the WHO chart for the Indian population. I don’t think any studies were done on Ladakhi children to prepare this chart.

Anaemia at high altitude has always been overestimated. Haemoglobin level at high altitude rises in response to hypoxia. The body increases the carrier of oxygen i.e., haemoglobin to compensate for the lack of oxygen in the atmosphere. When we have more haemoglobin, we will have more oxygen molecules supply to each tissue. So, when we calculate haemoglobin at high altitude a correction has to be made to compensate for the increase in haemoglobin in response to lack of oxygen. Simply put, if your haemoglobin level is nine it will be recorded as seven. Similarly, in cases your haemoglobin level is 13, which is not anaemic, it is recorded as 11, which is regarded as anaemic. This is because the extra haemoglobin value is due to high altitude, and has to be subtracted to calculate the actual haemoglobin value. As a result, many children are being recorded as anaemic. The correction is based on research carried out by the American health agency Centers for Disease Control and Prevention (CDC) based on studies done among high altitude communities living in the Andes. This may or may not apply to the people of Ladakh.

The correlation is complex. The adaption at high altitude communities in the Andes is said to be different from that of the communities living on the Tibetan plateau. It is said that the Andean communities have not developed the physiological adaptations to high altitude conditions as evident among the residents of the Tibetan plateau. Furthermore, it is not clear to me if the anaemia study only focussed on haemoglobin value or if a more detailed investigation was carried out. We need to know if a person is truly anaemic before we label them as anaemic. This requires more tests in addition to their haemoglobin level. I doubt that such tests were done. In fact, I am not aware of any large study on anaemia in the last 20 years in which important parameters such as iron levels were done without which we cannot reach any conclusion about anaemia prevalence.
I am aware of one study involving 840 students in Leh district that was done by a Netherland-based NGO called School Health Checks. After recording data over two years, the interpretation of the data was interesting not only because of its results but also because of the actual observation. This study assessed haemoglobin through spectrography (Hemocue) using blood drawn from a finger prick. When someone had very severe anaemia say a haemoglobin level less than 5.5 gm per decilitre), they carried out more advanced tests such as a smear examination at Sonam Norboo Memorial Hospital in Leh. Other advanced tests such as iron studies, B12 and folate levels were not done.

After recording the data, they interpreted it using the CDC correction based on chronic exposure to high altitude. They concluded that the prevalence of anaemia among school students in Leh as 82%. They were astonished by the result as they had physically examined all the children. The pattern of distribution of anaemia among different age groups did not correlate with other known population groups. The investigation team included a qualified physician, a paediatrician, a biologist, and an epidemiologist. Based on the conclusion that emerged, they were sure that something was wrong with the result, the methodology or that the criteria they were using was too strict. So they applied a mild correction recording the altitude of Leh as 2,000m above mean sea level (amsl) and that of Turtuk as 1,500m amsl. They then applied the CDC criteria once again and the anaemia prevalence was 66%, which is still higher than the national average. Another interesting observation they made was that Ladakhi children eat a large amount of sweets, chips and packaged noodles, which may have contributed to the anaemia. They also observed that often parents are the ones who provide children with these products for consumption. It is interesting to note that during the COVID-19 pandemic when children were at home, the intake of such food has increased manifold and probably so has the prevalence of anaemia.

In this regard, a more detailed study with a larger sample size is required. It is said that we are drowning in data but starved of knowledge. This is especially true in this case of anaemia in Ladakh. If data is misinterpreted, it will make no sense or can be senseless or even disastrous. The base of the data analysis pyramid has a pool of data. The layers above include information and knowledge. The tip of the pyramid is wisdom. This implies that right analysis and use of data can lead to wisdom. Our understanding of anaemia in Ladakh has a long way to climb, on this pyramid.

By Dr Spalchen Gonbo

Dr Spalchen Gonbo is a Paediatrician based in Leh

Do not let it go!

As the father entered my clinic with his ailing child, I could not help wonder why they were travelling at a time when the world was still struggling to manage the COVID-19 pandemic. The child had an acute respiratory infection along with acute mountain sickness. I voiced my thoughts and asked him, “Why are you travelling?” I wanted to understand the thought process of someone travelling for leisure when the whole world was still reeling from the COVID-19 pandemic. It seemed rather odd to me. We are still in the midst of a pandemic that has spread along travel routes. There is no doubt that the man standing in front of me was a good father and I could see how deeply he cared for his child, “I had promised him a trip a year back but we were not able to travel due to the COVID-19 outbreak. Just as the lockdown eased this year, we decided to pursue the plans we made last year. Now, I see that it was a mistake.” It reminded me of a wise Ladakhi proverb, “Lda marings jaga rings” (You tolerated it [in this case, restrictions] for a month but not a day more).

