Monday, 19 May, 2008
Based on its geographic location, Ladakh should be rife with digestive problems. Nestled in the Himalayas of Jammu and Kashmir, it lies where two hot spots for gastro-intestinal problems intersect — India and high altitude.In the United States, digestive problems are the No. 2 cause of workdays missed. In India, they are thought to be the No. 1 cause. Low sanitation and a diet heavy in grain are thought to be some of the main culprits. The poor are most affected.According to Dr. Ghulam Mohd of the Leh Government Hospital, gastro-intestinal diseases “are very common” in Ladakh. Men and women are affected equally and illnesses occur most in people over the age of 14. He says about 99 percent of patients with gastro-intestinal diseases in Ladakh have the bacteria known as Helicobacter pylori present in their stomachs.Helicobacter pylori, or H. Pylori, is found in 40 percent of the world’s population. One-sixth of those infected develop stomach ulcers. It is theorized that H. Pylori blocks acid from traveling to the upper-digestive system. Although the bacterium decreases the likelihood of developing cancer of the esophagus, it increases the chances of developing stomach cancer.In the West, plummeting rates of H. Pylori directly correlate with a decrease in incidence of stomach cancer, while cancer of the esophagus is becoming more common. The reverse is true in the Far East — H. Pylori is much more prevalent, leading to high rates of stomach cancer. One possible reason for low rates of H. Pylori in the West is good sanitation. In places where there is poor sanitation, the bacteria infects up to 90 percent of the adult population. Aside from stomach cancer and ulcers, gallstones are common ailments in Ladakh.Mohd cited poor sanitation as another cause of digestive problems. He said illnesses were especially common in summer, when the heat allows bacteria to multiply in water and food. As in the rest of India, digestive illnesses are most common among the poor, due to lack of education and access to sanitation.In contradiction to Mohd’s claim that digestive problems are common among Ladakhis, when surveyed, three female students at SECMOL (Students’ Educational and Cultural Movement of Ladakh, a school outside of Leh meant to refine students’ skills in English and prepare them for 10th through 12th class exams) said gastro-intestinal illnesses are not common at all. This perception could be due to the students’ lack of exposure to life outside Ladakh. They may not recognize the presence of digestive diseases as a major problem because they don’t consider the diseases serious. The girls said digestive problems peaked in summer, but for a different reason. During the summer, they said, people eat too many apricots.When three male students were surveyed, they said digestive illnesses were, in fact, common among Ladakhis. They also said problems are most prevalent in summer.Amchi Tsewang Rigzin from the village of Saspol said, “In Ladakh, there are many (gastro-intestinal) disease patients.” He said that people over age 15 are most affected and agreed with Mohd that illnesses occur equally among men and women. According to the Amchi, or traditional Buddhist doctor, problems increase in spring, when the body produces more phlegm. In Amchi medicine, phlegm is associated with laziness. Tsewang said it increases acidity in the stomach, making people more susceptible to ulcers and stomach cancer. According to Rigzin, waiting long periods of time to eat also increases the acidity in one’s stomach. Most Ladakhis are farmers and may delay meals if they are working.He said problems are most common in Eastern Ladakh, a predominantly Buddhist region, and Chantang, a nomadic village. Nomads eat mostly meat and have little variety in their diet. In Nubra and Sham, farming villages where people have more access to fruits and vegetables, incidence of gastro-intestinal illnesses is low.Ladakhis prefer to cure digestive illnesses naturally. They consider it very important to keep the mid-section warm. To combat cold, which is thought to cause or worsen digestive problems, they drink warm water and wrap their middles with a scarf or blanket. Rice soup, a simple, bland dish, is eaten because it is very easy to digest. For persistent problems, they see an Amchi.Rigzin Sandup, a freshman in college in Leh, said that Amchis “have a lot of strength.” He would normally prefer to go to an Amchi if he were ill. Amchi medicine is known in Ladakh for being all natural, eco-friendly and free of side effects. He later noted, “If it is serious, I would definitely go to (a Western-style) doctor.”Tsewang said that he rarely sends patients to a Western-style physician — only if they are in critical condition. On occasion, a Western physician will send a patient to an Amchi if the patient remains in the hospital for an extended period of the time without being cured.Both the Amchi and Western physician said ulcers and hemorrhaging are common, which can be attributed to the prevalence of H. Pylori among Ladakhis. While there are antibiotics to treat H. Pylori, decreasing the recurrence of ulcers and a patient’s chances of developing stomach cancer, antibiotics are generally less effective at high altitudes. It seems that bacteria cause most serious digestive problems in Ladakh. All surveyed groups and interviewees mentioned that problems peak during the warmer seasons, when bacteria can easily breed in food and water. Students at SECMOL mentioned spoiled food as a common cause of gastro-intestinal illness.The group of female students at SECMOL said that many people in Leh, the capital city of Ladakh, get ill because the flush toilets drain into the drinking water supply. There is a problem with leaking septic tanks in Leh. In Ladakhi villages, people use composting toilets, which don’t require any water.Mohd said digestive illnesses are common in Zanskar, an area that is rural like most of Ladakh. He stated the “backwardness” of people there as a cause. However, gastro-intestinal diseases are not isolated to a certain region of Ladakh, age group, gender or lifestyle. Farmers, nomads and city dwellers all suffer. The real problem is sanitation, not just in rural villages, but in the modern city of Leh as well. Improvement of sanitation throughout Ladakh would greatly decrease the prevalence of gastro-intestinal illnesses by decreasing exposure to bacteria, including H. Pylori.Digestive diseases are so common in Ladakh that some Ladakhis do not even realize there is a problem. Indigestion tends to be treated at home, and only when a serious or persistent illness is observed do people seek medical attention. Not noticing a serious illness or recognizing its persistence early on may factor into the high incidence of stomach cancer in Ladakh. In addition to improved sanitation, Ladakhis should seek medical attention at the first warning signs of a digestive problem beyond simple indigestion. They can also get tested for H. Pylori and take antibiotics so as to prevent stomach cancer from developing.
