Yushu Earthquake Survival

Overview.

It is very difficult to communicate the kinds of geographic (think 13,800 ft, bad roads), language and cultural challenges that we work with.  Even the advent of air transport in Yushu doesn’t mitigate that fact.  When I left Surmang in late September, it was 8:30 in the morning.  When I arrived at Beijing it was 1:30 the next morning. It is a shorter ride from LA to Beijing than from Yushu.

Generally in 2011 we continued to go about our business operating a remote/high performance clinic and CHW public health outreach projects. But there was a twist. Unlike previous years, 2011’s activities were framed by strategic objectives defined in our government partnership --because of the Boston Consulting Group (BCG) Strategic Plan.  It was not just a matter of getting doctors or MPHs to our site, it was a matter of looking at our work so that its successes could be exported, where appropriate, to the 4 other clinics we are now partnered with. So our doctor training became prototype doctor training; our CHW training became more of a prototype for Village doctor training in the four townships we are partnered with.

In addition we were lucky to get the hands-on participation of very high-level MD/PH experts such as Ray Yip, Amy Levi, Dawn Factor, Mary Wellhoner, Mariette Wiebenga, Karen Deutsch, Tim and Cat Silbaugh. Joining us from the business community were John Holden of Hill & Knowlton, Jim Zimmerman of Sheppard Mullin, Rachel Lee of BCG, Ed Sun of Milbank, Bill Valentino of Beijing City University, and Julie Hu, Nike.  So we expanded our connection to stakeholders, both in the government, PH profession, and business community. Thanks to all for a remarkable year.

What we tried to achieve.

General: 

• continued support and expanded capacity of  clinic and clinic doctors continued input and training of CHWs.

• continued and expanded capacity of CHWs

• Strategic: a shift from training of Clinic docs and CHWs to prototype training of docs and CHWs to use across our 4 township partner clinics

• Including broad sectors of stakeholders from public and government

How we went about it.

• Treating about 1,000 patients per month for free including meds, no questions asked
• Maintaining low-cost clinic services (about $7/patient visit vs. $35 for government township clinics).
• Maintenance of Clinic: Repair of Clinic roof and Clinic solar electrical system
• Gathering information about the catchment from BCG and summarized in their Strategic Report
• Continued CHW training focusing on maternal risk factors, prenatal counseling, delivery
• Gathering information on needs and opportunities for our partnership from the on-site work at Xiewu Township Clinic by Ray Yip and Dawn Factor.
• Gathering 80 people for China’s first Rural Health Festival
• Using the results and recommendations of the Festival to focus on mobilizing community public health through CHW and Village doctor training.
• Changing the training of our Clinic docs from pure primary care to managing training of docs (Phuntsok) to managing the training of CHWs (Drogha).
• Hiring the retired Yushu Director of Public Health to manage Village doctor and the Xiewu Clinic training and Surmang prototype implementation.

History of Success.

• Generally, advancing the legitimacy and respect among the stakeholders:  patients, CHWs, doctors (our own & at Xiewu), government buy-in (through open-ended participation in transparent process and analysis.

• 1000 patient visits/month at Surmang Clinic

•  High number of CHW (home) deliveries:  126

• Low infant mortality 9.8% vs. 16% for hospital deliveries

• Low maternal mortality  -- 0%

• Providing training at the Xiewu Clinic for clinic doctors and village doctors.

Thanks to all our supporters on Globalgiving. 

We could not do this without your help. Your share of support is your share in our success story. Please contact me so that we can get your input and advice on how we can be more successful, and how we can work together to attract wider support.

best wishes for 2012,

Lee Weingrad

Links:

• http://www.surmang.org

• CHW Report Dawn Factor (PDF)
  
• Table of CHW Statistics (PDF)
  

Just like that, there was no transition from sea-level Beijing to 14,000’ Surmang. Copious juniper smoke billowed dayglo white and moved in all directions in Tibet’s clear azure sky. Children and dogs were running around. On the stage, with her hand to her ear, her song quickly jumped four octaves and pierced the rarified air and into the vastness in this nomad's world, as through the same gusty wind snapping the prayer flags would carry her sound to mountain­tops as well. Got my attention. Like her song, this bejeweled Khampa Ti­betan woman is at once majestic, playful, and threatening. When it was over, she took a second to collect herself, to bring herself back to the earth. She said, “we offer our pure hearts through pure sounds as a prayer, an offering to the compassionate ones beyond space and time. Once they have heard my voice, they will give blessings to all the earth. The blessings of the silent world can travel to us by the sounds of our songs.”

At the same time, laughter of women danced across the yard. And on this particular day, they are all dressed in the red t-shirts announcing them as participants of the Surmang Foundation Rural Health Festival, kicking off the 5 day affair with some entertainment and some blessings.

The Back Story

The event itself was modeled after “The Indonesian Rural Weaver’s Festi­val” run several years back by an NGO called Threads of Life. I first saw their video three years ago, when I stumbled upon Threads of Life’s mag­nificent store in Ubud, Bali. I wanted do for rural health, women and chil­dren, what the Indonesian Festival did for weaving.

