Surmang Foundation

We work in a place that is 97% ethnic Khampa Tibetan. Our mission is to promote health among the ultra-poor, those who earn less that US 14/day, in remote Qinghai Province, China. With few roads, cars or electricity, creating access to services is a high priority.Our goal is to create greater access to health care and earlier intervention, applied to mother and child health. He hope to overcome world-record high maternal and infant mortality/morbidity. We have accomplished this with a regional medical center, a model for rural health care delivery among the ultra-poor that is being prototyped in the Yushu Public Health System.
Jun 3, 2013

Rolling Out the Surmang Model in East Tibet

leaving Kham
leaving Kham

What can be further from my world in sea level S. California, than to go to the Tibetan Plateau to work with Surmang Foundation? I was there in June to help advance the rollout, the prototyping of their rural health model, a model that seeks to bring sustainable quality care to 4 impoverished townships in Yushu Prefecture, East Tibet. It was a startling journey, a great adventure.

According to the WHO, health is “the complete physical, mental and social well-being and not merely the absence of disease or infirmity.” When you work with a view like that you can’t help but meet kindred spirits on your journey. And that is exactly what happened to me.

Despite the snow-capped 18,000’ peaks, the lush green valleys with grazing yaks and horses, my whole experience came down to people. Connecting to people I would otherwise never know.  And that connection is what I saw and what I took home to the US with me.

You might think knowledge is the crucial element, but care cannot be delivered without a sound human relationship.  People caring for people.  Teaching in medicine relies on the same principles – it all comes down to people. As doctors we all share in both the suffering of patients’ debilitation and the joy of patients getting better.  

My travels confirmed what I already suspected: from America to East Tibet, our shared journey of health transcends culture.  As far away as East Tibet, the doctors I recently trained went into medicine to care for the patient. That is also why I, an American physician, also went into medicine. Helping to close the gap between the health levels in both places is why I volunteered for Surmang Foundation.

What I found was that despite cultural, language and physical differences, the common ground of caring was our common language.

Traveling with ace interpreter Mathilde Patureaux, we went to four Townships:  Mozhang, Xialaxu, Xiewu and Longbao. At an average elevation of about 4000m (about 13,000’) we made our way through ice, snow, sleet and snow to deliver our model.  We did this through Surmang Foundation Physician Professional Development Training Modules (PTDM), developed by 2012 Surmang intern Christal Chow. The PDTM was founded upon the principle that no matter where we practice, we are all physicians who went into medicine with the aim of helping people.  

The course is made up of 8 modules of clinical content, based on the diseases most common in East Tibet.  For example, as essential hypertension is a common problem in East Tibet, it is part of the first module. We discuss the topic, go through how to identify hypertension, take a blood pressure reading well, what medications are available at their clinic, and based on those medications available, how to treat.

At the beginning a qualitative asset assessment composed of 21 questions was completed to get to know the physicians and their communities. It is the buy-in from getting to know the physicians that allowed for trust and changes to in-patient care.

But the program wasn’t open to everyone. Only those with high motivation and desire to improve their community were selected for the program.  The training is one-on-one, opening lines of communication, establishing a strong physician-to-physician relationships, and ultimately leading to changes of practice that improve patient care.     
 
 

Worms in her Ear.

“Doctor, there are worms in her ear,” the mother said.

“How do you know?” I asked through our translator --originally from France-- who translated from English to Mandarin. A Tibetan doctor who translated from Mandarin to Tibetan, to a concerned parent who responded in Tibetan that the child was irritable, but did not have a fever and was eating well.  

The parents had never seen the worms in the ear, but they expected that was the reason she was irritable.  I took out an otoscope (instrument to look in ears), that I had borrowed from a friend in the United States and peered in the child’s ears. I only found some earwax and eardrums that were normal. The baby had a little bit of a runny nose, appeared well, and had normal vital signs. It was most likely a cold.  The Tibetan doctors and I discussed the case as well as how to use an otoscope. They told me that they do not have any medication for worms in their clinic and that they also do not have an otoscope. Although worms are a common pediatric problem in East Tibet, I was thankful to have not seen any worms in the ear, as our medications were limited. We let the family know that we did not see any worms in the ears, and they went home happy.

