Adherence

to

HAART

therapy

measured

by

electronic

monitoring

in

newly

diagnosed

HIV

patients

in

Botswana

Aims

This

pilot

study

was

designed

to

evaluate

the

feasibility

and

benefits

of

electronic

adherence

monitoring

of

antiretroviral

medications

in

HIV

patients

who

recently

started

Highly

Active

Anti

Retroviral

Therapy

-LRB-

HAART

-RRB-

in

Francistown

Botswana

and

to

compare

this

with

self-reporting

Introduction

Botswana

is

one

of

the

countries

worst

affected

by

the

HIV

pandemic

with

a

prevalence

of

approximately

of

the

entire

population

-LSB-

-RSB-

An

estimated

of

those

aged

years

are

HIV-positive

and

it

is

estimated

that

one

in

every

eight

children

is

born

with

HIV

-LSB-

-RSB-

Since

the

nation

has

embarked

on

the

provision

of

antiretroviral

drugs

for

all

its

eligible

citizens

by

implementing

the

MASA

program

-LRB-

The

national

antiretroviral

therapy

program

was

given

the

name

MASA

the

Setswana

world

for

dawn

-RRB-

The

use

of

potent

antiretroviral

combinations

has

provided

unprecedented

opportunities

for

effectively

treating

HIV

disease

by

suppressing

viral

replication

and

has

led

to

dramatic

decline

in

HIV

mortality

-LSB-

-RSB-

Adherence

to

antiviral

regimens

in

HIV

infected

patients

is

essential

for

adequate

suppression

of

viral

replication

When

adherence

falls

below

a

certain

level

intermittent

viremia

will

occur

and

this

may

increase

the

chance

of

the

development

of

resistant

strains

possibly

followed

by

therapy

failure

-LSB-

-RSB-

In

contrast

nonadherence

to

the

prescribed

antiretroviral

regimens

is

associated

with

a

rapid

selection

of

resistant

HIV

strains

resulting

in

treatment

failure

-LSB-

-RSB-

The

required

high

level

of

antiretroviral

drug

adherence

in

a

poor

resource

setting

remains

therefore

a

serious

concern

Assessment

of

adherence

in

HIV

patients

such

as

in

this

pilot-study

may

also

provide

tools

to

allow

feedback

and

education

on

an

individual

health

care

provider

patient

base

For

this

reason

patients

in

the

Botswana

Infectious

Disease

Care

Centers

-LRB-

IDCC

-RRB-

treatment

program

are

urged

at

each

visit

to

the

IDCC

facility

to

comply

with

the

prescribed

ART

regimen

This

occurs

in

three

stages

-LRB-

-RRB-

in

group

instruction

sessions

together

with

other

HIV

patients

and

individual

counselling

by

a

trained

nurse

or

pharmacist

-LRB-

-RRB-

by

their

individual

health

care

provider

-LRB-

physician

-RRB-

and

-LRB-

-RRB-

by

the

pharmacist

In

addition

patients

are

usually

accompanied

by

a

close

family

member

who

is

asked

to

assist

or

remind

patients

of

the

pill

intake

-LRB-

adherence

partner

-RRB-

Reliable

information

about

the

actual

tablet

intake

is

a

prerequisite

for

any

form

of

management

or

modification

of

the

adherence

to

therapy

It

has

been

recognised

that

many

of

the

traditional

methods

of

assessing

adherence

such

as

pill

counts

diaries

or

self-reports

are

unreliable

Electronic

monitoring

enables

the

recording

of

the

time

points

of

pill

bottle

openings

This

method

also

has

drawbacks

and

may

underestimate

adherence

-LSB-

-RSB-

and

of

course

it

does

not

provide

evidence

of

actual

ingestion

of

the

drug

-LSB-

-RSB-

Despite

these

drawbacks

it

has

been

so

far

the

closest

to

a

gold

standard

for

adherence

measuring

-LSB-

-RSB-

although

other

methods

remain

of

value

A

new

method

to

measure

adherence

to

prescribed

medication

regimen

is

the

use

of

electronic

monitoring

-LSB-

-RSB-

Such

systems

commonly

rely

upon

a

microprocessor

located

in

the

cap

of

the

medication

container

where

time

and

date

of

each

opening

are

recorded

Each

cap

opening

and

closing

is

assumed

to

reflect

a

single

medication-taking

event

The

data

stored

in

the

microprocessor

are

transferred

to

a

computer

database

and

uploaded

for

analysis

-LSB-

-RSB-

Other

methods

like

self-reporting

pharmacy

records

and

pill

counts

tend

to

overestimate

patient

adherence

by

anywhere

from

-LSB-

-RSB-

This

study

was

designed

as

a

pilot

study

to

evaluate

electronic

adherence

monitoring

in

an

HIV

infected

patient

group

that

was

put

on

antiretroviral

medication

for

the

first

time

A

secondary

objective

was

to

compare

the

adherence

measured

by

electronic

monitoring

with

that

of

self-reporting

by

means

of

a

medication

diary

Methods

Patients

Thirty

consecutive

patients

were

recruited

into

the

study

during

the

period

October

All

were

patients

with

an

AIDS-defining

illnesses

and/or

cell

counts

-LRB-

uL

-RRB-

who

were

offered

HAART

according

to

the

Botswana

Guidelines

on

Antiretroviral

Treatment

-LSB-

-RSB-

All

patients

were

ARV-naïve

Design

This

was

a

trial

in

which

treatment-naïve

patients

were

monitored

with

regard

to

adherence

to

prescribed

anti-HIV

medication

Patients

were

not

informed

about

the

use

blinded

of

the

electronic

monitoring

system

and

were

only

asked

to

return

their

pill-bottles

at

each

visit

to

the

pharmacy

when

they

returned

for

a

refill

and

a

consultation

Patients

were

also

supplied

with

a

self-reporting

form

The

study

did

not

involve

study

related

interventions

and

the

subjects

were

not

required

to

change

behaviour

in

any

way

The

subjects

were

informed

that

the

medication

was

supplied

in

special

containers

that

had

to

be

returned

to

the

clinic

but

not

about

the

monitoring

system

to

prevent

bias

The

study

was

approved

by

the

hospital

management

and

the

chief

physician

of

the

department

of

internal

medicine

Treatment

regimens

The

treatment

regimen

used

consisted

of

reverse

transcriptase

inhibitors

-LRB-

NRTIs

-RRB-

plus

nonnucleoside

reverse

transcriptase

inhibitor

-LRB-

NNRTI

-RRB-

Patients

started

the

recommended

first-line

treatment

with

three

different

agents

These

were

zidovudine

and

lamivudine

in

a

combination

tablet

Combivir

-LRB-

CBV

-RRB-

plus

efavirenz

-LRB-

EFV

-RRB-

or

nevirapine

-LRB-

NVP

-RRB-

Male

and

female

patients

who

were

not

anaemic

were

prescribed

Combivir

medication

whereas

anaemic

patients

-LRB-

Hb

mmol

-RRB-

were

given

stavudine

-LRB-

-RRB-

and

lamivudine

medication

The

stavudine

dose

was

adjusted

according

to

bodyweight

-LRB-

or

mg

-RRB-

All

patients

except

females

in

the

reproductive

age

category

were

given

once

daily

EFV

All

females

of

the

former

category

were

prescribed

NVP

at

a

mg

once

daily

dose

for

days

which

after

assessing

the

liver

function

parameters

was

increased

to

mg

twice

daily

The

continuation

of

NVP

or

EFV

was

dependent

on

the

absence

of

significant

rise

in

hepatic

enzymes

-LRB-

AST

and

ALT

-RRB-

Approximately

of

those

who

started

the

NVP

or

EFV

treatment

are

able

to

continue

this

medication

Patients

returned

to

the

IDCC

after

a

month

for

a

medical

check

and

refill

of

their

prescription

unless

clinical

events

dictated

earlier

visits

to

the

clinic

The

treatment

starters

were

booked

to

see

the

doctor

after

the

first

weeks

of

therapy

After

seeing

the

doctor

the

self

recorded

medication

card

and

the

electronic

monitors

were

collected

and

the

data

stored

in

the

microprocessor

were

transferred

to

a

database

in

the

computer

Following

this

each

bottle

was

refilled

and

provided

with

a

new

label

with

medication

instructions

Most

patients

received

a

refill

for

a

period

of

month

some

however

for

a

shorter

period

The

potential

side

effects

were

discussed

with

each

patient

The

results

of

the

first

analysis

of

the

electronic

monitors

were

not

used

in

any

counselling

The

electronic

monitors

were

MEMS

IV

Track

Cap

devices

-LRB-

Aardex

Zug

Switzerland

-RRB-

with

a

MEMS

IV

Communicator

for

read-out

of

the

results

Study

endpoints

The

primary

study

endpoint

was

the

adherence

level

measured

-LRB-

over

a

minimal

period

of

weeks

-RRB-

by

the

percentage

of

days

on

which

the

patients

took

a

correct

dosing

over

the

monitored

period

Adherence

was

also

expressed

as

the

number

of

pill-intakes

recorded

on

a

self-reporting

forms

designed

to

reflect

the

intended

schedule

and

timing

of

treatment

In

the

event

a

patient

opened

his/her

bottle

more

than

was

prescribed

-LRB-

surplus

opening

-RRB-

it

was

assumed

that

the

patient

correctly

took

the

prescribed

pills

However

occasions

on

which

a

patient

opened

less

than

the

prescribed

dose

frequency

were

considered

as

adherence

failures

Sequence

and

duration

of

trial

period

Each

patient

was

immediately

given

counselling

and

made

familiar

with

the

ART

treatment

During

the

counselling

session

emphasis

was

given

with

regard

to

the

need

of

strict

adherence

of

the

prescribed

medication

and

to

methods

to

prevent

disease

transmission

They

were

also

informed

about

the

self-reporting

form

and

given

a

pen

to

mark

taking

a

treatment

with

a

cross

ART

medication

was

started

thereafter

and

the

adherence

to

the

pill

intake

schedule

was

monitored

by

means

of

using

electronic

monitors

and

self-recording

for

a

period

of

weeks

At

the

start

of

the

treatment

electronic

monitors

containing

medication

for

a

period

of

weeks

were

provided

After

an

evaluation

by

the

doctor

at

day

of

treatment

the

electronic

monitors

and

self-reporting

form

were

collected

and

the

data

in

the

microprocessor

were

entered

in

the

database

The

electronic

monitors

were

subsequently

refilled

with

medication

for

the

next

period

of

month

A

new

self-reporting

form

was

also

given

Patients

were

given

-LRB-

in

case

of

Lamivudine/Zidovudine

NVP

or

EVF

-RRB-

or

electronic

monitors

-LRB-

in

case

and

NVP

or

EFV

-RRB-

Patients

recruited

in

the

study

were

asked

to

return

the

electronic

caps

and

the

self-reporting

form

on

each

occasion

of

a

visit

to

the

IDCC

A

self-reporting

form

was

issued

at

the

start

of

the

study

This

form

contains

rows

where

the

patient

had

to

mark

with

x

each

time

they

took

the

pill

at

the

correct

time

As

some

people

in

Botswana

could

not

read

or

write

this

form

was

kept

very

basic

A

pencil

was

given

to

every

patient

who

participated

in

the

study

Results

A

total

of

HIV

infected

adults

were

enrolled

in

the

study

In

five

patients

full

data

could

not

be

obtained

because

of

various

reasons

This

leaves

an

evaluable

group

of

-LRB-

male

female

average

age

years

range

years

-RRB-

Twenty

patients

completed

the

monitoring

period

and

the

mean

follow-up

period

was

days

-LRB-

range

days

-RRB-

The

reasons

for

lack

of

follow-up

in

the

five

patients

varied

but

in

three

patients

it

was

due

to

mortality

In

these

three

cases

as

the

relatives

or

nursing

staff

did

not

know

about

the

value

of

the

medication

bottle

-LRB-

due

to

the

blinding

of

the

patients

-RRB-

the

bottles

were

not

returned

One

patient

was

admitted

to

hospital

where

the

nursing

staff

discarded

the

pill

bottles

One

patient

failed

to

return

for

follow-up

Full

follow-up

was

not

obtained

in

another

five

patients

for

various

reasons

This

included

technical

failure

of

the

compliance

monitor

in

two

cases

and

a

change

in

the

return

date

of

the

subjects

who

then

received

a

refill

in

a

normal

container

Adherence

assessed

from

the

dosing

histories

compiled

by

electronic

monitoring

are

shown

in

Table

Table

-LRB-

-RRB-

of

the

patients

-LRB-

n

-RRB-

by

MEMS

caps

and

self-reportingPatient

numberTCFollow-up

-LRB-

days

-RRB-

MEMSSelf

reportLamivudine

zidovudine

-LRB-

bd

-RRB-

EFV

-LRB-

od

-RRB-

Lamivudine

-LRB-

bd

-RRB-

NVP

-LRB-

od/bd

-RRB-

-LRB-

bd

-RRB-

Drop

out/non-retrievel

codes

-LRB-

TC

-RRB-

are

Lamivudine/zidovudine

Efavirenz

-LRB-

EFV

-RRB-

Lamivudine/Zidovudine

Nevirapine

-LRB-

NVP

-RRB-

Lamivudine

Nevirapine

and

stavudine

-LRB-

-RRB-

and

Lamivudine

and

Efavirenz

MEMS

indicates

the

data

combined

for

all

different

treatments

Patient

numbers

are

not

consecutive

because

patients

who

died

have

been

omitted

Reasons

for

drop

out

and

nonretrieval

death

MEMS

thrown

away

missed

by

investigator

-LRB-

patients

showed

up

on

another

date

than

the

investigator

expected

-RRB-

and

lost

to

follow-up

Assuming

that

surplus

opening

of

the

bottles

was

associated

with

correct

medication

intake

the

mean

adherence

level

was

-LRB-

SD

range

-RRB-

When

surplus

openings

were

calculated

as

incorrect

the

adherence

decreased

to

-LRB-

SD

range

-RRB-

-LRB-

data

not

shown

-RRB-

Seven

patients

-LRB-

-RRB-

had

an

adherence

under

a

level

at

which

virological

failure

increases

substantially

-LSB-

-RSB-

Examples

of

the

medication

records

obtained

from

the

electronic

monitoring

device

are

shown

in

Fig.

for

a

patient

with

good

adherence

and

a

patient

with

low

adherence

to

the

regimen

Fig.