Sometimes, I struggle to make sense of some people’s behaviour especially when it puts themselves and others at risk. Perhaps, they are in some sort of denial. Or, perhaps they are trying to forget the events of the recent past. People seem to be looking for any reason to step out of their homes to explore the world and meet people. This is not reasonable behaviour to cope with a pandemic. The behaviour of the youngsters especially seems dangerous. It is evident on social media platforms where one can see youth inciting and challenging others to follow suit. People seem to be tired of restrictions imposed to curb the spread of COVID-19.

Sometimes I am amused to see so many people roaming around unnecessarily and helping the novel coronavirus spread. And yet, it is painful to see a tourist, who has been travelling to different corners of Ladakh for more than a week, test positive for COVID-19 when they are tested in preparation for their return journey. We are in the midst of the second wave and anticipating the third wave soon. We cannot take chances with this virus. Perhaps touring is something that we can delay for a little while longer. Going out unnecessarily not only exposes us to infections but also increases risks for others who we might meet during our travel.

We have all faced difficult times since early 2020. People have spent most of this time indoors. They have been maintaining physical and social distance from others. This time has been a nightmare for many people. Initially it was due to financial issues and the psychological impact of uncertainty. In due course, most people have had to face the reality of the pandemic in the form of personal losses due to lives claimed by COVID-19. Many children have been orphaned after their parents died of this dreaded disease. It is not surprising that people are now looking for ways to forget the past.

These difficult times will not last forever. Things will be normal again. We will be touring again. We will be partying again. We will dine with our friends and relatives soon. However, at present we need to be realistic about the challenges we face. We need to change our mind-set. We need to focus on the qualitative aspects of our lives rather than the quantitative ones.

In this context, we must not let our guard down yet. We need to embrace this nightmare for a while longer. Do not let it go! We need to let the images of overwhelmed hospitals linger in our minds for some time. We need to remember that oxygen was our basic need like food and water not very long back. We should let the sights of overworked crematoria and bodies floating in various rivers haunt us for some more time. We must not forget the bad times that we have all lived through. Only this will make us more cautious and refrain from behaving irresponsibly and inviting more pain.

By Dr Spalchen Gonbo

Dr Spalchen Gonbo is a Paediatrician based in Leh.

Preparing for the third COVID-19 wave

Even as the second wave of the pandemic reaches its peak in India, people are already anticipating a third wave. Pandemics and epidemics generally progress in waves before they ebb. There is also speculation, particularly in the media, that the third wave will put children at greater risk. The first wave mostly involved the elderly and those with co-morbidities. In the second wave, many people in their 30s and 40s suffered severe symptoms and fatalities. The logical conclusion drawn from this is that the next wave will put children at greater risk. This seems plausible as children and teenagers are yet to be vaccinated for COVID-19.

However, this does not account for the fact that many children, including new-borns, are already being infected by SARS-CoV-2 at present. In fact, whenever we test a child who has been in contact with an adult patient, they not only come positive but also have a higher viral load than adults. However, they exhibit milder symptoms or are asymptomatic though some children have developed moderate to severe symptoms including ones who developed Multisystem Inflammatory Syndrome in Children or MIS-C. However, these remain rare manifestations of the disease in children. That said, more infections are now being reported for children compared to earlier. In fact, the number of children infected rose to 15% in the second wave compared to 4% earlier. A recent study by AIIMS, New Delhi and WHO found high sero-positivity amongst children, which means they have been equally susceptible to COVID-19 as adults.

Children seem to have innate or acquired immunity. Innate immunity is immunity a child has at birth through antibodies transferred during the third trimester as well as antibodies found in the mother’s milk that offers protection from various infections in the first year of life. It may also be an acquired immunity, which is something a child develops in response to infections. For instance, children in day-care centres and schools are exposed to many respiratory infections, which may result in them having a higher baseline of antibodies for respiratory viruses. This might provide some protection from SARS-CoV-2.

We see respiratory infections as a disease of children. In fact, many children suffer at least one episode of cough and cold each year and, unlike adults, they develop high fever and severe symptoms. Crèches and schools are ideal breeding grounds for such viral infections, and many children get infected at the same time. Through such incidents, children develop immunity that lasts for a long time. This immune response possibly provides cross immunity for SARS-CoV-2. However, it is worrisome that schools are currently closed and there is less community transfer among children. Thus, the immunity may wane over time and children may start developing symptomatic infections including COVID-19.

