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Health

Tibet poses some unique and particular risks to your health, mostly associated with altitude. There is no need to be overly worried: very few travellers are adversely affected by altitude for very long, and greater risks are present in the form of road accidents and dog bites.

Make sure you’re healthy before you start travelling. If you are going on a long trip, make sure your teeth are OK. If you wear glasses, take a spare pair and your prescription.

Sensible travellers will rely on their own medical knowledge and supplies. Outside Lhasa and Shigatse there is very little in the way of expert medical care. Make sure you travel with a well-stocked medical kit and knowledge of how to use it.

Before You Go

Health Insurance

Tibet is a remote location, and if you become seriously injured or very sick, you may need to be evacuated by air. Under these circumstances, you don’t want to be without adequate health insurance. Be sure your policy covers evacuation.

Recommended Vaccinations

China doesn’t officially require any immunisations for entry into the country; however, the further off the beaten track you go, the more necessary it is to take all precautions.

Plan well ahead (at least eight weeks before travel) and schedule your vaccinations – some require more than one injection, while others should not be given together. Note that some vaccinations should not be given during pregnancy or to people with allergies.

Discuss your requirements with your doctor, but vaccinations you should consider for this trip include the following.

Chickenpox (Varicella) Discuss this vaccine with your doctor if you have not had chickenpox.

Diphtheria & Tetanus Vaccinations for these two diseases are usually combined and are recommended for everyone. After an initial course of three injections (usually given in childhood), boosters are necessary every 10 years.

Hepatitis A The vaccine for Hepatitis A (eg Avaxim, Havrix 1440 or VAQTA) provides long-term immunity (at least 20 years) after an initial injection and a booster at six to 12 months. Hepatitis A vaccine is also available in a combined form, Twinrix, with hepatitis B vaccine. Three injections over a six-month period are required, the first two providing substantial protection against hepatitis A.

Hepatitis B China (although not so much Tibet) is one of the world’s great reservoirs of hepatitis B infection, a disease spread by contact with blood or by sexual activity. Vaccination involves three injections, the quickest course being over three weeks with a booster at 12 months.

Influenza The flu vaccine is recommended for anyone with a chronic disease, such as diabetes or lung or heart disease. Tibet has a high rate of respiratory illness, so all travellers should consider vaccination.

Measles-mumps-rubella (MMR) All travellers should ensure they are immune to these diseases, either through infection or vaccination. Most people born before 1966 will be immune; those born after this date should have received two MMR vaccines in their lifetime.

Pneumonia A vaccine is recommended for anyone over 65 or those over 55 with certain medical conditions.

Polio Everyone should keep up to date with this vaccination, which is normally given in childhood. One adult booster is then needed (as long as the full childhood course was completed), particularly if travelling to a country with recent polio activity, such as Nepal. This should be discussed with your doctor.

Rabies Rabies is the most common infectious-disease cause of death in China. Vaccination is strongly recommended for those spending more than a month in Tibet (especially if you are cycling, handling animals, caving or travelling in remote areas) and for children. Getting pretravel vaccination means you do not need to receive Rabies Immunoglobulin (RIG) after a bite. RIG is very unlikely to be available in Tibet. If you are prevaccinated and then bitten, you need only get two further shots of vaccine, as soon as possible, three days apart. If not prevaccinated, you require RIG plus five shots of vaccine over the course of 28 days. The full series of vaccination does not require any boosters unless a bite occurs.

Tuberculosis The risk of tuberculosis (TB) to travellers is usually very low, unless you’ll be living with or closely associated with local people in high-risk areas. Recommendations for BCG vaccination vary considerably around the world. Discuss with your doctor if you feel you may be at risk. Vaccination is strongly recommended for children under five who are spending more than three months in a high-risk area.

Typhoid This is an important vaccination to have for Tibet, where hygiene standards are low. It is available either as an injection or as oral capsules. A combined hepatitis A–typhoid vaccine was launched recently.

Yellow Fever This disease is not endemic in China or Tibet and a vaccine (proven by an International Health Certificate) is only required if you are coming from an infected area (parts of South America and Africa).

Medical Checklist

If you require a particular medication, take a good supply, as it may not be available in Tibet. Take along part of the packaging showing the generic name rather than the brand to make getting replacements easier. To avoid problems, have a legible prescription or letter from your doctor to show that you legally use the medication.

Following is a list of items you should consider including in your medical kit for travelling in Tibet.