The otoscope and I were far from Los Angeles. Being a blonde-haired, blue-eyed doctor, I was quite an enigma. I would probably have stopped traffic, if there were any traffic to stop. In the village restaurant, the children would watch me as my chopsticks teetered to drop noodles on the table. We all would smile at each other across the room. To arrive at the remote clinic and village, we drove through streams, mud, and rocky roads. We were about 3 hours from the hospital, above the tree line, in a mystical snowy (even through it was the end of May), mountainous land.  

Although the city had no electricity and no running water, we had a generator at the clinic that ran in the evenings. The physicians were all extremely hospitable, and we sat in the kitchen tent to eat lunches and dinners together.  The clinic was still under construction, built after the Yushu earthquake of 2010. Something I found unexpected and amazing was the level of hope of these physicians, who felt that the effects of the earthquake was stimulus for construction of new buildings and also brought the hope of electricity and running water someday soon.  I was, needless to say, excited to be there and to learn from and train the physicians there.  These physicians are truly on the frontier, taking care of anyone sick at a moment’s notice.  I found we shared much as physicians, as we talked about gastrointestinal complaints, dermatology, and the physical exam.

We also shared much as people. We ate with our trainees and slept in places provided by the clinics. On the last night I drew a smashed, congealed Snickers bar out of my bag, and broke it into 4 lopsided, jagged pieces. We laughed as we chewed, seeing each other’s faces through the light of a battery-operated lamp. “This is very, very good,” one of the Tibetan physicians said. It was one of her few lines of English she said to me, and she said it to emphasize how really good the chocolate bar was. From the medical education, patient interactions, majestic scenery, to the Snickers bar, as I boarded the plane to take me back to Beijing and S. California, I had to agree, yes this was all very, very good indeed.

patient exam
patient exam
Training in Maozhuang
Training in Maozhuang
Snow in June
Snow in June
Alien Life Forms
Alien Life Forms
Our home in Longbao
Our home in Longbao
Me, Mathilde and Phuntsok
Me, Mathilde and Phuntsok
The lonely road to Longbao
The lonely road to Longbao
Patient exam Xiewu
Patient exam Xiewu
10 baby exam
10 baby exam
Maozhuang
Maozhuang
Xialaxu temp. clinic
Xialaxu temp. clinic

Links:

Mar 7, 2013

2012 - 2013 next steps for the Surmang Model

Mother and Child
Mother and Child

When the heads of foreign foundations that support orphanages talk with me here in Beijing, I ask them: “Why are there so many orphanages in Tibetan regions?”  It’s because the mothers are dying in pregnancy or childbirth in record numbers.  “Why not work further upstream?” 

When we think of the challenges to Tibetan culture, conventional wisdom lists economic, political or environmental challenges as the major obstacles. Yet, the biggest challenges are actually found further upstream. They are the death of mothers during pregnancy or delivery, the death of children in the first 5 years of life. When a nomadic or farming mother dies, the family often craters.

As in the rest of the developing world, today’s top killers in ultra-poor regions of China are maternal death around childbirth and pediatric respiratory and intestinal infections, evidenced by Yushu Prefecture’s high maternal and infant mortality.  Yet, as Laurie Garrett correctly points out, there are no marches down 5th Ave. for dying women, or celebrity endorsements for children dying of diarrhea.

Yushu Prefecture has off-the-charts high maternal mortality (according to our own stats, 3000/100,000 live births vs. the national Chinese average of 31.9 per 100,000 live births) and high infant mortality (200 versus the China’s national average of 13.8 per 1,000 live births).

Yet, compared to seemingly opaque, economic, political or environmental challenges, it is possible to eliminate maternal mortality. Surmang Foundation has proven just this. In 2011, the last year of record, Surmang Community Health Workers reported zero maternal mortalities.

In 2010, a 7.1 magnitude earthquake leveled Yushu, leaving over 5,000 people dead and all schools and hospitals in rubble.  Although the first response was swift in China, the disaster opened the door to leapfrogging the quality of the public health system.

The Yushu Public Health Bureau turned to Surmang Foundation for such a solution.

