Bill Hulme, Tom Ingram, and David Lonsdale-Eccles share their experiences of Shangri-La

On arriving in Lhasa, we found that our more cynical suspicions of "Shangri-la" were sadly confirmed. The city, which at one time comprised Tibet's religious core of the Potala palace, the Barkor square, Jokang temple, and a few houses, has been transformed in 40 years into a massive patchwork of Chinese style, bathroom tiled buildings sprawling for miles along the valley. Traditional Tibetan buildings have made way for neon lights and brothels lining the holiest pilgrimage routes throughout the city.

A&E departments

An Italian non-governmental organisation, Comitato Internazionale per lo Sviluppo dei Popoli (CISP), has set up and partly funded the foundation of Tibet's first emergency departments. The scheme has been running now for three years, and the prevailing attitude of the local doctors was that the Lhasa accident and emergency ward was the best in Tibet. This was soon put to the test as the casualties started to roll in by foot, taxi, or ambulance. We were soon hedging our bets on whether it would be another nomad who had been fighting with a knife, a prostitute deliberately overdosing on Tibetan medicine, or someone who had been in a road traffic accident.

The Chinese and Tibetan staff dealt with these tasks in a confident manner, but we soon realised that sometimes their prioritising of them was somewhat different to ours. We were once left dumbfounded when we found that a penetrating stab wound had been immediately stitched up without attending to the patient's airway, and by then the patient had stopped breathing and was beyond resuscitation. The CISP doctor and nurse have given regular training on the job plus advanced trauma life support and advanced cardiac life support training sessions on many occasions over the years, but it seems that this practice is not fully implemented yet.

Healthcare system

China is now considered the focus of the communist system since the collapse of the Soviet Union. We therefore imagined a healthcare system based on universal access and equality for all citizens. It was a surprise that it is in fact a completely private system where even the most basic investigations and treatments are paid for in cash and on the spot. Unconscious patients had their pockets searched for enough money to pay for an x ray film, or they simply did not receive one at all. The prices of some of these interventions were often in excess of what a rural worker would earn in six months, and so many could not afford even the most basic levels of care necessary to keep them alive in the department. Half of doctors' pay comes directly from prescribing and carrying out procedures, and many patients with seemingly trivial illnesses were admitted to the ward at Rmb200 a night (£15), with intravenous antibiotics at extra cost, which would drain the resources of a family for weeks. This may explain why many Tibetans seek help from traditional herbalists in Lhasa.

The charity initially wanted to supply the hospital with previously lacking reliable water, electricity, and heating supplies, whereas the hospital directors requested 40 ambulances with satellite tracking for Lhasa's 200 000 population, in addition to a computer network and computed tomography scanners for the department. The Italian doctor present eventually managed to formulate a plan for an emergency medical care system throughout Tibet, with promises of high tech equipment to follow at a later stage. When we were there medical equipment worth $100 000 was delivered to NagQu district hospital to set up an emergency room, which also required painstaking training of the staff in trauma management. In the past, ventilators and high tech scanning equipment donated to Lhasa hospital by Japanese companies, but the erratic power supply and lack of trained technicians left them collecting dust after a few weeks. Money is not everything

We have come to the conclusion since our brief stay of seven weeks in Lhasa and in NagQu district hospital that funds alone will not completely cure the problems facing the healthcare system in Tibet. Life expectancy in Tibet is only around 45 years; death is usually caused by trauma, ischaemic heart disease, and "sky disease" (stroke). These can largely be attributed to preventable risk factors such as diet, smoking, and undiagnosed hypertension. Hygiene conditions have definitely improved in the larger settlements in the past 40 years, but it is still common practice to defecate in the street.

The biggest impact on overall health and life expectancy has been basic healthcare and public health interventions to reduce smoking and improve the diet. Facilities such as computed tomography and magnetic resonance image scanning, so sought after in Lhasa, have little impact in a country where most die without ever reaching any hospital or clinic, which could be three days away. The hospitals, in trying to catch up with the rest of China, need to have basic hygiene and sanitation inside their buildings and a health policy that tackles the widespread poverty, poor diet, and lifestyle outside.

CISP is now trying to work on the next Stage - the aim is to improve the treatment of victims of accidents, poisonings, and fights by managing those who would die without basic trauma care. Instead of merely throwing money at the problem, training staff on the ground and allowing affordable treatment to the poorer people by means of basic, robust equipment seem to be far more effective. It seems that the existing health system caters only for the newly emerging upper classes and has forgotten the remaining population, which needs equal priority in all aspects of medicine.

It is obvious that China faces problems caused by the strain on resources that results from its huge population. Cooperation with other countries in trade and help in building its infrastructure might ensure that all have access to basic care and also provide an invaluable lesson for all parties concerned.