Emily Brown / Bristol Foundation Trainee
Emily jumped at the chance to spend her elective promoting porter welfare with the International Porter Protection Group in Nepal. She has now (reluctantly) settled back into life in the UK and wants to share her experiences and spread the IPPG word.
Where did I go?
My ten-week medical elective was spent with the International Porter Protection Group (IPPG) at their Rescue Post and Porter Shelter at 4450m in the village of Machermo. This village lies in the picturesque Gokyo Valley in the Khumbu (Everest) region of the Nepalese Himalaya. It is reached by a light aircraft flight from Kathmandu to the mountain airport at Lukla (not for the faint-hearted!) and from there it’s roughly a week’s trek. A couple of days after leaving Lukla, the trail branches off from the main Everest base camp route and the valley becomes less visited by tourists, quieter and arguable even more beautiful.
Although the Gokyo valley is a less busy trekking route than the Everest valley, it is becoming increasingly popular. It is a particularly dangerous valley in terms of altitude illness because it is difficult to descend quickly – the crucial step in saving the lives of those unwell with altitude illness. This makes IPPG’s presence there all the more important.
The IPPG is run entirely by volunteers and works for the safety of mountain porters around the world but with particular focus in Nepal.
“In 1997, a young Nepali porter employed by a trekking company became severely ill with altitude illness. He was paid off and sent down alone. It took just another 30 hours for him to die. He was 20 years old and left behind a wife and two small children… IPPG was formed to prevent these recurring tragedies.”
Mountain porters face many occupational health and environmental hazards. IPPG recognises this and the poor treatment of this vulnerable group – they work to improve the conditions of mountain porters worldwide. IPPG’s mission is for every porter to have: “access to adequate clothing, boots, shelter and food (appropriate to the altitude and weather); medical care when ill or injured; and insurance”.
IPPG also works with a number of other organisations to promote the welfare of porters, including Community Action Nepal, Himalayan Rescue Association and Kathmandu Environment and Education Project.
The Porter Shelter and Rescue Post, Machermo
The Porter Shelter and Rescue Post at Machermo is a joint project between IPPG, Community Action Nepal, The Sagamartha National Park and local villagers who make up the Local Management Committee. The Rescue Post is staffed by IPPG volunteers during the trekking seasons (March-May and September-November) and the running of the post is overseen by Chhewang (manager) and Kanchha (cook). The post offers shelter (dormitory style accommodation and a kitchen) and free medical care to porters. Trekkers are also treated at the post for a fee and it is these fees, together with donations, that allow the charity to function. The volunteers at the post give an educational talk each day about porter welfare and altitude illness to trekkers currently staying in the village with the aim of increasing awareness and understanding of these issues. As of the 2014 season, there is also a second Porter Shelter and Rescue Post at the village of Gokyo (a day’s walk up the valley).
So what did I do?
I arrived at Machermo after a beautiful (and breathless!) seven day trek in from the Tenzing-Hillary airport, which perches on the mountainside at Lukla. My roles at the Rescue Post included carrying out consultations with sick porters and trekkers and helping to give the daily talk to trekkers about altitude illness and porter welfare. I was also involved in collecting data regarding altitude illness and helping with the seasonal maintenance of the Rescue Post.
Daily life was very enjoyable and was spent tending to patients whenever they arrived, along with completing chores around the post, heating water in the solar concentrator for a bucket shower, going out for walks and playing a lot of cards and backgammon! We were extremely well fuelled by all the fantastic and varied food that Kancha produced for us – momos were a firm favourite! It was pretty chilly at times, especially earlier on in the season and we always eagerly awaited 5pm when the yak dug stove was lit! In terms of communication with home, this was understandably limited but it was possible now and again. There was internet about one and a half hours walk away and the Rescue Post has a satellite phone connection, which people can ring in on. And then, there’s always the option of sending a post card – although, 6 months down the line, the ones I sent still haven’t arrived home. I’m remaining optimistic that they’ll turn up eventually though!
In terms of medical treatment, we saw 129 patients during the season – half of these were trekkers and half were Nepali locals and porters (Chhewang or Kanchha translated when needed). The pre-monsoon season is typically quieter than the post-monsoon season, with the latter usually seeing 250-300 patients. Patients could turn up at any time, day or night, and we were occasionally called out to seeing unwell trekkers in their lodges or to meet people on the trail.
Half of our patients had altitude-related illness – one or more of acute mountain sickness, high altitude cerebral oedema (HACE) and high altitude pulmonary oedema (HAPE). The other half had a range of problems including gastritis, gastroenteritis, minor trauma, respiratory infections and various ophthalmology and dental problems.
