No booze, no blues, fewer bruises!

Ever since humans learnt the art and science of brewing alcoholic beverages, the regulation and consumption of alcohol has troubled communities, governments and people the world over. There are people who like to consume the occasional glass of alcohol as it relaxes them, while there are others who become addicted and pay a price with their health or worse their own lives and that of others. Alcohol has been linked to a range of diseases. It also has a strong correlation with a number of social evils. It is not surprising that many religions have strict rules regarding the consumption of alcohol. Similarly, alcohol is strictly regulated and heavily taxed in many countries.

In this context, we have had an interesting experiment in Ladakh over the last few months. Alcohol has not been available in markets across Ladakh for four months now and nothing has happened! Nothing happened in two aspects. No one, or at least a majority of the people, did not feel like they were lacking something and secondly, there have been fewer road accidents and violence in this period. The sale of alcohol in Ladakh has stopped for some time now and it is still not being sold. It was also not available in army stores and canteens. Ladakh has been on abstinence during this period.

In many ways, Ladakh has been like several states in India especially Bihar, Gujarat, Nagaland and Mizoram: The government in each of these states has banned the sale of alcohol. Bihar banned production, sale, storage and transportation of alcohol on its soil in a major policy shift in 2016 in an effort to create a society where every woman finds solace and safety in her home and community without having to deal with the spectre of domestic violence. This happened at a time when Bihar was the sixth largest consumer of alcohol in the country.

While in many states alcohol has been formally banned, this is not the case in Ladakh, especially Leh. There have been plans to make alcohol more easily accessible by giving licences for bars and restaurants. However, civil society organisations, especially women’s group, objected to this and as a result very few bars have come up so far. Alcohol remains a luxury. It is something we can live without. There is a minimum legal age for the consumption of alcohol. At 18 years, Ladakh and Goa have the lowest minimum legal age for alcohol consumption. In states such as Delhi, Punjab and Maharashtra only people above the age of 25 years are allowed to buy or consume alcohol.

I have heard various arguments in favour of making alcohol more easily available in Ladakh. One such argument is that Ladakh is a popular tourist destination and so alcohol should not be banned in the region. This is rather interesting for the simple reason that alcohol should not be consumed at high altitudes especially by someone who is not acclimatised. Alcohol generally increases urine output, which means it reduces fluids in the body unless it is constantly replenished. This means that alcohol consumption reduces the body’s capacity to acclimatise to high altitude conditions and increases risks of various altitude-related diseases.

In addition, alcohol causes respiratory depression and can depress the respiratory drive necessary for acclimatisation. Some people believe that it is good for a cold area as it warms the body. However, it actually has the opposite effect even though it gives the consumer a warm feeling. We have often seen people dying due to hypothermia after consuming a large amount of alcohol as they become unaware of the cold and die in their sleep. In emergency rooms at hospitals, doctors often smell the victims of road accidents or any other unconscious person to check for the smell of alcohol as drunk driving is a major cause of road accidents.

As I was thinking about all this, I was struck by the fact that we are never satisfied with how much we have of certain things in our lives. One example of this is the number of tourists visiting Ladakh. There was a time when 50,000 tourists in a year was a very large number. In the period after COVID-19 pandemic, there have been years in which over 500,000 tourists have visited Ladakh. Despite this, many people related to the tourism sector continued to argue for the need to find new ways to attract more tourists to Ladakh. We may agree or disagree with this proposition but we do need to weigh in various factors in determining how much is enough. That said, in my opinion making alcohol freely available cannot be justified in the name of promoting tourism or generating revenue for Ladakh or any other region. Ladakh has many other things to offer to tourists.

I had posted my views on social media about how alcohol was not available in Ladakh and that no one seemed to have a problem with it. Among the various responses I received was one from a person who frequently uses proverbs in daily conversations. The person used a Ladakhi proverb to make a point and said, “Sha dang mar la lhak milus!”Proverbs are a window into a society and its values, beliefs and wisdom. They often give us practical advice on various aspects of life. In this regard, I find Ladakhi proverbs to be very insightful as they have developed over several generations and encapsulates their collective experiences and norms. This means that proverbs are often open to multiple interpretations based on context and perspective. This proverb too can be interpreted in a number of different ways. “Sha dang mar la lhak milus!” roughly translates to, “Meat and butter have no leftovers!” one interpretation is that there will never be enough of food items such as meat and butter. This is interesting. Meat and butter are food items that are not essential and we can live without consuming them. They are food items that we tend to consume in large quantity when we have more resources available. This is also true for alcohol, which is something we can live without. “Sha dang mar la lhak milus” in a way describes how our desires, yearnings, wishes for some things never wane. It speaks about how there are some appetites that are never whetted or satisfied. Some yearnings never subside. Some needs never diminish .And yes, some things are never enough!

By Dr. Spalchen Gonbo

Dr Spalchen Gonbo is a Paediatrician based in Ladakh.

The quality of care

There is a shift in attitude in public hospitals. Quality is the major change that is evident in our public hospitals. This is a welcome change. Most people rely on public hospitals for their healthcare needs as private hospitals are often not within reach for many. A friend recently delivered a baby at a private hospital and faced some complications. She ended up spending about INR 40 lakh (INR 4 million) for a two-month treatment. It is for this reason that we need to improve public facilities and their quality of care.

Ensuring quality care in public hospitals often requires healthcare workers to go beyond their mandated duties. In public hospitals, resources are often limited but patient volume is high. Thus, each healthcare service provider must wear multiple hats and multitask to deliver care efficiently without compromising on quality. Nurses may not only have to administer medications but also provide emotional support to patients and their families. Doctors may need to juggle complex cases with administrative tasks and hand-holding while teaching and imparting knowledge to other healthcare workers. Allied health professionals could find themselves taking on additional responsibilities to ensure smooth patient flow and continuity of care. Despite challenges such as understaffing and budget constraints, dedication to patient welfare must always remain paramount. Thus, healthcare workers have to use innovation and resourcefulness to provide comprehensive care using every available tool and technique to meet the diverse needs of each patient.

There is a common phenomenon at public hospitals wherein a minority of the workforce shoulders a significant share of the responsibilities, while the remaining members adhere strictly to their designated tasks. I observed this too when our hospital was preparing for National Quality Assurance Standards (NQAS) certification. In fact, one of the assessors commented on it while they were examining our facility.

