Thomas Bennett / 5th Year Medical Student / University of Plymouth
Tom wrote the winning entry for our 2017 Adventure Medic Elective Article competition. He penned this piece about his elective in the Himalayan mountains of northern India, where he travelled with the Himalayan Health Exhange. We hope you enjoy reading his lovely, reflective article as much as we did. If you’re considering this type of elective or trip yourself, enjoy his top tips at the end too. Thanks again to our competition sponsors who provided some superb kit as an incentive to write: Rab, Alpkit, Keela and Lifesystems.
The Himalayan Health Exchange
Last August, I was given the opportunity to join a month-long medical expedition in the Himalayan region of Kargiakh with the Himalayan Health Exchange (HHE). I joined them in their challenging mission to provide medical care to the underserved and often isolated peoples of the politically unstable Indian border state of Jammu and Kashmir. Each summer for over 20 years, by invitation of the local government, a team from HHE has visited the Zanskar region in order to deliver medical care to the local inhabitants, with primary and public healthcare objectives. Aside from direct medical care, the charity also uses proceeds from the trip to fund surgical procedures in the more southern city of Manali and also contributes to the training of Amchis: local providers of traditional holistic health care.
Our team included over 20 medical and physician-associate students from the UK, US and Canada as well as a core team of senior US doctors. We set out to visit villages far off the beaten track and our clinics were open to all, including local farmers, road workers, seasonal labourers from the valley, and even recreational trekkers. As access to many of the villages was only possible on foot, everything we needed for the trip was to be personally carried with the assistance of a small army of mules (47 of them to be exact).
To begin the expedition, we flew into New Delhi before connecting to the mountainous city of Leh to begin our acclimatisation period. Leh was largely comprised of traditional Buddhist architecture, with temples and palaces interspersed by winding alleyways, and strung together across the sky by colourful banners of prayer flags. This bustling tourist town provided a beautiful initial staging post for our team as we prepared for our weeks of trekking ahead. At our initial briefing we were reminded this would be the lowest point until the end of the trip, before which we would twice ascend to over 5,000m, breaching 5,400m at Phriste La Pass. Even in Leh at 3,505m elevation, a relatively modest height above sea level, the oxygen pressure in the air is around two thirds that at sea level. In practical terms this proved to cause one to become heavily short of breath on ascending the gentlest flight of stairs.
Physiological acclimatisation was an essential undertaking to reduce our risk of developing altitude related illnesses. These can be extremely debilitating and even fatal if not recognised and treated early. On previous trips, students had been evacuated due to illness after failing to follow acclimatisation instructions and exerting themselves too much early on; acclimatisation was viewed respectfully by everyone on the trip.
The best treatment for acute mountain sickness and its sequalae is descent, and the lead medics made it clear that their threshold for descent and evacuation was low. To help reduce the likelihood that we would develop altitude sickness, we were given strict orders. Rigorous hydration, rest, prophylactic acetazolamide (Diamox), and no alcohol. Remaining teetotal was to be no small feat for a group of medical students abroad (most post-finals) but given how far each of us had travelled, none was keen for an early and likely long and uncomfortable mule ride to the nearest road for evacuation.
To combat this real danger, we all submitted ourselves to the gruelling regimen and activities associated with acclimatisation. These included reading, drinking chai, regular naps and just lazily lounging about, trying not to exert ourselves. Surprisingly, even with added jet-lag, napping was perhaps the biggest challenge. Sleep at altitude is notoriously disturbed, with irregular and intermittent Cheyne-Stokes breaths causing sudden waking in the night, often to the alarm of an anxious tent-mate who may have just witnessed a very prolonged pause in breathing. In addition, we were all taking regular acetazolamide – a diuretic. As such, a night of undisturbed sleep was unheard of in the early part of the trip, as our bodies and kidneys took time to adapt physiologically to this new state of affairs.
