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Tibet

  • OVERVIEW
  • GETTING THERE AND AROUND
  • WHEN TO GO AND WEATHER
  • PRACTICAL INFORMATION / VISAS
  • HISTORY

OVERVIEW

The Land of Snows, the roof of the world. For centuries this mysterious Buddhist kingdom, locked away in its mountain fastness of the Himalaya, has exercised a unique hold on the imagination of the West. For explorers, imperialists and traders it was a forbidden land of treasure and riches. Dreamers on a spiritual quest have long whispered of a lost Shangri-la, steeped in magic and mystery. When the doors were finally flung open in the mid-1980s, Tibet lay in ruins. Between 1950 and 1970, the Chinese wrested control of the plateau, drove the Tibetans’ spiritual leader, the Dalai Lama, and some 100, 000 of Tibet’s finest into exile and systematically dismantled most of the Tibetan cultural and historical heritage, all in the name of revolution. For a while images of the Buddha were replaced by icons of Chairman Mao. Today, Tibetan pilgrims across the country are once again mumbling mantras and swinging their prayer wheels in temples that are heavy with the thick intoxicating aroma of juniper incense and yak butter. Monasteries have been restored across the country, along with limited religious freedoms. A walk around Lhasa’s lively Barkhor pilgrimage circuit is proof enough that the efforts of the communist Chinese to build a brave new (roof of the) world have foundered on the remarkable and inspiring faith of the Tibetan people.

For travellers, Tibet is without doubt one of the most remarkable places to visit in Asia. It offers fabulous monastery sights, breathtaking high-altitude treks, stunning views of the world’s highest mountains and one of the most likeable peoples you will ever meet. There’s Gyantse, in the Nyang-chu Valley, famed for the largest chörten (stupa) in Tibet, and hiking in Yarlung Valley, widely considered the cradle of Tibetan civilization. Base yourself in Tsetang and marvel at the monkey cave in Gangpo Ri or walk the monastery kora (pilgrim path). Your trip will take you past glittering mountain turquoise lakes and over high passes draped with prayer flags. Find a quiet spot in a prayer hall full of chanting monks, hike past the ruins of remote hermitages or make an epic overland trip along some of the world’s wildest roads. The scope for adventure is limitless.

For many people, Tibet is a uniquely spiritual place. Those moments of peace, fleeting and precious, when everything seems to be in its proper place, seem to come more frequently in Tibet, whether inspired by the devotion apparent in the face of a pilgrim or the dwarfing scale of a beautiful landscape. Tibet can truly claim to be on a higher plain.
This remarkable place is changing fast. Investment and tourism are flooding into the region, inspired by a new train line from China, and GDP is rising even faster than the train tracks to Lhasa. Unfortunately the modernisation is coming first and foremost on China’s terms. China’s current wave of tourists has been dubbed the ‘second invasion’, with a slew of new hotels, restaurants and bars set up and run by Chinese for Chinese. Once the remote preserve of hardy backpackers, it is now local Chinese tourists who dominate the queues for the Potala and Jokhang. Lhasa is booming and even small towns across the plateau are being modernised and rebuilt. With every passing month Tibet looks less and less like itself.

The myths and propaganda that have grown up around Tibet can be so enticing, so pervasive and so entrenched that it’s hard to see the place through balanced eyes. The reality is that Tibet is no fragile Shangri-la but a resilient land underpinned by a unique culture and faith. But you are never far from the reality of politics here. For anyone who travels with their eyes open, a visit to Tibet will be memorable and fascinating, but also a sobering experience. It’s a place that’s likely to change the way you see the world and that will remain with you for years to come. And that’s surely the definition of the very best kind of travel.

GETTING THERE AND AROUND

Tibet’s transport infrastructure is poorly developed and, with the exception of the Friendship Hwy and the Qinghai–Tibet Hwy, most of the roads are in rough condition. Work is being undertaken to improve this situation – a vital aspect of Chinese plans to develop Tibet – but it is unlikely that travel in large parts of Tibet will become comfortable or easy in the near future.

The main problem for travellers short on time is the scarcity of public transport. There are no internal flights (except to Chamdo, a closed area) and only a handful of buses and minibuses plying the roads between Lhasa and other major Tibetan towns such as Shigatse and Tsetang.Most travellers band together to hire a Land Cruiser to get around Tibet but this isn’t absolutely necessary.

