Ecology of diseases in Ladakh Puuntsoc Stospan, New Delhi The primary objective of this paper is to analyse and understand the general disease pattern in Ladakh in relation to its ecology, environment and ethnic groups. Taking note of the importance gi- ven to environmental and socio-economic factors in the determination of the prevalence of disea~ ses in Ladakh, the paper examines to what extent the distribution and pattern of diseases are in- fluenced by geographical realities. Attempts have been made to identify both environmental physi: cal and socio-economic conditions and constraints which are decisively effecting the spatial pat- tern of diseases in Ladakh This paper is based on the statistical information available for the year 1983 obtained from the sta- tistical department of health, District Medical Officer (D. M. 0) office at Leh, statistical handbook published by the deputy commissioners office Leh. The information about the nutritional status of Ladakhi children is based on the survey conducted by Leh Nutrition Projectin summer 1982. Beside the survey done by myself in my own village and various monasteries in the Indus Valleys addi- tional information has been obtained from different medical specialist including the amchis (tradi- tional Ladakhi doctors) specially from my grandfather Lobzang Gendun who practices Amchi in Stok village, in order to highlight the prevalence of a local diseases in Ladakh Ladakh's situation in one of the geographically most negative areas in Himalaya with extreme environmental constraints of high altitude and harsh climatic conditions combines to act as the single most factor which determines the nature and types of diseases in Ladakh. Ladakh can be roughly divided into five ecological zones. 1. Nubra and Shyok Valley ‘The northernmost part of Ladakh, a mountainous region with wide open valleys. Less precipitation but high vegetation along the river valleys. The altitude of human settlement and cultivated area is lower, inhabited by both Buddhists and Baltis. Not easily accessible to outsiders, relatively less developed region. 2. Changtang ‘The eastern part of Ladakh, a cold mountain desert with lakes, extreme aridity, poor quality pasture land, short contrast of seasonal and day temperature. Inhabited by Changpas of Buddhist faith, prac- tise nomadic way of life, settlement is sparse and scattered. This region is not accessible to outsiders except for military personnels. 3. Indus Valley Predominantly inhabited by Buddhist Ladakhi, settied along the river beds and alluvial fans. Agricul- ture form of economy, relatively developed area. Easy accessible to outsiders. 4. Suru, Dras and Kargil A mountainous region of western and south-western part of Ladakh, predominantly inhabited by Balti Puriig and Aryan tribes, settled along the river beds and alluvial fans. Mostly practise agricul- ture farming 1648. Zanskar Valley itis a desolate mountain region characterized by faulted and deeply dissected relief. Extreme envi ronmental conditions, heavy snowfall in winter and with winter temperatures down to -30°C. Agr culture farming is practised in wide open river valleys as well as terraces and fans, inhabited by Buddhists. Practice of polyandry and monastic celibacy is common. A relatively isolated area with low level of development. Ethnically the Mongoloids or Tibetan-origin Buddhists live in higher altitude generally on the allu- vial fans than the Aryans or Indo-Iranian origin Muslims who are settled in the lower altitudes generally along the river basins. The Aryans also include some tribes who are neither Muslims nor Buddhists. They live in relatively isolated areas. Ecology of Tuberculosis Known as Lo-chong (glo-gchong) the prevalence of which was unknown in Ladakh has become a sizeable problem in the recent years; During the period 1982-83, 1.500 cases from Leh and Kargil districts were registered by the district T. B. hospital. Itis interesting to note that the prevalence of tuberculosis is related to Muslim dominated areas. The majority of cases were from Kargil, a Muslim dominated district, and Chuchot a Muslim dominated village in Leh district. Interestingly, even among the Muslims, tuberculosis is carried by Baltis, belonging to Shia sect or non-Sunni Muslims in Ladakh. Although the Muslim population in Leh district is only 15%, they constitute 75.6 % of tuberculosis cases, reported in Leh district in the month of May 1983. Though most of the cases