Summary: During a November 2000 visit to Shannan, Lhasa and Linzhi prefectures in the Tibet Autonomous Region (TAR), U.S. Embassy Beijing Environment, Science and Technology Counselor met with regional health officials to discuss the key health policy challenges facing Tibet. The officials explained that despite extensive central government subsidies, the region's health care infrastructure still significantly lags behind the rest of China -- reflecting the relatively backward state of general economic development, as well as the difficulty in supplying health services to Tibet's far-flung and sparse population. Certain endemic diseases, including tuberculosis, iodine deficiency, and Kashin-Beck Disease , are prevalent at unusually high rates in Tibet, and in certain areas nutrition may still be a serious problem. Hepatitis B is also a major challenge, but on the bright side HIV/AIDS has not yet had a measurable impact on the region (although no one is currently tracking the disease there). Several foreign governments and NGO's, in addition to the World Health Organization and the Red Cross, are providing assistance to Tibet's health sector. End summary.
As a result of this geographic spread, and the difficulty of transporting patients over rough roads to medical facilities, Tibetans who contract serious diseases deep in the hinterlands still often go untreated, or receive insufficient treatment. Doctors are also frustrated in treating chronic diseases such as tuberculosis which require a steady regimen of attention. Emergency medicine -- now handled in Lhasa City by a small fleet of ambulances supplied by a now-terminated cooperative program with the Italian government -- is even more difficult to provide in the far reaches of the region, and generally depends on patients being transferred to hospitals by family members. Given the risks of transportation, and the uncertainty of the quality of treatment upon reaching a hospital, many potential emergency patients end up taking their chances at home. TAR officials report that helicopters have been used infrequently by the military to assist stranded mountain climbers and foreigners (with well-funded medevac health insurance policies) from wealthy countries, but even their reach is limited by weather conditions and the plateau's high altitude.
Underfunded and Lagging Behind Eastern China
Tibetan health officials acknowledge that health services in the region generally lag behind those available in wealthier regions of China. At each administrative level -- region, prefecture, county, and township -- the official "grade level" of hospital services available lags one step behind what is common in eastern parts of the country. For example, one in five county-level hospitals reportedly cannot conduct simple surgery, and there is only one CT scanner in all of Tibet. Some facilities are staffed by aging ethnic Han doctors who were transferred to Tibet more than 30 years ago, and for whom replacements are not yet available.
Although solid data on health expenditure (especially data including household expenditure) are not available, extrapolating from budget data for certain TAR sub-districts leads us to conclude that total government expenditure on health in the region may be in the range of 400-500 million RMB ($50-60 million), or somewhere close to 5% of regional GDP. Much of this funding goes to investment in health infrastucture, however, so it is plain that –- similar to the situation in other regions of China – a large part of the actual cost of individual medical treatment in Tibet is still paid for by each individual patient. (Nationwide, health expenditures are about 5% of GDP.)
Government funding for health expenditure comes primarily from the central government, and from transfers from provincial governments, via several channels, including health infrastructure investment spending. According to TAR officials, starting in 1993, each individual Tibetan has (in theory, at least) had access to a maximum of 15 RMB per month in central government health coverage (for a total potential value of 450 million RMB, or $54 million, per annum), as the government health coverage system was switched from one of full subsidies to only partial subsidies. In 1998 -- faced with the self-reinforcing difficulty common in many developing countries of "bad hospital lacks patients and so becomes worse" -- Tibet started a "Cooperative Health Coverage System" (charging residents a set fee for basic health coverage), aimed at providing steadier income for local clinics in a bid to improve local health service coverage. Tibet officials believe that the new system is enhancing the ability of lower-level facilities to provide decent medical services, while also raising the consciousness of the populace concerning the importance of preventive medicine. This system has now been implemented in 89% of Tibetan counties and 53% of townships.
Iodine deficiency-related illnesses also occur at an unusually high rate throughout Tibet. Iodine is not naturally available on the Tibetan plateau, and currently only 29% of the population receives iodine supplements. A factory to produce iodized salt was built in Tibet, but it has not proven successful in addressing the problem due to the ready availability of cheaper (and illegal) non-iodized substitutes, both inside and imported from outside the region. In addition, some ethnic Tibetans are reportedly suspicious of factory-iodized salt. Iodine deficiency-related problems, such as retardation and goiters, are most common in Qamdo Prefecture, although they also visible in areas of Ali and Naqu Prefectures.