of

data

of

from

patients

with

good

and

respectively

poor

adherence

Adherence

assessed

by

means

of

self-reporting

The

mean

adherence

assessed

by

means

of

self-reporting

of

medication

intake

was

with

two

-LRB-

-RRB-

patients

recording

adherence

level

lower

than

Adherence

by

self-reporting

differed

significantly

from

the

adherence

measured

by

the

MEMS

monitors

method

-LRB-

p

paired

t-test

-RRB-

Three

patients

did

not

hand

in

their

diary

Discussion

In

this

pilot

study

we

assessed

the

use

of

MEMS

monitors

to

study

the

adherence

to

antiretroviral

medication

prescribed

for

HIV

patients

living

in

a

low

resource

health

care

system

We

demonstrated

that

assessment

of

adherence

with

this

technique

is

feasible

and

may

provide

useful

results

There

was

an

approximately

drop-out

rate

of

the

recruited

patients

due

to

inability

to

recover

data

or

early

mortality

This

may

seem

unacceptable

in

a

well-resourced

health

care

system

It

is

a

reality

in

many

countries

where

patients

present

with

much

more

advanced

disease

when

there

are

sometimes

great

difficulties

coming

to

the

hospital

and

patients

can

often

not

be

reached

by

telephone

or

mail

as

they

do

not

regularly

have

a

postal

address

It

is

likely

that

some

association

exists

between

failure

to

return

to

the

hospital

and

adherence

to

the

drug

regimen

and

the

current

patient

set

therefore

may

reflect

an

overestimation

of

adherence

Self-reporting

of

medication

intake

has

been

shown

to

be

less

reliable

than

the

MEMS

monitors

-LSB-

-RSB-

Therefore

it

is

not

surprising

that

patients

recorded

adherence

levels

which

were

considerably

higher

compared

with

those

assessed

by

the

presumably

more

objective

electronic

monitors

Clearly

of

the

methods

used

to

measure

adherence

record

actual

intake

of

medication

and

there

are

even

indications

that

at

least

in

some

instances

self-reporting

is

a

more

accurate

record

of

adherence

-LSB-

-RSB-

Despite

these

findings

we

consider

the

MEMS

monitors

more

appropriate

for

a

developing

country

with

a

larger

potential

for

illiteracy

Patients

knowledge

about

the

monitoring

of

compliance

will

likely

affect

the

absolute

level

of

compliance

-LSB-

-RSB-

but

there

are

no

reasons

why

the

relative

ranking

of

compliance

amongst

patient

groups

is

affected

and

the

device

can

still

be

used

to

improve

adherence

In

this

study

we

chose

not

to

inform

the

patients

about

the

use

of

the

monitoring

device

One

of

the

critics

often

cited

about

the

electronic

monitor

is

that

the

opening

of

the

bottle

does

not

prove

ingestion

However

it

has

been

shown

recently

that

projected

plasma

concentrations

based

on

electronically

compiled

dosing

histories

correlates

very

well

with

directly

measured

concentrations

-LSB-

-RSB-

It

has

also

been

shown

that

t

in

HIV

patients

electronically

compiled

dosing

histories

strongly

correlates

with

viral

suppression

or

the

occurrence

of

virological

failure

-LSB-

-RSB-

It

is

therefore

assumed

that

this

method

is

a

fair

reflection

of

medication

intake

-LSB-

-RSB-

In

this

small

study

performed

in

HIV

patients

some

subjects

opened

their

bottles

more

often

than

needed

-LRB-

surplus

opening

-RRB-

Such

surplus

opening

was

not

considered

as

nonadherence

-LRB-

in

that

case

our

reported

adherence

level

would

be

lower

-RRB-

If

surplus

opening

had

led

to

extra

intake

of

medication

it

would

not

have

contributed

the

endpoints

of

virological

failure

or

the

induction

of

resistance

We

assume

therefore

that

such

surplus

opening

of

the

pill

bottles

had

occurred

for

other

reasons

Surplus

openings

occurred

especially

in

the

group

of

patients

that

had

to

take

a

once

daily

regimen

together

with

twice

daily

regimens

These

extra

openings

occurred

often

at

the

same

time

as

when

the

prescribed

twice-daily

regimen

was

taken

This

may

have

occurred

because

the

patients

were

unsure

about

which

bottle

belonged

to

which

medication

This

may

indicate

that

clearer

labelling

is

essential

especially

in

an

illiterate

society

Under-opening

most

likely

reflects

nonadherence

although

it

can

not

be

excluded

that

in

some

cases

patients

removed

several

tablets

at

the

same

time

However

such

behaviour

is

highly

likely

to

increase

the

chance

of

erroneous

medication

intake

and

was

for

this

reason

registered

as

nonadherence

Several

studies

have

indicated

that

medication

adherence

lower

than

approximately

increases

the

chance

of

virological

failure

and

the

development

of

resistant

virus

strains

-LSB-

-RSB-

The

result

of

this

pilot

study

indicates

that

even

after

careful

counseling

and

guidance

a

significant

number

of

patients

did

not

manage

to

adhere

sufficiently

to

the

twice-daily

pill

intake

regimen

This

observation

study

was

too

short

to

allow

an

analysis

of

the

clinical

impact

of

the

observed

low

adherence

in

such

patients

on

the

development

of

virological

failure

Additionally

reliable

measurement

of

viral

load

was

impossible

in

the

hospital

However

our

data

did

help

to

identify

some

patients

with

low

adherence

at

the

start

of

treatment

and

allowed

a

diversion

of

scarce

resources

for

extra

counseling

for

such

patients

The

outcome

of

monitoring

pill

intake

by

the

electronic

monitors

may

therefore

assist

in

timely

counseling

of

patients

with

regard

to

their

medication

intake

and

persistence

with

the

prescribed

regimen

Adherence

measurements

by

means

of

using

electronic

monitors

together

with

self

and

adherence

partner

recording

of

pill

intake

are

likely

to

be

useful

in

a

much

needed

larger

long-term

and

more

comprehensive

adherence

study

in

a

low-resource

health-care-system

setting

Such

a

study

can

contribute

to

directed

efforts

to

optimise

the

treatment

of

HIV-infected

patients

worldwide

B O B O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O B O O O O O O O O O O O O O O O O B B O O O O O O O B O O O O O O O O O O O O O O O O O O O B O O O O O O B O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O


