Morbidity Pattern of the 27th Indian Scientific Expedition to Antarctica

Introduction

India has had a regular ongoing Antarctic scientific research program since 1981, when the first Indian Scientific Expedition to Antarctica (ISEA) was launched. ¹ The expedition team consists of a summer and a winter team. The winter team spends between 12 and 15 months in Antarctica at the Indian Antarctic Station, Maitri (70°45′E, 11°44′S), from November to February of the year after next depending on the induction and deinduction times. ² Induction and deinduction begin in November, when the flights to Antarctica resume, and continue until February, when the flights cease and the expedition vessel departs. A proportion of the expedition team is inducted by air and the rest by sea for logistical reasons and to facilitate certain scientific activities. The team members are flown from Cape Town, South Africa, to the Novolazarevskaya station runway in central Queen Maud Land, East Antarctica, by the Antarctica Logistics Company International (ALCI) in a 6-hour-long flight. The runway is 10 km away from Maitri. The expedition vessel is an ice class ship. It carries some of the expedition team members and all the supplies needed for the station and the expedition during the year. The members board the expedition vessel from India or from Cape Town. The 27th expedition boarded the expedition vessel from India. The sea journey lasts approximately 25 days, including a 3- to 4-day halt in Cape Town. The ship docks at the Indian coastal camp at India Bay and offloads supplies there. The team members and essential supplies are transported to Maitri by helicopters, and the remaining supplies are transported during convoys in winters. The expedition vessel stays docked until the offloading of supplies and scientific activities of the summer team are complete. This period ranges from 1 to 3 months.

Maitri is located in East Antarctica about 100 km inland from the Princess Astrid coast at an altitude of 120 m above sea level. ³ The terrain is rocky and interspersed with lakes. The nearest port of civilization is Cape Town, 4000 km away. The temperature at Maitri varies roughly from 0°C in summer to about −35°C in winter. Wind speeds reach 150 km/h routinely during the winter. The humidity is low. The polar night and polar day are each 2 months long. Maitri was constructed in 1989 as a centrally heated permanent structure. It is a scientific research base that houses approximately 25 members of the winter team of the ISEA every year, comprising scientific and logistics staff.

On a regular basis, the winter team is selected after an interview process followed by a battery of medical examinations consisting of mental and physical health evaluations. The physical health appraisal includes a thorough examination by a general physician, surgeon, and ophthalmologist appointed by a medical board in consultation with the National Centre for Antarctic and Ocean Research. All team members undergo a complete blood count, liver and kidney function tests, blood glucose, serum cholesterol and triglycerides, and urinary examination by routine microscopy. They are also subjected to electrocardiography (with a treadmill test, if indicated) and chest roentgenogram. Those found medically or psychologically unfit for prolonged stay in Antarctica are excluded. The team selection is followed by an orientation, acclimatization, and training program at a high altitude camp organized at Auli (3000 m above sea level) in the Indian state of Uttarakhand for a duration of 15 days.

Healthcare is provided by 2 medical officers. The medical facilities at Maitri are basic. They consist of a consultation and treatment room, operation theater with general surgical instruments, an anesthesia machine, electrocardiography recorder, cardiac defibrillator, and basic radiological, hematological, and biochemical investigation facilities (online Appendix). Higher referral facilities are not accessible. Emergency evacuation is not possible from March to November, when flights to Antarctica cease owing to adverse climatic conditions, darkness, and unserviceable runway conditions. All the eventualities have to be managed with the basic infrastructure and amenities available. ⁴ An online specialist telemedicine option was not available until 2009 because of limited Internet accessibility, although specialist opinion could be sought by e-mail and telephone.

The diet of the expedition team members consists of normal Indian meals (rice, pulses, roti [wheat pancake], cooked vegetables, and meat or eggs). All the food materials are brought to Maitri once a year by ship. The supplies are brought to the station by multiple winter convoys from the Indian coastal camp, which involves heavy physical activity in extremely harsh climatic conditions and terrain. The convoys ply during the winters because the convoy route is almost completely on ice, which is completely frozen and hence stable and safe during the winter. Water is supplied from Priyadarshani Lake, which is a landlocked, glacier-fed freshwater lake about 200 m from the station. The water is pumped by booster pumps at the lake through an insulated, heated pipeline.

Recreational activities at Maitri include facilities for indoor and outdoor games, gymnasium, Indian and western musical instruments, a well-stocked library for books, and an audio and video library. Maitri also houses a multireligion place of worship.