Cost-effective, user-friendly, the experience at Surmang was that “financial determinism” is not the path to greater public health. It’s not a question of throwing more money at the problem. It’s a question of working strategically.

Surmang’s two dedicated doctors, Surmang’s corps of 59 Community Health Workers (CHWs), created a user-friendly system that is in some ways closer to “Moneyball” than conventional public health wisdom. The solution is not throwing more money at the problem. The solution is working smart. In the previous 10 years, 150,000 patients have visited the Surmang Clinic. This is a rate 10x higher than the township clinics. Treated for free, with free meds, the cost per patient visit was $7 net compared with $35 in the public health system. Maternal mortality in the Surmang region was reduced to zero. This is the model we will to export to the public health system. This is our contribution to Tibetan, Uigyur and Mongolian culture.

Yushu Prefecture is 97.5% ethnic Tibetan. It is one of the most Tibetan places on earth. The Surmang-Government partnership is in four townships in Yushu Prefecture: Xiewu, Xialaxu, Longbao and Mouzhang. The problems there are similar to the rest of the 40 million strong ultra-poor catchment: 

  • No access to health care because of no roads, no cars, no phones
  • No access to health care means that the system is not user-friendly – written forms for illiterate patients and cash-in-front procedures for cash-poor farmers and nomad
  • Lifetime-tenured doctors who are poorly trained and have no incentive. or exposure to, or access to quality medical training.

2012 was a bridge year for giving this project legs. This year, we will train over 40 new Community Workers and over 20 Township hospital doctors, with volunteer doctors from Tibet, China, the US and Canada. We will begin the long climb to establishing the Surmang model of rural health care as a sustainable prototype in China’s rural health care system. We will be doing something strong and something sustainable not only for the mothers and children of Yushu Prefecture, but for their culture and their economy: ensuring life for mothers and children.

best regards, and appreciation for your continued support,

Lee Weingrad

Links:

Nov 19, 2012

Field Visit

At Drogha
At Drogha's House

 Beijing to Yushu

On paper, the flight to Xining is an easy and straight shot westward from Beijing. Surrounded by a cocktail of unfamiliar sights and unknown languages, the 5-hour wait in Xining airport was an eye-opener and gave me a sense that I’d left East Asia behind. I was now in Central Asia.  Even though I’ve spent the last 3 years living abroad, I still had the sense of being launched into the unknown, maybe even another planet. A planet with less oxygen.  

 I had I put my fate entirely into Surmang’s big planning hands. I didn’t even understand where Surmang was in relation to Yushu. So there I was – no paperwork, directions, maps, no contact addresses. And coming from the Negev desert, I definitely was unprepared for the cold.

 I was filled with crazy ideas. What if I fell asleep and missed my flight? I wouldn’t be able to reschedule for that day. What if I didn’t get met at the Yushu airport, what then?

 

Arriving in Yushu

The plane dipped down into the Batang Valley amidst range after range of snow-capped mountains. Departing the terminal, my worries dissolved into the broad smiles of Phuntsok and Drogha, Surmang’s doctors, who were waiting for me at the exit gates with a sign.  Actually I didn’t need the sign. Their smiles and shining faces were enough -- Drogha’s two rosy cheeks and big smile, the exact same ones captured in all the photos I’ve seen, and Dr. Phuntsok with his cowboy hat. A wave of excitement and calmness washed over me.

 Traveling into town I understood bits and pieces of Phuntsok’s mandarin, and much less of his Khampa Tibetan.  Drogha spoke a little English. Between partial sentences and hand gestures, we were able to make some sense of each other and have a few laughs on our drive to Yushu/Jiegu.

 

My first night: Yushu with Drogha’s family

Drogha and her family were extremely warm and open. At the center of their home stove blazed with heat and I took my place right next to it.  I had anticipated the cold. But even with 2 pairs of pants, 2 pairs of socks, and layers of clothes under my winter jacket, I was still shivering.

 While I was at their home, I could neither communicate with Drogha’s Khampa Tibetan speaking parents nor her 3 year old daughter. But despite the lack of verbal communication, I understood the language of  their, genuineness, their warmth of their hospitality. It was like visiting my own relatives --Drogha and her mother kept giving me food. It started with a cup of hot tea and cookies and slowly progressed to breads, home made yogurt, and more tea. Then came dinner!.