were from rural areas, hospital staff reports that there is a seasonality of having high incidence of T. B. patients in summer months. If this is so, then it suggests that the cases reported are also Muslim labourers or Baltis of Kargil district who migrated to Leh town and adjacent areas during the summer time. The cases of tuberculosis reported from Chuchot, a permanent Balti village situated along Indus river, were as high as 24 % of the total cases reported in Leh hospital for the month of May, although the size of the village is smaller than Leh. New. B. Patients Percen- Hospital/Village puton treatment tage Leh Town 8 10.6 Tiksey Buddhist Village 6 8.0 Chuchot Muslim Village 18 24.0 Ckurbuchan Buddhist Village W 14.6 Kalsi Buddhist Village a 2.6 Timisgam Buddhist Village 6 8.0 Saspol Buddhist Village 4 3 Nubra Muslim & Buddhist 19 26:3 Tuberculosis patients under treatment in the month of May 1983. —Source- Statistical Department DMO Leh. Itis surprising that 19 out of 74 patients or 26.3% of the . B. cases were reported from Nubra. Since the break up of data is not available it was suggested that the cases have been reported from Turtuk and Takshi-Tang a Muslim populated areas, India occupied in the 1971 war with Pakistan. The factors which are responsible for the prevalence of tuberculosis among Balties are: poor economic conditions; close and congested living; eating together from one plate; lookka sy- 165stem/smoking; pardha system among females; poor environmental sanitation; low level of lite- racy. Tuberculosis cases are also reported significantly among the Dhog-Pas of Dha and Hanu villages. Dhog-Pas are also non - Buddhist tribe sharing similar social and economic conditions to Baltis. As high as 11 cases or 24 % were reported at Ckurbuchan health center located nearest to Dha and Hanu. Doctors from Leh T. B. hospital also referred to these villagers having chronic cough. Therefore it can be noticed from the above characteristics that social and economic factors are mainly responsible for the significant prevalence of tuberculosis among the non-Buddhist popula- tion in Ladakh. This was also observed from the fact that the villages where Buddhists are predo- minant, locaeding adjacent to Muslim or Dhog-Pa villages, had either low incidence of tuberculo- sis, or it was very insignificant among them. Beside the above mentioned factors, there is another ecological aspect of the distribution of tuber- culosis in Ladakh. In general, most of the tuberculosis cases come from a belt of villages along the Indus river and very little incidence is reported from the villages located on the alluvial fans. The most possible cause is the dust. Small and invisible dust partices presentin the atmosphere in the Indus Valley due to the inversion of temperature, injure the lungs which reduces the resistences to fight against tuberculosis. There is yet another feature which is interesting in the context of pulmonary tuberculosis in Stok, a Buddhist-populated village. A strong relationship is found between families having high number of livestock and number of family members suffering from pulmonary tuberculosis. Out of 90 major households 15 are practing sheep farming and also rich in livestock. In some farms the number of livestock exceeds 500. The numbers of people carrying tuberculosis among these households are higher than the households having few livestock or no livestock at all. In some households tubercu- losis is a known family history. It is possible that itis mainly caused by burning of gtsog-Ichi, highly concentrated and thick bricks of animal waste collected from drok or abrog (transhumance) and used as fuel in winter. The possibility of their suffering from zoonisis is also expected among these people. This may be true for all the parts of Ladakh but no study is being done so far. Common diseases among Buddhist Ladakhis Most of the commonly reported symptoms among the Buddhist people were ‘minor illness’ which are caused by their eating habits and social practices. Digestive disorders like Dyspepsia, indigestion, stomach pains are the common symptoms commonly reported in Leh hospital. During the period April and May 1983 59.12 % patients were found having dyspepsia. Most of these far- mers were Buddhist farmers. Among the possible causes doctors and amchis attribute this to Buddhist drinking of Chang or local beer and eating of cold food which is eaten outside in the field during the sowing and