Slideshows
Slideshow: China/Tibet October/November 2006. Beijing to Lhasa on the new high altitude train to enjoy the sights and sounds of Tibet. Then overland by jeep to Nepal.

Flash6: Annapurna Circuit, Nepal, November, 2006 Highlights from a 16 day trek covering the Annapurna Ciruit, 130 miles and included crossing a 17,700 foot pass.

During Nepal’s two primary trekking seasons, volunteer doctors from around the globe staff the Himalayan Rescue Association (HRA) clinics. One is in the prosperous village of Manang, on the Annapurna Circuit route. The other is in Pheriche, at 14,400 feet along the popular Kala Patthar trek that offers spectacular views of Mt. Everest. The impetus to create the clinic back in 1973 was based on observations by a former American Peace Corps volunteer, John Skow. Hiking up in the Khumbu, Skow noticed that many trekkers were getting sick and dying from Acute Mountain Sickness (AMS). These foreign trekkers, and many Nepalese, had no clue about acclimatization at high altitude or the symptoms of AMS. Skow felt that deaths could be minimized through education. He met with Nepalese officials and others. After several meetings, the HRA was formed with several trekking companies donating some cash. The first clinic opened in 1973 in Periche. The Manang facility was opened in November 1981. For the last twenty-five years, the HRA has helped make Himalayan trekking safer for foreigners while also providing diagnosis and treatment to the local population.

RESCUE A BIT OF MISNOMER
The HRA doesn’t do mountain rescues in the traditional sense. HRA physicians rarely venture from Manang or Pheriche to pluck stricken climbers or injured trekkers from the side of a cliff or a trail. The HRA’s main function is to create awareness and educate some of the estimated 70,000 + trekkers that visit Nepal annually about altitude sickness, an umbrella term that covers Acute Mountain Sickness (AMS), high altitude cerebral edema, known as HACE or water accumulation in the brain, and high altitude pulmonary edema (HAPE), a condition where water accumulates in the lungs.

HRA clinics have less emergency equipment than an ambulance carries in most Western countries. Using limited resources and diagnostic equipment, HRA doctors are able to treat some people at the clinic with minor injuries like twisted ankles, sore knees, or minor abrasions. They may be able to help facilitate transfer for injured trekkers – via donkey, hand-carried stretcher or helicopter – to better equipped facilities. The clinic doctors spend most of their time educating foreign trekkers about altitude sickness, treating minor ailments, and administering to the area’s residents for no or greatly reduced fees.

One study asserts that HRA seems to be helping: A paper published in the Journal of Travel Medicine assessing the proportion of AMS, high altitude pulmonary edema (HAPE) and high altitude cerebral edema (HACE) from 1983 to 1995 in HRA aid posts’ patients concluded that “although there is a linear increase of trekkers entering the Himalayas in Nepal, the findings revealed that HAPE and HACE have not increased over time. One possible explanation may be that awareness driven by organizations like the Himalayan Rescue Association may be effective in preventing the severe forms of AMS.”

Another more recent study in 2005 published in Wilderness and Environmental Medicine journal contradicts this assertion and states that “a large population of at-risk high-altitude travelers may be relatively naive to the dangers of altitude sickness. Overall, respondents were interested in learning more about altitude sickness. Physicians and the Internet are the most attractive sources of information for this population.” This is not a promising trend given the country’s recent rise in foreign travelers. It looks like the HRA’s efforts are more needed than ever.

DAILY LECTURES HELP EDUCATE TREKKERS ABOUT AMS
About 30,000 trekkers make their way through Manang each year on their journey around the spectacular Annapurna massif. The HRA wants people to know that going too high, too fast is the single most important cause of AMS. Doctors give daily lectures about AMS to interested trekkers at a small hall located next to the clinic.

At almost 11,500 feet (3,500m) on the Annapurna circuit, the most popular trek in Nepal, the Manang aid post sees more local people than Pheriche. Manang is warmer than Pheriche and takes only about a week to reach from the Besi Sahar trail head. Manang is also the layover place where most trekkers spend two days acclimatizing before attempting to cover the next 6,500 feet (2,000 meters) to the pass at Thorung La.

The Pheriche clinic is located close to 14,000 feet (4,200 meters) and serves the large number of trekkers looking for close-up views of Mt. Everest. The volunteer doctors pay their own way to and from Nepal and staff the posts during the main trekking seasons, pre-monsoon (February to early May) and post-monsoon (early October to early December).

