A lower incidence of chronic mountain sickness (CMS) has apparently been observed in Tibetans in comparison to Andeans of South America. In the past, the hypothesis of "geographic differences" has been constructed to explain these population differences. In order to assess the importance of this hypothesis in the development of CMS, this article will first review the geographic factors of the Qinghai-Tibetan plateau where Tibetans live. The plateau is bounded by the Himalayas in the southwest and the Kunlun and Aljin mountains in the northeast. It towers over southwestern China at an average elevation of 4000 m above sea level and is known as "the roof of the world." Covering more than 2.5 million km(2), the Qinghai-Tibetan plateau is the highest and largest plateau in the world. The plateau has a highland continental climate and a very complex topography with great variations. Second, at what altitude do Tibetans live? In 1990 it was estimated that 4,594,188 Tibetans live on the plateau, with 53% living at an altitude over 3500 m. Fairly large numbers (about 600,000) live at an altitude exceeding 4500 m in the Chantong-Qingnan area. People of Tibetan ethnic descent are lifelong high-altitude residents and cannot easily move to higher or lower elevations. Over 90% of the population are engaged in farming and herding. The upper altitude limit of crops is around 4500 m, while the nomads reside above 4800 m and 5500 m. Recently, mining activities in the plateau have sustained a part of the population that lives permanently at altitudes between 3700 and 6000 m. Therefore, the Tibetans living in the Qinghai-Tibetan plateau live at an altitude as high as the Andeans in South America. Thus the apparently low incidence of CMS in Tibetans cannot be ascribed to "geographic differences." We propose that the genetic adaptation to hypoxia that has occurred in Tibetans is of importance in CMS.