harvesting periods Another common diseases among the Buddhists is joint pains known as dumbu (griim-bu).This is more particularly in Lamas above 40 years of age. This was due to the whole day and night siting in the monasteries. It was possible that their sitting in the cold adu-khang generally aggravates the pains. In the Tiksey Gompa (dgon-pa), out of 57 Lamas, 31 had complained of having rheuma- toid joint pains. Out of these 9 older Lamas, had acute problems of rheumatism. In Himis Gonpa though most of the Lamas were not present in the monastery, the older Lamas present in their grwa-shag had complaints rheumatism. In Likir also the incidence is quite high. Out of 38 Lamas in dukang (adu-khang) or assembly hall, 16 Lamas complained of suffering from joint pains. But in the case of Spituk Gompa, the picture is quite different. Out of 54 Lamas present in the yarnas 166(dbyar-gnas) assembly in Spituk, only 12 Lamas had problems of joint pains. The reason for the low figure was explained by a Lama that the older monks had not come to attend the assembly but were living in Sankar, Gonpa in Leh, Sabu Gonpa in Sabu, and Kurfhuk Gonpa in Stok. Another rea- son for this low figure in Spituk is due to better living conditions since it had 24 hour electricity supply from military station. Secondly it had easy excess to kerosene and other fuel from military areas. Thirdly, being nearest to Leh, it has access to clinical facilities. Most of the Lamas also told me that they have good contacts with the military hospital in Leh. Leprosy zenad (mdze-nad) It is interesting to know that leprosy is common among the Buddhist population. Out of 135 cases reported in Leh hospital for the year 1983, 125 or 92.6 % patients belong to Buddhist faith. This could be explained because of the Tibetan refugees who have maximum cases of leprosy. One refugee settlement alone had 37 % of all the leprosy cases in Ladakh. This disease is male dominant in nature. According to Leh doctors leprosy is also significant in the tribal people. Eye problems Eye problems are common in Ladakh and the type of eye problems differ from one ecological zone to other. According to local doctors the problemis attributed to people living in smoky rooms. Like many other aspects the life styles of Ladakhis are geared by climatic conditions and geogra- phical features surrounding them. The existing physical relief has therefore played an important role in shaping their way of living. The eye problems in Ladakh are also indirectly linked to their way of living which are rigidly determined by its environment. The factors which are responsible for the prevalence of eye problems are. In the Indus Valley, its geographical features create dusty environment especially in the after- rnoons which frequently causes people to suffer from eye irritant conjunctivities. Secondly the cold climate accompanied by strong winds do not permit people to have a good ventilation system to escape smoke from Chansa kitchen cum dining and living room, living in which ultimately causes eye problems among the people. Another possible cause for this problem is due to the burning of gtsog-Ichi which serves as a good quality fuel but its smoke not only produces eye problems but also many other health problems. In Dras and Kargil areas strong winds and also the Muslims idea of not having ventilation system cau- ses tremendous eye problems. In Zanskar region the cause of eye problems is due to reflected rays of snow, as the region remains snow-covered for many months. In Changtang plateau the semi-desert and sandy topography causes sand reflection rays that become harmful forthe eyes. According to eye specialists blindness is frequently due to cataracts and glaucoma and not due to vitamin A deficiency. Goitre Paba (Iba-ba) Itwas perhaps surprising that there was no case of goitre, since endemic goitre is common in the Himalayan region mainly in the Tarai belt. Nubra Valley is the only area where goitre cases. 