Thus, provision of quality care in public hospitals requires some added responsibilities and innovative thinking from healthcare workers. It’s about doing the same job differently. It’s about shouldering responsibilities. It is fundamental that workers cultivate a profound sense of ownership about their workplace akin to nurturing a personal venture. When employees feel that they have a genuine stake in their workplace, they become more than just workers. This sense of ownership instils a profound sense of responsibility creating an environment where individuals are not just carrying out duties but actively contributing to everyone’s collective benefit. They take pride in their work. Each worker recognises their role in the organisation’s success and failure.

There is a need to identify such workers along with mechanisms to encourage greater involvement from all staff members. By fostering a culture of appreciation and accountability, public hospitals can cultivate a more equitable and productive work environment. This will ultimately benefit healthcare workers as well as the patients they serve. Some workers become invaluable assets to specific workplaces due to their unique skills, experiences, and relationships built over time. Treating them alike and rotating them could disrupt workflow and diminish institutional knowledge. It’s important to recognise and retain such valuable contributors to maintain stability and excellence at the workplace.

A friend once mentioned that in countries like the USA, initial postings for doctors are often determined by the need of the healthcare system or the government, while subsequent postings may be more flexible and based on the preference of the worker while their performance will also influence these decisions.

Private facilities generally have a system to identify and recognise such workers. Such systems generally do not exist in public facilities. Without acknowledgment of their hard work, morale among such individuals may decline and impact team cohesion along with quality of care provided to patients. Furthermore, the absence of consequences for those who do not actively engage beyond their prescribed duties perpetuates a culture of complacency. Without accountability measures in place, there is little motivation for individuals to exceed expectations or contribute beyond the bare minimum. The minority who fulfil only their basic duties often go unchallenged, as there is a systemic acceptance of their limited involvement.

This reminds me of a Ladakhi proverb, “Chu skakan la shabash met chukar chakkan la kabkyon met!” The proverb translates as, “There is no one to praise for fetching water and no one to blame for breaking the pitcher.” This famous Ladakhi proverb reflects the views of the dedicated workers who are assets of an institution but often remain unrecognised. This statement encapsulates the frustration of unrecognised efforts and consequences in a system where neither diligent work nor negligence is acknowledged or held to account. It illustrates a lack of appreciation for those who fulfil essential tasks and a failure to address or discipline those who underperform.

By Dr Spalchen Gonbo

Dr Spalchen Gonbo is a Paediatrician based in Ladakh

Are we addressing teenage delinquency correctly?

Doctors and teachers are often celebrated for the importance of their work. Teachers and doctors are supposed to be kind, empathetic, and compassionate. One generally does not hear of a doctor or teacher being kind and empathetic as this is normal. However, we do hear about unruly doctors and teachers and thankfully their persistence in the role is short-lived as they lack the basic skills. On the other hand, the concept of an empathetic police officer is less common. In fact, an empathetic police officer makes the news as they stand out as an oddity! This is borne by the fact that the news celebrates police officers who use their brain instead of brawn to reform a hardened criminal.

I have been thinking of this in the context of rising teenage delinquency in Ladakh, especially Leh town. Teenage delinquency refers to a range of behavioural traits exhibited by adolescents, including substance abuse, vandalism, theft, and violence that are deemed as unlawful or harmful. Recently, a teenage delinquent crime solved by the police was celebrated by the media as a success story. The police personnel involved in this case were projected as ‘brave’ as initial rumours claimed that even the police were scared of these delinquent teenagers!

It was common knowledge in our society that these teens would frequent public gatherings, especially Buddhist marriages, where they would demand alcohol. They would also visit Muslim marriages and enjoy a full course Wazwan meal! Refusing to comply with their demands would invite their wrath and they would smash a few car panes while leaving the party. People claim that one should not call the police as they would allege that the police were also scared of these hooligans. It is possible that these teenagers trusted their hosts’ tendency to comply with their demands to avoid any disruption that might mar the happy atmosphere. This only encouraged the delinquent teenagers. It turns out that they are an organised group—I would not call them a gang—working through social media that remained unchecked for a long time.

There was mixed reaction to the police action. Many found it insensitive to term these teenagers as ‘criminals’. Police action was necessary as it’s their job to arrest anyone who violates the law. Unfortunately, this police action was chacrterised by intensified severity as these teenagers had recently assaulted law-enforcement officers. The broader implications of such confrontations highlight the necessity for measured and balanced law enforcement responses to bridge the gap between maintaining law-and-order, and safeguarding individual rights while avoiding over-reactions that may erode community trust. Otherwise, there were routine reports of people, even the elderly, being assaulted by teenagers in cases of road rage. I remember one case in which an elderly man was beaten by a few youngsters as he did not let them overtake him. As he lay injured on a hospital dressing table, he said, “Rangber rangi nyospa! (It is my fault). I should have let them overtake me on time! They have now beaten me…”

There is no reason to believe that the police were scared of them. This was a misconception. However, their activities remained unchecked for a very long time and it grew to a level that they could soon have started taking lives. A psychiatrist friend said that this was bound to happen as no one, including law-enforcement agencies, took them seriously. They were juvenile delinquents initially who were turning into criminals. They seem to have lost their way and need to be handled with care.

The police have arrested the alleged culprits, including the kingpin, adults who were juvenile delinquents, and a juvenile in conflict with the law. Does this story end with their arrest? I think this is just the beginning if such cases are not handled properly. It should be a wakeup call for our society and law-enforcement agencies to check our preparedness to deal with teenagers in conflict with the law. We must handle a delinquent teenager before they grow into a criminal.

Communities play an important role in preventing and addressing teenage delinquency. By fostering a sense of belonging and support, communities can create a protective buffer against negative influences and provide opportunities for positive engagement. Local government, NGOs, and community leaders can collaborate to establish after-school programmes, sports clubs, art initiatives, and other activities to channel the energy of teenagers to constructive outlets. Engaging teenagers in such programmes will keep them away from potential delinquency and nurture their talent and interest. In many parts of the world, civil society members have come out to check activities of unaccompanied minors in public spaces or after certain time in the day/night. There is a general notion among parents in Leh that something is amiss in local schools leading to social pressure to send their wards to costly boarding schools outside Ladakh. Many see this as a good investment for their child’s future without realising that they remain vulnerable in many ways. To use a metaphor from pschylogy, we seem to be responding to this problem with a flight response rather than to fight it.

