To the Editor:
Drs Ghimire and Pun have made some important points about problems that continue to put Nepali porters at risk of developing acute mountain sickness (AMS). Our answers to their questions are as follows: Exclusion criteria were established solely by taking a history. This can be difficult in any population. Many porters were unaware of the medical conditions mentioned, with the exception of AMS, with which most were familiar. The Nepali doctors, using colloquial language, asked specifically about each exclusion criterion. For example, diabetes was “chini rog,” meaning “sugar disease.” In the discussion we have touched on the reasons for a low incidence of AMS in these porters. It is also possible that trekking porters are a self-selected group from which AMS sufferers have to some extent been excluded over the years. Because there was such a high dropout rate, the power of the study was so weak that no conclusion could be drawn about the efficacy of acetazolamide. We did not find any evidence of a taboo regarding medication, but as you are probably aware, rural Nepalis are generally reluctant to take medication, often preferring to trust local healers (shamans). The porters were apparently fit and healthy and sometimes “macho,” so we suspect that there might have been some reluctance to take medication despite their initial agreement. Some were persuaded by their sirdars to stop their trial medication. However, we were unable to question many porters who dropped out of the study, so we cannot give a precise answer. We agree that porters’ options are limited by the demands of trekking schedules, but this has to change. Sick porters should not be forced to continue trekking and then be abandoned to descend alone. We hope that the results of our study will increase local awareness, thereby supporting the efforts of such organizations as the International Porters Protection Group (IPPG) and Porters’ Progress, who are trying to improve the education and working conditions of Nepali porters. The Mountain Medicine Society of Nepal could play an important role in advising and working with trekking companies to reduce the risk of AMS in this vulnerable group of lowland porters. We agree that better education is vital. The Nepali doctors who enrolled the porters in this study did their best, counseling them carefully about the risks of AMS and the role of acetazolamide. They also advised them about what to do if they had AMS symptoms, and they treated those porters who exited the trial due to AMS.