The lure of extreme sports

ecently, I watched a remarkable documentary on Netflix, 14 Peaks: Nothing Is Impossible. It tells the extraordinary story of the Nepali mountaineer Nirmal 'Nimsdai' Purja and his seemingly impossible ambition to climb all fourteen of the world's peaks taller than 8,000 metres. These peaks are scattered across the Himalayas and Karakoram in Pakistan, Nepal, China and India. Purja completed the campaign over a period of just seven months in 2019. The feat placed him among the most celebrated high-altitude mountaineers in the world. I found the documentary captivating. The scenery is breathtaking, the physical challenges extraordinary. The determination of the climbers is difficult to comprehend. The film captures the beauty of the mountains, but also their indifference to human ambition. A mountain does not care how experienced, determined or courageous a climber may be. At extreme altitude, nature controls the outcomes. As I watched the film, another thought kept coming to mind: why would anyone repeatedly expose oneself to mortal danger? Perhaps this is a question only a mountaineer can answer. As a physician, I found myself looking at the same events from an entirely different perspective. I could admire the courage, discipline, endurance and extraordinary physical fitness required to climb such mountains but wondered at the wisdom of repeatedly placing one's life in such extreme danger. The question became even more poignant because I have had a few personal encounters with high altitude. Many years ago, when I was relatively young, I travelled to Switzerland with a group of doctors to attend a medical conference in Geneva. During the trip, we visited Zermatt, one of the most spectacular mountain resorts in the Swiss Alps. We travelled part of the way by bus; then continued our journey by train. Eventually, we used a series of cable cars to ascend toward the higher reaches of the mountains. We climbed to approximately 4,500 metres, where everything around us was covered in snow. Even at that relatively modest altitude compared to the great Himalayan peaks, I was conscious of the possibility of altitude sickness. As a physician, I was perhaps more aware than some of my companions of what reduced atmospheric pressure and oxygen availability could do to the human body. Fortunately, we tolerated the ascent well. None of us developed significant symptoms and the experience became one of the memorable journeys of my life. A few years later, I had another encounter with altitude, this time closer to home. During a visit to Gilgit and Hunza, we planned an excursion toward the Pakistan-China border. We travelled directly from Hunza toward the Khunjerab Pass, which is approximately 4,700 metres—or about 15,400 feet—above sea level. The altitude was considerably greater than that of many mountain destinations. I remember experiencing some light-headedness and a mild sensation of air hunger. Fortunately, these symptoms were manageable and did not progress. Nevertheless, I was conscious that we were entering an environment in which the human body is operating under very different physiological conditions. I was reminded of an important principle of high-altitude medicine: at altitude, there is less oxygen available to the body because atmospheric pressure falls as altitude increases. Our bodies compensate through increased breathing, an increased heart rate, and, with acclimatisation, physiological changes that improve oxygen delivery. But these compensatory mechanisms have limits. At very high altitudes, particularly above 8,000 metres—the so-called 'death zone'—the margin for physiological error becomes extremely small. Another memorable experience occurred a few years ago in Azad Kashmir. Five of us, friends since our college days, had gathered together. One of our friends was from Kashmir. He lived in Muzaffarabad and had arranged an excursion to a beautiful high-altitude lake in the region, Rati Gali Jheel. We travelled by jeep to the base camp. The journey took several hours. From there, we continued on horseback for another forty minutes or so before reaching our destination at roughly 13,000 feet. The horse ride was memorable. The scenery was extraordinary. Glaciers surrounded the lake and the mountains rose majestically around us. It was one of the places where nature seems unreal. When we returned to the base camp, the difference in altitude had become apparent. All five of us were in our late sixties. We felt unusually tired and lethargic. As a physician, I recognised that the symptoms were likely related, at least in part, to reduced oxygen availability and the physiological demands of altitude. Fortunately, nothing more serious than that happened. We returned safely to our guesthouse and the journey remains a beautiful memory. These experiences were modest compared with the conditions faced by high-altitude mountaineers. I had never attempted to climb a major peak. I had simply visited high-altitude regions, remained there for a while and returned to lower ground. Yet even these relatively brief encounters gave me some appreciation of what the human body faces at altitude. Then came the tragic news from Broad Peak. An international expedition led by Nirmal Purja was caught in an avalanche during its descent from Broad Peak, an 8,051-metre mountain in the Karakoram. All ten members of the expedition died. The group included climbers from Nepal, Pakistan, Oman, China, Britain and the United States. Purja, famous for climbing all fourteen 8,000-metre peaks, was among those who perished. I could not help thinking about the documentary I had watched only recently. The man I had watched on the screen, looking so stout and experienced, demonstrating extraordinary determination and courage was among the victims of the very mountains he had conquered. This brought back the question that had troubled me while watching the documentary: after a person has achieved the seemingly impossible, what compels him to return - again and again - to an environment in which one mistake, one avalanche, one sudden change in weather, or one equipment failure can end his life? I ask this question not as an objection to mountaineering, but as a physician and as someone who has spent more than four decades trying to preserve human life, even at extremes of age. I understand that passion cannot always be explained by routine logic. For some people, the mountain is not simply a mountain. It is a challenge, a teacher, an adversary - perhaps even a source of meaning. The psychological attraction of extreme sports is complex. There is the exhilaration of overcoming fear, the satisfaction of mastery, the search for novelty and intense sensation, the desire to achieve something few others have accomplished and sometimes the powerful feeling that one is pushing the boundaries of human possibility. There