Triggering for Submaximal Exercise Level in Gastric Exercise Tonometry : Serial Lactate , Heart Rate , or Respiratory Quotient ? Gastric exercise tonometry is a functional diagnostic test in chronic gastrointestinal ischemia . As maximal exercise can cause false-positive tests , exercise buildup should be controlled to remain submaximal . We evaluated three parameters for monitoring and adjusting exercise levels -LRB- heart rate -LSB- HR -RSB- , respiratory quotient -LSB- RQ -RSB- , and serial lactate measurements -RRB- in 178 tests in both healthy volunteers and patients suspected of gastrointestinal ischemia . Exercise levels above submaximal occurred in 20 % of HR - , 2 % of RQ - , and 5 % of lactate-monitored tests -LRB- P < 0.05 for HR vs. RQ and lactate -RRB- . Low levels were seen in 5 % of HR - , 10 % of RQ - , and 41 % of lactate-monitored tests -LRB- P < 0.01 for lactate vs. HR and RQ -RRB- . High levels resulted in 43 % false-positive tonometry results compared to 19 % of all tests -LRB- P < 0.001 -RRB- ; low levels did not result in more false negatives -LRB- 5 % vs. 6 % -RRB- . Although RQ monitoring yielded the greatest proportion of optimal exercise tests , serial lactate monitoring is our method of choice , combining optimal diagnostic accuracy , low cost , and simplicity . Introduction For diagnosis in patients with suspected chronic gastrointestinal ischemia , we have previously shown that gastric exercise tonometry can be used as a functional test providing information about the adequacy of the gastrointestinal mucosal perfusion -LSB- 1 , 2 -RSB- . In these studies it was demonstrated that during 10 min of submaximal exercise , gastric ischemia occurred only in patients with splanchnic artery stenosis . An extreme exercise level may cause false-positive tests , as shown in a study in healthy volunteers , where lactate levels exceeding 8 mM resulted in gastric ischemia in 50 % -LSB- 3 -RSB- . Furthermore , it may be conceivable that exercise of very low intensity can lead to false-negative results in exercise tonometry used for diagnosing chronic gastrointestinal ischemia . In order to prevent false-positive and false-negative tonometry tests , the exercise intensity should be monitored throughout the test , and if necessary , adjustments of the workload should be made in order to obtain an optimal exercise test . Exercise intensity can be monitored by various parameters including arterial plasma lactate concentration , decrease in serum arterial base excess -LRB- BE -RRB- or bicarbonate concentration -LRB- which are both directly related to lactate level -RRB- , heart rate -LRB- HR -RRB- , and respiratory parameters -LSB- respiratory gas exchange ratio -LRB- RQ -RRB- = carbon dioxide output -LRB- VCO2 -RRB- / oxygen uptake -LRB- VO2 -RRB- -RSB- -LSB- 4 -RSB- . In this study we evaluated and compared three consecutive time periods in each of which a different parameter was used for monitoring the exercise intensity and adjusting the workload in order to obtain a submaximal exercise test . Initially HR monitoring was used ; in the second period exercise intensity monitoring and adjustment were guided by monitoring of RQ . In the final period exercise intensity was monitored by serial rapid lactate measurements . Subjects and methods In 10 volunteers -LRB- 5 females , 5 males ; mean age , 25 years ; range , 23 -- 28 years -RRB- and 157 patients -LRB- 59 males , 98 females ; median age , 55 years ; range , 13 -- 82 years -RRB- , 178 tonometry exercise tests were performed . The volunteers were tested as part of a more extensive study investigating the effect of two different exercise levels on gastric tonometry -LSB- 3 -RSB- . All patients were suspected of having symptomatic chronic gastrointestinal ischemia . Their clinical presentation was that of unexplained abdominal pain , weight loss , diarrhea , or gastric ulcers . Gastric tonometry exercise testing was performed as a diagnostic function test in addition to duplex sonography and selective angiography of the splanchnic vessels . Some of the patients in this study have been previously described in a publication by our group investigating the diagnostic potential of gastric exercise tonometry -LSB- 1 -RSB- . The procedure of gastric tonometry exercise testing was described in detail in a previous study -LSB- 3 -RSB- . In short , a standard nasogastric tonometry catheter was inserted and connected to an automated air tonometry device that was set up to measure intragastric partial carbon dioxide pressure -LRB- PCO2 -RRB- every 10 min . All subjects were studied after a fasting episode of 4 hr . Ranitidine , 100 mg , was given intravenously 90 min prior to exercise testing . A radial artery catheter was introduced in the nondominant arm to allow sequential arterial blood sampling . Exercise was performed on an electromagnetically braked bicycle ergometer -LRB- Lode , Groningen , Netherlands -RRB- . Monitoring exercise intensity and adjusting the workload The maximal workload -LRB- Wmax -RRB- was estimated using standard criteria , i.e. , age , sex , and weight -LSB- 5 -RSB- . The exercise episode was started at 10 % of Wmax , and in the first 4 -- 6 min the workload was increased every minute by 10 % of Wmax . The workload was intended to remain constant thereafter at a submaximal exercise level . Three different approaches for monitoring the exercise intensity and -- if necessary -- guiding additional adjustments of the workload were evaluated in consecutive periods . First period : HR-triggered tests Exercise intensity was monitored by measuring HR , aiming for a HR in the last 4 -- 5 min of 80 % of maximal predicted HR -LRB- HRmaxpred -RRB- . HRmaxpred was calculated by the following formula : HRmaxpred = 210 − 0.65 , age -LSB- 6 -RSB- . Second period : Respiratory gas exchange ratio -LRB- RQ -RRB- - triggered tests The workload adjustments were guided by measurement of the RQ , aiming for an RQ of 1.0 in the last 4 -- 5 min of the exercise episode . This RQ was chosen as it indicates the anaerobic threshold Third period : Lactate-triggered tests In 40 of the RQ-triggered tests serial rapid lactate measurements were done during exercise at t = 0 , 4 , 6 , 8 , and 10 min . These measurements were not used for guiding the exercise intensity , but to develop a lactate-based exercise triggering protocol . From the results of rapid serial lactate measurements in the RQ-triggered period , an algorithm was developed for triggering the exercise intensity -LRB- see Table 1 -RRB- . We aimed for a lactate concentration of 4 mM in the last 4 min of the test . In parallel with RQ triggering at an RQ value of 1.0 , this lactate level resembles the anaerobic threshold , at which redistribution of blood flow patterns is initiated.Table 1Algorithm for lactate-guided exercise intensity adjustmentsStart at 10 % of predicted WmaxIncrease workload by 10 % of Wmax every minute -LRB- at t = 1 , 2 , 3 , 4 , 5 , and 6 min -RRB- Lactate measurements at t = 4 , 6 , 8 , and 10 minIf lactate > 3 mM , decrease workload by 10 % of WmaxIf lactate not > 1 mM , increase 2 × 10 % of Wmax In the first two periods -LRB- HR and RQ triggering -RRB- the tests were performed at the pulmonary function department of our hospital . During these exercise tests a 12-lead electrocardiogram was recorded -LRB- Case 12 ; Marquette Electronics Inc. , Milwaukee , WI , USA -RRB- . HR was recorded every minute . Breath-by-breath oxygen uptake -LRB- VO2 -RRB- and RQ were measured by a respiratory gas analyzer system -LRB- Oxycon-α ; Jaeger , Bunnik , the Netherlands -RRB- and recorded every 30 sec . In the third period -LRB- rapid serial lactate triggering -RRB- the test was performed at the gastroenterology function department ; HR was monitored , but respiratory parameters were not monitored . Arterial blood samples for determination of base excess -LRB- BE -RRB- , bicarbonate -LRB- blood gas analyzer ; Radiometer ABL520 , Copenhagen , Denmark -RRB- , and lactate -LRB- enzymatic assay ; Cobas Fara ; Roche Diagnostics , Branchburg , NJ , USA -RRB- were drawn , in parallel with the 10-min tonometry interval , before and immediately at the end of the 10-min exercise episode . Rapid serial lactate measurements were performed using a small portable lactate analyzer -LRB- Accutrend ; Roche Diagnostics , Almere , the Netherlands -RRB- , specifically developed for use during exercise testing . Using this device , measurement results were available within 60 sec after blood sampling . The tests evaluated in the present study were all aimed at a submaximal level : lactate level -LRB- or BE decrease -RRB- at or just above 4 mM -LRB- the anaerobic threshold -RRB- and not exceeding 8 mM . After comparison with arterial lactate measurements -LRB- see Results -RRB- , BE decrease during exercise was used as the parameter assessing the exercise intensity -LRB- Fig. 1 -RRB- . The optimal exercise level was a BE decrease of between 3 and 7 mM . Less than 3 mM and more than 7 mM were regarded as low and high exercise levels , respectively.Fig . 