Drug abuse among youth seems to be increasing in our society. Teenage delinquency and drug abuse are often intertwined and form a troubling behavioural cycle. As adolescents face challenges and peer pressure, some may turn to substance use as a way to rebel or cope. This risky behaviour can lead to criminal activities, disrupting their lives and future. Conversely, engaging in delinquent acts can expose teenagers to environments where drugs are prevalent. Comprehensive strategies are needed to address this issue with a focus on education, prevention, and support. Without proper treatment and support, vulnerable youth struggling with substance abuse may resort to criminal behaviour to sustain their addiction. Such a scenario underscores the importance of an effective de-addiction facilities to address the physical aspects of addiction along with counselling and social reintegration. The absence of a quality drug de-addiction centre could amplify delinquency among teenagers. However, ladakh still lacks such a centre.

Once a teenager in conflict with the law has been apprehended, the manner in which police handles them is very important. I have heard parents claiming that police action messes up everything and how the police abused a teen in their custody in front of their parents. In frustration, many parents too abuse their children while they are in custody. One such boy I met remembers his father commenting in front of everyone while he was in police custody “We would have been happier if you had died.” Another adolescent boy once told me about an instance when he did not hear the police siren and did not allow the police to overtake his car. He was stopped and slapped by the police. He recounted, “A policeman tapped a gun on my chest and said “Nono, why do we think we carry a gun? I can shoot you!” The boy said he felt very weak and traumatised. Such experiences plant seeds of resentment and distrust towards authority figures and could push teenagers away from law-abiding behaviour.

A criminal record that usually follows will hamper the future prospects of a teenager leading to a cycle of repeated offences and increasing the burden on the justice system. Empathetic policing needs to be promoted by providing law-enforcement agencies with comprehensive training that emphasises emotional intelligence, active listening, and conflict resolution skills. This will help arm officers with skills to handle delinquent teenagers with a compassionate mindset rather instead of brute strength. It is for this reason that the Juvenile Justice (Care and Protection of Children) Act (JJ Act), 2015 mandates a special dedicated police unit to deal with teenage delinquency. Currently, we have police officers assigned to deal with juveniles at every police stations but they always have additional duties. Thus, there are no dedicated juvenile police units in Ladakh as of now.

A senior law officer once recounted an incident from his youth when he was slapped by a policeman for ignoring a police siren as part of an official’s entourage. This is unfortunate. The people in uniform must instil a sense of security rather than fear. I am happy that the siren culture has stopped now. Now, whenever I hear one I am confident that it is an ambulance on a medical emergency. Officers, especially ones in uniform, must have a simpler and more approachable presence in peaceful areas like Ladakh without needing an elaborate entourage and a wailing siren. The subtlety of their conduct will strengthen the peaceful environment. We have had officers who travelled in simplicity or even walked to their office. These unadorned officers symbolised true strength and are testament to the fact that real power does not require extravagant displays. Such restrained authority will convey a sense of relatability, bridging the gap between law-enforcement agencies and the public.

The juvenile police unit hands over the future of the delinquent teenagers to the judiciary.The JJ Act mandates that every district to have a Juvenile Justice Board. It also mandates that the first class magistrate be a member of the board and should have special knowledge or training in child psychology. Thus, the law does see the need for a trained and empathetic judiciary to address teenage delinquency as their decisions hold the power to either rehabilitate or exacerbate the issue. If the judicial system is not empathetic it risks alienating troubled youth and potentially worsening their behaviour. An empathetic approach can break the cycle of delinquency, offering guidance and support instead of punitive measures.

The JJ Act outlines the legal framework to handle cases involving minors who are accused of committing crimes. It provide a separate system for juvenile offenders, taking into account their age, maturity, and potential for rehabilitation. It focusses on rehabilitation and reintegration rather than punitive measures for young offenders. Rehabilitation programmes such as de-addiction, counselling, education, vocational training, and mentorship offer teenagers the opportunity to grow and change positively. The lack of a social support, dedicated rehabilitation and de-addiction centre, counselling, juvenile police units, safe house and shelters are important aspects of a more sensitive approach to address teenage delinquency. Ladakh has a long way to go in this regard.

By Dr Spalchen Gonbo

Dr Spalchen Gonbo is a Paediatrician based in Ladakh

Mangoes and the mountains

A senior colleague was once presenting a case study on high altitude illnesses at a conference. He started by saying, “Being born at high altitudes is like being born with a disease.” I found some truth in his words as I started monitoring my blood pressure (BP). When I was posted in Chushul in Changthang, my blood pressure was high (130/87) while in Leh it is pre-hypertensive (128/84). And, when I travel to New Delhi and check my BP after a good night’s sleep, it is a perfect 120/76.

High altitude is a poorly understood subject. I remember the case of a boy who had a clot in his heart. Although it was associated with exposure to high altitude conditions and the boy was a non-native individual, we still had to carry out all tests to check for different factors that cause blood to clot in circulation. All the tests were normal, which meant that the clot was due to high altitude. The child still lives in Ladakh but continues to take an anticoagulant and no one dares to stop the medication as the risk remains high. We could try stopping the medication to see if the clot recurs, but this could possibly be fatal.

The Indian Army is said to have lost more personnel to high altitudes than to enemy bullets. That said, the Indian Army is perhaps one of the few institutions that knows a lot about high altitudes and its effects on the human body.

Lately, I have been observing an increase in migration of people from the plains to Ladakh. They claim they are coming to Ladakh for business opportunities, pleasant weather in the summer and kind people. Although many return home, some choose to stay back. If we make a random visit to Sonam Norboo Memorial Hospital, Leh (SNM Hospital, Leh) at most times we will find that more than half the patients are non-native individuals. That is surprising as the number of non-native individuals in Ladakh is significantly lower than the local population. Does this mean that more non-native individuals are getting sick in Ladakh?