Also, adults suffer a more severe impact from COVID-19 due to an overreaction to the virus (cytokine storm) by their robust immune system. The young and naïve immune system of a child will give a normal response rather than an aggressive immune response when they get the virus. The intense immune reaction is what causes damage—often irreversible—to the lungs and other organs in adults.

Vaccination is the only plausible explanation for the shift in the age group of people severely infected by COVID-19 in India’s second wave. Vaccination and precautions are protecting the elderly. This might imply that a proportionally higher number of children will be infected in the third wave if they are not vaccinated even if they suffer fewer symptoms. It is also possible that early communication on COVID-19 focussed primarily on risks faced by the elderly. Younger people may have been a little careless and faced greater exposure to the virus. We were unprepared for the second wave. We are now anticipating the third wave. There is an urgent need to increase the vaccination process in India and include the paediatric population, especially those over 12 years of age. At the same time, we must create and upgrade infrastructure to treat children across the country. We must learn from our own failures and the experience of countries where a number of children died from COVID-19.

By Dr Spalchen Gonbo

Dr Spalchen Gonbo is a Paediatrician based in Leh.

The power of causality

As of 1 May, 2021, all adults in India are now eligible to receive the COVID-19 vaccine. Very soon, the vaccine will also be made available to the age group that is most vulnerable to COVID-19: Children. However, that will only happen once the safety profile of the vaccine becomes clearer. This is how vaccines evolve. In the chronology of vaccine development, we are past the Phase III trials for COVID-19 vaccines and are now in Phase IV. Generally, companies receive licences for vaccines once they successfully finish Phase III trials. After this, the effort is to generate more data to improve the safety, efficacy and effectiveness of the vaccine with the ultimate aim to save more lives with minimal side effects.

As with all vaccines, the COVID-19 vaccine too has evolved. Thankfully, it is becoming clearer that the vaccine is effective in preventing infection and serious symptoms and deaths. Unfortunately, many of us have been labelling many ailments they suffer as side effects of the vaccine. Most side effects actually caused by the vaccine were temporary and expected. Of course, with time the vaccine will become safer just as the current vaccine is safer than its initial versions. Vaccines are constantly improving based on unwanted effects observed in people. This is the beauty of medicine, which is not only a science but also an art. Knowledge, skills, and tools evolve over time and are constantly improving.

How does one navigate the deluge of information and misinformation online on the side effects of the COVID-19 vaccine? In my opinion, it is important to be cautious and critical but not trust hearsay. One way to do this is to focus on causality. Say there is an observed effect (say some ailment), which is attributed to a cause (in this case the vaccine). It is possible that the observed effect is not due to the assumed cause. In statistics there is the concept of P value that provides insights on how significantly a cause is correlated with an effect.

In this context, if a dangerous side effect is more evident in a population that has received a drug or vaccine than the general population, then the effect has a higher correlation with the cause as evident in its P value. Thus, if the P value is significant we can infer a cause-effect relationship. Using this rationale, the side effect of blood clotting that many attributed to the vaccine was found to be statistically insignificant. In addition to such an evaluation, one must also weigh risk and benefit of a medicine and vaccine. So for instance, one might have to weigh the possibility that a vaccine may cause some side effects that are not life threatening on the one hand with possibility of the risk of contracting a dreaded disease in the absence of a vaccination.

People have a tendency to relate some effects to some causes irrespective of their actual correlation. This depends on a variety of factors including personal experience, social beliefs and trends. As a doctor, I have been witness to this many times. Many parents have told me that their child was vomiting in the morning but also started experiencing diarrhoea or had developed a rash after taking the medicine I had prescribed. Many times such correlations are illogical. For instance, people relate a variety of food with sore throat, fever, abdomen pain etc. but rarely correlate smoking or alcohol with any of their known side effects! Research has shown a very significant correlation between smoking and various forms of cancer. Similarly, consumption of alcohol correlates with various forms of cancer and hypertension to name a few effects. Thus, the tendency to draw certain cause-effect relations often reflects personal and social biases rather than actual correlations.

This conclusion was driven home for me recently when a friend developed a sudden deterioration in his vision. He is 22 years of age and required prolonged treatment to recover completely. I am glad that he is fine now. However, I was also relieved that he developed these symptoms before taking the COVID-19 vaccine. He was planning to get the COVID-19 vaccine as he works in the healthcare sector when he developed these symptoms and he had to defer the vaccination. I am certain that if he had developed these symptoms after taking the vaccine, many people would claim that it was a side effect of vaccination as he is too young to have such a disease. 
It also reminded me of an incident from my childhood. We used to visit an archaeological ruin at Gyamtsa, which local folklore said would have been similar to Alchi monastery had it been completed. According to the folklore, some divine beings were building the monastery and they wanted to complete it before dawn when humans would wake up. However, a donkey started braying in the middle of the night. Donkeys generally bray for different reasons, including the onset of dawn. However, in this case this donkey started braying in the middle of the night. On hearing the donkey, these divine beings ran away and the monastery remained incomplete. I still blame the donkey whenever I pass the ruins! I now realise that am being unfair to the donkey. A donkey brays at dawn but its braying does not cause dawn. Thus, I should be blaming whoever started correlating dawn with a donkeys braying.