1Relationship between arterial lactate concentration after exercise and BE decrease at the end of the exercise period For comparing the results of HR and RQ measurements with BE decrease as the indicator of the exercise intensity reached , the following parameters were used : maximum RQ reached -LRB- RQmax -RRB- , total time RQ > 1 -LRB- RQt > 1 -RRB- , maximum heart rate reached -LRB- HRmax -RRB- as a percentage of HRmaxpred , and total time of HR > 80 % of HRmaxpred -LRB- HRt > 80 -RRB- . Statistics All values are given as mean ± SD unless otherwise stated . P values < 0.05 were considered statistically significant . Correlations between lactate and BE and lactate and bicarbonate decrease , and between both HR and RQ parameters and exercise intensity as measured by BE decrease , were calculated using Spearman 's rank test . For comparison of HR and RQ parameters with exercise level -LRB- as divided into low , optimal , or high -RRB- , one-way ANOVA with Bonferroni post hoc analysis was used . Group comparisons of the tonometry results of high and low exercise levels versus all tests and the diagnostic accuracy of tonometry in the different monitoring episodes were performed using chi-square testing . Results HR triggering In 39 tests -LRB- 10 in healthy volunteers and 29 in patients -RRB- HR triggering was used . In 22 -LRB- 56 % -RRB- of these HR-triggered tests the mean HR in the last 4 min equaled the target HR of 80 % ± 5 % of HRmaxpred . In nine tests -LRB- 23 % -RRB- the target HR was not reached ; in five of these the subjects were using β-blocking medication . In eight tests -LRB- 20 % -RRB- the HR was > 85 % of HRmaxpred . The resulting exercise levels as measured by BE decrease are listed in Table 2 . In three tests the exercise intensity was too low . In two the target HR was not reached ; one of the subjects used β-blockers . Two tonometry results were true negative ; the other was false positive.Table 2Resulting exercise intensities for the three triggering regimesExercise level -LRB- BE decrease , < 3 mM -RRB- -LRB- BE decrease , 3 -- 7 mM -RRB- -LRB- BE decrease , > 7 mM -RRB- Triggering methodLowTargetHighHR -LRB- 39 tests -RRB- 3 -LRB- 8 % -RRB- 27 -LRB- 69 % -RRB- 9 -LRB- 23 % -RRB- * RQ -LRB- 84 tests -RRB- 8 -LRB- 10 % -RRB- 74 -LRB- 88 % -RRB- 2 -LRB- 2 % -RRB- Lactate -LRB- 55 tests -RRB- 23 -LRB- 41 % -RRB- ** 29 -LRB- 53 % -RRB- * 3 -LRB- 5 % -RRB- Note . Values are given as numbers -LRB- percentage of total for triggering method -RRB- . * P < 0.05 and ** P < 0.001 comparing the three triggering regimes . Of the eight tests with an erroneously high exercise level , in only one test was the HR too high . The other six tests in which the HR was too high resulted in the submaximal exercise levels aimed for . When analyzing the 110 tests in which both HR and RQ were recorded , only a weak correlation was observed both between HRmax and exercise intensity and between HRt > 80 and exercise intensity as measured by BE decrease -LRB- r = 0.23 and r = 0.20 , respectively ; P < 0.05 -RRB- . There was no significant difference for the HR-derived parameters comparing low , target , and high exercise intensity . Figure 2 displays the comparison of HRmax for the three exercise intensity groups.Fig . 2HRmax -LRB- 95 % confidence interval -RRB- at low , target , and high exercise levels HRmax is expressed as percentage HRmaxpred RQ triggering In 84 tests RQ triggering was used . In 67 -LRB- 80 % -RRB- of these tests the target RQ of 1.0 was reached while the mean RQ in the last 4 min was 1.0 ± 5 % . In 11 tests -LRB- 13 % -RRB- the target RQ was not reached and in 6 tests -LRB- 7 % -RRB- the mean RQ in the last 4 min exceeded the target RQ by more than 5 % . Of the eight tests with a low exercise level , the target RQ was not reached in four . In both tests with a too high exercise intensity , the mean RQ in the last 4 min was > 1.05 . When analyzing all 110 tests in which RQ was monitored , positive correlations were found for comparing RQmax and RQt > 1 with BE decrease -LRB- r = 0.34 and r = 0.38 , respectively ; P < 0.0005 -RRB- . When divided into low , target , and high exercise intensity groups , both RQmax and RQt > 1 showed significant differences among the three groups -LRB- P < 0.0005 ; one-way ANOVA with Bonferroni post hoc analysis -RRB- . Figure 3 displays the comparison of RQmax for the three exercise intensity groups . Lactate triggering In 55 tests lactate triggering was used . In 26 of these tests the target lactate level of 4.0 mM in the last 2 -- 4 min was not reached . This resulted in a BE decrease below 3 mM in 19 tests . In two tests the rapid lactate measurements exceeded 8 mM at t = 6 or 8 min . In one , the resulting exercise level was too high -LRB- BE decrease > 7 mM -RRB- . Of the 27 tests in which the target lactate levels were reached -LRB- at least 4 mM at t = 6 or 8 min , and remaining below 8 mM -RRB- , the resulting exercise levels were too low in 7 and too high in 2 . Arterial lactate vs BE decrease and bicarbonate decrease In 78 tests both arterial lactate levels and blood gas parameters were obtained . A high degree of correlation of both BE decrease and bicarbonate decrease with lactate level after exercise was found : r = 0.93 and r = 0.89 , respectively -LRB- P < 0.0005 -RRB- . Figure 1 displays the relation between arterial lactate and BE decrease after exercise . Mean paired difference between lactate and BE decrease was 0.7 -LRB- SD , 0.7 -RRB- mM , and that between lactate and bicarbonate decrease was 1.4 -LRB- SD , 0.9 -RRB- mM . Comparison accuracy of exercise tonometry at low , target , and high exercise levels As shown in Table 1 , lactate triggering resulted in significantly more low exercise levels compared to the other two regimes -LRB- P < 0.001 -RRB- . Fig. 3RQmax -LRB- 95 % confidence interval -RRB- at low , target , and high exercise levels False-negative tonometry results were found in 10 of all 178 tests -LRB- 6 % -RRB- . Low exercise levels did not result in an increase in false-negative tonometry tests : in only 2 of 10 -LRB- 5 % -RRB- false-negative tests was the exercise level too low ; 1 test was RQ-triggered , the other lactate-triggered . Tonometry results were false positive in 34 of all 178 tests -LRB- 19 % -RRB- . Of the 14 tests with a too high exercise level , in 6 -LRB- 43 % -RRB- the tonometry tests were false positive -LRB- P < 0.001 comparing high exercise level vs. all tests -RRB- . Three of these tests were HR-triggered -LRB- but HR did not exceed the target HR -RRB- , two RQ-triggered , and one lactate-triggered . The sensitivity and specificity of tonometry exercise testing for gastrointestinal ischemia did not differ among the three groups -LRB- 82 % and 73 % , respectively -RRB- . Discussion For optimal diagnostic accuracy , the exercise level in gastric exercise tonometry can be monitored and adjusted by RQ measuring or , alternatively , by serial arterial lactate measurement . Although the latter resulted in more tests with lower than desired exercise levels , this had no influence on diagnostic accuracy . The greatest problem relating to exercise level in gastric exercise tonometry is the above-submaximal , or maximal , test , as this is associated with 43 % false-positive tests in this study . In maximal exercise , splanchnic blood flow is severely reduced and can lead to reduction below the level required to maintain aerobic metabolism . Although data on the splanchnic vascular responses to maximal exercise have not been established , ischemia has been established frequently in these circumstances -LSB- 3 , 7 -RSB- . In a study on splanchnic blood flow in trained volunteers , mean superior mesenteric artery blood flow fell by 38 -- 49 % after a 10-min exercise test at 70 % of maximal workload -LSB- 8 -RSB- . It has been shown that the flow reduction in the celiac artery exceeds that of the superior mesenteric artery but still does not exceed about 50 % -LSB- 9 -RSB- . Therefore the normal splanchnic flow after submaximal exercise remains well above the normal lower level of normal splanchnic blood flow , which is estimated as approximately 30 % of the normal baseline value -LSB- 10 -RSB- . This explains why submaximal exercise does not result in ischemia in subjects with normal splanchnic vessels . Gastric ischemia during submaximal exercise can be seen in patients with splanchnic stenoses or in patients with reduced cardiac output -LSB- 1 , 11 -RSB- . Thus , for practical clinical purposes 10 min of submaximal exercise seems adequate to distinguish between normal and pathological gastrointestinal vascular responses . Some exercise should be performed to allow for blood flow redistribution and reduction of the splanchnic blood flow and , thus , provocation of ischemia . However , the minimally required level is currently unknown . Even with very low-intensity exercise in healthy humans a significant shift in blood flow from the abdominal viscera to the exercising muscles was observed -LSB- 12 -RSB- . Thus submaximal exercise as currently advocated might not be necessary , and lower lactate levels may suffice for diagnostic testing . Triggering on RQ measurements resulted in the highest proportion of tests within the target range but has disadvantages . It requires a pulmonary function laboratory with specific devices for measurement of exhaled carbon dioxide and inhaled oxygen , making the test expensive and more complicated . The advantage of RQ monitoring in minimizing the proportion of below-target exercise level did not result in a lower number of false-negative tests in this study . The major advantages of the serial lactate measurement are its simplicity and low cost . This rapid test can be performed by paramedic personnel and enables determination of lactate within 60 sec . This enables adequate monitoring and triggering of exercise levels . A gastric tonometry exercise test , a routine procedure at our hospital in patients suspected of chronic gastrointestinal ischemia , takes 15 min of a doctor 's time and 2 hr for a registered nurse . Moreover , the currently available air tonometry device allows for accurate and reproducible measurements without the hassle and problems associated with classically used saline tonometry -LSB- 13 -RSB- . In conclusion , by using RQ and serial lactate measurements , adequate exercise levels for gastric exercise tonometry can be achieved . Rapid lactate measurements and the presented algorithm for gastric exercise tonometry are feasible for daily clinical practice .