Setting out from Leh early in the morning, our fleet of 4x4s made light work of the initially well-constructed roads, ascending thousands of metres over the course of the day before we crossed the second highest road pass in the world, Taglang La (alt 5,328m), well before lunch. At this point members of the group were recording oxygen saturations of 69% and the first case of altitude-related sickness was spotted amongst our ranks. One of the senior medics who hadn’t spent much time in Leh due to a delayed flight hadn’t managed to acclimatise and was feeling very unwell. Fortunately, by the time he had become symptomatic our route ahead had begun to descend again. Camp was still hours away and so our driving speed increased significantly. He improved rapidly and completely following our sharp descent.
This gear shift seemed to coincide with a rapid deterioration in quality, or in some cases even presence, of the roads. This should have come as no surprise, we had overtaken the tarmac laying team earlier that morning and began to pass small teams of construction workers armed only with pick axes and shovels. Haste on these narrow and rudimentary roads felt like a recipe for disaster. Many of them were hand-cut from crumbling and landslide-prone Himalayan rock and barely allowed passage of a single 4×4, let alone the large oncoming trucks which often halted our progress and forced us to gingerly pass along the cliffs edges all too often. The multitude of poetically poignant anti-speeding/drink drive signs which punctuated the roadside did little to calm our nerves.
“Safety on the road means safe tea at home”
“Better to be ‘Mr late’ than ‘late Mr’”
“Don’t be risky, lay off the Whisky”
We eventually arrived safely on a windswept plateau just outside of Sarchu village, halting our thrilling and spectacular descent and providing a welcome respite from the motion sickness-inducing ride down. After setting up near to a local Indian army camp, we said goodbye to our vehicles and it became apparent that from there on, we were to be entirely self-sufficient and that all travel would be on foot or hoof. With that, we were also reminded we would be without phone signal, Wi-Fi, treated water, or a conventional toilet for the next three weeks, the latter of which would certainly take some getting used to. After pitching our tents for the first time, the early sunset and clear evening provided the first of a series of incredibly beautiful skies featuring the brightest of moons and clearest Milky Way that most of us had ever seen. The budding photographers amongst the group revelled in this, as the rest of the team turned in early before the first day of clinic.
Our first clinic days started soon after sunrise, with a huge pot of hot milky chai and an enormous breakfast spread to kick-start each session. Pancakes, French toast and fried eggs were a common treat.
Each clinic followed a similar format, with individuals rotated across all stations. A group provided initial triage, recording basic physiological observations and a main presenting complaint, before showing the patient to the relevant medical tent where they were seen by an assorted medical team. This team usually consisted of three students: a historian; a scribe; and an observer, with a supervising ‘resident’ and translator when possible. Patient evaluations were a team effort, which significantly helped as the process of taking a history via a translator (sometimes using three different languages at a time) was a challenge which was new to most of us. Each student would present the case to the supervising physicians and a shared plan was made, with the patients input. They were subsequently shown to the pharmacy station where appropriate medications and instructions were dispensed by our charming and cheeky resident monk – co-expedition leader and practical joker ‘Lama Ji’. He was a senior Buddhist monk, local teacher, and spoke a range of local dialects which proved invaluable throughout this often-convoluted process. In total we would see around 500 patients over 10 clinics throughout the trip, with nearly 90 seen on the busiest day.
After our first clinic in Sarchu, we continued through the valley and reached the Zanskar region, where we held clinics in Tangste, Khangsar, Testa, Kyng and Kargiakh villages. We were given a grand welcome at Phuktar Monastery, the site of one of our final clinics. Hundreds of years old, it was carved into the mountainside centuries ago and has since been home to around 70 monks and monklets (school-age monks in training).
