Spring 2001; Volume 2, Number 1
Health Care in Tibet: Clinical and Policy Perspectives
Mary Maish, M.D.
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Nestled in the foothills of the tallest mountains on earth, Tibet offers literally breathtaking views from the top of the world. Most people in Tibet live at altitudes greater than 3,500 meters; this imposes a significant burden on the cardiopulmonary system, which in turn challenges the performance of the healthcare system. Unfortunately, the healthcare system currently fails to meet many of the needs of the Tibetan people. It is difficult to predict exactly what changes will have to be made in basic medical care and national health policy in order to raise Tibet to some minimum health standards. Nonetheless, this article aims to enhance our understanding of the Tibetan healthcare system and to address some of its shortcomings.
A few months ago, I spent time in Tibet investigating its healthcare system and, more specifically, the status of pulmonary diseases. During this time I identified four major pulmonary diseases that substantially contribute to the morbidity and mortality of the Tibetan people. In addition, I found several areas in which the health system in general is failing to provide adequate services to the Tibetan community. It is clear that changes need to be made to reduce the morbidity associated with pulmonary diseases as well as to improve the quality of Tibetan health care at large.The Tibetan Health Care System
Levels of Health Care
There are four distinct levels of health care facilities available in Tibet: the prefectural or municipal level, the county level, the township level, and the village level. Tibet is comprised of seven prefectures, each with varying numbers of counties, townships and villages. In my investigations of three of the seven prefectures, I discovered that healthcare resources vary tremendously between these levels as well as between prefectures.
At the prefectural level, there are a handful of hospitals with mostly adequate facilities to treat pulmonary diseases. Between the hospitals are several adult ventilators, a good supply of oxygen, nebulizers and inhalers, basic medications and occasionally a pulmonary specialist. Each hospital has its own x-ray and laboratory department. At least one hospital is equipped with a CT Scan facility and a bronchoscope. Almost all are equipped with a few patient care beds, oxygen, intravenous capabilities and medications. The county-level hospitals are more sparsely equipped; there is little available beyond basic laboratory and x-ray facilities. There are also a number of county-level clinics, both private and public, where basic medical needs can be attended to, but more complicated conditions are referred to the hospital. Finally, the two township level facilities I observed were poorly equipped to treat pulmonary diseases; the doctors used only a stethoscope for diagnosis and basic antibiotics for treatment.Pulmonary Diseases In Tibet
While pulmonary diseases are not the greatest cause of morbidity and mortality in Tibet, they are the most widespread. The most common pulmonary diseases found in Tibet are TB, pneumonia, asthma, and lung cancer. Deficiencies in the basic structure and delivery of health care prevent these pulmonary diseases from being adequately treated. In all of China, the Tibet Autonomous Region (TAR) included, Tibet has the highest incidence of TB. Lung cancer is not so prevalent, however, and other parts of China have a much higher incidence. It is difficult to estimate the incidence of either pneumonia or asthma because the former is over- and the latter is under-diagnosed.Risk Factors
Along with the extreme altitude, there are many environmental and cultural factors that stress the pulmonary system in Tibet. The dry, dusty air is irritating to the upper airway of the pulmonary system and can predispose individuals to asthma. Although pollution is not yet visible, leaded and diesel fuels, coal and wood burning stoves, and the nearly constant burning of sage incense all contribute to pollution.
As in any culture, there are also factors in Tibetan culture that are detrimental to the respiratory system. The most obvious poison is cigarette smoke. Both first- and second-hand smoke effects are significantly contributing to the high rate of pulmonary diseases in this country. In addition, the practice of spitting into public areas, common among the Chinese and Tibetan peoples provides an excellent mode in which to transmit bacteria such as TB. Sharing a meal - that is, eating off the same plate with others - is another simple way pulmonary infection is spread.Tuberculosis
In Tibet, an estimated 5% of the population has TB, making this disease perhaps the most significant pulmonary health hazard in the nation. There are many reasons why TB remains a problem in this country. First, there is neither a screening program in place, nor is there any consistency in how patients are identified, treated, and followed-up. Also, there there is a deficiency in patient education with regard to tuberculosis which leads to problems of non-compliance. Finally, the movement of people in and out of Tibet, as well as within the region itself, has vastly increased in the last 50 years. With the recent influx of Han Chinese, Muslims, Mongolians, Turks, and tourists, the amount of TB brought in from other areas has increased and has made the disease more difficult to control.Pneumonia
Every respiratory infection in Tibet is diagnosed as pneumonia until proven otherwise. Most doctors I interviewed said that anytime a patient arrives with signs and symptoms of a pulmonary infection they treat that patient with antibiotics. If the patient does not improve, then they consider alternative diagnoses. This is especially true in the rural areas where the facilities are severely limited. Most doctors who suspecte pneumonia perform chest x-rays when the technology is available, while other doctors just treat patients empirically. However, few doctors perform a sputum culture before initiating treatment. Treatment regimens vary, but most patients with suspected or confirmed pneumonia are started on IV antibiotics and then converted to oral antibiotics after some improvement. The duration varies from a total of 4-14 days.Asthma
Environmental conditions such as cold, dry, dusty air, are common triggers for asthmatics. In Tibet, asthma is under-diagnosed. Most of the doctors I spoke with felt that asthma was not a disease but rather a symptom of another disease. They could not distinguish between wheezing, the symptom, and asthma, the disease. There is a lack of the basic medications and supplies needed to treat this disease, and many patients with suspected asthma are treated with antibiotics. Some physicians admitted that they would not know how to use some of the newer medications and supplies even if they had access to them. This reveals a clear lack of education both in the areas of diagnosis and treatment of asthma. These findings were also confirmed by the work of the Dutch Red Cross.Lung Cancer
While lung cancer does not appear to be so prevalent, it is my observation that this disease is also under-diagnosed. The risk factors for acquiring the disease, namely smoking, are clearly present. In their early stages, patients with a cough are treated with antibiotics, but incomplete resolution of the cough is not investigated on a regular basis. Patients who later display symptoms of late-stage lung cancer, including weight loss and malnutrition, often die of respiratory failure with unknown causes.