During the season, seven patients (all of whom were trekkers) were evacuated by helicopter. These evacuations were for high altitude cerebral oedema and/or high altitude pulmonary oedema. It is worth bearing in mind that helicopter evacuation is very weather dependent – it can only happen during the day in clear visibly. In reality this means that helicopter evacuations rarely happened after lunch when the cloud tends to come in. This can present some problems as most people become unwell with altitude illness later in the afternoon once they start to feel the effects of the new altitude that they have reached that day. This meant that most of our seriously unwell patients spent the night at the Rescue Post receiving treatment and were evacuated out the next morning.
A typical case
A typical case of altitude illness was a 69 year old trekker who presented at around 6pm one evening. She had been feeling unwell for the past 5 days. Initially, she had a headache, she hadn’t been sleeping well and she had a cough. This progressed to feeling short of breath, particularly on lying down. Her trekking partner reported that she had been unsteady on her feet for the last few days and had appeared confused at times forgetting where she had put things, which was unusual for her. On examination, her oxygen sats were 78% (which is low even for 4450m), heart rate 90 bpm, respiratory rate 35, BP 128/62 and temperature 37.6ºC. On auscultation of her chest, she had crackles in the left mid zone. She demonstrated moderate ataxia on assessment of heel-toe walking. Our impression was that she had both HAPE and HACE – her low oxygen saturations, high respiratory rate and chest crackles suggested HAPE and her confusion and ataxia suggested HACE. We treated her accordingly with acetazolamide, dexamethasone and nifedipine. It was too late in the day for a helicopter evacuation and the patient opted to return to her lodge for the night with her friend. We advised helicopter evacuation the following morning, particularly as the trail down from Machermo is slow to lose height and even in full health it is still 2-3 day walk back to the airport at Lukla. In addition, HAPE is known to worsen on exercise. However, the patient was insistent that she wanted to walk out. There was little we could do other than ensure she had enough medication to take with her.
This case illustrates some of the ethical and moral problems that we faced during the season. Often trekkers did not want to accept that they were potentially seriously unwell and they did not follow our advice to be evacuated. In addition, we faced some problems with language barriers – we tended to some patients with severe HACE and HAPE with no way of communicating with them in a language they understood.
As a medical elective, the season at Machermo gave me fantastic experience of working in a remote high altitude wilderness environment and I gained a lot of knowledge about the recognition and treatment altitude illness. We had limited treatment options and very black and white decisions needed to be made – ‘does this patient need a helicopter or not?’. This is in many ways far from relevant to medical finals and everyday UK practice but nevertheless, very applicable to places that I would like to work in the future.
Occupational health of mountain porters
Due to the nature of the work at the post, a key focus of mine during the season was the occupational welfare of porters. To fully consider this and the surrounding issues, it is important to understand that there are a number of different types of mountain porter:
- Trekking porters – carry trekkers’ kit, food, tents. They are either employed by trekking companies or they are employed directly by independent trekkers who are not using a trekking company.
- Supply porters – transport supplies for the region. These supplies include food for locals and tourists and building materials for new lodges. Although these porters are paid by locals to transport the goods, the majority of what is being transported can be directly linked back to the tourist industry.
- High altitude porters – working at high altitude on mountains such as Everest.
All mountain porters face many hazards during their daily work. Indeed, IPPG state that porters suffer from more illness and accidents than Western trekkers. They are exposed to a number of environmental hazards, including high altitude and the cold, which puts them at risk of altitude illness, hypothermia and frostbite. The risk of these problems arising is accentuated by their lack of adequate clothing and footwear, lack of shelter, lack of sufficient food and lack of appropriate medical care. In terms of accommodation, sometimes porter may be able to stay at the lodge with their western trekking group but only if the lodges are not full with trekkers and they will have to pay a large proportion of their wage for this shelter. The reality is that lodges are often full and porters have no choice but to sleep out in caves; which are regularly passed along the main trekking trails. Life in the Everest region is expensive compared to other areas of Nepal, so a large proportion, if not the entirety, of a porter’s wage is spent on living costs and trying to get an adequate calorie intake – this means they are very reliant on tips from trekkers to make any profit at all. Thankfully, in some villages there are now dedicated porter shelters, such as the IPPG porter shelters at Machermo and Gokyo.
Regarding porter injury and illness, the risk of this is increased by the unbelievably large and heavy loads that many porters carry on a daily basis. It is unfortunately not uncommon for a porter to carry far beyond the 30kg limit that IPPG recommends; and, if this were not arduous enough, they will be walking perhaps 30km in a day, at high altitude, wearing a pair of flip flops for footwear – a task that most of us couldn’t even consider doing at sea level with all the latest outdoor kit. Indeed, throughout the season we saw many examples of porters with inadequate clothing and footwear – watching porters carrying loads many times their size wearing a pair of flip flops was an almost daily occurrence. Often the porters carrying the largest loads are supply porters as they are paid by weight and so there is a huge incentive to carry heavier loads. However, load size issues are present with both trekking and supply porters.