A study of the health disorders experienced by such expeditions would aid the understanding of the impact of such extreme environments on long-term dwellers. Such an analysis would be useful in planning health services in future Antarctic expeditions and also to prepare future polar physicians for the expedition. Reports of such analyses from Antarctica are sparse.

The primary aim of this study was to analyze the incidence of various disorders observed in the team members of 27th ISEA (winter team) at the Indian Antarctic Station, Maitri, from February 2008 to January 2009. An assessment of the severity of each ailment and the management provided is also attempted.

Methods

The analysis included all members and medical room consultations. The duration of study corresponds to the official wintering period, February 2008 to January 2009. Medical consultation records were retrospectively reviewed. Some team members had preexisting illnesses, which were detected during the preinduction medical examination conducted in India. These individuals were already receiving treatment. The preexisting illnesses have also been considered in the analysis.

The expedition doctors carried out health examination of all team members every 2 months. This included a personal interview, weight (and basal metabolic rate), blood pressure, pulse, respiratory rate, and general physical examination, including dental hygiene.

Results

The 26 expedition team members were all men between 27 and 59 years old, with a mean age of 43 ± 9.40. Table 1 shows all preexisting health disorders and changes in treatment during the expedition, and Table 2 shows all other medical problems.

The team members with diabetes mellitus were constantly encouraged to adhere to the recommended diet apart from regular medication. Artificial sweeteners (aspartame tablets) were available at the station. Special care was taken for clinical examination for diabetic foot. Neither of these 2 team members needed insulin until their return to India.

During supply convoys to the coastal camp, the convoy team drove for long hours on ice in tracked snow vehicles and was engaged in loading and unloading containers onto trailers towed by the snow vehicles and in fuel decanting. These activities were a potential source of injury, although no serious injuries were reported during the 27th ISEA. The team usually avoided working in very windy or blizzard conditions and in darkness. The convoy team had full freedom to decide when the conditions were too dangerous to continue work and hence to avoid unnecessary risk. A heated and lighted living module with an attached generator accompanied the convoy team for rest and shelter at night and during adverse climatic conditions. One medical officer always accompanied the convoy to provide medical support.

Oral ulcers were seen predominantly in the early part of the wintering period. These were all mild in nature and were treated by oral anaesthetic gel, multivitamin capsules, and oral hygiene measures. The incidence of oral ulcers was reduced when dietary modifications (sprouts of chick peas, wheat, green gram [mung bean], and fenugreek seeds) and multivitamin supplementation were introduced in the diet on a regular basis.

Dryness of eyes was managed by administering Ocurest eye drops (phenylephrine, naphazoline, menthol, camphor) provided to the team. The patients responded well.

Constipation was noticed mainly in the month of July, which is the coldest time of the year and the most stressful period in Antarctica. It was treated by prescribing isabgol (psyllium) husk and laxative syrup and by emphasizing regular physical exercise and a high-fiber, low-fat diet.

Only 1 case of mild cold injury in the form of chilblain was diagnosed during the expedition. Calamine lotion for local application was prescribed with good response. Cold injuries were rare during the 27th ISEA because good quality clothing and heating arrangements are available in ISEA. Clothing systems available to expeditioners included 3 layers: an inner layer consisting of thermal underwear, a middle layer consisting of woolen shirt and trousers, and an outermost layer consisting of a dungaree that was waterproof, windproof, and capable of protecting against extreme cold. Woolen socks, gloves with liner, and balaclava were provided. Sleeping bags, snow boots, and waterproof trekking shoes were also issued to every member. An adequate amount of spare clothing was available. Individuals involved in physical activity were advised to avoid rigorous activity to reduce sweating, which could freeze on exposure to cold. Adventure activities were discouraged, as was a prolonged stay away from the station unless required for operational reasons and to carry out scientific studies. Adequate heating arrangements were made available to the touring party in the form of a blower and a generator set whenever possible.

Three cases of Tinea pedis and one of Tinea capitis were detected during routine health checkups. These were in all probability of a longstanding duration and preceded the expedition. All 4 team members were prescribed clotrimazole ointment for local application. One patient with T pedis was also prescribed tablet fluconazole 100 mg twice daily. He responded well to treatment.

One new case of hypertension was diagnosed in March 2008 and was initially advised a salt-restricted diet. Because control of hypertension was unsatisfactory, he was started on tablet losartan 25 mg once a day in May 2008. Tablet alprazolam 0.25 mg once a day was added in June 2008 with satisfactory control of hypertension. Alprazolam was stopped in August. No further fluctuation in blood pressure was noticed, and hence the drug dosages remained unchanged.

One team member reported with a 0.5-cm piece of wood embedded in the palm of the left hand while doing carpentry work. It was removed without incision with forceps and topical neomycin application was advised. Recovery was uneventful.