Minibuses run to most monasteries around Lhasa, and to Shigatse, Gyantse, Sakya and Lhatse. Hitching is another possibility; you will still have to pay, but only a fraction of the amount for a Land Cruiser. You’ll need to be more self-sufficient and prepared to wait perhaps for hours for a ride. Hitching in Tibet can be the best way to get around but it can also be very frustrating, and there are risks. Those with more time can, of course, trek or cycle their way around the high plateau. A combination of hiking and hitching is the best way to get to many off-the-beaten-track destinations. By 2009 you may even be able to take the train from Lhasa to Shigatse.

Hitching is never entirely safe in any country in the world, and we don’t necessarily recommend it. Travellers who decide to hitch should understand that they are taking a small but potentially serious risk. That said, in Tibet hitching is often the only alternative to hiring an expensive Land Cruiser and so has become a fairly established practice. Few foreigners travel long distances by truck these days. The authorities impose heavy fines on truck drivers caught transporting foreign travellers and may even confiscate their licence. Sometimes you can get a lift on a pilgrim truck or an organised passenger truck.

If you are headed out to fairly remote destinations you should be equipped to camp out for the night if you don’t get a ride. One guy we heard of waited so long for a lift to Mt Kailash that he built a chörten from stones out of boredom. By the time he got a ride it was more than 1m tall! There are also plenty of half-empty Land Cruisers heading down the Friendship Hwy to pick up a group, or returning after having dropped one off. It’s a wonderful feeling to finally get a lift in an empty Land Cruiser after being rejected all day by a stream of dilapidated trucks travelling at 30km/h!

Normally you will be expected to pay for your lift, especially in a Land Cruiser. The amount is entirely negotiable, but in areas where traffic is minimal, drivers will often demand quite large sums. It’s a good idea to start hitching a few kilometres out of town because then you know that traffic is going in your direction and is not about to turn off after 400m. This is especially important if there is a checkpost nearby. It’s best to walk through the checkpost yourself and wait for a lift out of sight on the other side.

The most common hitching gesture is to stick out one or two fingers towards the ground and wave them up or down. If you are hitching long distances without a permit you’ll have to lay low at checkposts. Perhaps your best chance is to hook up with a truck that is itself slightly illegal and therefore inclined to drive through the checkposts at night. Apart from the checkposts, the likeliest place to be caught is at a hotel.

Car: Renting a Land Cruiser (plus driver) and splitting the cost among a band of travellers has become the most popular way of getting around in Tibet. Tourists are not permitted to drive rental vehicles in Tibet.Prices depend largely on the kilometres driven (roughly Y3.50 per km) not the time taken, meaning that you can often add an extra day to your itinerary for minimal extra cost. Prices are higher on trips where a permit and both guide and driver are needed.

Guide fees are normally calculated at around Y150 per day and permits generally cost around Y150 per person. Land Cruisers have room for four passengers (plus a guide) and their luggage. Even then, someone will have to sit on a fold-up seat in the back. The guides provided on budget tours are normally useless. The best learned their English in Dharamsala but don’t have a formal guide licence (the government won’t give licences to Tibetans who have travelled to Dharamsala).

The best place to hire vehicles is Lhasa. Before organising a vehicle, check the notice boards at the main budget hotels. The most popular destinations are the Nepali border, Nam-tso and Mt Kailash, but there will probably be a few notices about more-obscure destinations. The availability of vehicles has improved recently, but in the peak months of May, August and September there can still be a squeeze and prices can rise.

Hiring a vehicle is subject to a few pitfalls and we get many complaints from travellers over the quality of the car, the guide and problems relating to reimbursements after an unsuccessful trip. If possible, it is a good idea to reach an agreement that payment be delivered in two instalments: one before setting off and one on successful completion of the trip. This gives you more leverage in negotiating a refund if your trip was unsuccessful (one reason why agencies are loathe to do this).

Drawing up a contract in English as well as Tibetan or Chinese can be a good idea and your agent may already have one. List your exact itinerary, the price and method of payment and pin down in writing any detours or monasteries you want to visit. Once you are on the road your driver will be reluctant to detour even a few kilometres off the listed itinerary.

Above all, get together with the driver before the trip and go through the main points of the agreement verbally. You are likely to have far fewer problems if you can reach friendly terms with your driver by treating him with respect – giving him some cigarettes or some kind of small gift – rather than waving a contract in his face. Remember, it may be worth spending a few hundred yuan extra (it’s not much spread between four people) to hire a vehicle from a bigger and more reliable agency. Note that most higher-end agencies can only arrange your trip if you book it from outside Tibet, so that they provide the original TTB permit to get you into Tibet.

