Insulin storage in the Upper Himalayas.

There are, however, resource-poor environments where keeping insulin warm enough is an issue. These include mountainous areas such as the Himalayas and the Andes, located in relatively less affluent countries. One such ‘cold desert’, located in the Himalayan state of Himachal Pradesh, in India, is Spiti. Located at an altitude of approximately 3000–4500 m above sea level, Spiti remains snowbound for up to 6 months in a year. Temperature extremes range from 30°C in summer to –20°C in winter. Persons living with diabetes in Spiti source their insulin and ancillary supplies from the state capital Simla, in bulk. Facilities for monitoring of glucose and for medical check-ups are limited, especially during the winter season. Insulin storage and disposal also pose significant challenges, and these are cited by patients as excuses to avoid insulin when it is suggested to them.