Certain regions of Tibet also suffer from Kashin-Beck Disease (osteoarthritis deformans), a rare endemic disease, at extraordinarily high rates, making Tibet the most severely affected region worldwide. In some villages (mostly in Qamdo Prefecture in eastern Tibet, but also in Naqu Prefecture in northern Tibet), the prevalence rate can be as high as 80%. Kashin-Beck (known literally in Chinese as "big bone disease") can lead to retardation, birth deformities, and stunted growth. The cause of the syndrome is still undetermined, with some experts blaming genetics, others diet (particularly a lack of selenium), and still others believing that elements present in the soil may be the cause. As a result, attempts to address the illness (for example by increasing the amount of rice in the local diet) have thus far been unsuccessful. Resettlement has not been attempted due to uncertainty over the cause of the disease, and the relatively large area affected. Some foreign NGO's –- primarily Medicins Sans Frontieres (Doctors Without Borders) -- have been working on the problem. (Note: Kashin-Beck Disease should not be confused with Keshan Disease, another rare endemic disease common to both eastern and western China; in Tibet, Keshan Disease cases have occurred mainly in the central part of the region.)
Some experts are also concerned that malnutrition continues to be a problem in Tibet, even as the local economy continues to grow at double-digit rates, and the government claims rapid improvement in personal income levels and living conditions. Tibetan officials admit that malnutrition is still a serious problem, and express the most concern about nutrition problems among herders, who often subsist on a rather narrow diet of lamb and purchased barley, with little in the way of vegetables to supplement their diet. Other experts, however, worry that nutrition problems may also exist among farming households that are selling too much of their crops to the region's expanding cash economy, and retaining too little for personal use, purchasing instead less-expensive and less-nutritious substitutes. (Note: As part of the Great Leap Forward movement that lasted for several years starting in 1958, Tibet experienced severe food shortages due to misguided planting of rice and wheat in substitute for traditional barley. Currently, the government subsidizes the growing of both wheat and barley. Barley remains the dominant crop, especially at higher altitudes, with wheat making little progress as a proportion of planted area during the 1990's.) It is clear that nutrition education continues to be an important task for Tibet.
With regard to other common diseases, Hepatitis B carrier rates in Tibet are above national averages. The rate in Lhasa City, at about 15%, is the highest in the TAR. Rates are lower in rural areas. (According to the Chinese Academy of Preventive Medicine, overall Hepatitis B prevalence in Tibet is several percentage points above the national average of nearly 10%.) Hepatitis C rates are lower than the national norm in Tibet (Hepatitis C is often spread through unsafe injections.) Despite the availability of relatively unpolluted water sources, common diarrheal diseases are also prevalent in the region due to lack of public consciousness concerning hygiene.
Finally, HIV/AIDS has not yet made an "official" appearance in the TAR, with zero confirmed cases (among permanent residents) to date. Health officials think that this may be due to the isolation of the population and the relative absence of an intravenous drug abuse problem. On the other hand, the authorities admit that no special AIDS-monitoring programs are in place, so cases of HIV or AIDS infection may very well be going unreported. Other poor regions of China without AIDS monitoring programs have discovered, once testing was commenced, significant populations of HIV-positive individuals (the AIDS patients having been treated only for the various syndromes related to the underlying infection). When AIDS is officially confirmed as having arrived in Tibet, it is quite likely that the largest population of infected persons will be found first in Linzhi Prefecture, due to its border with heavily-infected Yunnan Province and its relatively large floating population, including prostitutes and soldiers. Tibet sees quite a few travelers coming to and from India and Nepal, which have quite high rates of HIV infection, but many of these travelers are religious pilgrims, probably lowering the likelihood of sexual transfer.
HIV infections contracted via paid blood donors could also become a problem in the future, since the TAR has not yet succeeded in establishing a contributions-based blood bank system (the government has recently budgeted 9.5 million RMB to address this problem). While paid blood donors exist, the "market" for blood and blood products is not well-developed, so the most common (and relatively safe) practice is still to recruit blood donors from within a family or work unit in time of need. Genetic research based on blood sampling is not common in Tibet, and no such research by foreigners is currently taking place, say health officials.
NGO's from developed countries have also been active: the U.S.-China Medical Education Fund provided $1.6 million worth of teacher training and medical education materials; Heart to Heart (an Oklahoma-based charity) has delivered large amounts of drugs and medical supplies to the region; Medicins Sans Frontieres has been very active in Tibet; the U.S. Catholic Church has provided mobile surgery vehicles; and the Swiss and Dutch Red Cross organizations are considering investing more than $20 million in medical schools for Shigatse and Naqu Prefectures. In addition, the U.S.-based Seva Foundation has provided for over 20,000 free cataract removal operations in Tibet, arranged through the Tibet Development Fund. On a smaller scale, the Tibet Poverty Alleviation Fund and the Tibet Child Nutrition Project are active in the Tibetan health sector.