Bus: Bus travel in Tibet is limited but with some time and a little effort you can get to most places in this book by bus or minibus. Most services originate in Lhasa or Shigatse and run to any town that has a sizeable Chinese presence. Smaller towns may have just one daily bus that runs to Lhasa in the morning and returns in the afternoon.Many bus stations in Tibet will not sell bus tickets to foreigners, which leaves you in the hands of private or pilgrim bus services.

Even the larger private buses may be reluctant to take foreigners (notably between Lhasa and Shigatse) because they don’t have government permission and/or insurance to take foreigners. Accidents do sometimes happen: in 2007, 13 tourists were killed when their tourist bus crashed between Lhasa and Shigatse. On a long-distance bus you will probably be required to stow your baggage on the roof if you have a bulky backpack. If possible, check that it is tied down properly (bus drivers normally do a good job of checking such details), lock your pack as a precaution against theft and make sure you have all you might need for the trip (food, water, warm clothes etc). Try to see what everyone else is paying for the fare before you hand over your cash. You can expect to spend a lot of time sitting around waiting for minibuses to fill up.

WHEN TO GO AND WEATHER

Weather:
Tibet has similar seasons to China, though with lower temperatures due to the higher altitudes. Winters (November to March) are cold (the average temperature in January is -2°C) but there isn’t all that much snow. Summers (May to September) have warm days with strong sunshine and cool nights. At higher elevations (ie above 4000m) even summer days can be chilly. During spring and autumn you need to be prepared for four seasons in one day, including the possibility of snowfall. There are some regional variations; northern and western Tibet are generally higher and colder.

The monsoon affects parts of Tibet (particularly eastern Tibet) from mid-July to the end of September (July and August bring half of Tibet’s annual rainfall).

When to go:
Climate is not such a major consideration when visiting Tibet as many people might imagine. For a place nicknamed ‘The Land of Snows’, there’s a surprising lack of snow. The boom in domestic tourism means that Lhasa swells with Chinese tourists in the summer and particularly in the week-long holidays around 1 May and 1 October. Finding accommodation can be trickier during these weeks, so try to have something nailed down by lunch time. Winter is very cold, many restaurants are shut and snow can close mountain passes, but some travellers swear by the winter months. There are few travellers about at this time and Lhasa is crowded with drokpas (nomads). The average temperature in January is -2°C. Spring, early summer and late autumn are probably the best times to visit Tibet.

March is a politically sensitive month in the country and there is occasional tightening of restrictions on travellers heading into Tibet at this time, but the weather’s pretty good. April brings reliable weather in eastern Tibet and discounts on accommodation and vehicle rental in Lhasa. Mt Everest is particularly clear during April and May. From mid-July through to the end of September the monsoon starts to affect parts of Tibet. (The months of July and August bring half of Tibet’s annual rainfall.) Travel to western Tibet becomes slightly more difficult, the roads to the east are temporarily washed out and the Friendship Hwy sometimes becomes impassable on the Nepal side or on the border itself.

Trips to Mt Kailash can be undertaken from April to October, although September and October are considered the best months. October is also the best time to make a trip out to the east. Lhasa and its environs don’t get really cold until the end of November. It’s worth trying to time your trip with one of Tibet’s festivals. New Year (Losar) in January or February is an excellent time to be in Lhasa, as is the Saga Dawa festival in April or May.

PRACTICAL INFORMATION / VISAS

Costs: Accommodation and food are both very economical in Tibet. The major expense – unless you have plenty of time and enjoy rough travelling – is getting around. If you really want to see a lot in a short space of time, you will probably have to consider hiring a vehicle and driver. Shared hired transport tends to work out at around US$30 per person per day. The per-person cost for a group of six travelling with stops from Lhasa to the Nepali border is around US$200.

Getting into Tibet is also relatively expensive. Train packages from Xining start at around US$170 (including permits), while the cheapest package by air costs around US$245 from Chengdu. If you don’t hire transport (and it is still perfectly possible to see most of the places covered in this guide if you don’t), costs are very reasonable. If you are staying in Lhasa and visiting the surrounding sights you can do it comfortably on US$20 per day, staying in a dorm room or sharing a double. Outside the cities, daily costs drop drastically, especially if you’re hitching or hiking out to remote monasteries. Keep in mind that entry tickets can really add up: visit Lhasa’s main sights and you’ll end up shelling out around US$60 in entry fees. At the other end of the scale there’s a lot more scope to go top end these days, at least in the cities. New five-star hotels, paved roads and a luxury train look set to take out much of the rigour of a visit to the Roof of the World.