By Dr Spalchen Gonbo

Dr Spalchen Gonbo is a Paediatrician based in Leh.

Managing neighbours

Having a good neighbour is a blessing. It’s always useful to have a neighbour. Getting to know one’s neighbour comes with a wide range of benefits including enhanced safety, shared sense of community, mutual sense of responsibility, lifelong friendships and a helping hand nearby. Whether one needs to borrow some sugar or needs some emotional support, a good neighbour is always there to help. This is because they are in close physical proximity in times when even a close relative or a dear friend living at a distance may not be of much help.

Sometimes, even a bad neighbour can be more helpful than a relative who lives some distance away! There is a wise Ladakhi proverb that should give us much to think about. It goes, “Thag-ring nge nyen sang khim-tses se gra gyal” (A bad neighbour is better than relatives who live far away). These words of wisdom not only apply to individuals and families but also to countries.

We are supposed to be living in the most peaceful era in the history of humankind. It is a time when war has become uncommon, famines are rare and epidemics were considered to be impossible as progress in science meant that any disease could be treated. Humans are on the brink of overcoming the concept of mortality and may even achieve immortality. It is said very soon humans will be able to overcome aging and then find ways to live as long as one wants. Science promises to reduce age to a number. At the same time, sickness and diseases will be rare and humans will only die in accidents or through fatal injuries.

Many philosophers are of the opinion that war will become very rare as humanity has come to realise that it does not solve any problem. Instead, it only leads to suffering, death and destruction and in the end, there are no winners or losers. In the past, war has been fought over ego, territorial gain and natural resources like forest and oil. Most civilised societies have now learnt that natural resources are something to be conserved rather than exploited. At the same time, we have created alternate renewable energy sources that have made us less dependent on oil and gas. We now have the technology wherein a car can run for a year on a litre of water, rechargeable batteries or solar energy. Other causes for war include gold, diamond and other such resources, which we are now able to produce in laboratories. So, war seems to have become redundant!

India has always been a peace-loving country. It is a country that has always been concerned about the welfare of its citizens. It is a country where people have a voice, the freedom to express their views, to disagree and to question each other and the government. It is a country where the voices of people are heard. It is the world’s largest democracy where people regularly exercise their freedom and right to elect people to form a government.

India is a welfare state and its citizens enjoy a wide range of freedom and rights unlike many of our neighbours. India’s friendly attitude towards its neighbours and its yearning for peaceful relations has often been interpreted by them as a sign of weakness. We have been provoked a number of times into war by our neighbours but each time we have managed to teach them a lesson. I wish that we are able to improve our relations with ‘bad’ neighbours like China and Pakistan and resolve our differences. And this is not only my view as a citizen of India but also an emerging global consensus that a change in the attitudes of our neighbours will help improve these relationships. In my opinion, it’s better to improve our relationship with neighbours like China and Pakistan instead of concentrating solely on friendships with distant countries like the USA. All of us must learn from the example of countries that are actively working on resolving their differences and working on uniting rather than disintegrating.

That said sometimes small arguments and fights are necessary to resolve issues or teach a lesson to an annoying neighbour so that they learn a lesson in their own language. In psychological terms, this is called ‘mirroring your neighbour’s behaviour’. They should learn that a war with India will be very costly and that it will bring destruction to both sides. I hope and pray that the heroic fight and sacrifices by our soldiers in the Galwan valley goes a long way in improving our relation with our neighbours and a spirit of friendship prevails in our general neighbourhood!

By Dr. Spalchen Gonbo

Dr. Spalchen Gonbo is a Paediatrician based in Leh.

Photograph by Tsering Stobdan

The vanishing ‘glaciers’

The COVID-19 pandemic caught everyone unawares and ill-prepared. Even developed countries have discovered that they do not have sufficient medical facilities and health workers. Everyone has been fighting the COVID-19 pandemic with limited recourses and even countries like the USA and Italy have found that their budgetary allocation for health is not enough. People have now started talking about the fact that we don’t have enough doctors and sufficient number of beds in hospitals. Unfortunately, the health workers do not have the necessary personal protective equipment. This is true for all countries around the world. Even developed countries are struggling to source ventilators and protective gear such as masks.