For instance, I remember Laxmi (name changed), a labourer, who planned and had her delivery at SNM Hospital, Leh on the advice of her friend. Laxmi delivered a 1.1 kg baby at SNM Hospital after an emergency operation as her BP was very high. The mother-child duo stayed in the Special Newborn Care Unit (SNCU) for two months and returned to their home outside Ladakh just before winter set in. We faced a lot of challenges in managing the baby. The most important challenge was poor weight gain and oxygen dependency. We had a hard time weaning the baby off oxygen support. After staying at SNM Hospital for 62 days, it was finally time for Laxmi and her family to leave Leh. If Laxmi were to have her next delivery in her native place, she would probably have a full-term, healthy and normal delivery. She would probably not require ICU care for the baby. However, Laxmi is not convinced by this sound piece of advice as she found the hospital staff very ‘humane’ and helpful.

High altitude and being a non-native individual are important risk factors for giving birth to a low-birth baby. Data reveals that most low-birth babies at the hospital are non-native individuals. Similarly, we advise many non-native children who develop symptoms of heart failure due to exposure to high altitude conditions to immediately descend to their native place or low altitudes. Over time, we have realised that most of these children are from the plains of Nepal. One of our senior physicians has devised a simple question to judge which Nepalese individuals would develop high altitude illness in Ladakh. He would ask if mangoes grow in their native place. If the answer was “Yes”, then they are from the plains and not adapted to high altitudes. On the other hand, if the answer was “No” then they are from high attitude areas and would not face much trouble adapting to the altitude in Ladakh.

High altitude is also not an ideal birthing place for people from the plains. A lot of studies have found higher incidence of pregnancy-related complications and a higher incidence of low-birth babies among lowlanders giving birth in high altitude areas. We are seeing an increasing rate of birthing among Nepalese in Ladakh with some people coming specially to deliver at Leh. This contrasts with the traditional practice called ‘Chacrahuaycco’ among the Quechuas of South America. Chacrahuaycco translates to: “Let’s go down to the fields” wherein a pregnant lady migrates to lower altitudes for childbirth. They would return to higher altitudes only when the child is a year old. This helps them ensure that the baby is healthy. In my opinion, non-native women in Ladakh should also adopt this practice.

Among native Ladakhis who are assumed to be well-adapted to high altitudes, the frequency of such birth issues is very low and their foetuses are said to grow well under hypoxic conditions. Non-native individuals not only record a higher rate of low-birth weight and higher incidence of birth complications but they also record longer hospital stay and higher infant mortality rates. Ladakh has a very low infant mortality in the National Family Health Survey (NFHS). Leh recorded 17 infant mortalities in 2022 of which nine were non-native individuals.

There is an acclimatisation method called “climb high, sleep low’ which we often seem to ignore knowingly or unknowingly. It is important that information about acclimatisation reaches every person coming to Ladakh. We often see patients being rushed to hospital after a night halt while travelling from Manali to Leh. The night halts are usually at Sarchu or Pang and both these places are located at an altitude higher than Leh town. It is not advisable for an individual who has not acclimatised to sleep at these altitudes. However, such a stay may not be a problem for an acclimatised person travelling from Ladakh to Manali.

There are some medical conditions that can prove lethal at high altitudes. We often see tourists with diabetes, uncontrolled sugar, uncontrolled hypertension, and coronary stents visiting Ladakh. They are often not aware of the risks posed by these conditions at high altitudes and may require specific precautions and care. Certain medical conditions are health hazards at high altitudes. For instance, asthma does not worsen at high altitudes but the cold can induce an asthma attack. Patients on home oxygen must not visit Ladakh. Medical illness that can be aggravated by exertion can also prove fatal. Visitors should not be anaemic and have a haemoglobin count higher than 10. Similarly, obesity is also a risk factor for high altitude illness and a person suffering from it may find it difficult to acclimatise to high altitudes.

Sickle Cell Disease (SCD) is another condition that can be aggravated or cause problems at high altitudes. Though some SCD patients might have been diagnosed, a carrier may not be aware of the risks and may develop problems after exposure to high altitude conditions. I have seen at least three cases of sickle cell disease that were diagnosed in Ladakh when they developed complications due to hypoxia. Interestingly, there have been other cases such as a tourist from Mumbai who only became aware that their seven-month-old child had a congenital heart disease when the child was admitted to SNM Hospital for high altitude-related illness.

It should be a priority for the government to ensure that every tourist is aware of the risk posed by high altitudes and the importance of acclimatisation and other precautions. People from the plains should not plan a delivery in Ladakh or bring an already weak child to Ladakh. It might be a good idea to conduct health checks for all tourists. It should be mandatory to have a two-day acclimatisation.

This gives credence to the statement made by the senior doctor that “Being born at high altitude is like being born with a disease.” He made this statement after observing an increased incidence among non-acclimatised non-natives of surgical emergencies such as gut perforation and volvulus besides increased incidence of thromboembolic phenomenon like splenic infarction and mesenteric arterial occlusion at high altitudes due to ischemia.

There is one very realistic plot in the movie, 102 Not Out, which is very true in this regard. In the movie, actor Amitabh Bachchan plays the character of an elderly man who wants to visit Ladakh. His doctor asks him to get a complete medical check-up before embarking on such a trip. While doing the medical check-up, they discover that he has some ailments around which the plot of the film revolves.

By Dr Spalchen Gonbo

Dr Spalchen Gonbo is a Paediatrician based in Ladakh.

The importance of context

When NDTV showed the edited video of His Holiness the Dalai Lama interacting with a small boy it disturbed me as it distorted the facts and context in which it happened. I could not understand how someone can defame such an important figure without investigating it and contextualising the incident. I thought people do not deserve HH and that he should limit his public interactions.

In traditional Tibetan society, ordinary people would have very little contact with HH the Dalai Lama, except on special religious occasions or during festivals. Even among the aristocracy and religious leaders, access to HH the Dalai Lama was limited, and only a few were allowed to meet with him on a regular basis. This was partly due to HH the Dalai Lama’s busy schedule and the need to prioritise his time. I have heard stories about how people used to wait for several days, sitting around Potala Palace in Lhasa, to catch even a fleeting glimpse of the Dalai Lama. There are other stories of people who would just catch a glimpse of the window of the Dalai Lama’s room and return home satisfied.

