Small Sip of Water on the Hemkund Sahib

Todays quick read : a small pilot study on altitude sickness in Sikh pilgrims . Pilgrims progress up the Himalayas in a manner that will make experienced docs shudder , in part from a mindset that invites suffering – to a point. It is the same reality described in Basnyats Disoriented and Ataxic Pilgrims , from Gosaikhund in Nepal , where a large majority of the yatras suffered from AMS.

This small study ( 28 subjects , interviewed at the Hemkund Sahib temple @ 4330 meters ) is fuelled by two concerns : the rapid ascent , and the minimal fluid intake. The authors have set up a info page for coming pilgrims echoing the same concern about the water intake , urging a high water intake not only during but also before trekking up the Hemkund Sahib. Their main source for this is an article by Peter Hackett , mentioning advice handed out by the Himalayan Rescue Association – in 1975 (!) . This advice coming up now will surprise anyone who

* has read what Hackett ( who after extensive work with the HRA summited on Mt Everest as part of a medical research expedition , and now is the head of the Institute for Altitude Medicine in Telluride ) written on the subject afterwards :

..In reality you only need an additional liter to a liter and a half of water at altitude. Too much water is harmful and can dilute your body’s sodium level (hyponatremia) causing weakness, confusion, seizures, and coma.

* has read the advisory from the Himalayan Rescue Association over the last decade :

Maintaining adequate hydration

Adequate amounts of fluid (about 3 liters a day) are necessary in the mountains:- dehydration mimics altitude sickness and may even predispose to it. On the other hand excessive water drinking should also be avoided as this may lead to electrolyte imbalances.

( Also note that right from the start in -75 HRA talks of total fluid intake , not about drinking water : all fluids count , and the only unique value of plain water is a stronger push towards hyponatremia . )

* has read the relevant part of Hacketts first study : the outcome was that all participants lost weight , and that those who had the highest weight loss were the the ones who did not develop AMS :

Weightloss occurred in both groups , but was less in the AMS group (P0.07) . Indeed , the worse or higher the symptom score , the less the weight loss.

The other strong predictor for avoiding AMS was higher urine output. The second source quoted by Sahota and Panwar manages to find support for that . And only that.

Sources mentioned here :

Current acclimatization advice from Himalayan Rescue Association

A Pilot Study on the incidence of Acute Mountain Sickness at the Sikh pilgrimage to Hemkund Sahib

The incidence, importance and prophylaxis of acute mountain sickness – Peter Hackett & Drummond Rennie in The Lancet , 1976

Altitude Myths @ the Institute for Altitude Medicine

Nerin et al : Acute Mountain Sickness : Influence of Fluid Intake

For a non-medicalese version of acclimatization and hydration advice , see this interview with David Shlim , another veteran of the HRA clinic in Pheriche , fifteeen years as head of the CIWEC clinic in Kathmandu, and co-author of the CDC altitude advisory with Hackett.


The Pope As A Coca User

The one news story on coca ( well played , Evo Morales ) that will be remembered this year : the Pope “combated altitude sickness” on his visit to Bolivia by drinking coca tea.

The missing story , and context is found in his itinerary : the Pope had a textbook preparation for flying in to El Alto/La Paz by first going to Quito @ 2800 meters , and staying overnight . He spent less than four hours in La Paz the next day before flying out to Santa Cruz … altitude 416 meters.

To be expected , the usual media mix up on the altitude of La Paz and El Alto airport : the airport , and only the airport , is at 4000+ meters . The low , and posh , end of La Paz is nearly a thousand meters lower. Town center is 3600-ish. The common claim of the worlds highest airport is also off the mark : there are now five commercial airports at at 4000+ meters , and El Alto is the lowest. Yading @ 4411 meters in China is the highest , nearly four hundred meters higher than El Alto . It will be the second highest after the completion of Nakchu airport.

To Lhasa – By Train or Plane

The short version : adapting to high altitude takes time. You can travel to Lhasa fast , and spend time in hangover country before coming closer to full capacity again. The other option is to spend some time enroute , and get more out of each day. This should be an easy choice for anyone who has more time than money , since the time  in Tibet will be the most expensive days  on any trip to China.

