During a recent medical mission to Asia, I held several clinics for a small, extremely remote village of ethnic Tibetans living at high altitude.
Most of the villagers live off the land and, on occasion, perform odd jobs. Inhabitants have access to traditional Tibetan medicine, which is very helpful for certain conditions, but for optimal health the people understand that modern medicine is also necessary. Access to conventional health services is available, but villagers believe that the quality of both care and medication is suspect and that the available practitioners do not have their best interests in mind.
While life expectancy is relatively low, the villagers are deeply bonded through their cultural fabric and, despite their ailments, most have smiles on their faces and laugh easily.
Like wealthy Americans a world apart, many of their maladies are preventable and related to diet and lifestyle. By far, the most common condition identified is elevated blood pressure. Owing to the extreme altitude, the traditional diet comprises grain and meat, hard cheese and butter tea — all of which are highly salted and strongly spiced. Dietary vegetables are minimal and fruits are a rarity.
In addition, dental hygiene is visibly poor. The combination of chronic dental inflammation, high blood pressure and high cholesterol is a setup for plaque buildup in the arteries, heart attack and stroke.
Because these people spend so much of their time doing intense physical work and are known for carrying loads that far exceed their own body weight, there is little obesity and less diabetes. Instead, as a result and partly because of nutritional deficiencies, debilitating osteoarthritis is rampant. Knees are by far the most common musculoskeletal complaint, followed by elbows. Over the years, I have routinely seen advanced degenerative arthritis of the knees in the Himalayas among women in their 20s that one would not typically see in the U.S. before age 50.
Alcoholism is also widespread, and the drink is brewed at home. Many stick to fermented barley, which has an alcohol content between that of beer and wine. It also can be distilled and then is comparable in alcohol content to commercial hard liquor. Unlike American Indians, however, who were introduced to alcohol by colonists, family microbreweries are an ancient Himalayan tradition.
Rounding off the most commonly reported complaints is gastritis. This results at least in part from the spicy, salty diet combined with substantial alcohol intake. Public health studies also have shown high rates of H. pylori in this region, a germ that at high levels can cause gastritis and eventually stomach cancer.
In addition, roughly 1 in 5 patients reported complaints consistent with major depression. Notwithstanding a strong cultural fabric and substantial community support, socioeconomic and political challenges take their toll. Access to good education and quality jobs is not great, and freedom of movement is curtailed by the Chinese government. As such, some seem to feel trapped with their lot in life. A factor that appears to take much more of a toll on mental well-being is the death of a productive family member. There are also many families where only one person is required to support, at times, eight or nine dependents.
A basic understanding of hygiene continues to be quite limited. Lack of hand washing, bathing and proper sewage management as well as contaminated drinking water all affect the health of the villagers. Rates of amoebic dysentery, parasites and tuberculosis are also known to be high.
Tuberculosis, combined with a high smoking rate and paucity of chimneys with indoor fires for warmth and cooking, results in most villagers having a chronic cough. Mother-to-child transmission of hepatitis B at birth is also still common. Combined with alcoholism and parasites, some have liver failure and liver cancer.
To borrow a martial term, sometimes a medical mission, especially solo, is like practicing guerrilla medicine. One can be nimble and make a surgical strike, so to speak, but longitudinal programs are always needed. Ideally this population would now be routinely screened and treated for high blood pressure, cholesterol, parasites, hepatitis B, H. pylori, diabetes, TB and malnutrition.
However, any longitudinal program needs to be logistically feasible and culturally acceptable. In this part of the world, the village leader is key to process change.
Before my departure, arrangements were made for the village to acquire a digital blood pressure cuff and for everyone to be tested at monthly village meetings. I also left protocols for education regarding the dangers of high salt intake. Upon departure it struck me that, like affluent Americans, so much illness among inhabitants of the remote Tibetan plateau is related to lifestyle.
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Ira Zunin, M.D., M.P.H., M.B.A., is medical director of Manakai o Malama Integrative Healthcare Group and Rehabilitation Center and CEO of Global Advisory Services Inc. Please submit your questions to info@manakaiomalama.com.
