A reinvigorating environment, a “Khumbucure,” like an elixir, is what I need as an anti-dote to my Kathmandu ailments. An opportu-nity presents itself in the fall of 2001 to fly tothe Khumbu region (Mount Everest region inNepal), and I am here at Lukla’s spanking newairport with a glistening tarmac. I am the tripleader for a group of travelers to the HimalayanRescue Association (HRA) medical aid post atPheriche at 4300 m.

The next day we slowly climb up Namchehill to reach Namche Bazaar (3400 m). As wemake our ascent, we see hordes of merchantporters carrying 115 kg or more of Mount Ever-est whisky, San Miguel beer, and bags of rice.They receive Rs 8 per kg, and they make thisLukla to Namche run three times a week. Car-rying such a heavy load may predispose someof them to suffer from acute mountain sickness(AMS) (Roach et al., 2000). At Namche I exam-ine the herbal medicine shop and find that an-tiwrinkle cream is what sells very quickly.“Human characteristics don’t change,” Tenz-ing Tashi Sherpa, the Sirdar in our group, ex-plains to me. There are also Amchis (Tibetindoctors) offering their services in Namche now,something I had not encountered in my pastvisits here. On our way to the Namche mu-seum, we walk along the trail keeping the sa-cred mani stones to our right to gain sonam (re-ligious merit points). Inside the museum I learnabout the amazing documentation skills of theJesuit priests, who in 1717 were the first West-erners to note the existence of Mount Everest

(not known as Everest at the time). In Westernhistory the Jesuits were also the first to recordthe symptoms of mountain sickness (West,1998a).

The next day we are on our way to Thame(3800 m) to see the monastery on the side of acliff. We will also see the general area of thetreacherous Tashilaptse pass leading to Rowl-waling valley, where the poorer cousins of theKhumbu Sherpa reside. Relatively fewertrekkers go to Rowlwaling, and so it isnowhere as affluent as the Khumbu. We willalso gaze across in the direction of the NangpaLa pass to Tibet. This pass is now used exten-sively by Tibetan merchants who carry inex-pensive Chinese goods to sell at Namche. AtThamo (3600 m), a town before Thame, wemeet up with the famous Ang Rita Sherpa inhis house. He has climbed Mount Everest 10times without oxygen. Ang Rita certainlyproved Alexander M. Kellas, a British physi-ologist and climber, to be correct (West, 1998b).About three-quarters of a century ago, Kellaspredicted that Everest could be summittedwithout oxygen, even though many probablydoubted him at the time. Unfortunately, Kel-las died, possibly of gastroenteritis, while on areconnaissance expedition to Everest (West,1998b).

Gastroenteritis still plagues the traveler tohigh altitude, about 14% of trekkers have diar-rhea while trekking up to 4300 m in the Him-alayas (Basnyat et al., 1999). Just farther up the trail from Ang Rita’s house lives Appa

HIGH ALTITUDE MEDICINE & BIOLOGYVolume 6, Number 4, 2005© Mary Ann Liebert, Inc.

Letter from the Field

The Khumbu Cure

BUDDHA BASNYAT

Nepal International Clinic and the Himalaya Rescue Association

342

LETTER FROM THE FIELD 343

Sherpa, who holds the world record by climb-ing Everest 15 times, as of 2005.

On our way back from Thame we take a tourof the Austrian hydroelectric plant that has rev-olutionized life in many parts of the Khumbu.For example, from Namche Bazaar’s Panoramalodge, Sherab Jangbu allows me to use his well-heated computer room to send emails acrossthe world. I send a digital picture home. I amdumbfounded that I can do this. As a result ofthe availability of electricity for cooking, treesare now easier to conserve and the houses areno longer soot covered and smoke filled; hencethere will probably be less chronic obstructivepulmonary disease, another common problemin the mountains of Nepal (Pandey et al., 1988).

A trip to the Khunde hospital (3600 m) es-tablished by Edmund Hillary reveals a Cae-sarean section in progress by a visiting doctorfor a possible obstructed labor. I remember myfriend the Tibetan doctor at Patan hospital, Dr.Kundu Yangzom, telling me that vesicovaginalfistulas can be a complication of obstructed labor in patients she sees brought from themountains to the hospital, a very rare compli-cation in a western setting. Obviously, this pa-tient being operated on in Khunde was lucky,thanks to Sir Edmund.