Train , as in the nonstop Beijing -Lhasa run , or flying in , also from Beijing , are the options most will chose between The benefits or risks are the source of intense speculations , but with the massive numbers of travellers to Lhasa  there is also some hard data now.

Reality check : one in three will get altitude sickness , coming in by train  from Beijing .
And this is good news : twice as many get it on flyins.

The high figure for AMS is a shocker for many , but is in the same order for Cusco travellers , and a 2011 study from Lhasa, which also found that AMS was more common on flyins. Early stages are of AMS are undramatic , and many won’t even think of the hangover like situation as sickness. On the other hand a few , depending on bad luck in the genetic lottery in combination with really fast ascent do get severe AMS. The rare and worst case scenario is pulmonary edema , which only appeared in the flyin group – see the notes and reading suggestions below.

There is a rich flora on speculations regarding the train vs plane issue , the main reasons given for not taking the train being that it a) runs too low for benefit , or b) it runs too high . A conservative plotting of altitude as the available amount of oxygen , factoring in the extra oxygen on the train , gives this elevation profile between Xining and Lhasa :



Fly in to Xining at 2283 meters , sleep minimum one night there . Every extra night at 2000+ is a major positive factor. Next leg of the trip to Lhasa by train or plane . The reason you probably haven’t heard of the flyin option from Xining is that you couldn’t , until this year. Train is still better than the plane , from two reasons : you get more time between Xinings and Lhasas altitude , and you spend your first day at 3000+ meters at rest. Think of it as being locked up in a Lhasa hotel room , with a oxygen tank by your bed . And with a lot better views.


Fly in from one of the international airports Beijing , Kunming or Chengdu . Obviously not my recommendation for firstcomers to high altitude – the chances of getting really sick are low , but the chances of the first day or two being spent in hangover country are excellent.


The really good news here is that there are a number of interesting options that are even better than the two day options , if you are willing to spend more time .

Take the train from Lanzhou , near the Beijing-Lhasa halfway point at Xining, and add acclimatization time at Labrang. Lanzhou is at 1600-ish meters , which is too low for effective acclimatization. Labrang monastery , an important pilgrimage site for Tibetans , is only a few hours away with bus , at 2945 meters.

Kunming ( altitude 1850 ) : International airport , and railway point.

Still too low for effective acclimatization , but a convenient gateway to the large Kham Tibetan region in Yunnan. Take the train to Lijiang @ 2400 meters ( and a day tour on the worlds highest cable car ) , onwards to Shangri La/Gyalthang .


Shangri La old town was very interesting until a few months after my visit , when a massive fire destroyed most of it. Lots of other good reasons to visit the region – see  Losangs blog for a wealth of information on Kham and Amdo regions.

Chengdu : International airport (CTU) , and railway.

Chengdu is abysmally low , but gives  easy access to higher ground in the Kham Tibetan region. Kangding/Dartsedo is reached same day with bus. Despite it’s modest altitude at 2600-ish meters Kangding is serviced by the third highest airport in the world at 4280 meters , so you can boost your acclimatization by flying back to Chengdu and take a flight to Lhasa . A cheaper , more environmentally friendly day trip  to 4000+ is taking the cable car from near the town center.


The medical issues with travelling fast to 3000+ meters altitude are well known since decades back – see the guidelines from International Society for Mountain Medicine or CDC. With litterally millions coming in to Lhasa every year , two million by train , it’s now also  possible to make large scale comparisons between different travel modes , with comparable  groups.

Incidence of High Altitude Illness Among Unacclimatized Persons Who Acutely Ascended To Tibet ( Yeshung Ren et al in High Altitude Medicine & Biology )

This describes the results  of  monitoring flyins to Lhasa in a 3268 strong group of military personell. 57 % had various degrees of AMS , 12 %  vomited and received medical attention  , 2 % started to develop pulmonary edema.

A Survey of Acute Mountain Sickness And Vital Signs in Subjects Ascending To Lhasa Via The Qinghai-Tibet Train ( Younjun Luo et al in Scientific Research and Essays )

A similar group of military personell , forty nine persons , was closely monitored during the train ride and for a long period in Lhasa . AMS peaked in 14 % of subjects during the first three days in Lhasa. Worst outcome , in four out of fortynine , was a AMS score of 4 at the Tangu La pass high point and first and second day in Lhasa. One person vomited at the Tangu La. None developed pulmonary edema.