O O O B I O O O B O O O O O O O O O O O O O B O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O B I I O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O B I I O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O B O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O B I O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O B O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B B I O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O B O O O O O O O

chronic gastrointestinal ischemia
tonometry
diagnosis
exercise test
exercise level


Perceived

Conflicts

Between

Pastoralism

and

Conservation

of

the

Kiang

Equus

kiang

in

the

Ladakh

Trans-Himalaya

India

An

emerging

conflict

with

Trans-Himalayan

pastoral

communities

in

Ladakh

's

Changthang

Plateau

threatens

the

conservation

prospects

of

the

kiang

-LRB-

Equus

kiang

-RRB-

in

India

It

is

locally

believed

that

Changthang

's

rangelands

are

overstocked

with

kiang

resulting

in

forage

competition

with

livestock

Here

we

provide

a

review

and

preliminary

data

on

the

causes

of

this

conflict

Erosion

of

people

's

tolerance

of

the

kiang

can

be

attributed

to

factors

such

as

the

loss

of

traditional

pastures

during

an

Indo-Chinese

war

fought

in

immigration

of

refugees

from

Tibet

doubling

of

the

livestock

population

in

about

years

and

increasing

commercialization

of

cashmere

-LRB-

pashmina

-RRB-

production

The

perception

of

kiang

overstocking

appears

misplaced

because

our

range-wide

density

estimate

of

kiang

km

-LRB-

CL

-RRB-

is

comparable

to

kiang

densities

reported

from

Tibet

A

catastrophic

decline

during

the

war

and

subsequent

recovery

of

the

kiang

population

apparently

led

to

the

overstocking

perception

in

Ladakh

In

the

Hanle

Valley

an

important

area

for

the

kiang

its

density

was

higher

-LRB-

km

-RRB-

although

even

here

we

estimated

the

total

forage

consumed

by

kiang

to

be

only

compared

to

consumed

by

the

large

livestock

population

-LRB-

km

-RRB-

Our

analysis

nevertheless

suggests

that

at

a

localized

scale

some

herders

do

face

serious

forage

competition

from

kiang

in

key

areas

such

as

moist

sedge

meadows

and

thus

management

strategies

also

need

to

be

devised

at

this

scale

In-depth

socioeconomic

surveys

are

needed

to

understand

the

full

extent

of

the

conflicts

and

herder-centered

participatory

resolution

needs

to

be

facilitated

to

ensure

that

a

sustainable

solution

for

livelihoods

and

kiang

conservation

is

achieved

One

of

the

seven

equid

species

in

the

world

the

kiang

Equus

kiang

occurs

in

parts

of

China

and

India

with

small

populations

also

reported

from

Pakistan

and

Nepal

Unlike

the

Asian

wild

ass

E.

hemionus

of

which

the

population

has

declined

drastically

over

the

last

century

kiang

continues

to

have

a

wide

distribution

with

fairly

large

populations

-LRB-

Schaller

-RRB-

Within

India

Ladakh

-LRB-

approximately

to

E

N

to

N

-RRB-

remains

a

stronghold

for

the

kiang

-LRB-

Fox

and

others

Shah

-RRB-

where

local

Buddhist

communities

have

been

fairly

tolerant

of

the

species

and

large

herds

of

kiang

can

be

relatively

easily

seen

in

eastern

Ladakh

Kiang

is

classed

as

a

Least

Concern

species

under

the

IUCN

Red

List

category

however

the

Western

Kiang

E.

k.