During the expedition, one individual had 2 episodes of clinically suspected acute appendicitis. This 44-year-old man presented to the medical consultation room on March 11, 2008, with abdominal pain, which was mild initially but gradually increased in severity. Clinical examination revealed marked tenderness in the epigastrium and right iliac fossa with rebound tenderness in the right iliac fossa. He was clinically suspected as a case of acute appendicitis and was started on intravenous antibiotics (cefotaxime, metronidazole, and gentamicin) and intravenous fluids. He responded well to this conservative treatment within 8 hours. The intravenous antibiotic regimen was continued for 3 days. Thereafter, he was switched to oral antibiotics (co-amoxiclav and secnidazole) for 5 days. The same person again presented with similar complaints on June 1, 2008. Examination again revealed tenderness in the right iliac fossa with rebound tenderness. He was again clinically suspected as a case of acute appendicitis. The previous treatment regimen was repeated with comparable outcome. Hence surgical intervention could be avoided in both instances, although the operation theater had been prepared for a possible surgical intervention. The doctors of the nearby Russian station, Novolazarevskaya, were also contacted and requested for assistance if surgery was deemed necessary. Conducting a surgical procedure in Antarctica is a major undertaking, and usually medical officers prefer to avoid it unless absolutely essential.

The cases of psychiatric disturbances did not need medication. They were counseled and advised regular physical exercise and to maintain a balanced schedule of sleep, work, and recreation. During the polar night, informal sports competitions, computer classes, English-speaking classes, and music classes were organized. Daily yoga and meditation sessions were held throughout the expedition, and daily movies were organized. All important Indian festivals were celebrated.

Discussion

Antarctica provides a challenging work environment for physicians in that they live in the community that they serve and share common facilities. The physicians tend to know the personality traits and personal problems faced by an individual, both at a physical and an emotional level, much better than in a formal healthcare delivery system. This has the advantage that physicians are able to offer health-related advice in both a formal and informal manner. A formal appointment is not needed and no fee is involved. This, however, has the disadvantage that the distinction between the professional and personal life of a physician is blurred. Although most of the health problems are relatively minor, and the patient load is less, the physicians are challenged in a resource-poor setting by the lack of support staff, referral, and evacuation facilities. Further, doctors have to exercise extreme care during professional interactions with the team members, most of whom are beset with the psychological stress of extreme isolation in an extreme climate and terrain with prolonged periods of darkness.^5,6

The preexisting illnesses reported during the expedition may lead to significant discomfort and morbidity in a remote environment like Antarctica, with its limited healthcare facilities, apart from heightened anxiety levels. Thus, a close watch for progression of disease is necessary. Comprehensive preinduction medical checkups are mandatory in national expeditions. ⁷ Lifestyle diseases like hypertension and diabetes mellitus should be monitored diligently because of the inherent problems in managing the complications, if they occur, in Antarctica and other remote locations. Blood pressure is known to increase in Antarctic expeditioners, ⁸ and an increased incidence of cardiovascular disorders has been reported during winters in temperate regions.^9,10 In the opinion of the authors, clear-cut guidelines need to be formulated regarding selection of team members having diabetes mellitus and hypertension. The requirement for strict adherence to dietary restrictions and regular medications should be made clear to the patients before the expedition. The follow-up pattern of the patients and adherence to the physician's instructions should be taken into consideration before clearing such individuals for the expedition. Patients with uncontrolled diabetes or hypertension and those with a history of complications should not be permitted on Antarctic expeditions. Tailor-made arrangements for medication of such individuals should be made so that there is no shortfall of medicines, oral as well as injectables. The individuals might also be instructed to carry an adequate stock of prescribed medicines to last the duration of the expedition. Although no complications were noticed during the study period, the physicians should be trained and equipped to manage such eventualities.

During the study period, 1 team member did not need any medical assistance. Traumatic injuries were the most common presentations, although there were no fractures. Previous studies have also observed that traumatic injuries were the most common causes of morbidity in Antarctica.^11,12 These have been observed to occur most commonly during recreational outdoor activities like skiing and snowmobile driving. ¹³ As a preventive measure, such activities were not encouraged at Maitri during the 27th ISEA.