But it was a long road to from concept to completion. It took an earth­quake, a partnership with the Chinese Government, a robust Community Health Worker program, and most importantly the on-the-ground contribu­tion of world-class rural health experts from around the globe. I had to wait 3 years until all the pieces were in place.

The realization of this idea was like many other Foundation ideas; it was the “Field of Dreams Model”: build the field and they will come. For years we had talked, speculated and dreamed about extending what we had accomplished at Surmang to other regions. We had worn out the idea of the region’s uniqueness, its Tibetan-ness and started to see this place as emblematic of a wider catchment of China’s ultra-poor nomads and farmers–whose most disturbing baggage was extreme maternal and in­fant mortality.

About two years ago, thanks largely to Ray Yip of the Gates Foundation and Peking University Institute of Population Studies, we actually started talking about the Surmang Model or Prototype, because we understood what we had done, its potential and where we wanted to go. An impor­tant element, actually the important element, was and is the buy-in from the local community we serve, especially women who mobilize their communities for public health. These are the 40 Surmang Community Health Workers, and since the inception, this program has heard their voice. These women are the arms and legs of our clinic. Without local in­digenous buy-in we would be like a building without a foundation, no matter how inspired our vision. But the question remained: how to propel our project from a one-off, “stove-piped” project into something that could be sustainable, something that could work within the public health system?

It wasn’t until the disastrous 2010 Yushu earthquake, that we had the an­swer to that question, when we had the opportunity to enlist the partner­ship of the government in rolling out this model in the shadow of the earthquake’s epicenter. In December of last year we signed the game-changing agreement with the Chinese government to help restore the township health system through the adaptation of the Surmang model. Another 6 months would pass after that, because Boston Consulting Group developed a plan for implementing the agreement. At the same time Dr. Yip had fleshed out the way in which we could induce best prac­tices in these township clinics by working with the reform measures found in the Rural China Medical Scheme.

But there was a gap in our planning: how to connect these remote farm­ing and nomadic communities to their larger rural township clinic? The answer was by mobilizing these communities for public health in much the same way we’ve done it at Surmang: through Community Health Workers and a more vigorous township doctor program.

We had the commitment of 5 world-class rural public health experts: Dr. Amy Levi, Chmn., Midwife Department, UCSF, Dr. Mariette Wiebenga, Dr. Mary Wellhoner, MPH, Karen Deutsch, RN, MPH, and Dr. Dawn Factor MPH. They agreed to come to Surmang for a Rural Health Festival, one that would put our CHWs in center stage, at a peer-led conference. The festi­val was designed to have these women share their different travel experi­ences, their village life, their major problems and their proposed solutions. Did I mention bonfires, singing and dancing?

The Festival

There were a lot of ways it could fail. We needed to put up and feed 60 people for 6 days in a remote corner of E. Tibet: beds, quilts. We needed to send out trucks to go get them. We need to build a team who felt a part of it. Nike gave us bright red shirts and baseball caps with the festival logo on them in Tibetan, Chinese and English. We had banners, prayer flags. We had tags with names of all the registrants. We had 4 trilingual Ti­betans as coordinators. We had a Chinese chef!

I was a little nervous the first day. Would this fly? Would they see it as a foreign expert affair? When would they start to take ownership of this process? The answer to the last question was: immediately. From the opening ribbon-cutting by the government to the departures on flatbed trucks and minibuses, everyone seemed so happy to just be there, to be together, with no responsibilities other than telling their story and express­ing their hopes for the future.

The first day the CHWs gathered in groups and vividly told their travel sto­ries and shared information about the places they came from. Two days later, they were discussing their biggest health problems. It was a defining moment for the festival: It looked like an ice flow had suddenly burst. Their animated discussions segued into skits they designed to role-play these problems.

A few hours later the groups performed their skits. The action ranged from the dramatic to the Marx Brothers, and evoked 17^th c. Italian commedia dell’arte with its exaggerated movement, outside, temporary stages, and various props in place of extensive scenery. The action was full of colorful characters such as foolish old men, devious hospital administrators, or offi­cials full of false bravado.

A poor, Illiterate nomadic woman with a troubled pregnancy was to told to fill out forms in Chinese, come back in the afternoon, and offer big de­posits before they could be treated. Then someone tells her about a free clinic at Surmang. She goes there: no forms, no money and presto, in a few minutes of labor, she gives birth to a health, bouncing teddy bear!

Nights consisted of a final banquet and a bonfire circled by traditional Ti3 betan dance. They offered their own version of Annie Lennox’s anthemic “Sing”:

Sing, my sister... sing! Let your voice be heard What won't kill you will make you strong Sing, my sister... sing!

The last day consisted of the women creating an action plan for the next steps. Everyone agreed that our energy should be put on mobilizing communities for public health. That Surmang Foundation could strengthen the ties between nomads, farmers, men, women and public health knowledge. That we should build bridges between the community and the village clinics and township clinics. All of our PH experts agreed that this kind of bottom-up approach was the heart of any institutional re­form we could offer.