kiang

which

occurs

in

Ladakh

is

classed

as

data

deficient

-LRB-

Shah

-RRB-

Yet

with

growing

integration

of

the

local

economy

of

Ladakh

with

better

developed

cash

markets

pastoral

communities

are

fast

losing

their

tolerance

towards

the

kiang

and

it

is

increasingly

seen

as

a

competitor

of

livestock

-LRB-

Fox

and

others

-RRB-

Ironically

its

relatively

large

population

and

conspicuousness

are

becoming

concerns

for

the

continued

conservation

of

the

species

Although

the

species

is

not

persecuted

-LRB-

except

for

driving

them

away

from

pastures

by

herders

on

horseback

-RRB-

in

Ladakh

largely

due

to

the

Buddhist

beliefs

of

the

local

pastoral

communities

this

perceived

conflict

is

currently

one

of

the

most

serious

issues

being

faced

by

the

local

district

administration

and

the

wildlife

department

with

vehement

demands

for

compensation

Indeed

a

decreasing

tolerance

for

the

species

may

lead

in

future

to

a

worsening

willingness

to

preserve

it

There

is

a

belief

among

the

administration

that

Ladakh

's

rangelands

are

presently

overstocked

by

kiang

and

that

they

are

degrading

the

pastures

-LRB-

Anon

-RRB-

Over

the

last

decade

as

a

measure

to

protect

forage

from

kiang

and

make

it

available

to

livestock

the

local

government

and

some

nongovernmental

organizations

have

started

fencing

the

most

productive

pastures

the

sedge

meadows

near

rivers

and

streams

thereby

increasing

forage

availability

for

livestock

and

reducing

the

available

habitat

for

the

kiang

-LRB-

Richard

Bhatnagar

and

Wangchuk

-RRB-

The

purpose

of

this

article

is

to

document

this

intensifying

conflict

between

pastoralism

and

conservation

of

the

kiang

in

Ladakh

The

kiang

subspecies

in

question

is

categorized

as

data-deficient

by

the

IUCN

-LRB-

Moehlman

-RRB-

We

examine

the

primary

ecological

socioeconomic

and

political

aspects

of

kiang

human

conflict

and

summarize

the

results

of

our

rangewide

surveys

of

the

kiang

population

in

Ladakh

We

also

discuss

the

growing

linkages

between

a

traditional

way

of

life

and

the

global

cashmere

market

and

their

consequences

for

conservation

of

the

kiang

Methods

Study

Area

Administratively

the

Ladakh

region

in

the

state

of

Jammu

and

Kashmir

-LRB-

India

-RRB-

is

divided

into

two

districts

the

western

Kargil

district

and

the

eastern

Leh

district

Leh

district

is

a

high-altitude

cold

desert

spread

over

approximately

This

rain-shadow

region

is

semiarid

to

arid

with

winter

temperatures

dropping

to

below

°C

Western

and

central

Leh

are

mostly

rugged

relatively

lower

in

elevation

and

inhabited

by

agropastoralists

The

eastern

part

of

the

district

called

Changthang

on

the

other

hand

comprises

high

plateaus

and

rolling

hills

-LRB-

usually

m

-RRB-

interspersed

with

lake

and

river

basins

that

have

moist

patches

of

relatively

dense

graminoid

vegetation

Most

of

the

remaining

arid

region

is

dominated

by

medium

to

sparse

steppe

vegetation

Changthang

covers

approximately

and

is

inhabited

by

the

nomadic

Changpa

community

and

Tibetan

refugees

both

of

whom

primarily

rear

goat

and

sheep

According

to

the

human

census

in

conducted

by

the

government

the

population

of

the

Leh

district

was

with

the

majority

-LRB-

-RRB-

being

in

the

western

region

The

population

is

sparse

in

the

Changthang

-LRB-

-RRB-

with

a

density

of

approximately

km

Ladakh

is

home

to

a

diverse

assemblage

of

wild

carnivores

ungulates

and

birds

-LRB-

Pfister

-RRB-

Within

Ladakh

the

kiang

occurs

in

the

eastern

Changthang

part

of

the

Leh

district

Our

survey

covered

most

of

this

region

from

the

Pangong

Tso

in

the

North

along

the

eastern

border

with

Tibet

to

Hanle

in

the

south

-LRB-

Figure

-RRB-

We

divided

the

entire

region

into

five

blocks

based

on

their

location

and

overall

similarity

in

terms

of

topography

and

vegetation

and

surveyed

each

block

-LRB-

Table

-RRB-

Our

repeated

counts

of

kiang

were

conducted

in

the

Hanle

Valley

This

valley

-LRB-

E

N

approximately

-RRB-

extends

from

the

Zanskar

mountains

in

the

south

to

the

Indus

Valley

in

the

north

into

which

the

Hanle

River

drains

at

Loma

The

higher

reaches

are

primarily

rolling

mountains

and

plateaus

while

the

mid

and

lower

portion

is

a

wide

valley

fringed

by

a

high

range

exceeding

m

on

the

east

and

a

lower

more

gradual

ridge

on

the

west

Fig.