Economy:
China’s epic drive to develop its western hinterland has had a considerable impact on Tibet, and its economy is booming. Growth over the last six years has averaged an impressive 12%, trade is growing at 50% and GDP hit $3.7 billion in 2006. New businesses and hotels are popping up everywhere, spurred on by investment from China’s eastern provinces.

Not all Chinese are here to earn money, though. Wealthy urban Chinese tourists are flocking to Tibet in droves to spend it, and tourism is an increasingly important source of revenue. Tibet currently receives three million tourists in a year, a rate growing by an amazing 40% annually. This influx bring in US$300 million each year. More than 93% of tourists to Tibet are Chinese. Over 30, 000 tourists arrived at Lhasa airport during the May 1 national holiday.

The 2006 opening of the train line between Tibet and Qinghai Province has had a huge effect on both tourism and economic growth, cutting transport costs by US$23 million in the first year alone. The train also transported over 1.5 million additional people to Tibet during the same period The Tibetan plateau has rich deposits of gold, zinc, chromium, silver, boron, uranium and other metals. The plateau is home to most of China’s huge copper reserves.

A single mine in northern Tibet is said to hold over half the world’s total deposits of lithium. Chinese scientists announced the discovery of five billion tonnes of oil and gas in the Changtang region in 2001. Reports indicate mining now accounts for one-third of Tibet’s industrial output. Mining has long been traditionally inimical to Tibetans, who believe it disturbs the sacred essence of the soil. Many fear that the train will speed up mining.

The Chinese name for Tibet, Xizang – the Western Treasure House – now has a ring of prophetic irony. There is an increasing economic and social divide in Tibet. Per capita disposable income currently stands at over US$1000 in the towns and only $260 in the countryside. Many Tibetans maintain that Chinese immigrants are the real winners in the race to get rich in Tibet, while China protests that it is simply developing and integrating one of its most backward provinces, at a large financial loss.

Money: For your trip to Tibet bring a mix of travellers cheques (say 60%), cash in US dollars (40%) and a credit card.

ATMs:
Several ATMs in Lhasa and Shigatse accept foreign cards. The Bank of China accepts Visa, MasterCard, Diners Club, American Express and Plus. The Agricultural Bank accepts Visa, Plus and Electron. Check before trying your card as many ATMs can only be used by domestic account holders. The maximum amount you can withdraw per transaction is Y2000 with the Bank of China and Y1000 with the Agricultural Bank. Cards are occasionally eaten, so try to make your transaction during bank hours. For those without an ATM card or credit card, a PIN-activated Visa TravelMoney card will give you access to predeposited cash through the ATM network.

Taxes: Although big hotels may add a tax or ‘service charge’ of 10% to 15%, all other taxes are included in the price tag, including airline departure tax.

Travellers cheques: Besides the advantage of safety, travellers cheques are useful to carry in Tibet because the exchange rate is higher (by about 3%) than it is for cash. The Bank of China charges a 0.75% commission to cash travellers cheques. Cheques from the major companies such as Thomas Cook, Citibank, American Express and Bank of America are accepted.

HEALTH:
Before you go:
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.

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, it’s a good idea to have a legible prescription or letter from your doctor to show that you legally use the medication.

Insurance:
Keep in mind that 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 immunizations for entry into the country; however, the further off the beaten track you go, the more necessary it is to take all precautions. The World Health Organization (WHO) requires travellers who have come from an area infected with yellow fever to be vaccinated before entering the country. Record all vaccinations on an International Health Certificate, available from a doctor or government health department.

Plan well ahead and schedule your vaccinations because 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.

It is recommended that you seek medical advice at least eight weeks before travel. Note that there is a greater risk of all kinds of disease with children and during pregnancy. Discuss your requirements with your doctor, but vaccinations you should consider for this trip include the following:

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.

Polio
This serious, easily transmitted disease is still prevalent in many developing countries, including Tibet’s neighbouring countries, India, Pakistan and Nepal. 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. This should be discussed with your doctor.