  • Antibiotics – useful for everyone travelling to Tibet to avoid the risk of receiving poorly stored local medications; see your doctor (antibiotics must be prescribed) and carry the prescription with you. It's good to have two types: one for lung infections, and one for general skin and other infections.
  • Antifungal cream or powder – for fungal skin infections and thrush
  • Antihistamine – for allergies (eg hay fever), to ease the itch from insect bites or stings, and to prevent motion sickness
  • Antiseptic (such as povidone-iodine) – for cuts and grazes
  • Bandages, Band-Aids (plasters) and other wound dressings
  • Calamine lotion, sting-relief spray or aloe vera – to ease irritation from sunburn and insect bites or stings
  • Cold and flu tablets, throat lozenges and nasal decongestant
  • Diamox – to aid with the prevention of altitude sickness
  • Homeopathic medicines – including gentiana for altitude sickness, echinacea for warding off infections, and tea-tree oil for cuts and scrapes
  • Insect repellent, sunscreen, lip balm and eye drops
  • Loperamide or diphenoxylate – ‘blockers’ for diarrhoea
  • Multivitamins – for long trips, when dietary vitamin intake may be inadequate
  • Paracetamol (acetaminophen in the USA) – for pain or fever
  • Prochlorperazine or metaclopramide – for nausea and vomiting
  • Rehydration mixture – to prevent dehydration (eg during bouts of diarrhoea); particularly important when travelling with children
  • Scissors, tweezers and a thermometer – note that mercury thermometers are prohibited by airlines
  • Sterile kit – in case you need injections in a country with medical hygiene problems; discuss with your doctor
  • Water-purification tablets or iodine

Websites

There are several excellent online travel-health sites. From the Lonely Planet website (www.lonelyplanet.com) there are links to the World Health Organization (WHO) and the US Centers for Disease Control and Prevention.

Further Reading

Lonely Planet’s Healthy Travel – Asia & India is a handy pocket size and packed with useful information, including pretrip planning, emergency first aid, immunisation and disease information, and what to do if you get sick on the road. Travel with Children from Lonely Planet also includes advice on travel health for younger children.

Other detailed health guides you may find useful:

Medicine for Mountaineering by James Wilkerson is still the classic text for trekking first aid and medical advice.

Pocket First Aid and Wilderness Medicine by Jim Duff and Peter Gormly is a great pocket-size guide that’s easily carried on a trek or climb.

The High Altitude Medicine Handbook by Andrew J Pollard and David R Murdoch is a small-format guide full of valuable information on prevention and emergency care.

Travellers’ Health by Richard Dawood is comprehensive, easy to read, authoritative and highly recommended, although it’s rather large to lug around.

In Tibet

Environmental Hazards

Hypothermia

Tibet’s cold climate must be treated with respect. Sub-freezing temperatures mean there is a risk of hypothermia even during the summer season, when high areas around western Tibet and the northern Changtang can be hit without warning by sudden snow storms. Exposed plains and ridges are prone to extremely high winds and this significantly adds to the cold. For example, on a 5000m pass in central Tibet in July, the absolute minimum temperature is roughly -4°C, but regularly occurring 70km/h winds plunge the wind-chill factor or apparent temperature to -20°C.

Always be prepared for cold, wet or windy conditions, especially if you’re out walking at high altitudes or even taking a long bus trip over mountains (particularly at night).

Hypothermia occurs when the body loses heat faster than it can produce it and the core temperature of the body falls. It is surprisingly easy to progress from very cold to dangerously cold through a combination of wind, wet clothing, fatigue and hunger, even if the air temperature is above freezing.

Symptoms of hypothermia are exhaustion, numb skin (particularly toes and fingers), shivering, slurred speech, irrational or violent behaviour, lethargy, stumbling, dizzy spells, muscle cramps and violent bursts of energy. Irrationality may take the form of sufferers claiming they are warm and trying to take off their clothes.

To treat mild hypothermia, first get the person out of the wind and rain, remove their clothing if it’s wet and replace it with dry, warm clothing. Give them hot liquids (not alcohol) and some high-energy, easily digestible food. Do not rub victims; instead, allow them to slowly warm themselves. This should be enough to treat the early stages of hypothermia. The early recognition and treatment of mild hypothermia is the only way to prevent severe hypothermia, which is a critical condition.

