A Review of Medical Problems in Himalayan Porters

Abstract

Porters have accompanied trekkers and climbers to high altitude since the earliest expeditions in the Himalayas. As the existing body of knowledge on high-altitude medicine expands, the focus remains on trekkers or climbers. And published literature on medical problems in the large porter population remains sparse. It is well known that porters working at high altitude in the Nepal Himalayas are often lowland dwellers and are as prone to high-altitude illnesses such as acute mountain sickness, high-altitude pulmonary edema, and high-altitude cerebral edema as the trekkers are. Other illnesses such as diarrhea, respiratory illnesses, and infections also occur in this population. In this review, studies reporting these findings will be discussed along with the local context of socioeconomic barriers to adequate health care for these porters.

Ever since the earliest expeditions, adventurers sought to explore remote locations throughout the world enlisting the help of locals to carry the loads required. High-altitude areas were not exempt. With the first foreigners setting foot in the Himalayas around 1907 (West and Kellas, 1989), a cycle of need was identified. The tourists needed to transport heavy equipment and food through arduous terrain, and the local population needed to earn money. Thus, the Porter–Trekker relationship started, as both porters and trekkers were invaluable to each other. As the hikes and treks moved to higher elevations, there was recognition of illnesses related to high altitude. As years have passed, the knowledge about altitude illnesses in trekkers and mountaineers has steadily increased. In most of the studies examining medical problems at high altitude, it is the tourist population that has been the focus of scientific work. The population who make travel to such extremes possible by carrying heavy loads trudge along, seemingly unnoticed and neglected.

In this review, we will focus on the porters in Nepal, a Himalayan nation famous for high-altitude adventure activities. We will aim at discussing about porters from lowland regions trekking to high-altitude regions on a seasonal basis.

In a poverty-stricken country such as Nepal, where 55% of the population live below the international poverty line of US$1.25/day (Kalimili and Fantom, 2016), poor people originating from low-altitude areas may be drawn to work as a porter to supplement their subsistence farming and as a means for providing an education for their children. There are multiple health risks that are involved with working as a porter, especially at high altitude (Malville et al., 2001; Bauer, 2003; Doocy et al., 2007; Koirala et al., 2018). The resurgence in tourist numbers after the 2015 earthquake means the numbers of porters going to high altitude will also have increased (van Strien, 2018).

In a study of workload trends of two high-altitude clinics in Nepal, it was noted that around 40% of patients seen at Pheriche aid post are Nepalese and often porters. With limited education, improper clothing and equipment, and very little knowledge of the potential medical problems, these lowland porters, who commonly reach altitudes >5500 m, may not be well suited for the hypoxia of high altitude (Basnyat et al., 1999).

Coming from a low socioeconomic background and having to work as much as they can to earn enough, the health-seeking behavior of these porters is noteworthy in that they only tend to visit health facilities once they become close to incapacitation. Most porters do not have any form of medical or evacuation insurance when they fall ill during their work. Nepali staff and porters are often reliant on the preparedness and resources of the trekking group to reduce the risk of medical problems. Although helicopter evacuation for medical reasons is getting more accessible and often may happen for minor complaints in tourists, the porters do not have easy access to medical evacuation (Dawadi et al., 2020).

In a recent survey among porters in the Khumbu by Koirala et al., the lack of knowledge about health issues among porters and how to tackle them at high altitude, carrying more than recommended loads, and financial pressure to complete a trip despite ongoing problems were highlighted. The study also emphasized some common medical problems faced by the porters, which included altitude illness, cough, and trauma among others (Koirala et al., 2018).

There have been other studies that focus on the biomechanics of load carrying and pulmonary physiology (Bastien et al., 2005). Detailed studies on medical problems faced by the porters are limited. One study done in the Annapurna region highlights medical problems in both Nepali and foreign nationals in the route. They report fewer medical problems in the Nepali nationals (porters and staff) compared with foreign tourists (Drew et al., 2011). However, they also mention that this might reflect lower reporting of perceived problems in the porters as compared with trekkers.