Rabies
China has a significant problem with rabies, which is worsening. Rabies is now the most common infectious disease cause of death in China. Only India reports more human cases annually. The 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. Pretravel vaccination means you do not need to receive Rabies Immuno Globulin (RIG) after a bite. RIG is very unlikely to be available in Tibet, and there is such a worldwide shortage that for the first time the CIWEC Clinic in Kathmandu reports that it cannot source any (at the time of writing). 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. Thus the management of any bite or scratch is greatly simplified if you have been vaccinated. Current expert opinion is that 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. As most healthy adults don’t develop symptoms, a skin test before and after travel to determine whether exposure has occurred may be considered. Recommendations for BCG vaccination vary considerably around the world. Discuss with your doctor if you feel you may be at risk. It 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 oral capsules. A combined hepatitis A-typhoid vaccine was launched recently but its availability is still limited. Check with your doctor to find out its status in your country.

Yellow Fever
This disease is not endemic in China or Tibet and a vaccine is only required if you are coming from an infected area. These areas are limited to parts ofSouth America and Africa.

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.

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

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

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

Medical checklist:
Following is a list of items you should consider including in your medical kit for travelling – consult your pharmacist for brands available in your country. Antibiotics – useful for everyone travelling to Tibet to avoid risks of receiving poorly stored local medications; see your doctor, as antibiotics must be prescribed, and carry the prescription with you:
 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
 Homeopathic medicines – useful hom¬eopathic medicines include 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, which may occur, for example, 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

While you're there
Availability & cost of health care
Self-diagnosis and treatment can be risky, so you should always seek medical help where possible. 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 Chengdu or Kathmandu.

Global Doctor Chengdu Clinic
(8522 6058, 24hr emergency number 139-8225 6966;www.globaldoctor.com.au; Ground fl, Kelan Bldg, Bangkok Garden Apts, Section 4, 21 Renmin Nanlu) offers pre-Tibet medical examinations and a Tibet Travellers Assist Package that can be useful if you are worried about an existing medical condition. See the website for details. In Kathmandu, the

CIWEC Clinic Travel Medicine Center(www.ciwec-clinic.com; Lazimpath)
near the British embassy, has a lot of experience with altitude-related illnesses and is a good resource if on the way to or coming from Tibet. The website also offers useful medical advice. Antibiotics should ideally only be administered under medical supervision; however, this may not always be possible. Ensure you have been given clear instructions by your prescribing doctor. Take only the recommended dose at the prescribed intervals and use the whole course, even if the illness seems to be cured before the medication is finished. Stop immediately if there are any serious reactions and don’t use the antibiotic at all if you are unsure that you have the correct one. Some people are allergic to commonly prescribed antibiotics such as penicillin; carry this information (eg on a bracelet) when travelling.

Avian influenza (bird flu)
Influenza A (H5N1) or ‘Bird flu’ is a subtype of the type A influenza virus. This virus typically infects birds and not humans. There have been some cases of bird-to-human transmission, although this does not easily occur. Very close contact with dead or sick birds is the currently principal source of infection.

Symptoms include high fever and typical influenza-like indicators, with rapid deterioration leading to respiratory failure and, in many cases, death. The early administration of antiviral drugs such as Tamiflu is recommended to improve the chances of survival. Immediate medical care should be sought if bird flu is suspected. There is currently no vaccine available to prevent bird flu. For up-to-date information check these two websites:

Hepatitis:
A general term for inflammation of the liver, hepatitis is a common disease worldwide. There are several different viruses that cause hepatitis, and they differ in the way that they are transmitted. The symptoms are similar in all forms of the illness and include fever, chills, headache, fatigue, feelings of weakness and aches and pains, followed by loss of appetite, nausea, vomiting, abdominal pain, dark urine, light-coloured faeces, jaundiced (yellow) skin and yellowing of the whites of the eyes. People who have had hepatitis should avoid alcohol for some time after the illness, as the liver needs quite a while to recover.

Hepatitis A is transmitted by contaminated food and drinking water. You should seek medical advice if symptoms present, but there is not much you can do apart from resting, drinking lots of fluids, eating lightly and avoiding fatty foods.

Hepatitis A is most often spread in China and Tibet as a result of the custom of sharing food from a single dish rather than using separate plates and a serving spoon. It is wise to use the disposable chopsticks now freely available in most restaurants in Tibet, or else buy your own chopsticks and spoon. Hepatitis E is transmitted in the same way as hepatitis A; it can be particularly serious for pregnant women.