The present Dalai Lama is different in this way. He makes sure to bless everyone. I expressed my opinion that the Dalai Lama should limit his public interactions, especially with people of other faiths, to a friend, who is an atheist. The friend disagreed and said that the Dalai Lama has so much more to offer beyond Buddhist religious teachings. This is true. The Dalai Lama is revered by people around the world irrespective of their faith including all Ladakhi communities including Muslims, Christians, Hindus, and Sikhs. In fact, the Ladakhi Sunni Muslim community had the Jama Masjid in Leh inaugurated by the Dalai Lama when he visited Leh.

In fact, when HH the Dalai Lama is in Ladakh he makes it a point to visit all places of worship during his stay. If Ladakh has religious harmony, then HH the Dalai Lama is one of the big reasons for it. When I was a student in Jammu, we would often wait at Jammu Airport whenever we got news that the Dalai Lama was flying out as Jammu is the nearest airport from his official residence in Dharamsala. I remember one incident when he was to fly out from Jammu and many students had gathered at the airport. Among us was a Sikh youth who was studying at Jammu University. HH the Dalai Lama has this habit of teasing and being playful with people. He has a great sense of humour, which also makes him very popular. He is known to play with the moustache and beard of a Muslim or kiss a man of his age. This has never seemed vulgar to me. Anyway, returning to the incident I was recounting, he spotted the Sikh boy, caught hold of him and said, “Hey, I have seen you somewhere.” He was already in tears when HH the Dalai Lama held him with his hand and managed to reply that he was seeing HH the Dalai Lama for the first time. HH, the Dalai Lama replied in jest, “Oh, in a previous life perhaps!” The Sikh boy was in tears and felt blessed. A common friend told me that he didn’t wash his hands for week after he had been touched by HH the Dalai Lama.

I have also noticed that HH the Dalai Lama always has a relevant response to every question. There was an inter-religious meeting in Ladakh when a non-Buddhist person complained that the Buddhists of Leh did not allow the sale of meat on days that are regarded as holy according to their calendar. HH the Dalai Lama had a very practical response to this. He suggested that they buy a large refrigerator and stock it with as much meat as possible the day before these days. Though this was a practical response, HH the Dalai Lama is not one to ever impose his religion or religious views on anyone else. In this case, laughter followed his comment. As it died down, HH the Dalai Lama added that one should respect the religious views of others in society.

During the Kalachakra event in 2014 in Leh, I was working at Sonam Norboo Memorial, Leh. I remember prior to the actual event, we would discuss how we would attend the sermons. The Kalachakra event probably marked one of the biggest congregations in the history of Leh with more than 100,000 visitors. And yet, I remember work at the hospital going off very smoothly. I remember a surgeon friend commenting that they witnessed very few road accidents in that period. In fact, very few people actually visited the hospital for emergencies. I don’t have a reasonable explanation for this sudden dip. However, it is possible that people were driving more cautiously. Perhaps people were very careful and considerate to others on the road. I don’t remember any traffic issues in Leh at the time. In fact, the town seemed that peaceful. People would give lifts in the car to strangers. Many small families would pool their cars and travel together. Others would dine together after the sermon for 15 long days. There was a sense of peace and brotherhood in the air at the time.

A similar view was expressed by a Ladakhi Muslim during the protest at Polo ground recently. The peaceful protest was held out of respect for HH the Dalai Lama and to protest the manner in which the issue was being discussed in the mainstream media in India. It also reminds me of the incident in Lingshed in 2013. The whole village was in tears when HH the Dalai Lama’s tour to the village was cancelled. The next year, HH the Dalai Lama stayed in the village. I still remember the evening, which had a unique sense. The people did not seem inclined to return to their homes and lingered around his residence in a strange silence. Everyone would keep looking at the room where he was and say, “He is in that room. We are so lucky!”

With regard to the recent incident, there are some people who argue that HH the Dalai Lama’s actions were inappropriate. There were others who seem to have malice and seem intent to destroy or defame him. There are still others who have used this incident to try and gain some publicity and attention on social media. Tibetans and religious scholars have viewed the incident as a plain and simple playful interaction. I really think it all depends on how you look at it and how you contextualise the interaction. Would one ever do something that one regards as wrong, in full public view, in front of cameras and an audience? The playfulness of HH the Dalai Lama with his audience cannot be equated or judged by Western culture that has often been understandably traumatised by powerful leaders taking advantage in private of their public stature. Thus, their responses ranged from sensationalist hype to ones that interpreted the incident in its cultural context and HH the Dalai Lama’s pure and jovial nature.

It may be said that non-Buddhists may find it hard to accept that HH the Dalai Lama has transcended worldly sensibilities. A person of his level of realisation dwells in absolute compassion towards all beings, has universal love towards all sentient beings, expresses appreciative joy towards all the goodness around and has unwavering equanimity of mind. His mind cannot be disturbed by lust, greed or aversion. As I look back, I find it rather alarming that media houses such as NDTV are not diligent and careful in their coverage, especially when they are dealing with a sensitive issue that can hurt people’s sentiments. They should have investigated the issue more thoroughly before airing it. I am not concerned about what some celebrities have said on social media as there is a constant barrage of mindless chatter on such platforms. However, when these views are broadcast on national television, then it is concerning. They should remember that it was a playful act with a specific cultural history by an 87-year-old in front of a 100-strong audience, including cameras, and not a secretive act in private meant to harm anyone.

By Dr Spalchen Gonbo

Dr Spalchen Gonbo is a Paediatrician based in Leh.

Save our boys!

I never really considered the question of our boys earlier as like everyone else, I was in the Beti padao  beti bachao mode! This changed when I was looking at the list of doctors selected for government jobs: There were more Ladakhi girls than boys on it. This got me thinking. Most offices in Leh seem to be dominated by women. Generally, the few males present perform lower-level jobs like say a security guard or a driver. While I respect all jobs, it does make you wonder about our boys!

I decided to do a headcount in the two offices to which I have easy access: SNM Hospital, Leh and Sub District Hospital, Nubra. I found that a majority of the staff are women. There were 285 females and 70 males in the staff at SNM, while the number of doctors is equal at 25 each. In SDH, Nubra, we have 62 females and 28 males in the staff, and four of the seven doctors are female. In addition, three other lady-doctors look after other parts of Nubra in Panamik, Turtuk, and Bogdang.