In the next section, we attempt to shed light on common illnesses encountered by porters in Nepal.

High-Altitude Illnesses

Contrary to popular belief, all porters are not high-altitude Sherpas. In fact, a large proportion of them are from different ethnic backgrounds and live in low altitudes and only go to high-altitude areas for work (Malville et al., 2001; Newcomb et al., 2011; Koirala et al., 2018). Thus, they too are susceptible to acute mountain sickness (AMS) like everyone else. This susceptibility is in contrast to the high-altitude Sherpa porters who may be genetically better adapted to high altitude (Droma et al., 2008). Studies looking at medical illnesses in porters and trekkers in the Manaslu region of Nepal revealed that 8%–12% of porters suffered from AMS (Basnyat and Litch, 1997; Hillenbrand et al., 2006). Another study done in the Khumbu reports a much higher (37%) rate of AMS in non-Sherpa porters at 4400 m (Basnyat and Le Master, 2001a). Although studies about the incidence of high-altitude pulmonary edema (HAPE) and high-altitude cerebral edema in porters are lacking, there are numerous case reports that highlight that these problems do, indeed, occur in porters. But, because of late reporting of symptoms, the sick porters usually present in extremis (Basnyat et al., 1999; Fagenholz et al., 2007; Baniya et al., 2017). The Sherpa porters have now generally been replaced by other lowland ethnic groups such as Rais, Limbus, Chhetris, and Bahuns who are probably more predisposed to suffer from altitude-related problems. These porters are, therefore, at the same risk of altitude illness as a trekker would be (Basnyat and Le Master, 2001a). Lack of knowledge about the symptoms, prevention, and reluctance to report any symptoms may account for the rate of altitude illness among porters (Newcomb et al., 2011).

The fact that porters may also be equally at risk of altitude illness is very important for trekking groups, companies, and tourists to recognize because there is often a false preconception that porters working at high altitude all hail from high altitude and are, hence, relatively immune to high-altitude illness. It is paramount to realize that this is not the case and attention has to be given to the porters traveling with the expedition.

Diarrhea

Acute diarrhea is, by far, the most common illness occurring in travelers to Nepal (Pandey et al., 2010). The risk factors of poor hygiene, lack of water in high-altitude locations, eating habits, and not treating drinking water are at work not just for travelers but also for the porters. The local population also suffers from diarrheal diseases (Pokhrel and Viraraghavan, 2004). All studies that have looked at medical problems in porters have mentioned that gastroenteritis and diarrhea occur commonly. However, the rates of diarrhea in porters were reported to be less than those of the trekkers traveling with them (Basnyat and Litch, 1997; Drew et al., 2011). Diarrheal illnesses can be very incapacitating for the porters and they may continue to carry heavy loads despite being dehydrated, as they may not complain due to the fear of losing their job. In addition, because it is spread by fecal oral transmission, diarrhea may spread rapidly to other individuals in the traveling party.

Other Infections

Although high-altitude trekking and climbing is an important attraction for tourists to Nepal, it is relevant to note that Nepal lies in the subtropical climate zone and various infections (such as diarrhea as discussed earlier) are common in Nepal, including vector-borne diseases (Basnyat et al., 2001b; Murdoch et al., 2004; Pokhrel and Viraraghavan, 2004). The porters as part of the local population share the same burden of infections, when they are at home and when they work. Apart from the very common gastrointestinal and respiratory infections, others such as enteric fever, dengue, typhus, viral hepatitis, and influenza are also frequently encountered in those traveling to high altitudes (Basnyat et al., 2001b; Amatya et al., 2020). In addition, tuberculosis is a major public health problem in Nepal, with 44,000 new cases reported in a year throughout the country, and nearly 10,000 cases still undiagnosed or unreported [National Tuberculosis Program Nepal Annual Report 2073/74 (2017)]. Cough in a porter may be due to tuberculosis and not the ubiquitous Khumbu cough. Finally, mitral stenosis after rheumatic heart disease, an infection that is common in Nepal (Shrestha et al., 1991, 2012), may be asymptomatic at lower altitude but due to pulmonary hypertension of high altitude, porters may present with pulmonary edema and may be misdiagnosed as HAPE (Hultgren, 1992).