After walking along a trail lined with rhodo-dendron trees, junipers, red barberry bushes,and pine trees, we arrive at Tengboche (3900m). A watchful lammergeier circles the skies. Iintroduce my group to a lama, Nima, who wasmy porter 10 years ago, when he was barely 30.He presented on the trek with a painfullyswollen right toe, which happened overnight.It was easy to diagnose gout, which is a scourgein Nepal and regularly affects young people,unlike the natural history of this disease in theWest. Anyway, portering and gout are cer-tainly not a happy combination. I am glad hehas a more sedentary job now.

The next day from Mong La (3900 m), wherelegend has it the lama met up with God, thebreathtaking Ama Dablam (6800 m) appearsmagnificent. Tenzing Tashi tells me that lastmonth (October 2001) there were 18 teams try-ing to climb this mountain and the 18 Nepaliliaison officers had plenty of free time!! Tenz-ing Tashi has climbed this mountain, and hesays that this is significantly more technical

(specially if you are fixing the ropes yourself)than the pedestrian “yak route” to the summitof Everest.

We are now at the village of Phortse (3800m). The Khumbu at one time was well knownfor people with goiters, especially from this vil-lage, the elders say. The cause was uniodizedTibetan salt. A porter tells me in graphic Nepalithat the present Maoist insurgency that isplaguing the country is like a carbuncle on agoiter, an unneeded obstacle on top of a largerproblem. I couldn’t agree more!

At Pangboche (3800 m) the next day, a 55-year-old woman in my group has a cruciate lig-ament tear of her right knee, and it is verypainful for her to walk. Together with TenzingTashi, we organize a helicopter rescue. In themeantime I am asked to see a Sherpa who isdizzy and has melena for three days after a hec-tic marriage celebration. I give him omeprazoleand try to put him (for free) on the rescue he-licopter, but the Sherpa declines after consult-ing his sacred books. The timing is inauspiciousto go to a hospital in Kathmandu. Helicoptershave become like taxi services as there are al-ways helicopters waiting in Lukla for emer-gency evacuations. I remember a time in theKhumbu when you had to wait for days for arescue helicopter. I give the Sherpa with thegastrointestinal bleeding more omeprazole andhope he does well.

At the Pheriche medical aid post (4300 m) wemeet the two volunteer doctors, Julie Wilsonand Denise Merrit. They are energetic and en-thusiastic, despite the unrelenting cold andmeager life-style. A few words about the his-tory of this clinic may be interesting to readers.

The idea of a medical aid post in the Hi-malayas was first conceived in Davis, Califor-nia, by a Peace Corp trainee for Nepal namedJohn Skow. When he asked his instructors atDavis what facilities were available for treatingmedical problems in trekkers and climbers inthe Nepal Himalayas, he was told none existed.He wished to do something about this. Whenhe came to Nepal, he likes to say his “head-quarters” for forging ahead with this projectwas a “ jhola” (a bag) slung across his shoul-der. (His main job, however, was teaching En-glish to students at a village in Western Nepal.)He was enthusiastically supported by Mr. Tek

344 BASNYAT

Chandra Pokherel of the trekking agency Him-alayan Journeys, who was very keen about theprogress of this altitude project. In the fall of1973 the aid post at Pheriche opened for thefirst time with, initially, a French nurse,Danielle Laigret. Later in the fall, Dolly Lafever,an American nurse, and Tashi Sherpa, who hadtraveled extensively in Nepal with the famousSwiss traveler Tony Hagen, ran the post, whichwas essentially a yak hut. The first doctor to beinvolved with helping the HRA was the alti-tude expert Dr. John Dickinson from ShantaBhawan Hospital in Kathmandu. At that timeany patient with AMS flown in to Kathmanduwould be seen by John at the hospital and, asa result, he was able to make numerous clini-cal observations about the illness (Dickinson etal., 1983). John, however, did not do a seasonat Pheriche. The first doctor to do so was JohnWinter, who arrived in the fall of 1974, fol-lowed by Peter Hackett (spring 1975), who car-ried out extensive work on mountain sicknessand published his first, seminal, milestonework from this region (Hackett et al., 1976). Atthis time, a very kind and helpful doctor, Pro-fessor Hyata of Tokyo Medical College, waspersuaded by Mr. Pokherel to raise moneyfrom Japan to build the physical structure ofthe clinic so that they could move out of theyak hut. Dr. David Shlim worked a record threeseasons (1979, 1980, and 1982) and lucidly ar-ticulated many preventive aspects of AMS thatare very much in use today (Hackett and Shlim,1996). In the spring of 1980, John Dickinson,Mr. P. P. Prasai, the chairman of HRA at thattime, and Kanak Dixit, a freelance photogra-pher, suggested to me (a medical intern) to doan elective in the mountains as a volunteer atPheriche. My wife Geeta (also a physician) andI snatched at the opportunity. For easy-goingKathmanduites, the many lessons we learnedat Pheriche would serve us well in the ensuingyears.