Altitude Illness in Qinghai-Tibet Railroad Passengers ( Tian Yu Wu et al in High Altitude Medicine & Biology )

Tian Yu Wu was a key figure in planning the health program for the workers constructing the railway to Lhasa , the worlds largest construction project at extreme , up to 5000+ meters , altitude. The key data here comes from 160 random Chinese lowlanders travelling straight to Lhasa , without any acclimatization stop at Xining. 31 % developed AMS , 4 % vomited at the Tangu La. Worst outcome : one person developed a balance disorder , which improved after receiving extra oxygen. He was given intermittent oxygen at Lhasa hospital , a clean bill of of health after a CT scan of the brain , and resumed his Lhasa tour after a single day of observation in the hospital.

Acute Mountain Sickness among Tourists in Lhasa, Tibet  – A prevalence study ( Labazangzhu , from Oslo University )

This is the result of survey among around two thousand tourists in Lhasa , nearly half Chinese , which gives a narrow advantage for the train and shows a AMS incidence of 51 %.  It has a number of problems making valid comparisons . It includes many different travel modes , persons normally living at 2000+ meters , and for example people travelling from Kathmandu in Nepal , which will include both unacclimatized persons coming directly from Kathmandu , and well acclimatized persons after  trekking at 3000+ meters.


AMS is obviously common enough on both the nonstop train run and flyins to Lhasa to consider medicating with Diamox. Talk it over with a travel doc , not your GP. In China you will invariably be offered Rhodiola/Hong Jian Tin instead , which has no documented effect ( including the few who used it on the the train in Wu’s study ) . Rhodiola is often presented as a unique Tibetan herb and tradition : it’s not . The plant is found over large parts of Asia and Europe , including my home mountains near the Arctic Circle and the Pyrenees . It has  been known to western tradition from the first century greek physician Dioscorides , was renamed by Linnaeus in the 18th century , and became a part of the Stalin era medical research in the twentieth .

The adjusted elevation profile comes from recalculating the effective altitude from the inspired  amount of oxygen on the train , factoring in the higher oxygen concentration after Golmud . John B West , editor of High Altitude  Medicine & Biology , measured the O2 concentrations on one of the first runs of the train , and calculated the effect to a 900-1200 meter lowering of the effective altitude. I plotted it as one thousand meters lower  , with a build up factor during the first 100+ klicks after Golmud – which still are lower than Lhasa on the map.

Manali Standoff

Todays hindi expression : chakka jam . A sit down protest – with cars. Manali has come to a near stand still as the National Green Tribunal actually almost stod it’s ground on the issue of banning diesel traffic up to the Rohtang La pass. In the end the long forewarned decision was transformed in to a cap on the total number of vehicles , and a heavy tax on diesel vehicles. Little love was won by this compromise.

The stakeholders in the conflict , with or without active advocates :

* the Rohtang La biotope , crossed by the “Great White Snake ” : Thousands of  four wheel drive cars , leaving a trail ..less than white behind them . Pristine white snow in beginning of the season turns more and more in to something resembling the floor of a oil pit in a auto shop.

* the Manali taxi drivers , who rightly remarks that paying five thousand rupees won’t make the vehicle less of a burden for the environment.

* the day tourists , many of whom have the chance of ” touching the snow” at the Rohtang as a key driving factor for coming to Manali . And now , when even the weather gods have been conspiring against them , found out yesterday that they can’t even come up to the snow line : the road always closes on Tuesdays so that Border Roads can do some effective road work. Right now the road past Marhi at 3000 meters is basically a one lane tunnel in the snow – see the photo in the sticky above.

* the Lahaulis on the other side of the pass , waiting for the first fresh veggies and provisions in months since the road closed for the winter .

* the military , who hardly needs any advocates : the Manali-Leh road probably shouldn’t even exist without the backdrop of the Aksai Chin war and the tension between India and Pakistan. At least not as early as as in 80’s.

