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.