Starting this season the aid post (fall 2001),has an oxygen concentrator that suppliesenough oxygen. Electricity is derived from thesun and a windmill. No more lugging oxygencylinders to the aid post, nor even using the hyperbaric Gamow bag for the treatment ofmore life-threatening forms of AMS. They have

hardly used the Gamow bag this fall the doc-tors say.

Julie Wilson recounts some tragic, pre-ventable deaths from the fall of 2001. A Koreangentleman lost his group, wandered aroundthe Khumbu glacier on the way to the basecamp, and was found dead, possibly due to hy-pothermia. A Dutch national in the Gokyo area(4700 m) felt he had AMS and decided to de-scend, taking an unconventional route, and fellinto a river and died. A Japanese person justtried to “brave it out” at high altitude and suc-cumbed to high altitude cerebral edema. In-variably, porters usually present to the cliniconly when they are too sick to continue. De-spite these disheartening, sad stories the vol-unteer doctors passionately continue to preachthe gospel of prevention of AMS and do thebest they can to help. Clearly, there are limita-tions and room for improvement.

Next evening at the village of Kyenzoma(3700 m) on our return journey, there is a sil-ver sliver of a moon over Thamserku (6600 m),even as Tawoche (6500 m) towers over the vil-lage of Phortse. The cornice on Ama Dablamis lit up in the moonlight, and in the valley be-low magnificent Dudh Kosi thunders down anarrow gorge and meanders on. The kaleido-scopic prayer flags flutter in the wind, andKhumbila, the sacred mountain of the Sher-pas, looms directly over us in all its serenity.The tranquility is palpable, and there is magicin the air.

REFERENCES

Basnyat B., Lemaster J., and Litch J.A. (1999). Everest orbust: a cross sectional, epidemiological study in the Himalayas at 4300 m. Aviat. Space Environ. Med. 70:867–873.

Dickinson J.G., Heath J., Gosney J., and Williams D.(1983). Altitude related deaths in seven trekkers in theHimalayas. Thorax. 38:646–656.

Hackett P.H., Rennie I.D., and Levine H.D. (1976). The in-cidence, importance, and prophylaxis of acute moun-tain sickness. Lancet. 2(7995):1149–1154.

Hackett P.H., and Shlim D.R. (1996). The high life: healthand sickness at high altitude. In: Encyclopaedia Bri-tannica, Inc., 1997, Medical and Health Annual; pp.24–35.

Pandey M.R., Basnyat B., and Neupane R.P. (1988).

LETTER FROM THE FIELD 345

Chronic bronchitis and cor pulmonale in Nepal. Mri-gendra Medical Trust, Kathmandu.

Roach R.C., Maes D., Sandoval D., Robergs R.A., IcenogleM., Hinghofer-Szalkay H., Lium D., and Loeppky J.A.(2000). Exercise exacerbates acute mountain sickness atsimulated high altitude. J. Appl. Physiol. 88(2):581–585.

West J.B. (1998a). High Life. A History of High AltitudePhysiology and Medicine. Oxford University Press,New York; pp. 10–12.

West J.B. (1998b). High Life. A History of High AltitudePhysiology and Medicine. Oxford University Press,New York; pp. 175–176.

Address reprint requests to:Buddha Basnyat, MD

Nepal International ClinicLal Durbar, GPO Box 3596

Kathmandu, Nepal

E-mail: Rishibas@wlink.com.np

Received June 13, 2005; accepted in finalform June 24, 2005