Short term there are only two winners at the moment : the Lahaulis have a chance of seeing the road not being one of the slowest roads in India ( often five hours or more for the fifty-ish klicks from Manali to Rohtang top) in peak season. The other winners are the tourists who choose to stay and take the tour buses … until the taxi drivers block them as well.

Long term the needs of the Army and locals will be solved by the Rohtang tunnel , but that’s years off still. The tunnel won’t make any real dent in the heavy traffic over the actual pass though , except in eliminating the heavy traffic nowadays the first week(s) after the spring opening.

The mid term solution is more people in less vehicles , i.e. ( clean , CNG ) buses. Like the HRTC buses plying the full Manali-Leh road these need to be custom made : bigger than the minibuses , but still with short enough wheelbase to navigate the hairpin curves.

The really bold move here would be going for a cable car ( rope way , as the Indians put it) . This would the litterally long term solution , since it would make Rohtang La a round the year safe attraction ,like the Jade Dragon.

And yes , there is a common denominator here : the taxi drivers will suffer horribly. Sometimes everyone can’t win . Maybe this conflict will be a preparation for Delhiites in what must come at home as well : Delhi has one of the best Metros in the world – and this isn’t enough. It also has some of the foulest air in India ( and Asia , worse than Beijing ) , and this won’t change until the traffic situation changes drastically there as well.

Kathmandu Earthquake

Mounting death toll in the 7.8 earthquake , latest estimate around one thousand. Effects go way beyond the Kathmandu Valley , including eighteen dead climbers on Mt Everest . The epicenter of the second , smaller ( 6.6 ) quake close to the start of the Annapurna Circuit .

* Tribuhvan airport is out : first for repairs , and after that military aircrafts will have priority. Indian Air Force is sending in Hercules and C130 planes with rescue personell and supplies.

* Friendship Highway to Lhasa is out .

* no clear word on the Everest Base Camps , on both sides of the border. now would not be a good time.

Everest : The Hidden Story Behind The First Ascent

History. Change.

A few times it comes down to a few people . Or just one.

In 1993 a great anniversary reception was made , celebrating the first Everest ascent. All the expected persons were found on the stage , and given their due respect. And then the expedition doc Michael Ward touched a well hidden raw nerve , saying ( condensed version )

” we’ve been told that that we succeeded because of our outstanding British climbers , good leaders and strong organisation. Well , we had all of that on earlier expeditions , and we failed. Not once or twice , but eleven times. ”

He then named the final deciding factor in reaching the top : a better understanding of how the human body works , delivered by the physiologist Griffith Pugh , and taking the consequences from that .


Pugh was what we’d today would call a boots and GoreTex doc, starting as a Army doc , training British soldiers in mountain warfare during WW2. Coming in to contact with the Everest effort he recognised that that climbers failed ( and ultimately often died ) from the same factors seen in the battlefield . They failed from being exhausted from dealing with cold conditions , and being starved on water , food and oxygen. Pugh then set out systematically to change all of that. He started with redesigning clothes : exchanging buttons for zippers. Introducing taffeta lining so that the anoraks would go down , and stay down , instead of hitching up from the backpack movement. New fabrics . Constructing new double walled tents , and having them tested first in wind tunnel labs , and then on the mountain. New sleeping bags that allowed turning in your sleep. The first inflatable ground pads for climbers.

Having dealt with cold , Pugh went on to food , and introduced the ration model we today still recognise not only from climbing expeditions but also from the International Space Station. One part very well calculated rations that will cover all the essential needs of the body – and one part personal favorites chosen by each member , the stuff that makes you want to go on.

Pughs first goal however was to end oxygen starvation , and making the climbers of the 50’s accept the use of oxygen was a long and bitter fight . It had already cost the first expedition leader his job , which didn’t mean that his successor Hunt was an enthusiast.

Climbers had two reasons for their resistance . One was tradition , seeing the use of oxygen as cheating. The other reason came from bad experience. The first oxygen rigs were basically bomb plane equipment ripped out from the cockpit , giving the flow rates that had proven to work well for pilots sitting in a chair. Climbers rightfully bitterly complained over the result : heavy equipment meaning more work with little relief from the extra oxygen. Lighter kits and more than double flow rates made a dramatic change , both in how climbers performed and in accepting the idea.