may also be an element of what psychologists call sensation seeking—a tendency in some individuals to seek novel, intense and complex experiences even when they involve substantial risk. Courage and risk-taking are not necessarily the same thing. Courage is often the willingness to face danger when there is a compelling reason to do so. Recklessness is accepting danger without adequately considering its consequences. The boundary between the two can sometimes get blurred. Mountaineering is certainly not the only activity in which this happens. The modern world contains numerous extreme sports in which participants deliberately expose themselves to potentially catastrophic injury. BASE jumping—jumping with a parachute from buildings, antennas, bridges or cliffs—is among the most dangerous. A study examining fatalities from 2007 to 2017 identified 223 fatal BASE-jumping events; 96 percent were attributed to impact or striking an object. Human factors, including failing to deploy the parachute properly and poor exits, accounted for a substantial proportion of fatal events. Wingsuit flying takes the concept further. The participants essentially turn themselves into human gliders, flying at high speed close to cliffs and other terrain. In one epidemiological study of 180 BASE-jumping fatalities recorded between 1981 and 2011, 39 involved wingsuits. Nearly half of these deaths resulted from striking cliffs and another 46 percent from ground impact. There are also free-solo rock climbers who climb without ropes; big-wave surfers who deliberately enter enormous and potentially lethal waves; cave divers who enter underwater cave systems where a navigational error can be fatal; high-altitude skiers who descend steep mountain faces; ice climbers who depend on fragile surfaces; and various forms of speed flying, cliff diving and other activities where a single mistake can result in catastrophic injury. I do not believe that all such sports should be condemned outright. Human beings have always explored boundaries. Exploration, adventure, curiosity and the desire to accomplish difficult things have contributed enormously to human progress. Mountaineers have explored places where few humans had previously ventured. Extreme athletes have demonstrated extraordinary capabilities of the human body and mind. The question is not whether we should eliminate adventure. The question is how much unnecessary risk we should accept in the pursuit of adventure. This distinction is particularly important because the consequences of an extreme-sport injury do not always end with the injured athlete. A climber who dies leaves behind parents, a spouse, children, siblings and friends. A person who survives with a severe spinal cord injury, traumatic brain injury or permanent disability may require lifelong care. The emotional and financial consequences can extend to the entire family. As a physician, I have seen how devastating disability can be—not only for the patient but also for those who must become caregivers. A few minutes of excitement can sometimes result in decades of dependence. There is another dimension that is often overlooked in high-altitude mountaineering: the people who make these expeditions possible. Sherpas, high-altitude porters, guides, rescuers, and local support workers frequently assume enormous risks while assisting climbers. The dangers are therefore not always borne by the person nominally seeking the adventure. This raises an ethical question that deserves more attention: how much risk is acceptable when others may have to risk their lives to rescue you? We must acknowledge that risk can never be eliminated completely. Even highly experienced climbers using sophisticated equipment and carefully planned expeditions can encounter an avalanche, rockfall, sudden storm, crevasse, equipment failure or unexpected medical emergency. The recent Broad Peak tragedy is a painful reminder of this reality. Ten experienced people lost their lives in an environment that can become lethal within minutes. Medical science can help, but it cannot defeat nature. At high altitude, prevention is far more important than treatment. Acclimatisation, careful monitoring, weather forecasting, appropriate equipment, experienced guides, reliable communication, conservative decision-making, and knowing when to turn back can all reduce risk. No summit is worth dying for. This principle is particularly important. The mountain will still be there tomorrow. A summit can be attempted again. A record can be broken by someone else. An expedition can be postponed. A competition can be abandoned. A human life cannot be postponed. I sometimes wonder whether the greatest achievement in mountaineering is reaching the summit. Perhaps it is having the wisdom to turn around when conditions become dangerous. There is a famous mountaineering saying: 'Getting to the top is optional. Getting down is mandatory.' I find this particularly meaningful from a medical perspective. The purpose of any expedition should not simply be to reach the highest possible point, but to return safely to the people waiting at home. Perhaps this is where the philosophy of medicine and the philosophy of extreme sport meet. Medicine teaches us to preserve life, assess risk, anticipate complications and intervene before disaster occurs. Extreme sports teach determination, courage, discipline and resilience. There is no reason why these values must collide. We should not ask adventurers to abandon their passions. Instead, we should encourage them to pursue those passions intelligently. I remain fascinated by mountains. I love their beauty, their silence, their grandeur and the sense of humility they inspire. My own visits to the Swiss Alps, Hunza, Khunjerab, Skardu, Kalam and the mountains of Kashmir remain among my most cherished travel memories. But my years as a physician have changed the way I look at them. I see not only the summit but also the human being standing beneath it. I see the family waiting at home. I see the possibility of a rescue team risking their own lives. I see the consequences of a fall that cannot be reversed. I see the extraordinary fragility of the human body when confronted with forces far greater than itself. The mountains deserve our admiration. They also deserve our respect. Passion is one of the elements that makes human life meaningful. It drives explorers, scientists, athletes, artists, and physicians to accomplish extraordinary things. But passion without restraint can be destructive. Perhaps the wisest adventurer is not the person who repeatedly asks, 'How far can I go? Perhaps it is the person who knows when to ask, 'How much is enough?' For me, the tragedy of Broad Peak has made that question more difficult to ignore. The author is the former dean of medicine and allied sciences at Dow University of Health Sciences, Karachi