Musculoskeletal, ophthalmological, gastrointestinal and dental problems were particularly common. The ‘HHE special’ was a common management option for many of the adult patients we saw. This consisted of sunglasses, eye drops, and ranitidine. Gastro-oesophageal reflux seemed to be almost universal in adults over 25, perhaps linked to the common habit of eating a single large meal, often very spice-heavy, at the end of the day just before bed. The presence of Pterygium, a fibrovascular growth of conjunctiva, was also particularly prevalent. Severe cases can lead to visual loss and its prevalence is greatest in dry climates with high UV exposure. Over 70 patients were seen with symptomatic and asymptomatic pterygium and those with conjunctivital symptoms were given a combination of sunglasses and eye drops. Asymptomatic patients and adults who worked outside were also given sunglasses as a prophylactic measure to help prevent direct UV damage.
After each clinic had packed up, we would debrief as a collective. This provided a forum to discuss specific challenges faced, scope for improvement, and particularly interesting cases. A memorable example includes the epidemic of ‘adolescent hypertension’ (aptly named Chai-pertension) in one village. It was thought this was due to the seven-a-day chai tea habit taken up by many of the children, some as young as four years old. We advised them to cut down but knew full well the hypocrisy of our advice. I was drinking a similar amount myself by this stage and didn’t consider holding back, it was delicious.
Survival in the Himalayas
Compared with the relative comfort of Leh, the effort and physicality needed to subsist in this region was evident. Twenty-year-olds looked forty, forty-year-olds looked seventy and I could count the number of overweight patients seen on one hand. The staggering scale and extreme nature of the physical environment clearly exerted a significant impact on the people living within it; severe osteoarthritis and other labour-related musculoskeletal problems were our most common presenting complaint.
Each path we trekked along lead us past mile upon mile of rock walls built to contain livestock, mainly yak and goats. These were interspersed with large religious shrines covered in thousands of engraved stones, some hundreds of years old. The time and effort invested into each of these structures was staggering.
Despite this, many of these people were not only surviving, but thriving, testament to their active lifestyle, their strong bond with the landscape and their ability to manipulate it to their benefit without desecrating or over-exploiting it. Each time we passed through settlements, we were able to see how entire local river tributaries were deliberately coaxed laterally across rock faces to supply local homes and crops. I was surprised to see valleys full of lush fields of barley and wheat, contrasting starkly with the arid brown rock in the higher climes. Yak patties (mud, yak manure, and straw) covered facades of buildings as they dried in the sun, ready to be used as an indoor stove fuel source. This practice is associated with myriad respiratory conditions but is by far the most widely accessible and cheap fuel option and as such, chronic cough was an all too common complaint.
The Inadequacy of overseas aid
However, in contrast to these established communities, the immigrant labourers and road workers we saw at the start and end of the trip were a heart-breaking sight at the road side, and later in clinic. These people were working long physical shifts, sleeping under tarpaulins and barely earning enough to feed themselves, let alone the families many had brought with them. Speaking with them in clinic, we realised many would never earn enough to escape their occupation, or this region. They were emaciated, malnourished and often desperate. Those that needed referrals to city clinics (about three days’ travel in good weather) were essentially hopeless cases. Despite being offered free care, we knew that few would be able to take time off work or have the money to pay for travel.
This provided me with my first appreciation that despite best efforts, sometimes overseas aid and charity work can be wholly inadequate in serving to address the specific health inequalities that are endemic in some areas. The health problems we glimpsed were symptomatic of a significant lack of infrastructure or a system to provide for the whole population. I took some solace knowing that proceeds from our contribution were going towards training new medical professionals elsewhere in the region.
Evenings and free time
Each clinic day we held 15-minute oral presentations which had been allocated and prepared prior to the trip. The topics included high altitude physiology, altitude related conditions, hypothermia, infectious diarrhoea, tuberculosis, HIV, local religious practises and alternative medicine, women’s health and women’s health rights in India, and a practical hyperbaric chamber demonstration. These sessions helped to supplement our clinical experiences and prepared us well for subsequent clinics.