Trauma/Musculoskeletal Injuries

Wearing improper footwear and nonergonomic load carrying can make trauma and musculoskeletal problems more frequent among porters. Carrying excess weight can lead to back problems and potentially makes the porters more prone to falls, resulting in injuries (Malville et al., 2001). However, studies in the past have not shown increased orthopedic injuries in porters despite the heavy weights they carry (Basnyat and Litch, 1997). A physiological study on commercial porters in Eastern Nepal concluded that they can carry extremely heavy loads without persistent medical problems because of their unique technique of self-paced, intermittent exercise (Basnyat and Schepens, 2001c; Malville et al., 2001).

There has been a limit placed on loads that porters are allowed to carry. However, monitoring is still difficult and often missing. Porters are usually paid according to the amount of load they carry and, therefore, there is always a motivation to carry more. The increased physical exertion can easily predispose the porter from the lowland to an increased risk of altitude-related illnesses.

Frostbite/Cold Injuries

Although there are no formal data on the number of cases of frostbite among porters at high altitude, an assumption can be made that the rate is at least as high as in trekkers and climbers, with almost 40–50 cases in a year in Nepal (SD personal experience). A study done in neighboring Pakistan suggests high rates and poor prognosis of frostbite in porters. Improper gear, poverty, lack of knowledge on prevention or management, use of alcohol, and colder accommodation are likely factors (Hashmi et al., 1998). The same factors apply in Nepal. The lowland porters are especially at risk, as they may not be used to the cold, hypoxic environment, have improper gear (sandals and flipflops for footwear/cotton or wool gloves), and are unaware of the symptoms and what to do in case of cold injuries. Hence, frostbite cases in the local population that have been improperly managed by the patient or their friends are commonly seen. Frostbite can be devastating for porters. Proper medical treatment for frostbite is difficult to find in Nepal and when available may be expensive. Even when medical treatment is available, the porters usually arrive late to the medical facilities and, hence, might not be candidates for thrombolysis or prostaglandin analogues (McIntosh et al., 2019). Those that do arrive in time may be unable to get treatment because of the high costs involved. Any loss of tissues for the porters can rob them of their income, whether it is carrying loads or working in the fields. It is important to make sure that the porters have weather-appropriate gear and knowledge about frostbite symptoms and first aid.

Other Diseases

Uncorrected refractory errors, photokeratitis are more common in porters owing to lack of proper protective gear as well as reluctance to seek health advice (Basnyat and Litch, 1997; Drew et al., 2011; Gnyawali et al., 2017). Gastritis, commonly known among locals as the “national disease of Nepal,” is also well reported (Drew et al., 2011).

With poor health-seeking behavior being the norm among people from rural Nepal, other chronic and noncommunicable diseases can also be expected to factor in the health of the porters, who are usually from poor socioeconomic strata. Children working as porters experience a substantially increased risk of negative physical, emotional and educational outcomes due to their involvement in exploitive and dangerous work. Working as porters prevents access of children to education and, in turn, better employment, continuing the cycle of poverty in the long run (Doocy et al., 2007).

Mental Health

Common mental disorders have been shown to be associated with poor socioeconomic condition (Patel and Kleinman, 2003). Working under stress, away from their families in an inherently dangerous environment the porters might have psychological issues. With mental illness still considered a taboo in Nepali society, manifestations of this at high altitude can be potentially problematic and often go unreported.