HIV/AIDS exists in all corners of the world. On every continent, every country and every region. However, here in Ladakh, a remote part of the Himalayas, it seems that everyone including doctors denies its existence. This is alarming since India has the second highest prevalence in the world and 60 percent of South Asia’s AIDS cases. “AIDS is knocking on the door of Ladakh and wants to come in,” says a 17-year-old student. In reality, AIDS is very much present here. What I found was a culture that undermines the dangers of the virus and won’t let the epidemic taint a pristine picture.An understanding of the culture’s taboo approach to such matters is crucial in understanding why HIV/AIDS is not acknowledged in a public way. Dr. Ghulam Mohd of the Leh Government Hospital said that “AIDS does exist here, and we have seen cases.” Dr. Ghulam Mohd explained that the most common cause of death among young people included TB, diarrhea and pneumonia, which are all secondary infections of AIDS.I interviewed several students of Students’ Educational and Cultural Movement of Ladakh (SECMOL) as well as several students in villages. Almost every student said that HIV/AIDS does not exist in Ladakh. The way in which people in Ladakh have separated themselves from the virus can in part be due to the fact that they don’t like to talk about it. If they don’t talk about it, it doesn’t exist, and that concept is what reaches the people.Ladakh is made up of small villages scattered among high mountain passes. Their inaccessibility due to few roads can be part of the idea that they are completely separate from the world. The villages are secluded in beautiful valleys and along rivers.The remote sense of Ladakh is interrupted every summer when 50,000 domestic and foreign tourists come here. This makes it seems inevitable that the people of Ladakh would be exposed to the virus. Over half of a group of students reported that they had heard or believed that tourists sleep with tour guides. Several students mentioned that they thought that outsiders including Nepalis, Tibetans and Americans had AIDS. However, there was no connection drawn between the tourism and presence of Tibetans here, and their own vulnerability to the virus.Rural Development and You is a large non-governmental organization stationed in Leh. Its intern said that, “Yes, AIDS does exist here but mostly among non-Ladakhis.” From here my surety of its existence increased. The military’s presence in Ladakh is visible everywhere, from the second that you get off of the plane. The idea that soldiers from southern India were in Ladakh for three months triggered the idea of prostitution and its relevance in Ladakh. When a group of teenage boys were asked if they thought that there was prostitution in Ladakh, every one said yes. However when girls were asked, most said no. Several of the boys said that the presence of prostitutes could be attributed to the presence of the army. One student explained, “Prostitution is good for men who were away from their wives for a long time, but is not good because they sometimes spend all of their money and have nothing left.” However there was no mention of the effects on the women or potential health risks.Commercial sex workers play a key role in the spreading of the virus, especially in the early stages. When society doesn’t want to acknowledge that prostitution exists in Ladakh, these vulnerable women will continue to be at a high risk of both contracting and spreading the virus further. Without the knowledge of its relevance, women will not be able to be reached by prevention groups.Most students reported having some form of education about AIDS in school, whether it was through their science textbooks or guest speakers. But the message isn’t getting across if none of them know of its relevance here and how it can potentially affect them. The students had received education about AIDS in school, but their parents and grandparents still don’t know what the disease is. Students who are unable to discuss this issue with their parents feeds into the idea that AIDS is irrelevant. Because education hasn’t reached adults, the potential of it spreading among them without knowing it is a serious concern.Even though Ladakh has a very conservative society, students have no education about AIDS before age 15, leaving children uneducated about potential health risks when doing something as simple as getting an injection at the hospital where clean needles may not be used.Most students said that they would get tested if they thought that they had AIDS. However, none of the students knew where testing was available and they were afraid of social stigma. “We provide testing here, and do have people come in commonly for voluntary testing,” explained Dr. Ghulam Mohd. However the confidentiality and readily available testing is questionable.It is clear that HIV/AIDS is present in Ladakh, and will continue to be an issue until people acknowledge its existence openly. Without acknowledgement, the virus will continue to spread throughout Ladakh. The realization of its global impact, and that its relevance will not ruin their culture but strengthen it through a communal effort, can stop the virus.Thorough education should be required for all students including how the disease is transmitted, who are at the highest risk, where testing and treatment are available, as well as the proper use of condoms and other protective measures. Also, testing should be free, readily available and confidential. And finally the message of health officials needs to improve. There should be billboards, ads, propaganda and information in order to get rid of stigma. Addressing HIV/AIDS in Ladakh is crucial in keeping it from spreading further.