The last day also witnessed an auspicious event – one of our CHWs gave birth to a baby girl. That was the event that “dotted the i’s and crossed the t’s for us. As the last CHW departed, I looked at the remaining staff: “now we really have to go to work.”

Background -- Yushu

Last year, in response to the devastating Yushu Earthquake, Surmang Foundation and the Yushu Public Health Bureau created a partnership to not only restore the shattered township clinics.  The heart of the agreement was to take the Surmang Public Health Model and transplant it into the public health sector.  The two principal foci for the Surmang Model, since 2000, have been highly skilled doctors and access to services in the far-flung Surmang region. 

For people who haven't been there, Yushu Prefecture is like entering a Tibetan time warp.  95% of the population are ethnic Khampa Tibetan and about half of those are farmers and the remaining half are nomadic yak and goat herders. They had neither roads nor the wheel (except for prayer wheels) until the mid 50's.

These are a rugged people who live a tradtional pastoral existence of nomadic yak herding and alpine barley farming. It is an isolated place and one of the most beautiful places on earth. The region has 900 peaks that are taller than 5000 meters.   Yet it is this very isolation and low population density that allowed their traditions to flourish,  has kept government services --especially health care-- out of the reach of common Khampas.

Their barter economy and self-sufficiency flies in the face of public services that are fueled by cash.  The result is not only that they are among China's 40 million "ultra-poor" (earning less that US14¢/day).  The downstream result is among the highest infant and maternal mortality rates in the world.  We've figured out that a pregnant Khampa woman has a 1 in 15 chance of dying prior to or during delivery, a rate 3 x more dangerous than being a Us soldier in Afghanistan.

Prototyping the Surmang Model

What is even more difficult is the low-quality of training of the doctors they have, and the very low access women and children have even to those services.  This is something we decided to do something about. The Surmang Foundation Clinic, starting in 1992,  created another model, one that has two highly trained local providers.  But more that we've created a corps of 40 Community Health Workers (CHWs), women embedded in their communities who can assist in births, well-baby examinations and refer patients to the clinic. For all this inspired talk about the problem, it is also good to know that since 2000, the Surmang Clinic has provided free medical care (and meds) to over 150,000 patients.  Not only that but the per-patient cost is 1/7 that of comparable government clinics. It is this model that we are prototyping in 4 township clinics in Yushu Prefecture. But more important that the cost is the cost in lives.  Our Surmang Clinic has saved the lives of hundreds of mothers and children. How to inject this model into the public health system?

The first step in doing this is to train doctors in the 4 township clinics, encourage and incentivize best practices.  This model was developed by Dr. Ray Yip, China Director Gates Foundation, consulting in a private capacity.  Another step is the training of new CHWs at the 4 clinics. 

Kick-off

The main issue for these remote nomadic and farming people is not just access to health care services, but how the system doesn’t connect their traditional culture with the culture of health.  At Surmang we’ve added local buy-in because Community Health Workers are embedded in their villages, towns and encampments, saving hundreds of lives of babies and mothers and equally importantly being able to refer bigger problems to the Surmang Clinic.

The kick-off for this year's activities began early in the summer with volunteer doctors and public health professionals conducting residential training.  But the really big event, will be the 1st Surmang Rural Health Festival, Sept. 6 - 12. 

The festival will be a peer-led conference. Its goal is to showcase and celebrate our successful community-based public health projects.  Surmang Foundation has invited over 80 participants to the festival, 70 of whom are ethnic Tibetan, including all 40 Surmang Community Health Workers (CHWs) + 10 recent recruits. The activities will be a platform for our CHWs to share their knowledge, their experience and their inspiration.

 What makes this festival not just another conference is that its focus is not output-oriented, not being be led by public health experts on high who will transmit insight or techniques.  Rather its goal is to transmit the inspiration of the CHWs to each other and to extend their friendship to our new partners. Getting their whole-hearted buy-in is the essential point in our strategic partnership with the Government.

 Some of the activities include:  folk and religious dance, sharing travel stories, descriptions of nomadic and farming life, role playing of problems for remote women and children, demonstrations of their training and the road ahead.

 In addition to new CHWs from the Xiewu and Longbao regions will be 5 representatives of the Pendeba Foundation, community organizers from Western Tibet.  We are also happy to welcome a high-level delegation including

• Dr. Ray Yip, Country Director, Bill and Melinda Gates Foundation
• Dr. Mariette Weibenger, Holland,
• Amy Levi, CNM, PhD, FACNM, Clinical Professor,Director, Interdepartmental Nurse-Midwifery Education Program, HWPP Clinical Consultant, University of California, San Francisco
• Karen Deutsch, RN, MPH
• Dr. Dawn Factor, RN, MPH
• Dr. Mary Wellhoner, MPH
• Dr. Tim Silbaugh

Many other foundations in rural China do good work --but many, if not most do "stovepiped" solutions and don't address systemic weaknesses or sustainability.  In this way the partnership between Surmang Foundation and the Chinese Government is an historic effort to bring health to ultra-poor mothers and babies, via the steward of public health in China, the Public Health system.

Links:

• Surmang Foundation site