Acute Mountain Sickness

Acute mountain sickness (AMS; also known as altitude sickness) is common at high elevations; relevant factors are the rate of ascent and individual susceptibility. The former is the major risk factor. On average, one tourist a year dies in Tibet from AMS. Any traveller who flies to where the elevation is around 3600m is likely to experience some symptoms of AMS.

AMS is a notoriously fickle affliction and can also affect trekkers and walkers accustomed to walking at high altitudes. It has been fatal at 3000m, although 3500m to 4500m is the usual range.

Acclimatisation

AMS is linked to low atmospheric pressure. Those who travel up to Everest Base Camp, for instance, reach an altitude where atmospheric pressure is about half of that at sea level.

With an increase in altitude, the human body needs time to develop physiological mechanisms to cope with the decreased oxygen. This process of acclimatisation is still not fully understood, but it is known to involve modifications to breathing patterns and heart rate induced by the autonomic nervous system, and an increase in the blood’s oxygen-carrying capabilities. These compensatory mechanisms usually take one to three days to develop at a particular altitude. You are unlikely to get AMS once you are acclimatised to a given height, but you can still get ill when you travel higher. If the ascent is too high and too fast, these compensatory reactions may not kick into gear fast enough.

Symptoms

Mild symptoms of AMS usually develop during the first 24 hours at altitude. These will generally disappear through acclimatisation in several hours to several days.

Symptoms tend to be worse at night and include headache, dizziness, lethargy, loss of appetite, nausea, breathlessness and irritability. Difficulty sleeping is another common symptom, and many travellers have trouble for the first few days after arriving in Lhasa.

AMS may become more serious without warning and can be fatal. Symptoms are caused by the accumulation of fluid in the lungs and brain, and include breathlessness at rest, a dry, irritative cough (which may progress to the production of pink, frothy sputum), severe headache, lack of coordination (typically leading to a ‘drunken walk’), confusion, irrational behaviour, vomiting and eventually unconsciousness.

The symptoms of AMS, however mild, are a warning: be sure to take them seriously! Travellers and trekkers should keep an eye on each other, as those experiencing symptoms, especially severe symptoms, may not be in a position to recognise them. One thing to note is that while the symptoms of mild AMS often precede those of severe AMS, this is not always the case. Severe AMS can strike with little or no warning.

Prevention

If you are driving to Tibet from Kathmandu, you will experience rapid altitude gain. An itinerary that takes you straight up to Everest Base Camp is unwise; plan to see it on your way back if possible. The best way to prevent AMS is to avoid rapid ascents to high altitudes. If you fly into Lhasa, take it easy for at least three days; this is enough for most travellers to get over any initial ill effects.

To prevent AMS:

  • Ascend slowly. Have frequent rest days, spending two to three nights at each rise of 1000m. If you reach a high altitude by trekking, acclimatisation takes place gradually and you are less likely to be affected than if you fly or drive directly to high altitude.
  • Trekkers should bear in mind the climber’s adage of ‘climb high, sleep low’. It is always wise to sleep at a lower altitude than the greatest height that’s reached during the day.
  • Once above 3000m, care should be taken not to increase the sleeping altitude by more than 400m per day.
  • Drink extra fluids. Tibet’s mountain air is cold and dry, and moisture is lost as you breathe. Evaporation of sweat may occur unnoticed and result in dehydration.
  • Avoid alcohol, as it may increase the risk of dehydration, and don’t smoke.
  • Avoid sedatives.
  • When trekking, take a day off to rest and acclimatise if feeling overtired. If you or anyone else in your party is having a tough time, make allowances for unscheduled stops.
  • Don’t push yourself when climbing up to passes; rather, take plenty of breaks. You can usually get over the pass as easily tomorrow as you can today. Try to plan your itinerary so that long ascents can be divided into two or more days. Given the complexity and unknown variables involved with AMS and acclimatisation, trekkers should always err on the side of caution and ascend mountains slowly.

Treatment

Treat mild symptoms by resting at the same altitude until recovery, which usually takes a day or two. Take paracetamol or acetaminophen for headaches. If symptoms persist or become worse, however, immediate descent is necessary. Even 500m can help.

The most effective treatment for severe AMS is to get down to a lower altitude as quickly as possible. In less severe cases the victim will be able to stagger down with some support; in other cases they may need to be carried down. Whatever the case, any delay could be fatal.

AMS victims may need to be flown out of Tibet as quickly as possible, so make sure you have adequate travel insurance.