We attended one of the HRA’s altitude talks at Manang. Doctor Gunter Kittel, an Austrian now living in the South Pacific most of the year, was one of the two volunteer doctors staffing the Manang post in the post-monsoon 2006 trekking season. In a relaxed conversational tone, peppered with dry humor Austrian-style, he covered serious matters like spotting AMS symptoms. He discussed HACE and HAPE. Stressing the need to acclimatize, and explaining the adjustments your body needs to make as it ascends, he told us to ascend slowly, drink fluids and watch for symptoms like nausea, tiredness, sleeplessness or dizziness as well as coughing blood. Most importantly, Kittel stressed that AMS is serious and that fast action is required to help someone suffering from AMS – they need to descend immediately. It is important, he noted, that a person suffering from these symptoms should descend with a partner to assist them in the event their symptoms become debilitating.

We also learned that after reaching 9,842 feet (3,000 meters), the altitude that you sleep at should only be 1,000 to 1,300 feet (300 meters to 400 meters) higher than the previous day’s sleeping altitude, and how the various medications should be used.

Consult with a physician to see if you need to use medication such as Acetazolamide (branded as Diamox) as a prophylaxis. This may be helpful for forced rapid ascents (such as flying into Lhasa, Tibet, or La Paz, Bolivia), or for trekkers or climbers where a big altitude gain is unavoidable due to terrain considerations. People who have repeatedly had AMS in the past may also consider taking Acetazolamide. Note that the medication does not protect against worsening illness if you keep ascending when you already have symptoms.

Dexamethasone can be taken if a person is exhibiting AMS symptoms but should never be used during ascent. It will suppress the symptoms, but does not improve acclimatization. In the event of HACE there are three treatments: descend, descend, and descend. Immediate descent should be made to the last elevation where the patient awoke symptom-free.

CALLING A CHOPPER FOR HELP IS AN EXPENSIVE OPTION
Getting a ride on a slick will set you back around USD 3,000. Trekkers will need to contact someone in Manang, Jomson or Kathmandu who will be able to guarantee funds for the flight. In doesn’t hurt to contact your consulate to see if they can help. Bottom line, be prepared to walk out, or hire a donkey to carry you out if your injuries or condition is not life threatening.

SIDEBAR: TOURISM INCREASING IN NEPAL AFTER SEVERAL YEARS OF DECLINE
The recent cease fire in late November 2006 between the Maoist rebels and the Nepal government is sure to increase tourism to the area, AMS or not. The number of trekkers to the Annapurna region fell from 76,000 in 2000 to 38,000 in 2002 but has slowly climbed back up since then. Over 15,000 US citizens visited Nepal in the first 11 months of 2006. Nepal’s Ministry of Culture, Tourism and Civil Aviation noted that 29,407 tourists visited Nepal in the month of November 2006 with Indians making up 23%, Japanese 11%, British 8%, American 6.8% and German 5.9%.

But the cease fire hasn’t dampened the Maoist’s spirit on innovative taxation: On our trek on the Annapurna Circuit in November 2006, my wife and I paid about 1,500 Nepali rupees (about 21 USD) to the Maoists at a checkpoint five days into trip. We got a receipt that we presented to the last Maoist outpost on the last day of the trek, excluding us from further “taxes” to the “People’s Government of Nepal”. Terms of the new peace accord stipulated that the Maoists are prohibited from collecting this “fee” but many observers estimate it will be in place for at least the 2007 trekking season and quite possibly for several years to come. Travelers may have more than blisters, dysentery, and AMS to complain about during their trek.

SIDEBAR: HRA NEEDS MONEY AND DIAGONOSTIC EQUIPMENT
Volunteer doctors donate their time and live in the clinics. They have a dearth of diagnostic equipment. If you would like to donate money or equipment, contact the HRA at hra@mail.com.np

Mailing address:

HRA
Dhobichaur, Lazimpat (North Gate of the Royal Palace)
P.O. Box No. 4944
Kathmandu, Nepal
Phone: 977 1 4440292 / 4440293

You can transfer funds to them at:

Nepal Investment Bank Ltd.
Durbar Marg, Kathmandu, Nepal
Savings A/C No. 11983 40
Account Name: Himalayan Rescue Association Nepal