So where are all the men? This question sounds logical in a district headed by two women officers. The Deputy Commissioner and the SSP are both successful lady officers. In January, a Ladakhi girl lead India’s first daredevil biker’s group at the Republic Day parade in New Delhi. The Indian women’s ice hockey team, which is made up of Ladakhis, has started creating waves at different levels. The sex ratio in India is mostly skewed in favour of males and even in Ladakh the number of males is slightly higher than females.

Girls are taught to be independent from an early age. They are expected to help in the kitchen and with household chores, while boys are excluded from these ‘un-manly’ tasks. In most societies, girls are expected to stay indoors, while boys are allowed to roam about! Girls in Ladakh grow up in an insecure environment, which seems to work in their favour. Parents advise them to study even as they pamper the boys. Girls are told from an early age that she will leave the parents’ house and all that she will get is a perak, while her brother will live in the family house!

In Ladakh, many people own hotels and guest houses, and boys are expected to run the family business if he doesn’t get a job. The girl is expected to study well and move to her husband’s home after marriage. So the boys grow up with back up plans in the tourist industry, the army, and the family business. For girls, their plan A has to work! This sense of exclusion seems to be working in favour of our girls as they have to fight various odds and stay focused. They grow up to become confident and self-reliant young ladies. And when they go outside Ladakh to study or work, they go as independent individuals who can sustain and manage themselves well. The boys, on the other hand, become proud after learning to cook instant noodles!

With access to work in the tourism sector and with the army, boys become accustomed to ‘easy money’ from an early age. Although many of them do become independent and mature adults, many become addicted to drugs, alcohol and sex. In many cases, financial independence makes them vulnerable to addictive use of gadgets and consumption of pornography from an early age. They in turn cause harm to others in their peer group.

So where are our men? Most Ladakhi men are successful businessmen, politicians, hoteliers, entrepreneurs, and soldiers. Yet, many others are plagued by bankruptcy, alcoholism, substance addiction, and hooliganism and are considered to be threats to society. More recently, we have started hearing of various crimes being committed by Ladakhis, which we would blame on outsiders earlier. Most of these crimes are being committed by Ladakhi boys who are unemployed or doing petty jobs. We urgently need to help our boys. Our girls seem to be on the right track! We need to ensure that our boys grow up to become independent and self-reliant individuals. We need to ensure that they follow the lead of our girls to complete their studies. Parents must always treat their children equally and never discriminate between them. We must take our sons to the kitchen and have them help in preparing food and cleaning dishes. They must be taught to clean their room, wash dishes, and clothes. I say, “Save the boy child, the girls are shining. Beta bachao, beta padao!”

Editor’s note: This article was originally written and published in 2018

By Dr. Spalchen Gonbo

Dr. Spalchen Gonbo is a Paediatrician based in Leh.

Fever: A misunderstood friend

Recently, a friend with a speech impairment gestured to convey that his son had a fever. He tapped his hands over the forehead and frowned. That was enough for me to understand what he was saying. I tried finding the correct gesture in sign language for fever and realised that he had just used it. The gesture is similar to numerous emojis meant to convey fever. This always makes me wonder. Foreheads are the coolest part of the body even when someone has a fever.

Despite being the coolest part of the body, the forehead temperature check was the most popular screening method to check for fever during the COVID-19 pandemic. This is probably because it is the most accessible part of the body. A showroom or shop with an appropriately dressed man (and very rarely a woman) with a temperature gun was meant to convey that it is a safe place that is following COVID-19 protocols. Once I was rushing to check in at an airport and I asked the person with a temperature gun if my temperature was OK. He responded, “You are very cold, sir!”

The forehead is the most exposed part of the body and when someone sweats, it can become cooler than the rest of the body. When temperature guns became popular for checking fever, many people questioned its safety. It was then said that these gadgets do not emit any rays but collect rays emitted by the body and convert it to an electric signal, which is then displayed as temperature. Some people objected to having a gun-like object pointed at their forehead. In response, the norm changed to checking temperature on the wrist, which is also said to be more accurate.

Coming back to the question of fever, it is defined as having a temperature above the normal range due to an increase in the body’s temperature set point. The increase usually follows an infection. Like cough, fever is part of the body’s defence mechanism. Canadian Physician, and one of the founding professors of John Hopkins Hospital in the USA, Sir William Osler once declared, “Humanity has but three enemies; fever, famine, and war, of these by far the greatest, by far the most terrible, is fever.”

Fever was considered to be a disease in itself. It was much later that we learnt that fever is a manifestation of some disease usually an infection. It is not surprising that the symptom was mistaken for the disease as fever caused by infections has been a major cause of mortality in humans for over 200,000 years. Until the late 19th Century, approximately half of all humans were said to die from infections before the age of 15. Fever, as the most ancient hallmark of disease, dates back to a time before civilisation. By the 18th Century, fever was thought to be ‘a harmful by-product’ of infection. In the 16th Century, Italian Astronomer and Physicist Galileo Galilei invented the thermoscope, which was an equipment to measure changes in body temperature, including fever.

Fever has evolved as a defence mechanism. It is said to contribute to the host’s defence as the reproduction of pathogens can be hindered at higher temperatures. Fever has been described in various medical texts as assisting the healing process. Studies on various warm-blooded vertebrates suggest that they recover more rapidly from infections or critical illness when they develop a fever. Other studies suggest reduced mortality due to bacterial infections when fever is present.

Fever is a matter of great concern for parents and healthcare professionals, especially ones dealing with children’s health. This is because fever has been associated with dreaded outcomes in children. Doctors and parents often fear febrile convulsion (commonly called fever fit). However, we must remember that such convulsions have no correlation with the degree of fever and that not every child who has fever will develop a febrile convulsion.

Many people also develop fever after a vaccination. It is regarded as a good sign as it suggests that the body is reacting to the vaccine and developing the required antibodies to help the body’s immune system fight specific infections. Though many would argue that this fever does not need to be treated, very high fever must be controlled with antipyretics. A fever that is recurring after vaccination needs medical attention as it may be due to other causes.