A study by Bauer et al., about the health of the Inca Trail Porters in Peru, also highlights similar problems (back pain, fever, respiratory problems, stomach pain), with less altitude illnesses (Bauer, 2003). Unlike the Inca trail porters who suffered from lack of clothing and equipment, the availability of cheap Chinese clothes and shoes has offset that problem to some degree in Nepal.

Organizations such as the Himalayan Rescue Association (HRA, by providing free and/or inexpensive health care to porters in Khumbu and Manang) and International Porter's Protection group (IPPG; porters' shelters, health care, education) are working tirelessly to help improve the conditions of the Himalayan porters. The recent closure of the IPPG aid posts in the Gokyo Valley seems a backward step in porters' health. The aid posts catered for both tourists and porters alike, with the porters receiving free treatment. The closure (for whatever reason) has the potential to leave many porters as well as locals without access to health care, thus undermining the ongoing good work carried out by these organizations.

However, it is clear that more needs to be done by the trekking companies and the government to enforce responsible trekking (Küpper et al., 2012), ensuring proper treatment, compensation, and health care for the backbone of the Nepalese tourism industry. Making porters aware of their rights and responsibilities is an underemphasized area.

Finally, to be more focused in helping the porters, more research needs to be carried out regarding recent porter demographics, ethnic mix, safety, and well-being. Useful research could also include not only infectious diseases, including vaccination history in porters, but also the prevalence of other common diseases in porters in Nepal such as hypertension, diabetes, strokes, coronary artery diseases, and alcoholism (Table 1).

Table 1.

What Can Be Done

Education of porters

Educate porters about their rights, common health problems, the presentation, prevention, and treatment of altitude illnesses, the value of descent, and the available reputable local health facilities

Better health services

Increase the access to expedition doctors.
All health care costs should be free for porters and covered by the responsible hiring company.

Improved clothing and gear

Providing clothing and gear appropriate to the season and altitude is the responsibility of the hiring company.

Pretrek health evaluation

Chronic and recurrent health problems need to be addressed before starting the trip without jeopardizing possible employment opportunity.

Strictly regulated load carrying practices

Load should be weighed and rules regarding the loads carried by porters be enforced.

Porters should be made aware of the health consequences of carrying very heavy loads.

Health Insurance, evacuation, and follow-up

Health and evacuation insurance for porters (similar to other climbing staff) should be the norm and should be legally enforced.

Hiring companies should make and execute safe evacuation plans for sick porters.

Arrangements should be made for receiving the sick porter at the evacuation destination, safe transport to nearby hospitals, and follow-up care.

Awareness of clients

Clients should inquire about the clothing, shelter, and food of porters.

Clients should be made aware about load regulations for porters.

Ultimately, the clients must take some responsibility for the welfare of their porters.

Not doing business with companies with a poor track record of porter care.

Conclusion

There is still a large void that needs to be filled regarding knowledge about medical problems in porters. Simple checklist documentation (e.g., frostbite incidence) of porter health problems by the existing high-altitude check-posts would be very helpful to figure out the extent of the problem. Basic requisites of education and better socioeconomic status need to improve for better health status. Trekking agencies and groups need to understand and practice responsible trekking. Educating trekkers in porters' care and making them place pressure on trekking companies to guarantee porter care has been one of the tasks of the HRA and MMSM that needs to clearly continue at this time. The underutilized Union Internationale des Associations d'Alpinisme/International Climbing and Mountaineering Federation recommendations on how to choose trekking companies can help trekkers make responsible decisions (Hillebrandt et al., 2012). It is important to make sure health and evacuation insurance are in place for the porters and to provide regular first aid training. Pretravel assessment of health status and optimization in case of chronic diseases might need to be prioritized. Porters are the cornerstone of any expedition and deserve to be cared for by their employer. It could be argued that this is the responsibility of the trekker or the mountaineer to ensure this happens, especially in an impoverished Himalayan environment.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No external funding was received for the article.

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