 Without language, I relied solely on expression. And with Drogha and her family, I not only felt welcomed, but saw their genuine kindness and concern openly written in their facial expressions, a kind of universal language I understood from my travels.

 

Day 2: Journey to Surmang

When I awoke, there was snow covering the ground. It was the first snowfall of the year. David Wenbao joined me in Yushu. David worked for the foundation for many years and he knows what to expect. More than an interpreter, he became a guide to Tibet and Tibetan culture. He helped me to build a bridge into a place that was so completely foreign to me.

 The road to Surmang was long and bumpy. The roads became more difficult to see, more torturous as the sun slowly set behind the mountains. There were many mountains. Conditions worsened and more and more cars were stuck on the side of the road except for a truck which was stuck in the middle of the road, blocking all traffic. Driving cross country we created our own road.. Each time we reached mountain pass, Phuntsok took off his hat. David and Phuntsok would cry “ki ki, so so” rousing the life force, windhorse.  I started to get the idea --with each mountain peak we passed, there was another approaching. In the fading light was nothing but mountains after mountains.

 

Surmang

While the trip was long and difficult, Surmang was relaxing and peaceful. Without cellphone reception or internet, I happily disconnected from my familiar world and plug into Surmang’s. Yaks grazed on the grass, freely crossed the dirt road to drink from the rushing streams. The sky seemed like a factor in everything I saw. At 4200 m., (13,800 ft!) I felt like I could reach out and touch the clouds.

 At the clinic, I followed Phuntsok and Drogha. We saw patients on a daily basis. Babies with colds, old men with pus-infected broken teeth. A nun suffered from arthritic pain and Phuntsok performed acupuncture. Pregnant women were there for ultrasound. Other women came to make sure their IUDs were still in place. With each patient that walked through the door, Phuntsok had a vast amount of knowledge to share with me – the signs and symptoms he was looking for, why he prescribed the medication he did, the social problems of his patients that he took into consideration when he gave his medical advice.

 My first two years of medical school were spent basically learning a foreign language, medical English. I was okay with that, but going from medical English to Tibetan was a reach. Making matters worse, the Tibetan medical lexicon for Western allopathic medicine pales before the Chinese and so David used a Chinese to English medical dictionary in conjunction with translating Phuntsok’s Tibetan. Phuntsok would give the diagnosis, treatment and plan. David would look it up in the dictionary. The good news was Phuntsok would often recognize the English terminology. If that sounds difficult to understand in writing, it was much more difficult in person. When I had medical questions, Between English, Chinese, Tibetan, and a lot of visual observation, I was able to understand the whole clinical picture. The warmth of David and Phuntsok made these difficulties seem trivial and occasionally, fun.

 

The Baby Patient

We usually met for breakfast at Drogha’s home. One morning there was an old woman rocking slowly back and forth next to the stove. As I approached, I noticed her cradling her infant grandson, inside her winter chuba (winter greatcoat). The 3-month old had a fever for 3 days.

 When I listened to his lungs, I could hear rales – the crackling sound of pneumonia. The baby was listless. I peered down at him, and he stared intently back, wheezing with each breath, without cries or tears. The painful antibiotic injection elicited only a momentary whine, and then he continued to stare intently with large, brown eyes.

 All day we waited for him to get better. His temperature dropped, and we thought that he was on the home stretch to getting better. But the next day, his temperature went back up. Phuntsok made a decision. The baby needed to go to the hospital in Yushu. We would drive the infant halfway, and a relative would pick up the baby and drive the rest of the way to the hospital.

 That morning, we went to the baby’s house to pick up him and his mother, and father. Waiting for the family to leave, his mother began to sob. She was scared. Drogha rushed to her side. Somehow, she was able to calm the her. And away we all went, Phuntsok behind the wheel, mother and infant tucked into the front seat, and Drogha, David, the father and I in the back.