five

blocks

surveyed

for

kiang

in

eastern

Ladakh

during

to

The

estimated

viewscape

is

based

on

modeling

for

areas

visible

within

km

on

either

side

of

the

road

-LRB-

see

text

for

details

-RRB-

Distribution

of

kiang

in

Ladakh

is

also

shown

-LRB-

based

on

Chundawat

and

Qureshi

-RRB-

We

also

surveyed

some

additional

adjacent

areas

with

similar

habitat.Table

of

kiang

in

the

surveyed

blocks

of

eastern

Ladakh

IndiaSurvey

blockTransect

length

-LRB-

km

-RRB-

Area

-LRB-

-RRB-

No

KiangKiang

density

-LRB-

km

-RRB-

Loma-Demchok

-LRB-

Indus

-RRB-

Hanle

Parma

Pongong

-LRB-

CL

-RRB-

Data

Collection

and

Analysis

Through

archival

research

and

field

observations

we

documented

the

intensifying

human

kiang

conflict

in

Ladakh

We

describe

the

perceptions

of

the

Ladakhi

administration

regarding

this

conflict

and

the

efforts

they

have

undertaken

to

address

it

Through

archival

research

we

also

examine

recent

land-use

changes

in

eastern

Ladakh

describe

the

growing

pashmina

or

cashmere

industry

and

its

fallouts

for

the

kiang

human

conflict

Literature

was

also

surveyed

for

obtaining

information

on

the

past

status

and

distribution

of

the

kiang

We

also

obtained

data

on

livestock

populations

from

the

Sheep

Husbandry

Departments

in

Nyoma

and

Leh

to

estimate

the

livestock

density

in

eastern

Ladakh

We

had

informal

conversations

with

over

herders

to

learn

about

their

perceptions

regarding

conflicts

Our

data

on

the

kiang

population

in

Ladakh

come

from

rangewide

surveys

conducted

in

the

year

The

study

area

was

surveyed

from

a

slow-moving

vehicle

-LRB-

traveling

at

km/hour

-RRB-

and

areas

on

either

side

were

periodically

scanned

using

an

binocular

and/or

spotting

scope

On

every

sighting

animals

were

counted

and

classified

and

habitat

variables

such

as

topographic

feature

elevation

slope

aspect

dominant

plant

species

and

approximate

plant

cover

were

recorded

Classification

of

kiang

by

sex

was

not

possible

in

most

instances

due

to

the

similarity

between

the

sexes

especially

when

seen

from

a

distance

A

total

distance

of

km

was

covered

in

the

Changthang

traveling

on

an

average

km

per

day

We

also

covered

approximately

km

on

foot

in

the

upper

catchment

of

the

Hanle

Valley

Subsequently

in

the

spring

of

and

we

conducted

repeated

vehicle

counts

of

kiang

along

an

approximately

stretch

in

the

Hanle

Valley

which

had

emerged

as

an

area

with

moderate

to

high

kiang

density

during

the

survey

Density

for

kiang

and

livestock

was

calculated

by

estimating

the

area

covered

in

each

segment

using

Geographical

Information

System

-LRB-

GIS

-RRB-

tools

The

area

surveyed

along

the

roads

was

estimated

by

creating

a

viewscape

in

ArcInfo

which

effectively

created

polygons

of

all

area

visible

from

the

road

The

base

map

used

for

this

estimation

was

the

National

Imagery

and

Mapping

Agency

's

Vector

Map

Level

-LRB-

Digital

Chart

of

the

World

-RRB-

Edition

This

was

integrated

with

the

Digital

Elevation

Model

-LRB-

resolution

m

or

arc

seconds

-RRB-

Shuttle

Radar

Topography

Mission

-LRB-

SRTM

-RRB-

data

from

the

Space

Shuttle

mission

-LRB-

for

the

year

-RRB-

obtained

from

to

generate

maps

of

the

study

area

with

numerous

layers

of

information

that

included

elevation

aspect

and

drainage

After

creating

the

viewscape

we

used

a

cutoff

distance

of

km

on

either

side

of

the

road

within

which

all

visible

areas

were

calculated

This

was

generally

our

maximum

sighting

distance

for

the

kiang

-LRB-

most

Rangefinders

do

not

work

at

this

distance

-RRB-

We

estimated

the

extent

of

the

surveyed

areas

-LRB-

through

viewscapes

-RRB-

for

both

the

rangewide

surveys

as

well

as

the

region

of

our

repeated

kiang

counts

in

Hanle

Valley

As

a

preliminary

exercise

to

understand

the

extent

of

forage

consumption

by

kiang

vis-à-vis

livestock

we

estimated

total

daily

forage

consumption

by

kiang

and

livestock

through

established

relationships

between

body

mass

and

daily

food

intake

-LRB-

as

percent

of

body

mass

-RRB-

among

herbivores

-LRB-

Foose

-RRB-

In

the

absence

of

population

structure

data

for

both

kiang

and

livestock

we

used

adult

body

masses

-LRB-

averaged

between

sexes

-RRB-

from

Mishra

and

others

-LRB-

-RRB-

We

used

the

established

relationships

for

foregut

fermenters

-LRB-

goat

sheep

cattle

yak

cattle-yak

hybrids

-RRB-

and

hindgut

fermenters

-LRB-

kiang

horses

donkeys

-RRB-

as

appropriate

Forage

quality

in

the

highly

seasonal

cold

desert

steppe

of

Ladakh

is

expected

to

vary

strongly

between

seasons

with

high-protein

low-fiber

forage

being

available

in

summer

and

low-protein

high-fiber

forage

in

winter

We

therefore

estimated

forage

consumption

by

each

species

separately

for

winter

and

summer

using

the

relationships

for

low-protein

high-fiber

grass

hay

diet

for

winter

-LRB-

crude

protein

and

cell

wall

-RRB-

and

high-protein

low-fiber

legume

hay

diet

for

summer

-LRB-

crude

protein

and

cell

wall

-RRB-

-LRB-

Foose

-RRB-

For

hindgut

fermenters

daily

forage

intake

as

a

percent

of

body

mass

-LRB-

W

-RRB-

in

summer

was

estimated

as

W

and

W

in

winter

Similarly

for

the

ruminants

-LRB-

goat

sheep

cow

dzo/dzomo

yak

-RRB-

it

was

estimated

as

W

in

summer

and

W

in

winter

-LRB-

Foose

-RRB-

Results

and

Discussion

Genesis

of

the

Conflict

Kiang

Population

Changes

in

Recent

History

Kiang

inhabits

the

open

plains

and

rolling

mountains

of

the

Changthang

plateau

in

eastern

Ladakh

at

altitudes

between

m

and

m

It

has

a

total

estimated

range

of

approximately

in

Ladakh

-LRB-

Chundawat

and

Qureshi

Figure

-RRB-

The

species

was

common

in

Ladakh

during

the

earlier

part

of

the

century

-LRB-

Stockley

-RRB-

but

is

believed

to

have

declined

substantially

with

the

buildup

of

armed

forces

in

Ladakh

during

the

war

between

India

and

China

in

-LRB-

Fox

and

others

-RRB-

There

are

no

population

estimates

available

for

the

period

before

or

immediately

following

this

war

but

it

is

believed

that

the

population

had

recovered

by

the

The

only

published

estimate

of

their

population

comes

from

the

late

when

approximately

animals

were

estimated

to

occur

in

Ladakh

-LRB-

Fox

and

others

Shah

-RRB-

It

thus

appears

that

for

at

least

a

decade

after

the

war

the

kiang

population

remained

relatively

small

in

Ladakh

The

genesis

of

the

present

conflict

can

be

traced

back

to

the

early

by

which

time

their

population

had

apparently

recovered

-LRB-

Fox

and

others

-RRB-

The

prevalent

belief

in

Ladakh

during

that

time

and

one

that

continues

until

today

is

that

the

kiang

population

has

drastically

increased

in

eastern

Ladakh

because

many

animals

have

moved

from

Tibet

to

the

Indian

side

of

the

border

to

escape

persecution

-LRB-

Fox

and

others

Anon

-RRB-

Even

in

the

there

were

complaints

by

herders

regarding

the

extent

of

forage

consumption

by

kiang

and

consequent

competition

with

livestock

and

demands

that

the

government

should

drive

the

kiang

back

into

Tibet

-LRB-

Fox

and

others

-RRB-

Intensification

of

the

Conflict

Changing

Face

of

Pastoralism

in

Ladakh

The

Tibetan

plateau

was

inhabited

by

nomadic

hunting

people

years

ago

and

nomadic

pastoralists

have

been

herding

livestock

on

the

plateau

for

at

least

two

millennia

-LRB-

Schaller

-RRB-

The

nomads

who

became

Buddhists

presumably

in

the

last

millennium

live

in

tents

-LRB-

ribos

-RRB-

in

seasonal

camps

In

the

past

the

few

nomadic

groups

inhabiting

eastern

Ladakh

belonging

to

the

Changpa

community

traveled

distances

exceeding

km

during

their

seasonal

migrations

-LRB-

Phuntsok

Hagalia

-RRB-

This

has

recently

changed

and

most

seasonal

movements

are

now

restricted

to

within

km

-LRB-

Hagalia

-RRB-

After

the

there

has

been

a

steady

increase

in

the

population

of

the

Changpa

and

their

livestock

presumably

facilitated

by

access

to

better

health

care

provisions

and

subsidies

both

from

the

government

as

well

as

the

army

-LRB-

Chaudhuri

Phuntsok

Bhatnagar

and

Wangchuk

-RRB-

Supplemental

forage

provided

by

the

government

in

the

event

of

severe

winters

now

offsets

most

of

the

starvation-related

livestock

mortality

which

in

the

past

was

perhaps

an

important

factor

limiting

the

livestock

population

The

war

between

India

and

China

also

led

to

the

curtailment

of

movement

of

the

Changpa

herders

from

eastern

Ladakh

into

parts

of

Tibet

considerably

reducing

the

availability

of

grazing

land

Many

of

their

pastures

such

as

Skagzung

the

primary

winter

pasture

of

the

Rupshu

Changpas

-LRB-

Figure

-RRB-

became

unavailable

effectively

escalating

the

stocking

density

in

eastern

Ladakh

Furthermore

a

large

number

of

Tibetan

refugees

have

moved

into

eastern

Ladakh

with

their

livestock

herds

since

the

late

thus

contributing

to

a

substantial

increase

in

the

number

of

herding

families

and

the

livestock

population

-LRB-

Bhatnagar

and

Wangchuk

Hagalia

-RRB-

As

per

the

government

records

the

livestock

population

in

Ladakh

-LRB-

including

Changthang

-RRB-

has

doubled

in

about

two

decades

from

approximately

in

to

in

-LRB-

Richard

Bhatnagar

and

Wangchuk

-RRB-

In

Changthang

constituted

of

Ladakh

's

livestock

population

most

of

which

-LRB-

-RRB-

were

sheep

and

goats

One

of

the

most

important

livestock

products

from

the

region

is

the

pashmina

or

cashmere

a

fine

luxury

fiber

derived

from

the

underwool

of

the

local

Changra

goat

Traditionally

more

than

of

cashmere

from

Ladakh

has

been

used

for

barter

with

or

sale

to

traders

from

the

neighboring

Kashmir

region

under

a

treaty

with

the

erstwhile

kingdom

of

Kashmir

dating

from

-LRB-

Rizvi

-RRB-

Over

the

last

two

decades

however

cashmere

production

in

Ladakh

has

been

promoted

by

the

government

in

a

substantial

way

This

has

included

setting

up

of

goat

breeding

farms

efforts

at

improving

yield

and

provisioning

of

veterinary

services

to

nomads

that

has

brought

down

the

kid

mortality

rates

to

from

an

estimated

-LRB-

Jina

-RRB-

However

the

efforts

at

increasing

the

per

animal

cashmere

yield

have

apparently

had

very

limited

success

-LRB-

Jina

-RRB-

suggesting

that

increasing

cashmere

production

necessitates

an

increase

in

the

goat

population

More

recently

with

part

support

from

the

central

government

of

India

the

International

Fund

for

Agricultural

Development

and

the

UNDP

the

Ladakh

administration

has

set

up

a

cashmere

de-hairing

plant

expected

to

result

in

considerable

added

value

to

the

cashmere

from

Ladakh

-LRB-

Joshi

and

Morup

Mital

-RRB-

Presently

Ladakh

contributes

merely

kg

-LRB-

-RRB-

to

the

global

cashmere

production

and

the

administration

is

eager

to

increase

Ladakh

's

contribution

in

global

trade

The

recent

intensification

of

human

kiang

conflict

needs

to

be

viewed

against

these

socioeconomic

and

political

developments

The

human

and

livestock

populations

in

kiang

habitat

have

significantly

increased

in

the

last

four

decades

due

to

factors

ranging

from

better

healthcare

to

the

influx

of

refugees

Furthermore

promotion

of

production

and

value

of

cashmere

has

meant

that

livestock

rearing

is

fast

becoming

a

cash-based

enterprise

that

increasingly

caters

directly

to

the

lucrative

global

cashmere

market

Herders

are

realizing

the

importance

of

every

bit

of

pastureland

in

maximizing

cashmere

production

and

see

kiang

as

a

direct

threat

to

pasture

production

Against

this

background

it

is

perhaps

not

surprising

that

people

are

fast

losing

their

tolerance

of

the

kiang

The

Ecological

Context

Current

Kiang

Population

and

Relationships

with

Livestock

In

our

rangewide

survey

of

the

kiang

we

surveyed

an

estimated

area

of

which

is

of

the

total

range

of

the

kiang

in

Ladakh

-LRB-

Chundawat

and

Qureshi

-RRB-

We

recorded

a

total

of

distinct

kiang

groups

totaling

animals

The

average

density

in

the

surveyed

blocks

was

-LRB-

CL

-RRB-

kiang

km

with

the

highest

abundance

along

the

upper

Indus

from

Loma

to

Demchok

followed

by

the

Hanle

Valley

-LRB-

Table

Figure

-RRB-

With

an

overall

livestock

population

of

-LRB-

as

per

unpublished

records

from

the

Nyoma

office

of

the

Sheep

Husbandry

Department

-LRB-

-RRB-

-RRB-

in

the

Nyoma

and

Durbuk

blocks

that

comprise

the

Changthang

region

of

Ladakh

the

livestock

density

in

the

region

was

km

Thus

in

terms

of

density

kiang

represents

only

of

the

total

herbivore

population

-LRB-

kiang

and

livestock

together

-RRB-

in

the

Changthang

with

the

bulk

being

contributed

by

goats

-LRB-

-RRB-

The

group

sizes

of

kiang

observed

during

the

rangewide

survey

varied

from

to

The

mean

group

size

was

-LRB-

CL

-RRB-

with

most

of

the

sightings

-LRB-

-RRB-

being

of

solitary

animals

Most

kiang

were

seen

in

open

wide

valleys

-LRB-

n

-RRB-

followed

by

stony

slopes

-LRB-

-RRB-

and

very

rarely

in

broken

areas

-LRB-

-RRB-

There

were

no

sightings

on

slopes

steeper

than

We

observed

kiang

between

elevations

of

and

m

with

most

sightings

between

and

m.

Most

kiang

groups

-LRB-

-RRB-

were

seen

on

sedge

-LRB-

Carex

spp.

and

Kobresia

spp.

-RRB-

and

grass

-LRB-

Stipa

spp.

-RRB-

meadows

in

the

valley

bottom

which

were

occasionally

interspersed

with

bushes

of

Caragana

sp.

These

meadows

appear

to

be

critical

habitat

for

kiang

during

summer

and

winter

as

also

reported

by

Schaller

-LRB-

-RRB-

but

are

limited

in

extent

to

narrow

discontinuous

strips

in

moist

areas

along

valleys

The

remaining

sightings

were

in

areas

that

had

sparse

to

dense

Artemisia

steppe

-LRB-

with

Tanacitum

sp.

and

Sedum

sp.

being

the

other

dominant

plants

-RRB-

and

high

altitude

forb

meadows

-LRB-

Saussurea

spp.