Sponging is a popular method to reduce fever. While using such a method, it is important that we use lukewarm water or water at 35 degree Celsius to be precise. This is because cold water can cause closure of the vessels and hamper the transfer of heat from the core of the body where it is produced, to the skin, where it is lost. In other words, cold water will trap the heat inside the body. When the fever exceeds 38 degree Celsius, it is important to control it and avoid any further increase as it may lead to seizures. The sponge method is an effort to bring down the body’s temperature and provide comfort to the patient. Sponging is particularly important for infants and the elderly when they suffer from high fever, as they are more prone to such seizures. However, we must remember that sponging is not a treatment for fever. It only helps control body temperature.

Medications that lower fever are called antipyretics. As of 2019, studies correlating the use of antipyretics and the risk of death in those with infection have reported mixed results. In animal studies, worsened outcomes have been reported with the use of antipyretics in influenza as of 2010. However, such studies have not been carried out among humans. Already, there are different opinions among doctors on when to treat fever. Most fever guidelines advice treating fever above a certain degree only and they discourage the use of antipyretics in mild or even moderate fever. It is likely that the use of antipyretics to treat mild to moderate fever will be discouraged even more commonly in the future.

Fever can also be produced ‘artificially’ by a patient. This is done by artificially heating the thermometer or by self-administered pyrogenic substances. An artificial fever might be suspected if the pulse rate is significantly less than what would be expected for the degree of fever noted. One should consider this diagnosis for all patients when there is no other plausible explanation for a fever. Some patients who pretend to have fever may actually have a serious mental illness that may require medical attention.

On a lighter note, fever definitely needs more positive publicity. It does not help that it is often used to describe intense, nervous excitement as associated with sporting events, rock shows and political gatherings with terms such as cricket fever, music fever, and election fever. Perhaps a more appropriate word for these ‘symptoms’ is mania or collective madness. Unfortunately, no doctor can cure these ‘symptoms’!

By Dr Spalchen Gonbo

Dr Spalchen Gonbo is a Paediatrician based in Leh.

A chattering of coughs

Ahem. Here I am again! I am writing after a long time on a medical subject and its ‘cough’ this time. Cough can be a symptom for a diversity of diseases. Ahem! The sound of clearing your throat or a solicited cough is also used to attract attention and express disapproval, or embarrassment.

A cough can be dangerous in certain places and social contexts. For instance, I remember an incident when I was a cadet in the National Cadet Corps (NCC). During an army attachment camp, we were given a class on various war tactics including ambush. During the discussion on selecting the ambush team, the grey-haired Havaldar Major said, “Make sure no one in your ambush team has a cough!” We did not ask him for any reason!

A cough is your body’s way of responding to something that irritates your throat or airways. An irritant stimulates nerves that send a message to your brain. The brain then tells muscles in your chest and abdomen to push air out of your lungs to dislodge the irritant.  Thus, a cough is a protective mechanism. It helps the body to expel what it does not need. One example is when you are drinking water and some of it accidently enters your throat or the windpipe. Your body coughs it out. Similarly, you cough out respiratory secretions produced during an infection. Sometimes it can be an irritant. Sometimes it can be a wrong signal. For instance, wax in your ear can also make you cough as the throat and the ear canal have a common nerve. 

An occasional cough is normal and healthy. A cough that persists for several weeks or one that brings up discoloured or bloody mucus may indicate a condition that needs medical attention.

Almost every child in Ladakh has managed to get ‘Spitchham’ (spring flu/cold) after almost two years of a COVID-19-imposed school break. At present, children are once again being exposed to various infections, which is helping their bodies build up their immunity. This did not happen over the past two years as schools were closed and children remained in the relative isolation of their family homes.  

A cough that follows a viral infection may last for periods ranging from a week to three weeks. I often wonder about the best treatment for a viral infection: Medication or time? Many doctors would argue that time is the best cure as our body needs a few days to treat a viral infection as it develops immunity against the virus. So, is it necessary for us to visit a doctor? I would argue that one should visit a doctor who can then check the kind of cough and ensure that it is not associated with any form of pathology.

Some coughs last for a short time but some persist and linger. I often meet parents who say, “Everything is ok. My child goes to school, sleeps well and eats well but has been coughing for the last two weeks.” I sometimes wish I could respond by saying, “Sorry, I can’t do anything for this cough!” On an average, such coughs will last for one short week if treated or seven long days if left untreated!

Many parents give their child a cough syrup for a cough before they decide to visit a doctor. And they are rarely satisfied until the doctor changes the cough syrup during their visit. In my experience, we need to be more careful with the use of cough syrups. I find that cough syrups are a very typically Indian response to cough! We must remember that many cough syrups have been banned and many contain an irrational combination of drugs. Then there is a cough variant asthma. The symptoms are not like classic asthma, which includes shortness of breath and wheezing. Cough variant asthma is diagnosed based on being treated with certain medication and family and individual medical history that includes different forms of allergy. I would use the kind of medication that comes in the form of inhalers for a frustrating cough when other forms of treatment fail to treat the symptoms.

However, there are challenges related to the use of inhalers that we cannot ignore. Generally, many people have a misconception that inhalers are only meant for the elderly, which means many people refuse to use them. Others fear that inhalers are habit forming with various kinds of side effects. In my experience, inhalers are helpful and the drugs they contain have minimal side effects as they are in micrograms and very target specific i.e. they are delivered only where they are supposed to work.

Let me explain this with an example. Generally, a bitter-tasting drug is supposed to dilate the airways or supress a cough. However, if we ingest them orally they will first go to the stomach. Such medications are often laced with sugar and flavours to appeal to children and people sensitive to various tastes. The medication enters the stomach, where it may cause some irritation and in some cases even cause a child to vomit. It will then be absorbed into the blood and reach every part of the body. As it passes through the brain, it can make a child sleepy or drowsy. It can cause other such side effects on its way to the lung where it is supposed to act. In contrast, when you take the same drug through an inhaler, it goes directly to the airways and dilates them.