Having calculated and changing the rations of food and oxygen Pugh went on to the fluid rations. The British rations were extremely low , around a half liter per day. Pugh came up with what was called “copious ” drinking at that time. The problem came from the storm kitchens used at the time : Pugh introduced new kitchens and carrying enough fuel to smelt snow and ice efficiently.

This last part came to be the least understod of the changes Pugh introduced. It’s not even clear that Pugh made any connection between dehydration and altitude sickness – a common idea that many have tried to prove , with miserable results.

The fluid rations that took Hillary and Tenzing to the top …this is the part where many will start to guess wildly , starting from 5-6 liters per day . Actually it was 3-4 liters , and this is still the the recommendation from for example the Himalyan Rescue Association , after three decades of experience of running the Pheriche first aid clinic enroute to Everest. It also comes with a warning of the risks of binging on water. The Everest success led to a tradition of stressing fluid intake , taking it to another extreme. Today we know both that you can’t perform well on low, low water rations – and that the other extreme is at least as harmful : there are well documented deaths after extreme water intake , at all altitudes. This is slowly getting acknowledged despite the high water intake theory has been a pet project for a long time : last year British National Health Service finally gave up their recommendation that all visitors at any altitude , any degree of activity should drink almost the double ration of Hillary and Tenzing ( 4-6 liters ) , and halfheartedly replaced it with ” plenty of fluids”.

( This is lightly polished version of an evening talk at the SECMOL school , involving a bucket of water going round and nearly half being thrown out the door : ” this is not the Middle Way ” . A lot came from Pughs recently published biography , Everest – The First Ascent by Harriet Tuckey . State of the art on info fluid balance at altitude can be found in the evidence based guidelines from WMS at under ” other options” . )

High Roads News Sticky , 2015 (archive)

( updates right now from behind the Great Firewall , less
snappy )

DECEMBER 21st , LADAKH SNOWLOCKED : Srinagar-Leh closed , and BRO retreats from Marhi ( south side of the Rohtang La ) and Koksar (north) . No fresh veggies in Leh for a couple of months..

December 16th : Rohtang cleared from Manali , northern slope down to Koksar to be cleared by tomorrow.

December 12th : heavy snowfall closes the Rohtang La . Eleven centimeters of snow in Keylong & Kalpa. Light snowfall over the Kunzum La @ Saach Pass.

Heavy snowfall takes out Srinagar-Jammu-Leh road and Leh airport for a day , December 11th. Twenty inches of snow in Gulmarg.

Srinagar-Jammu road , December 8th : two militants killed , four wounded in confrontation close to Srinagar : two police , one tourist , one local .

Himachal weather update , November 27th : HP receivs a brief kiss of snow at the 2000 meter level ( Shimla , Manali etc ) . Day and nigh temperatures still above zero . One cm of snow in Keylong.

SRINAGAR-LEH UPDATE , NOVEMBER 12th : Srinagar-Kargil open in alternate direction , every second day.

Srinagar , November 6th : eleven CRPF police wounded in grenade attack. Expect tense situation until Modis visit is over.

November 5th : heavy snowfall in Drass , Kargil & the Zoji La, Srinagar-Leh road closed.

OCTOBER 26TH : MAJOR EARTHQUAKE IN AFGHANISTAN , hundreds of dead , shakes northern India – so far material damages only on the Indian side. Sad day in an already torn nation.

October 24th : Rohtang La now beyond the tipping point , subzero both day and night. The snowfall predicted in the coming days will be around for a long while.

September 24th : online permits introduced for day visits to the Rohtang La at Daily quotas :

500 commercial Manali vehicles
100 commercial Himachal vehicles
100 out of state commercial vehicles
300 private vehicles

Himachal Pradesh , September 22nd : first snowfall over the Rohtang , Baralacha and Kunzum La. Open roads.

Himachal Pradesh , August 31st : eighteen dies as a local bus plummets down to the Sutlej river bank near Rekong Peo on the NH22/Hindustan-Tibet road. In a case of spectacular bad timing bus drivers in Una district shut down all traffic the same day as a protest against proposed new road safety legislation.