Most doctors agreed that by the time patients are accurately diagnosed, they are severely ill. This is due to several factors. First, patients usually wait until they are critically ill before seeking medical attention because they cannot afford to go to the doctor for routine care. Second, doctors do not have facilities adequate enough to make an early diagnosis, for few places have x-ray facilities, and even fewer have CT or bronchoscopy technology. Finally, when a patient comes in with a cough, doctors think first about pneumonia and only later about lung cancer. Late diagnoses of lung cancer put affected patients' lives at risk.Issues of Health Policy in Tibet
While I have focused thus far on pulmonary disease, I will now turn my focus to broader issues of health policy. There are significant defects in the delivery of health care in Tibet, and the fundamental problems of the system are rooted in the most basic components of any sound health policy. The policy issues that need to be addressed are: standards of cleanliness, education and training, affordability, accessibility, and equity. Each is hindering the Tibetan people from achieving adequate health care.Standards of Cleanliness
Standards of cleanliness are generally low in Tibet. Sanitation is poor and public spaces, including sidewalks and streets, become convenient places to expel waste, human and otherwise. There is little in the way of hand-washing before a meal, or after the use of the toilet. Although poor sanitatioin is not such a concern for the spread of pulmonary disease, it is nonetheless a concern for health in general.
The lack of cleanliness standards is even more apparent in the medical realm. Of the 16 health centers I visited, few would be considered clean by western standards and none would be considered aseptic. Conditions are worse in the rural areas. Depending on the time of day, the clinics I witnessed had varying degrees of cleanliness, and the floors were often covered with dirt, spit, and cigarette butts. I saw a few facilities with sinks, but I never saw healthcare professionals actually using them to wash their hands. The operating rooms had a minimum level of sterility. Staff members were required to wear hats, masks, booties, and scrubs, but those were not necessarily clean. The surgical gloves were reused, and there was no autoclave or equivalent form of sterilization system present.Education and Training
Education and training of medical professionals is a very serious problem in Tibet. The training of doctors in Tibet comes in as many varieties as there are doctors. I found very little common ground between the doctors in the four levels of health care. There are almost no standards of education that need to be achieved before one can label himself as a doctor except for an exam that must be passed to open up a private clinic. In the rural areas, the situation is even more desperate, with most doctors having had no medical training at all. The training criteria are further complicated by the fact that there are three kinds of medicine being practiced in Tibet: Tibetan, Chinese and Western. (Most doctors practiced both Western and Chinese medicine.) The training for each of these is different, both in place and duration.
While the doctors are poorly educated about medical conditions, one also sees this ignorance prevalent among the Tibetan people. This lack of understanding results in delayed care-seeking and non-compliance issues that account for more serious disease. Most laypersons believe the medical wives-tales that are handed down through the generations, so many of them choose not to seek more advanced medical care. Moreover, there is little effort on the part of medical professionals to educate the public about the importance of disease prevention, early intervention, and where to obtain appropriate medical care.Affordability
The system of health care in Tibet is currently changing to a community medical system (CMS). In this new system, patients sign up at their community health center and pay a small annual fee plus a co-payment with each visit. Once enrolled, they can use the facilities in their community and will only pay a portion of the costs for physician visits and medication. Patients are encouraged to use the same doctor for routine visits so that doctors can become familiar with the needs of their patients. Those patients who are covered by the CMS plan will have access to affordable medical care even at the prefectural level. Those who do not, are required to pay out-of-pocket for services and medications, and if being treated at a hospital, are required to give a 1,000 RMB deposit.page 1 | page 2
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