On trekking days, we were free to use our evenings to recover. As well as excessive tea drinking, these time periods were revolved around competitive card games, diary writing, reading, listening to music and (attempting) yoga. We even adopted a curious local dog on the trip. ‘Trail Dog’, followed us for several days, snacking on leftover roti and providing much appreciated cuddles for the trekkers. Meals were freshly-prepared vegetarian dishes with Indochinese influence. They were of very high quality, and there was always plenty to go around, particularly important given that we were spending up to nine hours a day walking, ascending over 1000m on some.
One evening, we made use of an old cricket set the Sherpas who lead our trip had brought. It was an annual tradition that the Sherpas would play the students. As British students, there was certainly an expectation that we would field a reasonable team. Despite our questionable understanding of the specific rules we managed a decent result against a ruthless and clinical Sherpa side who showed no mercy. Fortunately, our US and Canadian counterparts made up for a lack of cricketing know-how with baseball style batting and fielding prowess, sending many a ball skyward for six with some spectacularly athletic diving one handed catches. This intro to cricket was a hilarious and invaluable bonding experience for the entire expedition team.
Why you should consider this (type of) elective
The Expedition to Kargiakh with HHE was filled with wonderful memories and was staffed by incredible people. We all treasured the bonds and friendships we developed whilst spending a whole month in the wilderness, and leaving everyone at the end was tough.
If you enjoy the outdoors, like a real physical challenge, have minimal personal hygiene needs, and an interest in expedition medicine or global health, this may well be the medical elective for you. I found an increased appreciation for the conditions, access to technology, global sanitation and medical care that we have in the UK, as well as deep respect for the people who call this harsh and beautiful area of the world their home.
Where / Kargiakh Valley, Ladakh, Jammu and Kashmir, India
When / August
How / All trip details and contacts and application forms can be found on the HHE website.
Price / The cost was £2,500 for the trip itself, which included all travel, meals and accommodation. Much of this money went towards the charity’s side project in the region (free surgery for those in need and training for local practitioners). An Indian Visa costs around £110. Return flights to New Delhi from the UK can be estimated at £500-£700 depending on when they are booked. Internal flights were about £40-60 each way to Leh.
- Look for bursaries to help fund this trip. The Royal Society of Asian Affairs helped me fund travel and some equipment costs by granting me a bursary.
- Pre-trip training will help you a lot. I used the cross trainer, with some hill running and dynamic stabilisation exercises (lunges/squats etc) for a month before the trip. This seemed put to me in good stead fitness-wise. Prepare to huff and puff anyway though.
- Sturdy boots, warm and weather-appropriate clothing are essentials. Conditions were generally dry with intense sun and freezing nights, with occasional snow and rain. As your mother would say, pack layers.
- I also found a significant part of my day was spent purifying my drinking water. Devices which can be connected to a camel-back style reservoir are ideal to speed this up.
- Out there, a good roll matt is worth its weight in gold. You don’t want to be filling up a slow puncture throughout the night like I was, and the terrain is rough. The thicker the better.
- Take a hangable lantern/torch for the toilet tent. Spiders love the tents and people miss the hole with surprising frequency.
- Sun cream became a commodity towards the end. Pack plenty if you don’t want to look like a leather handbag by the time you return home. Factor 30 at the very least.
- Duck-tape was probably the most important item I brought: do not forget it.
- Bring some sort of playing ball/ frisbee as this can provide hours of entertainment (we constructed one out of loo roll and duct tape which served us well).
- As always, a pack of cards is a travel essential.
- Try to bring your own sats probe (Amazon/eBay are cheap). It is helpful for triage duty and is surprisingly good fun to see how low you can go.
- The local welcome drink, Yak tea, is more of a savoury soup than a tea and has a not so subtle yak aftertaste – don’t be too generous with your helping.
- Loperamide, baby wipes and rehydration sachets are your friend.
Writing this months later, I would honestly say the cultural, spiritual and environmental characteristics of this place are the most incredible I have been privileged enough to experience and it is strong wish of mine to return in the future. N.B The medicine was cool too.