Personal views: Pilgrimage medicine
Authors: Buddha Basnyat
Journal: BMJ (2002)

Even as I observed this congregation of 5000 pilgrims at 4300 metres, ready to pray to the great Vedic deity Shiva at a magnificent mountain lakeside in Gosainkunda, Nepal, I knew that many were in no mood to pray. They were stricken with altitude sickness in its various forms—acute mountain sickness, high altitude pulmonary oedema, and high altitude cerebral oedema.


Acute mountain sickness, which is just like having a hangover, can be relatively benign (with a headache, some nausea, and tiredness), but high altitude pulmonary oedema and high altitude cerebral oedema are undoubtedly life threatening. The initial symptoms of acute mountain sickness are warning signs to be heeded carefully. Alas, many pilgrims climb too high too fast (from Kathmandu at 1300 metres to the lake in two nights) and totally disregard initial symptoms. 


Many pilgrims feel that the sickness they experience is caused by the scent of flowers



Just like many impatient tourists that come to trek in the foothills of the great Himalayas, these pilgrims too are a determined bunch and do not turn back even in the face of increasing symptoms. Many claim that once you undertake the pilgrimage it does not bode well for your spiritual welfare to give it up halfway.

Recent studies have shown that acute mountain sickness is rampant in this population of pilgrims to Gosainkunda and that many pilgrims are dehydrated because they are fasting. Many are so serious about the fasting that they do not even drink water. Women are more meticulous about fasting and sometimes they present with severe dehydration.

Many pilgrims still feel that the sickness they experience is caused by the scent of the flowers and alpine vegetation that grow on the wayside. This is akin to what many Catholic fathers thought in the early 18th century when they were crossing these Himalayan mountain passes. Indeed Spanish Jesuit fathers in South America were the first in Western literature to document the symptoms of altitude sickness. The scent of the flowers as the cause of altitude sickness does not make sense, as I am fond of reminding the pilgrims, because invariably the patients improve significantly on descent, even though the flowers are still giving off their scent.

We have tried to encourage the Nepali government to campaign to increase awareness of altitude sickness among pilgrims. This has happened to some extent, but thank God for dexamethasone, a well established treatment for high altitude cerebral oedema. Many healthcare professionals who have helped out at the Gosainkunda Lake can clearly testify to the usefulness of steroids.

One study postulated that the visions that these high altitude pilgrims often report may not actually be divine revelations but just hallucinations caused by the cerebral oedema. The pilgrim community may not favour this rather scientific explanation.

Gosainkunda is just one high altitude sacred place to which people trek. There are many such holy sites scattered in the Himalayas. Damodar Kunda, Dudh Kunda, Lake Tilicho, Kedarnath, Badrinath, Muktinath—these are some other examples. Finally, because of the immensely increasing fascination that Buddhism holds for people, many pilgrims, including vast numbers of Westerners, visit Lhasa (3600 metres), Tibet, the cradle of Buddhism. Many experience the ill effects of altitude. This is because there is no chance for people to acclimatise as they make their journey quickly by air or by road. Acetazolamide taken after consultation with their doctors could be a useful precautionary measure to ward off the ill effects of sudden hypoxia in Lhasa.

Pilgrims face other problems besides altitude. I have seen obese men and women, who can barely climb up stairs in their homes, undertaking high altitude pilgrimages on helicopter and horseback. Usually they decide to do this on the spur of the moment as a famous “guru” is going to lead them. The main problem is that you have to get down from the horse during the descent when the trail gets very steep, and your knees and hips may not be up to this. The pilgrimage then turns out to be a nightmare.

To get to many of these high altitude sites you may first have to go through cities such as Delhi or Calcutta where malaria lurks. Depending on the destination, it may be useful for pilgrim travellers to consider malaria prophylaxis and immunisation against diseases such as typhoid and hepatitis.

For pilgrims going to Mecca for the Haj, meningococcal vaccination would be particularly useful. The value of this was tragically demonstrated when some British citizens succumbed to meningitis on their return home from Mecca.

Pilgrimage medicine needs to be incorporated into the broader framework of travel medicine to ensure that pilgrims are aware of problems and diseases. Healthcare professionals can then effectively advise potential pilgrims depending on their destination and needs.