There are almost 300 million chronic carriers of hepatitis B in the world, and Chinahas more cases than any other country; almost 20% of the population are believed to be carriers. It is spread through contact with infected blood, blood products or body fluids, for example through sexual contact, unsterilised needles and blood transfusions, or contact with blood via small breaks in the skin. Other risk situations include contaminated medical equipment or having a shave, tattoo or body piercing with contaminated tools. The symptoms of hepatitis B may be more severe than those for type A, and the disease can lead to long-term problems such as chronic liver damage, liver cancer or a long-term carrier state. Hepatitis C and D are spread in the same way as hepatitis B and can also lead to long-term complications.

There are vaccines against hepatitis A and B, but there are currently no vaccines against the other types. Following the basic rules about food and water (hepatitis A and E) and avoiding risk situations (hepatitis B, C and D) are important preventative measures.

Hiv & aids:
Infection with human immunodeficiency virus (HIV) may lead to acquired immune deficiency syndrome (AIDS), which is a fatal disease if untreated. Any exposure to blood, blood products or body fluids may put the individual at risk. The disease is often transmitted by sexual contact or dirty needles. Vaccination, acupuncture, tattooing and body piercing can be potentially as dangerous as intravenous drug use. HIV/AIDS can also be spread through infected blood transfusions; some developing countries cannot afford to screen blood used for transfusions.

HIV cases in Tibet are on the rise, and anyone who intends to work or study in Tibet for longer than 12 months is required by the Chinese authorities to undergo an AIDS test.

If you do need an injection, ask to see the syringe unwrapped in front of you, or take a needle and syringe pack with you when travelling. Fear of HIV infection should never preclude treatment for serious medical ¬conditions.

Rabies:
This fatal viral infection is found in many countries. 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.

At the time of writing, no treatment for rabies was available anywhere in Tibet. If you have any potential exposure to rabies, seek medical advice in Lhasa (or ideallyKathmandu or Chengdu) as soon as possible in order to receive post-exposure treatment. 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 overChina, including Tibet. Why are they such a serious problem in China? Respiratory infections are aggravated by the high altitude, the cold weather, air pollution, chain smoking and overcrowded conditions, all of which increase the opportunity for infection. Another reason is that Chinese people tend to spit a lot, thereby spreading the disease.

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. The Chinese treat bronchitis, which can be a complication of flu, with a powder made from the gall bladder of snakes – a treatment of questionable value, but there is no harm in trying it.

No vaccine offers complete protection, but there are vaccines against influenza and pneumococcal pneumonia that might help. The influenza vaccine is highly recommended for travellers to China and Tibet, and is good for up to one year.

Sexually transmitted infections:
While HIV/AIDS and hepatitis B can be transmitted through sexual contact, other sexually transmitted infections (STIs) include gonorrhoea, herpes and syphilis. Sores, blisters or rashes around the genitals and discharges or pain when urinating are common symptoms. In some STIs, such as wart virus or chlamydia, symptoms may be less prominent or go completely unobserved, especially in women. Syphilis symptoms eventually disappear but the disease continues and can cause severe problems in later years. Although abstinence from sexual contact is the only 100% effective prevention, using condoms is also effective in the prevention of some infections. Gonorrhoea and syphilis are treated with antibiotics. Different STIs each require specific antibiotics. There is no cure for herpes or AIDS.

Traveller’s diarrhea
Simple things like a change of water, food or climate can all cause a mild bout of diarrhoea (la duzi – spicy stomach – in Chinese), but a few rushed toilet trips with no other symptoms are not indicative of a major problem. Even Marco Polo got the runs.

Dehydration is the main danger with any diarrhoea, particularly in children or the elderly as it can occur quite quickly. Under all circumstances, fluid replacement (at least equal to the volume being lost) is the most important thing to remember. Weak black tea with a little sugar, soda water, or soft drinks allowed to go flat and diluted 50% with clean water are all good. With moderate to severe diarrhoea a rehydrating solution is preferable to replace lost minerals and salts. Commercially available oral rehydration salts (ORS) are very useful; add them to boiled or bottled water. In an emergency you can make up a solution of six teaspoons of sugar and half a teaspoon of salt to a litre of boiled or bottled water. You need to drink at least the same volume of fluid that you are losing in bowel movements and vomiting. Urine is the best guide to the adequacy of replacement –if you have small amounts of concentrated urine, you need to drink more. Keep drinking small amounts often. Stick to a bland diet as you recover.