Jammu-Srinagar road OUT
impressive rains in Himachal , Mandi bus station under a lot of water
high and fast water in all Ladakhi rivers after days of continous rain
trekkers airlifted from Markha trek
Himachal weather forecast : more rain all coming five days
Leh , Srinagar , Kargil weather forecast : cloudy to sunny coming days
Manali Standoff , take two ( July 9th ) : NGT new hearing set to July 16th. July 6th : National Green Tribunal shut down all tourist activities at the Rohtang after previous court orders have been flaunted ( five thousand vehicles yesterday vs the permitted one thousand etc ) – and dock the pay of a number of Manali officials until changes are made. SAACH PASS OPENS , JULY 4th : this means finally all four routes to Leh are open. SPITI UPDATE , JUNE 25TH : Manali-Kaza still officially closed ( i.e. no buses yet ) , despite all contrary rumors. Bad , bad conditions from Gramphu and eastwards with snow and slush. Heavy rain predicted , also on the Shimla/Kinnaur route. J&K and Himachal weather update , June 23rd : monsoon kickoff , heavy to very heavy rain predicted coming days. Manali , May 26th : Supreme Court upholds the ruling of the National Green Tribunal : max 1000 vehicles per day to the Rohtang La , and a two tier tax on regular vs diesel vehicles. LADAKHI INROADS : JUNE 13TH : MANALI-LEH OPENS , 2015 : cfirmed on official Leh site , all vehicles , June 16th Light traffic only , still not confirmed from Le. Weather coming days : thunder , rain and some clouds. Interesting days. June 6th : Border Roads reaches the Baralacha La . Remaining road to be cleared Baralacha La to Sarchu , Leh-Sarchu already open. June 3rd : Rohtang weather coming days : snow and rain. + 4 degrees lowest nights in Keylong , still just under zero at the Rohtang. May 28th : Manali Taxi Union strike ends : same traffic limitations to the Rohtang , taxes on hold until June 8th. May 26 : Snowfall over the Rohtang and in Keylong (!) takes out the road again. Manali , May 22nd : Supreme Court rejects Manali Taxi Unions plea for a stop to the traffic limitations to the Rohtang La & diesel tax. Full hearing May 26th. Manali , May 20th : very calm days on the road below the snowline , with the NGT cap and taxi union strike. See separate post below. When the traffic over the Rohtang resumes : 1) no traffic on Tuesdays , same procedure as every year , only Border Roads maintenance 2) second priority HRTC buses for Lahaul , and eventually Leh . 3) third priority Rohtang day trippers , only 1000 vehicles per day , and the new diesel tax. Manali-Leh , May 15th : Rothang La open for cars , not buses . Open road from Keylong to Darcha. Temperatures still dancing just above/below the freezing point at the Rohtang La : still time for more avalanches. May 11h : HRTC buses now running from Koksar ( north side of the Rohtang ) up to Key long . May 4th : Rohtang cleared from Manali beyond Marhi up to Rani Nullah , i.e. six kilometers from Rohtang top. On the north side the bulldozers have grinded to a halt , after using up all the stockpiled fuel. Fuel to be airlifted in. Srinagar-Leh fully open , May 25th Srinagar-Leh OPEN , May 8th : Light vehicles only first , buses and trucks to follow after more work by the BRO. Fresh veggies for all – congrats ! May 2nd : first crossings of the Zoji La – on foot. April 18th : Zoji La cleared almost cleared now , from both sides. Borders Roads new goal to open within a week .Weather forecast coming days : mix of clouds , some more snow at the high end of the road, and later sunny . ZANSKAR : Kargil-Padum road open SPITI UPDATE June 23rd : some second and third hand reports of the Kunzum La now opened , no details. June 7th : open road Shimla-Kaza-Losar , BRO has ( one report so far ) reached the Kunzum La. . Manali-Kaza still closed after Batal . NEPAL , MAY 12th : NEW 7+ EARTHQUAKE, epicenter 68 klicks west of Namche Bazaar. Friendship Highway from Kathmandu to Lhasa out already after the first earthquake – massive destruction in Kodari/Dram