 It had been raining. The roads were wet and muddy. Some sections were closed and we were forced find our own way amidst the mud and stones. We drove, fishtailing, the wheels slipping and sliding, mud flying in all directions, caking the windows. Somehow, we managed to keep on moving, passing the smaller half buried cars. We went through this kind of terrain for 3 hours before meeting a relative at the halfway point.

 Here, baby, mother, father, and Drogha got into the little car and continued their way back to Yushu.

 The car now half empty, we turned around and headed back. Although our thoughts were still with the baby and family, the atmosphere lightened. As we approached Surmang, Phuntsok stopped and chatted with almost every single passerby. Some were friends of the clinic, some were community health workers, others were old patients. Phuntosk knew almost everyone.

 One elderly gentleman, riding a horse along the side of the road, carried 2 big bags of barley. We stopped, put the bags of barley in the car, and dropped them at one of the nomadic camps further along the road. Here, we picked up bags of Tibetan cheese and dropped it off at one of the village homes next to the clinic. There was this wonderful sense of effortless community.  

 When we finally returned, we told Drogha’s 3-year old daughter that her mother had left for Yushu. Without blinking an eye, without crying or any ndication of fear, she said, “Ok. I will go to my uncle’s house for dinner. Will you take me?” And that was it. I was so surprised at this little girl’s maturity. But then again, it should not have surprised me. Here everyone seems confident.

 Earlier in my trip, I had seen her be so insistent to “help” out with what other women were doing. She had taken a small table knife and began cutting vegetables. Not in a way that was entirely helpful, but in imitation of the adults around her. I had brought a small stuffed animal for her at the beginning of my trip. She seemed interested in it only because it was new, not because it was a toy.

 While at her grandparents’ house, she insisted on playing outside in the cold, “helping” out by moving the wheelbarrow around, which was twice her size. In the States, I babysat kids her age, who toted around their blankies and teddies. But this little girl, with toys and dolls on her bed, merely pushed them aside.

 

Fending without Drogha

With Drogha gone, the warm motherly environment also slowly dissipated. Phuntsok, David and I had to fend for ourselves, making tea, keeping the little home warm, and cooking meals. And it was hard! Thank goodness for house helpers.

 I’ve camped a lot. A lot. You think I would know how to start a fire. Build a little teepee of wood, get some kindling and viola! However, this is all within a fireplace. At Surmang, I didn’t know how to start a fire from yak dung. Especially in a wood burning stove.

 Cooking was a huge challenge. I consider myself a decent cook. But in a Tibetan “kitchen”, I was at a loss. There was no high, medium, low heat setting on a yak dung stove. The fire either burned hot or not at all.  I didn’t know how to boil rice because I didn’t know which pot to use. Some of them were too small for the open stove tops. It took me some time to realize that there were different ring sizes to place on top of the stove for different sized pots.

 

And my choice of rice for dinner was peculiar. Tibetans have rice for lunch and noodles for dinner. While I buy noodles at a store and simply boil them, Drogha had made them from scratch out of flour. And when dinner was over, how do you do the dishes? There was no running water. Drogha’s absence not only illuminated the difficulties of living in Tibet, but highlighted her talents. Drogha is successfully juggles her many roles within her community – mother, wife, and doctor.

 

Going Home

One week after my arrival, it was time to head back. Surmang was wonderful. I lived in a way that was so completely different from my upbringing. I left behind the material world that formed some part of my identity, and stepped outside of my comfort zone. Surmang, the environment and its people, shed light on what was important. Not fancy clothes, appearances, or money. All those things are worthless in Surmang. But relationships, people, conversation, life itself and how you choose to live it.  

 Right before the Yushu earthquake in 2010, Dr. Phuntsok decided to go to Yushu to visit his family. He arrived just in time for the earthquake, to be burried in rubble. He was lucky to survive. And he shared his new-found wisdom with me. Life is a gift. How to live it?

The torturous path to Surmang in October
The torturous path to Surmang in October
Mother of the sick baby
Mother of the sick baby
David, Phuntsok, patient and Rijie elder
David, Phuntsok, patient and Rijie elder
Drogha
Drogha's daughter "working"
Me, at one of the bridges over the Yangtse
Me, at one of the bridges over the Yangtse

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