Loperamide or diphenoxylate can be used to bring relief from the symptoms, although they do not actually cure the problem. However, neither is available in China. A good Chinese alternative treatment is berberine hydrochloride (huang lian su; 黄连素). Only use these drugs if you do not have access to toilets, eg if you must travel. These drugs are not recommended for children under 12 years. Do not use these drugs if you have a high fever, are severely dehydrated or have blood in the bowel motions.

In certain situations antibiotics may be required: diarrhoea with blood or mucus (dysentery), any diarrhoea with fever, profuse watery diarrhoea, persistent diarrhoea not improving after 24 hours and severe diarrhoea. These suggest a more serious cause, in which case gut-paralysing drugs should be avoided without seeking medical advice.

In these situations, a stool test may be necessary to diagnose what bug is causing your diarrhoea, so you should seek medical help urgently. Where this is not possible the recommended drugs for bacterial diarrhoea (the most likely cause of severe diarrhoea in travellers) are norfloxacin 400mg twice daily for three days or ciprofloxacin 500mg twice daily for three days. These are not recommended for children or pregnant women. There can be resistance to these medications for some of the bacterial causes of diarrhoea; in those cases, azithromycin, 500mg once a day, is recommended. This is also the drug of choice for children with dosage dependent on weight. A three-day course is given. Azithromycin may be considered under medical supervision in pregnancy. There is a new oral cholera vaccine that offers some protection against travellers diarrhoea, but only about 20% for three months. It may be suggested if you are at high risk of complications from diarrhoea. Two other causes of persistent diarrhoea in travellers are giardiasis and amoebic ¬dysentery.

Amoebic dysentery:
Caused by the protozoan Entamoeba histolytica, amoebic dysentery is characterised by a 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 might be a good idea to keep your own stock with you.

Cholera
This is the worst of the watery diarrhoeas. Outbreaks of cholera 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. If there is a delay in getting to hospital, begin taking Doxycycline. This may help shorten the illness, but adequate fluids are required to save lives. Seek medical advice if you think you may have this disease.

Giardiasis
Known as giardia, giardiasis is a type of diarrhoea that is relatively common in Tibet and is caused by a parasite, Giardia lamblia. Mountaineers often suffer from this problem. The parasite causing this intestinal disorder is present in contaminated water. Many kinds of mammals harbour the parasite, so you can easily get it from drinking ‘pure mountain water’ unless the area is devoid of animals. Simply brushing your teeth using contaminated water is sufficient to get giardiasis, or any other gut bug. 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.

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. Make sure that it is not you. Any traveller who flies or buses into Lhasa, where the elevation is just over 3600m, is likely to experience some symptoms of AMS. Take care to acclimatise slowly and take things easy for the first couple of days. Lack of oxygen at high altitudes (over 2500m) affects most people to some extent. The effect may be mild or severe and it occurs because less oxygen reaches the muscles and the brain at high altitude, requiring the heart and lungs to compensate by working harder. 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 is known to involve modifications in 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 about 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 are very common in travellers visiting high altitudes, and usually develop during the first 24 hours at altitude. Most visitors to Tibet will suffer from some symptoms; 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! 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 up 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 or bus into Lhasa, take it easy for at least three days; this is enough for most travellers to get over any initial ill-effects. At this point you might step up your programme by visiting a few sights around town. Within a week you should be ready for something a bit more adventurous, but do not push yourself to do anything that you are not comfortable with. To prevent acute mountain sickness:

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 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. High day climbs followed by a descent back to lower altitudes for the night are very good preparation for high-altitude trekking. Also, once above 3000m, care should be taken not to increase the sleeping altitude by more than 400m per day. If the terrain won’t allow for less than 400m of elevation gain, be ready to take an extra day off before tackling the climb.

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.
 Eat light, high-carbohydrate meals to keep up energy.
 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, usually 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.

However, the use Diamox is controversial. It can reduce the symptoms, but may also mask warning signs; severe and fatal AMS has occurred in people taking this drug. Travellers should discuss the use of Diamox with a travel health expert. Diamox should be avoided in those with a sulphur allergy, but you can discuss taking a trial of the medication at home if necessary.

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 solomanoin Tibetan and hongjingtian (红景天) in Chinese, though locals also recommendgaoyuanning (高原宁) and gaoyuankang (高原康). A box of vials costs around Y20 to Y35; take three vials a day.

Cuts & scratches
Wash any cut well and treat it with an antiseptic such as povidone-iodine.

Bedbugs & lice
Bedbugs live in various places, but particularly in dirty mattresses and bedding, evidenced by spots of blood on bedclothes or on the wall. Bedbugs leave itchy bites in neat rows. Calamine lotion or a sting-relief spray may help.