The fresh food brought by the ship for the expedition was exhausted soon after the end of the summer season because the supplies were loaded on the ship a few months (3 months including ship journey and summer stay in Antarctica) before its departure from Antarctica. As in our study, others have reported that oral ulcers may occur because of a lack of availability of fresh food. ¹⁴

Among minor illnesses, dryness of the eyes in Antarctica may be attributed to the extremely low humidity and dry weather conditions. ¹⁵ Constipation was noticed mainly in the month of July, which is the coldest time of the year and the most stressful period in Antarctica. Constipation can occur because of stress and poor dietary habits. ¹⁶

Cold injuries in modern-day Antarctic expeditions are almost entirely preventable, and we succeeded in preventing any serious cold injuries during the 27th ISEA. ¹⁷ However, accidental frostbite still occurs. ¹⁸

Our data provides support to the contention that upper respiratory tract infections are not common in Antarctica. A probable reason for this could be that Antarctica has a relatively sterile environment. However, an increased incidence has been reported in an earlier study during the overlap period between the incoming and outgoing winter team because of the introduction of pathogens into the relatively sterile Antarctic environment by the new team. ¹⁸ Another study reported similar incidence in newcomers and the old team. ¹⁹

No case of injury because of UV ray exposure was reported, although team members working outdoors regularly were noticed to have tanning of the skin. This is because all the team members wore full polar gear, including snow goggles, owing to the extreme cold whenever venturing outdoors even for short periods. The outdoor parties were encouraged to use sunblock lotion with UV ray protection.

Although an appendectomy is considered the treatment of choice for acute appendicitis, ²⁰ medical management of acute appendicitis has been tried successfully in remote settings. ²¹ Although the diagnosis of appendicitis in our subject could not be confirmed by imaging or operation, clinically we believe we also successfully managed this disease medically. Prophylactic appendectomy has also been advocated in certain population groups. ²² The authors believe that prophylactic appendectomy is too radical because the incidence of acute appendicitis has not been shown to increase in Antarctic conditions.

Psychiatric disturbances are a major morbidity in Antarctica even though few of these were noticed in the current study. Most of such disorders do not need medical intervention. They are usually subtle and do not interfere with the individual's well-being or work performance. Physicians have to be on their guard about when to intervene. A previous study suggested that the social environment at an Antarctic station is more important than the physical environment. ²³ For the psychological well-being of the team members, various recreational facilities were available as detailed earlier.

During the expedition, the team members did not develop any health disorder directly attributable to their prolonged stay in Antarctica, or any condition that was likely to have a long-term impact on their health. In previous reported studies, too, no long-term adverse health effects were noticed in the wintering team members of American Antarctic expeditions between 1963 and 1974. ²⁴

As in the civilized world, preventive care is the most cost-effective approach to healthcare and is of undeniable value in Antarctica as well. Poor nutrition as a result of prolonged food storage, poor dietary habits owing to stress, and lack of physical activity are all preventable as is vitamin D deficiency caused by lack of sunlight. Traumatic injuries caused by recreational outdoor sports can be minimized as well. The incidence of cold injuries and UV ray exposure-related ailments can be reduced by wearing adequate protective gear, as is the norm in most modern national research expeditions to Antarctica. It is also necessary to avoid sweating and unnecessary exposure to cold. ²⁵

It was during periodic health checkups that the new case of hypertension and all cases of T pedis were detected. Based on the principal author's experience, better preinduction training for expedition doctors would acquaint them with the disorders commonly encountered in Antarctica. They would also be in a better position to manage medical emergencies within the limited resources available to them. Such training must include training as a general practitioner and in emergency procedures. The expedition doctors should also be trained in minor surgical procedures, minor orthopaedic procedures including plaster casting, basic dental procedures like dental extraction and filling, operation and maintenance of laboratory equipment, and conducting hematological, biochemical, and radiological investigations. In the principal investigator's personal experience, a surgeon and an anaesthetist would be an ideal combination to provide healthcare coverage to an Antarctic expedition. The authors recommend a doctor-to-patient ratio of 1:10. Although most of the ailments encountered in Antarctica are minor and most expeditions do not face life-threatening situations, the station doctors should keep the available infrastructure in readiness for any such eventuality. Periodic health checkups are no less important than preinduction health screening. A general physical examination is usually sufficient. Quality of life can also be assessed using the Quality of Life module developed by the World Health Organization for future expeditions. ²⁶ The responsibility to oversee such measures and the condition of equipment should be assumed by a medical cell in the Antarctic centers in the respective countries. It should be ensured that an adequate stock of prescribed medicines is available for individuals with preexisting illnesses. Finally, telemedicine and Internet facilities should be available to all stations in this era.

Conclusions

Injuries continue to be the most common morbidity among Antarctic expeditioners. Nutritional deficiencies and cold-related injuries are relatively less common. The team doctors should be sensitized and well trained to manage expected and unexpected morbidities within the limited resources on site.