In terms of altitude illness, it is often not appreciated that most trekking and supply porters are not Sherpa (the indigenous people of the highlands who have some genetic protection against altitude illness). Whilst most of the high altitude porters working on Everest itself are indeed Sherpa, in fact most trekking and supply porters come from the lowlands and ascend to work during the trekking seasons. This means that they are just as susceptible to altitude illness as you or I, particularly at the start of the trekking season when they are not yet acclimatised.
An additional problem for porters is that a large number of them do not have insurance, particularly supply porters or those trekking porters who work independently rather than for a trekking company. This leads to problems if they fall ill – a western trekker who presents to the Rescue Post with severe altitude illness would likely be evacuated by helicopter; however, this quick and effective treatment is not an option for a porter who is not afforded the luxury of insurance. Instead, often the only option is to make the multi-day journey to lower altitudes on a yak or on the back of a fellow porter. In addition to the above, there is no social security in Nepal. This means that if a porter is unable to work or, in the worse case dies, their family and dependents are left in a very difficult position. In relation to this, during my season at the Rescue Post, on 18th April a fatal avalanche happened on Mount Everest. This was the most deadly disaster in Mount Everest’s history with 16 porters losing their lives. Many articles have been written about this disaster with many points of view expressed and it is not possible to discuss it in detail here. However, a key issue raised is that of insurance – the desperate need for wide spread, comprehensive insurance amongst porters. It is hoped by many that in the wake of the 2014 disaster this may become a reality, but it waits to be seen whether this will be the case.
Medical treatment of porters at the Rescue Post
During the season we treated roughly 20 porters at the Rescue Post. A variety of illnesses were seen including altitude illness, respiratory infections, gastroenteritis, wound infections, back/neck pain and snow blindness. Conditions that were particularly poignant, especially in terms of occupational involvement, were: infected scalp wounds from abrasion by the head strap that porters use to carry their loads; severe (and sometimes infected) blisters resulting from inadequate footwear, excessive loads and poor access to washing facilities; and finally snow blindness because of a lack of sunglasses. In addition, we saw many cases of altitude illness in porters who had ascended too fast and who had been placed at additional risk due to the exertion of carrying excessively heavy loads. Furthermore, some porters were significantly unwell (for example, with altitude illness and respiratory infections) but they were unable to rest and take time off work to recover because if they didn’t work they wouldn’t get paid and their trekking companies had strict itineraries to stick to and would carry on without them. This illustrates a key problem within the industry and the lack of regulation surrounding porter welfare.
It is clear that Nepalese porters face many occupational health problems. There is currently a lack of centralised national systems in place to protect porters and promote their welfare. The main independent forces acting to improve porter welfare are charities working in the region, such as IPPG. In terms of occupational health medicine in Nepal as a whole, there is evidence of the emergence of this field within Nepal; however the health of porters is rarely discussed despite their vital role in Nepal’s tourism industry. Looking to the future it is important to continue to increase trekkers’ awareness of porter welfare, which will hopefully result in trekking companies giving their porters better working conditions such as adequate clothing, footwear, accommodation, medical care, insurance and pay. Porters are the backbone of the trekking industry, which is a vital part of the Nepalese economy – we can but hope that the government will truly acknowledge this and that their involvement and regulation may also act to improve porters’ working conditions in the future.
I thoroughly enjoyed being part of the fantastic work that IPPG do and I feel extremely lucky to have been able to spend my elective in the Himalayas with the wonderful Nepali people. I have learnt a great deal, in particular about the occupational health problems of mountain porters and about altitude illness.
For more information on porter welfare and the work of IPPG please visit their website.
Key elective information
Where / with the International Porter Protection Group (IPPG) at their Rescue Post and Porter Shelter at 4450m in the village of Machermo, Nepal.
When / March – May 2014 (seasons run March – May and September – November each year).
Accommodation / at the rescue post with the other volunteers – you don’t have to pay for accommodation or food at the Rescue Post.
Supervision / the doctors volunteering that season. IPPG will ensure they are happy to supervise/teach a medical student.
Travel / Fly to Kathmandu. Internal flight from Kathmandu to the small mountain airport at Lukla. 6-7 day trek from Lukla to Machermo.
Costs: approximately £2000-3000 for 10 weeks depending on flights, vaccinations needed, how much independent trekking you do and how much kit you need to buy. You don’t have to pay IPPG to volunteer for the season but you need to cover all costs of getting to the Rescue Post (international and internal flight, porter and living costs on the trek to/from the Rescue Post).
Contact / http://www.ippg.net/ There is a section about medical electives on the website, including the application form. Deadlines for application are detailed on the website. There are also lots of reports from previous seasons on the website which have further helpful and interesting information.