167were found significantly. This could be partly explained for its different ecological environment. Some of the early travellers like Moorcroft mention goitre as an sizeable problem in Ladakh. The local Amchis also said that the prevalence of goitre was higher twenty years ago than now. If this is so then the only explanation for its eradication mainly lies in the consumption of iodised Indian salt after the trade with Tibet was closed. Respiratory infections. Lo (glo) The prevalence of respiratory infection was also high in Ladakh. The coughing is recognized as a separate unit in Ladakh. Ladakhis identify various kind of coughs. Lung-kog (rlung-kog) wind di- sorder, Krog-lo (akrug-glo) physical disorder, Skam-lo (skam-glo) dry cough, Cham-lo (achm-glo) cold cough, Gya-kog (braya-kog) hundred cough, ete. Respiratory infection is found irrespective of religion. In some areas coughing is prevalent in epi- demic form. A respiratory virus specially in winter is blamed for this disease. There is also a rela- tionship of higher respiratory infection in the villages situated at high altitude than in the valleys. The frequently channing weather is mainly blamed for it Heart Disease. Thag-shed (khrag-shed) Hypertension or persistent high blood pressure is a perennial problem irrespective of religious groups. This is an adult health problem. The consumption of Gur-gur Cha or Tibetan tea with salt and butter is blamed for the prevalence of high blood pressure. At the same time physicians in Leh hospital said thatthe high blood pressure does not lead to other associated diseases like nervous disorder, brain tumour, stroke among the Ladakhis.. Cancer Cancer among the Ladakhis is on the increase irrespective of religious groups, but according to doctors and Amchis this could just be a reflection of better diagnosis. ncy diseases in Ladakhi children The pattern of diseases among Ladakhi children is typical of many developing countries. According to a study made by Leh Nutrition Project, nutritional anaemia among Ladakhi children was quite significant. The doctors believe that it could be due to dietary iron deficiency in Ladakh. The report also says that vitamin A deficiency is not a great problem in Ladakh. Their survey showed a high prevalence of chronic protein-calories malnutrition, high incidence of nutritional anaemia and mild Vitamin B deficiency. No signs of vitamin C or vitamin D deficiency were disco- vered. Unlike other underdeveloped parts of India, where famine, drought and poor sanitation arrangements aren common, Ladakh has no case of starvation and because of cold climate worms do not exist. Health problems among children in Ladakh are primarily due to negligence of a child 168The shortage of manpower leads female members to work equally in the field, thus a child is left alone in the house or in the field and most of the children are reported by their mothers to be eating dirt. Seasonality of diseases The incidence of diseases commonly varies with season of the year. This is particularly true of prevalence of diarrhoea in Ladakh. All the villages situated along the Indus river as well as villages situated on alluvial fans have high occurrence of diarrhoea during thawing time that is in spring and autumn. Interestingly this picture is not true for Leh, Sabu and Phyang villages. In Leh diart- hoea is common in summer time especially among the children. The main cause for this occur- rence is because Leh attracts large number of outsiders especially labourers and businessmen from other parts of India as well as tourists. A large influx of food items e. g. green vegetables and semi-ripe fruits come to Leh. All these combine to bring infections in Leh and it's surrounding areas. Contaminated water supply is also responsible for a high incidence of jaundice in summer time, especially among foreign tourists. Measles and conjunctivitis are among the other serious problems in summer period. The prelevence of diarrhoea in villages along the Indus river is mainly people use it for drinking purposes and on the other hand in Leh town only spring water is used for drinking. According to Dr Padfield’s report diarrhoea is common in winter in Mangu and Hankar village and in Alchi it can occur at any time. Definite reasons for the seasonality of these diseases are not known as yet. It is generally observed in Ladakh that mortality rate is quite high in winter. Geographical variation of diseases There is some evidence to show that disease in Ladakh varies from one geographical region to another. In general, health problems are greater in or near the Indus valley than villages located further away on the terraces and alluvial fans. This has been observed from the figures collected by Dr Padfield for eight villages in the month of May in Indus and Marka valleys. Number ofchildren Numberofdiar- %of diarrhoea Village Location examined thoeacases cases Stakna near Indus: 38 15 34 Martselang near