The Char Dham Yatra, an annual pilgrimage to the four sacred shrines of Yamunotri, Gangotri, Kedarnath, and Badrinath in Uttarakhand, India, attracts millions of devotees from across the globe [1]. This influx of pilgrims, particularly during the peak season from April to November, poses significant challenges to the healthcare system in the region. The arduous trek, high altitude, unpredictable weather, and limited medical infrastructure contribute to increased morbidity and mortality among the pilgrims. During this yatra there is not only enhanced risk of high-altitude illness but also non-communicable diseases such as acute coronary syndromes & Stroke. In India, cardiovascular diseases (CVDs) are the leading cause of death and disability, contributing to 31.8% of all deaths and 14.7% of global disability-adjusted life years (DALYs) in 2017 [2]. The data shows an increase in deaths due to cardiovascular diseases, rising from 12.4 million in 1990 to 19.8 million in 2022 [3]. Despite a 34.9% decline in the global age-standardized mortality rate since 1990, ischemic heart disease and stroke remain the predominant causes [4]. In India, CVDs account for 27% of total deaths, with a disproportionately high age-standardized death rate of 272 per 100,000—higher than the global average [5]. The burden of CVDs has increased from 155.7 to 209.1 deaths per 100,000 between 1990 and 20166, with significant regional disparities, such as Punjab having nine times the ischemic heart disease burden compared to Mizoram [6].

Emergency medical services in Uttarakhand, particularly during the Char Dham Yatra, are critical due to the geographical and climatic adversities of the region. The doctors, who are at the frontline of providing emergency care, handle altitude-related illnesses and other medical emergencies such as acute coronary syndrome, acute shortness of breath, trauma related emergencies, stroke and mass casualty situations, as well as insufficient resources and logistical support [7]. The Char Dham Yatra faces challenges similar to rural healthcare, including remote locations, inadequate facilities, financial constraints, and limited awareness of altitude-related illnesses. Elderly pilgrims often depend on family, causing delays in seeking care, while cultural beliefs and psychosocial factors further hinder timely medical intervention. Improved infrastructure, awareness, and support are essential to address these issues [8].

The high-altitude environment of the Char Dham Yatra presents unique health challenges such as acute mountain sickness (AMS), high-altitude pulmonary edema (HAPE), and high-altitude cerebral edema (HACE), which require specialized knowledge and skills for effective management. Acute Mountain Sickness (AMS) typically occurs at elevations above 2,500 m (8,200 feet). However, susceptibility varies among individuals, and symptoms can manifest at lower altitudes in some cases. Factors such as the rate of ascent, individual acclimatization, and pre-existing health conditions influence the onset and severity of AMS [9].

General emergency care focuses on acute conditions such as cardiac arrest and stroke, using protocols like CPR and advanced life support. The key distinction lies in altitude-specific pathophysiology versus systemic emergencies, requiring an integrated approach in high-altitude healthcare. Thus, capacity building in primary management of such illnesses is pivotal for several reasons. Most of these emergencies require timely identification, intervention and referral to appropriate centre of choice. The patient should receive immediate initial stabilization in the form of maintenance of airway, breathing, circulation, disability assessment and exposure. By training the front-line workers about the maintenance of vital signs and timely referral can prevent significant mortality and morbidity.

Studies have highlighted that proper training in altitude medicine can significantly reduce the incidence and severity of these conditions [10]. Strengthening the capacity of these medical officers through targeted training programs and infrastructure development is essential to improve the quality and efficiency of emergency care during the Yatra. Therefore, this study aimed to evaluate the effectiveness of a comprehensive capacity-building program for medical officers involved in the Char Dham Yatra. This initiative is expected to not only reduce morbidity and mortality rates but also enhance the resilience of the healthcare system in Uttarakhand.