The drug acetazolamide (Diamox) is recommended for the prevention of AMS – take 125mg twice a day as a preventive dose. Be aware that even when you are on Diamox, you should not ignore any symptoms of AMS. Diamox should be avoided in those with a sulphur allergy.

Drug treatments should never be used to avoid descent or to enable further ascent (although they can help get people well enough to descend).

Several hotels in Lhasa sell a Tibetan herbal medicine recommended by locals for easing the symptoms of mild altitude sickness. The medicine is known as solomano in Tibetan and hóngjīngtīan (红景天) in Chinese, though locals also recommend gāoyuānníng (高原宁) and gāoyuánkāng (高原康). A box of vials costs ¥35 to ¥50; take three vials a day.

Heat Exhaustion

Dehydration and salt deficiency can cause heat exhaustion. Take time to acclimatise to high temperatures, be sure to drink sufficient liquids and do not do anything too physically demanding.

Salt deficiency is characterised by fatigue, lethargy, headaches, giddiness and muscle cramps; salt tablets may help, but adding extra salt to your food is better.

Frostbite

This is the freezing of extremities, including fingers, toes and nose. Signs and symptoms of frostbite include a whitish or waxy cast to the skin, or even crystals on the surface, plus itching, numbness and pain. Warm the affected areas by immersing them in warm (not hot) water or with blankets or clothes, only until the skin becomes flushed. Note: frostbitten areas should only be rewarmed if there is not a likelihood they will be frostbitten again prior to reaching medical care. Frostbitten parts should not be rubbed. Pain and swelling are inevitable. Blisters should not be broken. Get medical attention right away.

Food

Vegetables and fruit should be washed with purified or bottled water or peeled where possible. Beware of ice cream that is sold in the street or anywhere it might have been melted and refrozen; if there’s any doubt (eg a power cut in the last day or two), steer clear. Avoid undercooked meat.

In general, places that are packed with travellers or locals will be fine, while empty restaurants are questionable. Chinese food is usually cooked over a high heat, which kills most germs.

Sunburn

It’s very easy to get sunburnt in Tibet’s high altitudes, especially if you’re trekking. Wear sunglasses, loose-fitting clothes that cover your arms, legs and neck, and a wide-brimmed hat like the ones Tibetans wear (not a baseball cap).

Choose sunscreen with a high sun-protection factor (SPF). Those with fair complexions should bring reflective sunscreen (containing zinc oxide or titanium oxide) with them. Apply the sunscreen to your nose and lips (and especially the tops of your ears if you are not wearing a hat).

Infectious Diseases

Cholera

This is the worst of the watery diarrhoeas. Outbreaks are generally widely reported, so you can avoid problem areas. Fluid replacement is the most vital treatment: the risk of dehydration is severe, as you may lose up to 20L a day. Seek medical advice if you think you may have this disease. If there is a delay in getting to hospital, begin taking doxycycline.

Rabies

This fatal viral infection is found in Tibet. Many animals (such as dogs, cats, bats and monkeys) can be infected and it is their saliva that is infectious. Any bite, scratch or even lick from an animal should be cleaned immediately and thoroughly. Scrub gently with soap and running water, and then apply alcohol or iodine solution. Prompt medical help should be sought to receive a course of injections to prevent the onset of symptoms and save the patient from death.

If you have any potential exposure to rabies, seek medical advice in Lhasa (or ideally Kathmandu, Chéngdū or Běijīng) as soon as possible. Even in these centres full treatment may not be available and you may need to travel to Bangkok or Hong Kong.

Respiratory Infections

Upper-respiratory-tract infections (like the common cold) are frequent ailments all over China, including Tibet, where the high altitude aggravates symptoms.

Some of the symptoms of influenza include a sore throat, fever and weakness. Any upper-respiratory-tract infection, including influenza, can lead to complications such as bronchitis and pneumonia, which may need to be treated with antibiotics. Seek medical help in this situation.

No vaccine offers complete protection, but the influenza vaccine is highly recommended for travellers to China and Tibet, and is good for up to one year.

Amoebic Dysentery

Caused by the protozoan Entamoeba histolytica, amoebic dysentery is characterised by the gradual onset of low-grade diarrhoea, often with blood and mucus. Cramping abdominal pain and vomiting are less likely than in other types of diarrhoea, and fever may not be present. It will persist until treated and can recur and cause other health problems.