Indus 29 Z 24 Mangu near Indus 31 7 23 Alchi near Indus 61 4 6 Skiumarkha/ — awayfromIndus 75 3 4 Rumbak Total 240 38 15 Source: N.N. W., Dr Padfield. “A report written for Save the Children Fund”, Leh. In three villages Stakna, Martselang, Mangu, 29 out of 98 children or 30 % of them were suffering from diarthoea. The highest being Stakna with 39 % of children with diarrhoea. On the other hand in three villages of Skiumarkha and Rumbak together had only 3 out of 75 children or 4 % having diarrhoea problem. This can be partly explained from the fact that in Rumbak and Markha valley 169the source of drinking water is directly from snow melt water originating in the mountains above and around, therefore less contaminated, whereas in Stakna water supply is from a long irrigation canal which has generally low amount and contaminated water. As mentioned earlier diarthoea is common here during thawing period, when the canal carries muddy water. On the other hand diarrhoea in summer is mainly because the whole belt is liable to human waste contamination as the upper part of Stakna is occupied by labourers who are engaged with Stakna Hydro Project as well as road repair works. Another possible explanation is that there is high interaction of local people with the labourers ge- nerally coming from Bihar, Orissa and Kulu Manali who bring with them amoebiasis which are ge- nerally unknown in Ladakh. Itis interesting to note that in Stakna, Martselang and Mangu accor- ding to Leh Nutrition Project, the nutritional status of children was least good. Itis here that interre- lationship of malnutrition and diarrhoea is well known. Beside diarrhoea the Indus valley is also prone to many other diseases like measles epidemics which occur quite frequently. The villages at high altitude normally do not have measles, and itis clear thatin these places contact between villagers and outsiders is not high. From the above observations itis clear that there is a strong relationship between ecological envi- ronment and pattern of diseases in Ladakh. Almost all the diseases are either preventable or easily treated. Most of these diseases could be tackled by well trained and well supervised paramedi- cals. Medical professionals, governmental agencies, planners, voluntary organizations and re- searchers must focus their attention on these aspects of the problem. In the recent years new for- ces of change have brought in elements which are unhealthy for the ecological balance in Ladakh. References Cro0K. J., OsMaston. H., (eds) “Himalayan Buddhists Villages”. Enviroment, resourses, societies and reli- gious life in Zangskar. (in press) CUNNINGHam., A.: Ladakh Physical, Statistical and Historical with notices of the surrounding countries. Sagar Publ, New Delhi. 1977 (reprint) DenoaLercue, C.: Esquisse Ecologique du Ladakh (Himalaya Occidental) Ladakh, Recent Research n°2. Acta Biologica Montana 5, Université de Pau France, 1985, pp 25-46 ‘Misifa, R. P.: Nutrition and health in India. New Delhi NevRou, M.: Organisation de I'espace, isolement et changement dans le domaine Transhimelayen. Le Zanskar. Ladakh. Recent Research n° 2. Université de Pau France, 1986. pp 47-68. Osmasron, H.: The productivity of the agricultural and pastoral system in Zangskar (N. W. Himalaya). Ladakh. Recent Research n® 2. Acta Biologica Montana 5, Université de Pau France, 1985. pp 5-89. Paorieto, N. N. W.: A report written for Save the Children Fund. Rizw,J.: Ladakh, crossroads of High Asia. Oxford University Press, Delhi, 1983. ‘SToBDAK, P.: A survey of source material for the historical geography of Ladakh. Ladakh. Recent Research 1n°2, Acta Biologica Montana 6, Université de Pau, France, 1985. pp 69-74, ‘Sroabax, P.: Ladakhis ~ people of the mountain desert. The Times of India, (Travel Times). April 30, 1986, New Delhi, Bombay. Strachey, CAPTAIN H.: Physical geography of Western Tibet. Journal of the Royal Geographical Society, vol. 23(1983), pp. 1-68. SUxHatMe,P. V.: Feeding India's growing millions. Bombay. SINGH, T.: Studies in Himalayan ecology and development strategies. The English Books Store Ed., New Delhi; 1980. ‘Voura, R.: Ethno-historical notes on Nubra in Ladakh. Ladakh. Recent Research n° 2. Acta Biologica Mon- tana 5, Université de Pau, France, 1985. pp. 247-256 Vous, Ri. History of the Dards and the concept of Minaro traditions among the buddhist Dards in Ladakh In: Recent Research in Ladakh/ed. Kantowsky D. & Sanders R. 1983, pp. 51-80. 170