In the COVID-19 era, cough has received a lot of attention! Recently, researchers have started experimenting with the use of artificial intelligence (AI) to analyse different kinds of data to assist with diagnosis of various diseases. For instance, experiments are being conducted where cough sounds are being analysed by AI algorithms to detect and diagnose different types of known diseases such as pneumonia, pulmonary oedema, asthma, tuberculosis (TB), COVID-19, pertussis, and other respiratory diseases. I have my reservations with this approach to screening patients and diagnosis. There is a wise saying about coughs. It advises, “Cough of more than two weeks can be tuberculosis.” And the most reliable way of diagnosing tuberculosis is through a simple sputum examination. Tuberculosis of lung alone can produce a variety of coughs depending on the location of the infection. Thus, the use of cough sounds and recording as a screening tool may not be sensitive to such differences and so remain unreliable.

In addition, one can also have what is called a psychogenic cough, which is also called habit cough. We have all experienced situations where you know you should not cough and you try to supress your cough. Then you finally cannot supress it anymore and end up coughing much to your embarrassment. Nowadays, coughing of any kind attracts a lot of attention in public places each time there is a spike in COVID-19 cases.

Finally, there is the COVID-19 and the non-COVID-19 cough! Over the last two years people have developed their own methods of differentiating between the two and its often ‘more effective’ than many diagnostics tests and AI algorithms. Simply put, when someone else is coughing, it is a COVID-19 cough unless proven otherwise! At the same time, the cough one is having is always a non-COVID-19 one, which is generally ‘caused’ by a banana, beer or cold water!

By Dr Spalchen Gonbo

Dr. Spalchen Gonbo is a Paediatrician based in Leh.

Air evacuation of patients

It is 2016. We are lucky. A tourist in the executive class vacated his seat after declaring, “I can sit anywhere.” He moved to one of our seats in the economy class. An executive class seat has more space to accommodate our medical equipment. Unfortunately, the family of the patient was able to arrange only two seats in the executive class. The father had the baby on his lap fixed to a board. I had the breathing equipment in my hand with the oxygen cylinder strapped on my back.

We thanked the gentleman and settled down on the three seats that were now available to us. The father moved the armrest back as I unhooked the oxygen cylinder and handed it to the ground staff as we are not allowed to carry an oxygen cylinder on commercial flights. The airhostess handed me the onboard oxygen cylinder that we had booked in advance. However, there was a problem. The piping on our machine did not fit the new oxygen cylinder. The other oxygen cylinder had already been removed from the aircraft. I asked the airhostess for a blade. She looked at me suspiciously and said, “Blade on an aircraft?!” She then approached the pilot who emerged from the cockpit to give us the required permission. The airhostess took out a small box that contained articles such as bandages, a scissor, and a blade. I noticed that the pilot kept an eye on me as I took the blade and waited till I handed the blade back to the airhostess after cutting the pipe and fixing it to the new oxygen cylinder. We made it to New Delhi with no incident.

Fast forward to 2021. The neatly dressed officer in an air force dungaree declared, “We don’t have an oxygen cylinder on board! We do not have a stretcher either. You can carry whatever you want!” The nurse and ambulance driver who had dropped us to Leh air force base wanted to take the stretcher and cylinder back as it was in their ‘charge’ but I was not in a position to part with either. Finally they pleaded, “Doctor-saab, please bring the stretcher and cylinder back to Leh.” It was a smooth flight in the C-17 aircraft from Leh to Chandigarh. Later, the father used a private transporter to send the cylinder and stretcher back to Leh.

These are just two stories of air evacuation of sick patients from Ladakh for treatment that is not available here. Such cases require a lot of effort by the patient’s family along with intervention by the administration and help from the airline/air force. It is difficult to arrange such an evacuation at a short notice. There have been hundreds of such evacuations from Ladakh in addition to commercial air ambulances that cost in excess of INR 7 lakhs (INR 700,000).

We must constantly work to improve our healthcare system. COVID-19 has shown that a fine line separates life and death. This reality was driven home for me when I watched four of our doctors admitted to the COVID-19 ward during the second wave in 2021. Similarly, a fine line separates a patient and a healer too. A senior physician once told me, “It is for us, nono!” after I congratulated him when we acquired an ECHO machine and added that it would benefit patients. This is when he explained that it was not just for patients and that healers can become patients anytime. I saw a lot of wisdom in his words.

There are two district hospitals in Ladakh: Sonam Norboo Memorial Hospital (SNM), Leh and District Hospital (DH), Kargil. Both of them have recently undergone a major change in their status. They were two of 24 district hospitals in the erstwhile J&K state and are now the main hospitals of UT Ladakh. Since we do not have many facilities in these hospitals, referral is an important approach to treat many cases. This is also important when we provide care to high profile delegates who visit Ladakh.

There are plans to have a doctor and medical facilities in every corner of Ladakh irrespective of the population size. This is in contrast with Sri Lanka, which has a centralised system. Though Sri Lanka is a developing country, it has a good healthcare system. They have very few tertiary care centres and referral units function as stabilisation units. These units do not have doctors and are staffed by trained paramedics. These units are connected by an efficient transportation system, which includes helicopters and air ambulances to transport patients to well-equipped tertiary care centres.

Another approach is to use commercial aircrafts for patient evacuation. I am told that every flight from places such as Port Blair has nine seats reserved for patients at a nominal cost. Such a system would benefit people who cannot afford an air ambulance. Nine seats provide enough space to carry a patient on a stretcher along with a doctor, a nurse, and a relative and is much cheaper than an air ambulance.

We need to streamline the referral and evacuation system, as we cannot have every facility at our hospitals. It is simply not cost effective as many of them are not required on a regular basis. There have been instances in India in the recent past where patients have been referred to foreign hospitals by the government to receive treatment that is not available in the country. The Nirbhaya case was one such example. Thus, services provided by any hospital can never be ‘complete’.

At present the government has a state-sponsored referral system to the nearest tertiary care centres in Kashmir. However, we need to expand this to create an efficient air evacuation system, especially when we have no surface connectivity in the winter. The government currently pays for the air ticket of a patient and an attendant under the Janani Shishu Suraksha Yojana (JSSY). However, we need to streamline the process. At present, the army and the air force provide support to transport critical patients. However, their aircrafts are often not equipped to transport critical patients. At the same time, it requires a lot of paperwork to use commercial airlines including provision of basic facilities such as an onboard oxygen cylinder. It thus makes sense to have a more streamlined referral system for air evacuations from Ladakh with possible subsidies and support from the government.

By Dr Spalchen Gonbo

Dr Spalchen Gonbo is a Paediatrician based in Leh.

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