You should seek medical advice if you think you have giardiasis or amoebic dysentery, but where this is not possible, tinidazole or metronidazole are the recommended drugs. The better option of the two is tinidazole, which is not easily obtained in Tibet. If you are going to be travelling in high mountain areas, it’s a good idea to keep your own stock with you.

Giardiasis

Known as giardia, giardiasis is a type of diarrhoea. It's relatively common in Tibet and is caused by a parasite, Giardia lamblia, present in contaminated water. Many kinds of mammals harbour the parasite, so you can easily get it drinking ‘pure mountain water’, or even brushing your teeth with contaminated water. Symptoms include stomach cramps, nausea, a bloated stomach, watery, foul-smelling diarrhoea and frequent gas. Giardiasis can appear several weeks after you have been exposed to the parasite. The symptoms may disappear for a few days and then return; this can go on for several weeks. Treatment is with tinidazole, 2g in a single dose for one to two days.

Tibetan Medicine

The basic teachings of Tibetan medicine share much with those of other Asian medical traditions, which, according to some scholars, made their way to the East via India from ancient Greece. These traditions look at symptoms as indications of an imbalance in the body and seek to restore that balance.

The theory of Tibetan medicine is based on an extremely complex system of checks and balances between what can be broadly described as three ‘humours’ (related to state of mind), seven ‘bodily sustainers’ (related to the digestive tract) and three ‘eliminators’ (related to the elimination of bodily wastes). There is also the influence of harmful spirits to consider: 360 harmful female influences, 360 harmful male influences, 360 malevolent naga (water spirits) influences and, finally, 360 influences stemming from past karma. All these combine to produce 404 basic disorders and 84,000 illnesses!

How does a Tibetan doctor assess the condition of a patient? The most important skill is pulse diagnosis. A Tibetan doctor is attuned to 360 ‘subtle channels’ of energy that run through the body’s skin and muscle, internal organs, and bone and marrow. The condition of these channels can be ascertained through six of the doctor’s fingers (the first three fingers of each hand). Tibetan medicine also relies on urine analysis as an important diagnostic tool.

Yuthok Yongten Gonpo (1182–1251), the physician of King Trisong Detsen, who was born near Ralung Monastery, is credited as the founder of the Tibetan medical system. For more on Tibetan medicine, see www.tibetan-medicine.org.

If you get sick, you can get a diagnosis from Lhasa’s Mentsikhang, opposite the Barkhor. Two English-speaking doctors attend to foreigners on the 3rd floor.

Tap Water

The number-one rule is don’t drink the tap water, including ice. In urban centres Tibetans, like the Chinese, boil their drinking water, making it safe to drink hot or cooled. In the country and while trekking you should boil your own water or treat it with water-purification tablets, as livestock contaminate many of the water sources. Tea is always safe to drink. Locally brewed beer (chang) is another matter. It is often made with contaminated well water and there is always some risk in drinking it. Large 5L bottles of drinking water are available in most supermarkets.

Water Purification

The simplest way to purify water is to boil it thoroughly. At Tibet’s high altitude water boils at a lower temperature and germs are less likely to be killed, so make sure you boil water for at least 10 minutes.

Consider purchasing a water filter for a long trip (often more economical than buying bottled water). Total filters take out all parasites, bacteria and viruses, and make water safe to drink.

Chlorine tablets (eg Puritabs or Steritabs) will kill many pathogens, but not giardia and amoebic cysts. Iodine is more effective for purifying water and is available in liquid (Lugol’s solution) or tablet (eg Potable Aqua) form. Follow the directions carefully and remember that too much iodine can be harmful.

Availability & Cost of Health Care

Outside Lhasa and Shigatse health-care advice is patchy at best and non-existent at worst. Self-diagnosis and treatment can be risky, so you should always seek medical help where possible. Although we do give drug dosages in this section, they are for emergency use only. Correct diagnosis is vital.

Top-end hotels can usually recommend a good place to go for advice. Standards of medical attention are so low in most places in Tibet that for some ailments the best advice is to go straight to Lhasa, and in extreme cases get on a plane to Kathmandu or Chéngdū.

CIWEC Clinic Travel Medicine Center In Kathmandu. In operation since 1982 and has an international reputation for research into travellers’ medical problems. Staff members are mostly foreigners and a doctor is on call around the clock. Credit cards are accepted and the centre is used to dealing with insurance claims.

Global Doctor Chengdu Clinic In Chéngdū. Offers pre-Tibet medical examinations and a Tibet Travellers Assist Package that can be useful if you are worried about an existing medical condition.