Salsola

sp.

and

Polygonum

sp.

as

the

dominant

plants

-RRB-

At

a

landscape

level

covering

entire

eastern

Ladakh

of

the

total

daily

forage

consumption

by

large

herbivores

we

estimated

that

kiang

consume

and

livestock

-LRB-

Table

-RRB-

Among

livestock

goats

were

estimated

to

consume

the

maximum

forage

-LRB-

to

of

the

total

forage

consumed

-RRB-

followed

by

sheep

-LRB-

to

-RRB-

Table

density

and

estimated

forage

consumption

by

kiang

vis-à-vis

livestock

in

ChangthangSpeciesBody

weight

-LRB-

kg

-RRB-

Density

-LRB-

animals

km

-RRB-

Total

forage

consumption

in

summer

-LRB-

kg

km

-RRB-

Percent

forage

consumption

in

summerTotal

forage

consumption

in

winter

-LRB-

kg

km

-RRB-

Percent

forage

consumption

in

Livestock

Yak

cattle

Livestock

Body

weights

are

taken

from

Mishra

-LRB-

-RRB-

and

have

been

averaged

between

sexes

Note

that

this

will

result

in

an

overestimate

of

the

offtake

by

kiang

because

we

assumed

that

all

kiang

were

adult

Livestock

density

was

calculated

only

for

adult

animals

Our

subsequent

estimate

of

the

kiang

population

in

the

Hanle

Valley

-LRB-

the

region

between

Rongo

and

Kalangtartar

-RRB-

based

on

repeated

counts

between

and

yielded

a

density

of

-LRB-

CL

-RRB-

We

estimated

that

on

an

average

kiang

remove

only

to

of

the

total

forage

consumed

in

the

Hanle

Valley

with

the

greater

part

being

consumed

by

goats

-LRB-

to

-RRB-

followed

by

yaks

-LRB-

to

-RRB-

and

sheep

-LRB-

-RRB-

-LRB-

Table

-RRB-

Table

density

and

estimated

forage

consumption

by

kiang

vis-à-vis

livestock

in

the

Hanle

ValleySpeciesBody

weight

-LRB-

kg

-RRB-

Density

-LRB-

animals

km

-RRB-

Total

forage

consumption

in

summer

-LRB-

kg

km

-RRB-

Percent

forage

consumption

in

summerTotal

forage

consumption

in

winter

-LRB-

kg

km

-RRB-

Percent

forage

consumption

in

Livestock

Yak

cattle

Livestock

Synthesis

of

the

Conflict

Is

It

Real

or

Perceived

Most

wars

in

the

last

five

decades

have

resulted

in

detrimental

effects

on

wildlife

-LRB-

Blom

Dudley

and

others

Mishra

and

Fitzherbert

-RRB-

and

the

war

between

India

and

China

in

was

no

exception

particularly

from

the

viewpoint

of

kiang

conservation

Our

review

suggests

that

the

kiang

population

in

Ladakh

declined

drastically

in

the

years

during

and

after

the

war

between

India

and

China

in

the

possibly

due

to

hunting

land

mines

and

disturbances

associated

with

the

war

Thus

for

two

decades

during

and

after

the

war

a

generation

of

herders

presumably

saw

and

became

used

to

a

very

low

density

of

kiang

in

Ladakh

's

rangelands

Not

surprisingly

the

genesis

of

kiang

human

conflict

in

Ladakh

can

be

traced

back

to

the

the

period

by

which

the

kiang

population

had

recovered

It

seems

that

the

recovery

of

the

kiang

from

a

very

low

density

to

the

current

estimated

density

of

has

led

to

the

perception

to

a

generation

of

nomads

that

Ladakh

's

rangelands

are

now

overstocked

with

kiang

Available

estimates

from

three

regions

in

Tibet

place

the

density

of

kiang

between

and

kiang

km

-LRB-

Schaller

-RRB-

suggesting

that

the

kiang

density

in

Ladakh

is

comparable

with

those

in

Tibet

Furthermore

our

results

show

that

the

share

of

forage

consumed

by

the

kiang

vis-à-vis

livestock

is

relatively

small

-LRB-

in

the

whole

of

eastern

Ladakh

and

in

Hanle

Valley

-RRB-

Thus

at

a

landscape

level

the

perception

of

the

overabundance

of

kiang

in

Ladakh

and

of

kiang

compromising

cashmere

production

is

clearly

unfounded

Nevertheless

there

is

variation

in

kiang

density

locally

-LRB-

to

kiang

km

recorded

in

our

surveys

-RRB-

Kiang

occasionally

congregate

in

large

herds

and

can

together

remove

considerable

forage

from

the

low-productivity

Trans-Himalayan

pastures

Using

the

data

in

Table

a

group

of

kiang

-LRB-

the

largest

group

seen

during

the

survey

was

-RRB-

can

be

estimated

to

potentially

consume

kg

dry

forage

in

a

single

day

The

peak

standing

biomass

in

sedge

meadows

which

seem

to

be

important

kiang

habitats

has

been

estimated

in

the

adjoining

region

of

Spiti

at

kg

ha

-LRB-

Mishra

-RRB-

These

habitats

seem

critical

for

both

kiang

and

livestock

but

cover

a

small

fraction

of

the

landscape

with

an

estimated

in

the

entire

approximately

of

Changthang

Illustratively

this

means

that

in

a

single

day

a

large

group

of

kiang

can

potentially

consume

more

than

a

quarter

of

the

standing

biomass

from

ha

of

a

key

resource

area

This

consumption

is

also

very

similar

to

the

estimated

daily

forage

consumption

by

a

herd

of

goats

-LRB-

approximately

kg

-RRB-

Because

of

the

long

winters

-LRB-

November

to

April

-RRB-

and

short

summers

-LRB-

July

August

-RRB-

the

potential

for

regrowth

during

summer

is

low

aggravating

the

impact

Considering

the

potential

of

large

kiang

herds

to

remove

significant

amounts

of

forage

together

with

the

fact

that

grazing

areas

have

been

reduced

and

the

livestock

population

in

Ladakh

more

than

doubled

in

the

last

years

it

is

not

difficult

to

see

that

at

a

localized

scale

of

the

valued

sedge

meadows

some

herders

must

be

facing

serious

forage

competition

from

the

kiang

Given

the

intensifying

commercialization

of

cashmere

production

in

Ladakh

and

its

integration

with

global

markets

this

localized

forage

competition

is

perhaps

understandably

no

longer

tolerated

and

the

conflict

needs

to

be

addressed

immediately

However

it

must

be

borne

in

mind

that

the

problem

seems

to

be

evident

at

local

scales

and

will

need

to

be

addressed

at

that

scale

In

the

absence

of

any

scientific

understanding

of

the

conflict

so

far

or

efforts

to

document

it

this

local

conflict

has

already

begun

to

take

on

a

serious

political

dimension

The

politicians

and

the

district

administration

in

Ladakh

are

blaming

the

kiang

for

compromising

cashmere

production

and

the

wildlife

department

is

being

looked

upon

to

provide

a

solution

The

only

on-ground

reaction

of

the

district

administration

has

been

to

fence

large

productive

sedge

and

grass

meadows

from

the

kiang

In

the

Hanle

Valley

alone

an

estimated

ha

of

meadows

have

been

fenced

already

Three

fourths

of

our

total

kiang

sightings

during

the

rangewide

surveys

were

in

such

meadows

suggesting

that

this

is

an

important

habitat

for

the

species

and

continued

fencing

of

this

habitat

may

cause

a

decline

in

the

kiang

population

of

Ladakh

How

can

this

conflict

be

managed

Although

our

review

of

the

recent

history

of

political

and

socioeconomic

developments

in

kiang

habitat

and

our

estimates

of

density

and

forage

consumption

of

kiang

and

livestock

bring

to

light

interesting

dimensions

of

the

kiang

human

conflict

the

current

level

of

understanding

of

the

kiang

's

ecology

and

its

relationships

with

livestock

is

still

very

preliminary

Intensive

research

needs

to

be

promoted

to

assist

in

better

management

of

the

species

and

its

conflicts

with

humans

Monitoring

programs

need

to

assess

kiang

and

livestock

density

as

well

as

the

land

use

changes

in

kiang

habitat

Our

article

shows

that

the

problem

of

kiang

human

conflict

is

locally

concentrated

in

the

key

resource

areas

that

contain

the

sedge

meadows

and

management

strategies

need

to

be

devised

at

that

local

scale

Surveys

are

needed

to

identify

all

high-conflict

areas

and

adequate

compensatory

mechanisms

need

to

be

worked

out

for

herders

who

face

genuine

forage

competition

from

the

kiang

It

needs

to

be

examined

whether

the

fact

that

herders

share

the

forage

with

kiang

could

actually

be

used

for

adding

value

to

the

cashmere

produced

in

Ladakh

The

kiang

is

a

striking

and

conspicuous

wild

animal

that

may

provide

a

potential

for

ecotourism

Finally

after

taking

up

the

above

interventions

it

is

important

that

fences

on

the

sedge

meadows

to

exclude

kiang

be

removed

and

the

practice

of

fencing

discontinued

because

they

lock

out

key

resource

areas

from

the

kiangs

range

Without

access

to

key

resource

areas

kiang

and

other

wild

herbivores

such

as

the

Tibetan

gazelle

Procapra

picticaudata

may

face

severe

population

declines

in

Ladakh

O B O B O O O O O B I O O B O O O O O O O O O O O B O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O B O O O B O O O O O O O O O O O O O O O B O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O B O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O B O O B O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O B O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O B O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O

equus kiang
conflicts
pastoralism
nomads
livestock
ladakh