Ladakh is also experiencing these challenges. Everyone seems to be discussing the shortage of doctors and trying to finda quick solution. Weare suddenly confronted by the fact that we don’t have the necessary medical facilities and enough beds in our hospital. This led to a growing consensus on the need to increase the health budget. People started comparing the national budget allocation for defence and health. The budget for health is invariably miniscule compared to that for defence. A microscopic virus has emerged as the most dreaded enemy and even countries like the USA, which has a large defence budget and a sophisticated arsenal of weapons, seem helpless.

All of this made me wonder why we don’t have enough doctors in Ladakh. It seemed illogical when people complained that there was no doctor in their village. It reminded me of discussions about water shortage in Ladakh when we should actually be more concerned about vanishing glaciers! I was among four students from Leh who were selected for an MBBS course in 1994. In the 26 years since, more than 100 doctors should have been added in the health sector in Leh but barely 97 have been inculcated. The glacier is definitely not adding to the water supply!

Being a doctor is tough. People in other parts of the world are also leaving this profession. Fewer students are opting for a career in medicine. As a result, we currently have only two physicians in Leh district when the sanctioned strength is for five. Nubra, Khaltse, Skurbuchan, Tangtse and Nyoma do not have a physician. Each of these places has a sanctioned post for a physician. The only reason these posts remain unoccupied is that we do not have a physician to fill them. So these places will have to manage without a physician as we currently have a scarcity.This shortage will probably linger for the near future and people will keep complaining about it.

The relatives of India’s first COVID-19 victim did not blame the deadly virus for the death but accused the treating doctors of negligence.This is not entirely unexpected. In India, people encouraged health workers by beating utensils and clapping, while at the same time there were incidences of people pelting stones at health workers and doctors. Health workers in certain parts of the country have also been physically assaulted. Some hospitals forced doctors to treat suspected cases of COVID-19 without personal protective gear, while many others had no option but to work with minimal protection such as a simple mask.

I hope that after this pandemic ends, we will have better hospitals and every country will increase their health budget. Yet, we as a society must ponder on why we have such a shortage of trained personnel in this profession, which was once considered to be an attractive career. Why are our students not completing their education? Why are they dropping out ofschool? Why are they opting for a career in an industry such as tourism that is notoriously unpredictable and is threatening our environment and culture? Why are our youth not aspiring for a career in medicine? We cannot complain about the shortage of doctors unless we are able to answer these questions. Policy-makers must give due attention to unintended developments in the health sector and formulate policies to make the medical profession more attractive to students.

To return to my earlier analogy, we should focus on nurturing our vanishing glaciers instead of complaining about water shortage. The water scarcity is caused by receding glaciers. However, this is a global phenomenon. Glaciers around the world are receding due to human actions that have harmed the environment. It seems that we can only be a spectator to this unfolding crisis. We cannot stop industries. We cannot stop using our cars. We cannot stop polluting our environment. It will take our country a while to become carbon neutral, switch from conventional sourcesto renewable energy, to go organic, and to control our population. It will take a while despite knowing that we must not pollute our environment and instead nurture the environment.

On the face of it, environmental problems don’t seem to have a solution. Glaciers will vanish, the planet’s climatic system will change and Earth will become inhospitable once water sources become unfit for consumption. Many people argue that we may have to move to a new planet soon.There are people who are exploring if a planet like Mars that is inhospitable for humans can somehow be made more hospitable once Earth becomes inhospitable! I too believed that there are no solutions for Ladakh’s water crisis. I have heard people claim Ladakh’s water will last for a maximum of 30 years and that we must make full use of it while it lasts. These people argue that we should build hotels and make use of Ladakh’s resources to the maximum as we may have to leave the region at some point.

However, COVID-19 made me reconsider these beliefs. There is a solution to each problem we face today. Who would have thought that New Delhi’s sky will ever turn turquoise blue or that dolphins would once again visit Mumbai’s shores? Who would have thought that wild animals that had disappeared after their habitats were turned into roads and airports would return one day? The coronavirus has underlined the meanness of humanity. It has forced humans to think about other life-forms that share the planet with us and deserve kindness and compassion from us. Corona has made a profession in healthcare seem noble once again.

Humanity will surely survive this pandemic. I hope that we learn from this pandemic and equip our hospitals. Health should be a priority sector and these services should be accessible to everyone. I hope that humans will also understand the importance of prevention of diseases. Such new and evolving diseases don’t have a treatment, which means that we now have to learn to live with such viruses.

By Dr Spalchen Gonbo

Dr. Spalchen Gonbo is a Paediatrician based in Leh.