All lice cause itching and discomfort. They make themselves at home in your hair (head lice), in your clothing (body lice) or in your pubic hair (crabs). You catch lice through direct contact with infected people or by sharing combs, clothing and the like. Powder or shampoo treatment will kill the lice. Infected clothing should then be washed in very hot, soapy water and left in the sun to dry.

Leeches
In the damper, low-lying areas of eastern Tibet, leeches may be present. They attach themselves to your skin to suck your blood. Trekkers often get them on their legs or in their boots. Salt or a lighted cigarette end will make them fall off; however, the shock may cause the leech to regurgitate its stomach contents into the bite. This may lead to infection or just make the wound more difficult to heal quickly. Do not pull them off, as the bite is then more likely to become infected. It’s often best to let them fall off naturally. Clean and apply pressure if the point of attachment is bleeding. An insect repellent may help keep them away.

Food
There is an old colonial adage: ‘If you can cook it, boil it or peel it you can eat it…otherwise forget it.’ 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 well clear. Undercooked meat should be avoided.

If a place looks clean and well run, and the vendor also looks clean and healthy, then the food is probably safe. In general, places that are packed with travellers or locals will be fine, while empty restaurants are questionable. Chinese food in particular is cooked over a high heat, which kills most germs.

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 can 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.

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.

Hypothermia
Tibet’s cold climate must be treated with respect. Subfreezing temperatures mean there is a risk of hypothermia, even during the summer season. Even in midsummer, passes and high areas around northern Tibet and the 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.

The message is that you should always be prepared for cold, wet or windy conditions, especially if you’re out walking, hitching or trekking 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.

It is best to dress in layers. Silk, wool and some of the new artificial fibres are all good insulating materials. A hat is important, as a lot of heat is lost through the head. A strong, waterproof outer layer and a ‘space’ blanket for emergencies are essential. Carry basic supplies, including food that contains simple sugars to generate heat quickly and fluid to drink.

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.

Sunburn
It’s very easy to get sunburnt in Tibet’s high altitudes, especially if you’re trekking. Sunburn is more than just being uncomfortable. Among the undesirable effects (apart from the immediate pain and agony) are premature skin ageing and possible skin cancer in later years. Wear sunglasses, loose-fitting clothes that cover your arms, legs and neck, and a wide-brimmed hat like the ones Tibetans wear. Calamine lotion is good for treating mild sunburn.

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).

Water
The number-one rule is be careful of the water, especially ice. If you don’t know for certain that the water is safe, assume the worst. 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. Milk should be treated with suspicion as it will be unpasteurised in the countryside, although boiled milk is fine if it is kept hygienically. Soft drinks and beer are always available wherever there is a shop, and these are always safe to drink, as is tea. Locally brewed beer, chang, is another matter. It is often made with contaminated well water and there is always some risk in drinking it.

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. There are two main kinds of filters. Total filters take out all parasites, bacteria and viruses, and make water safe to drink. They are often expensive, but can be more cost-effective than buying bottled water.

Simple filters (which can even be a nylon mesh bag) take out dirt and larger foreign bodies from the water so that chemical solutions work much more effectively; if water is dirty, chemical solutions may not work at all. It’s very important when buying a filter to read the specifications, so that you know exactly what it removes from the water and what it doesn’t. Simple filtering will not remove all dangerous organisms, so if you cannot boil water it should be treated chemically.

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 tablet form (eg Potable Aqua). Follow the directions carefully and remember that too much iodine can be harmful.

Pregnancy
It is not advisable to travel to some places while pregnant as some vaccinations normally used to prevent serious diseases (eg yellow fever) are not advisable during pregnancy. In addition, some diseases are much more serious for the mother (and may increase the risk of a stillborn child) in pregnancy.

Most miscarriages occur during the first three months of pregnancy. Miscarriage is not uncommon and can occasionally lead to severe bleeding. The last three months should also be spent within reasonable distance of good medical care. A baby born as early as 24 weeks stands a chance of survival, but only in a good modern hospital. Pregnant women should avoid all unnecessary medication, although vaccinations should still be taken where needed. Additional care should be taken to prevent illness and particular attention should be paid to diet and nutrition. Alcohol and nicotine, for example, should be avoided.

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To all Aaradhana Teams! Its been an absolute pleasure to meet you all and I am very greatful for your hospitality and all the help I have received during my stay in Nepal. I hope you will continue this …

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