The winter months are quiet ones for our programs but not for our clinic projects nor the Khampa Tibetan patients. In October, the snows come down to about 3500m, the nomads fold up their sturdy yak hair tents, and with their herds of yak, horses and goats go to the lower elevations, to their villages and permanent homes. By December the passes close. The Surmang Clinic, the Community Health Workers and the 4 township hospitals are snowed in. For a time when the passes are closed, with days short, the families stay warm around the yak dung stoves eating tsampa and yak jerky, drinking salty butter tea.
For patients who are not facing life or death crises, wintertime brings farmers and nomads closer proximity to medical help than in the summer when the nomads are disbursed among the remote alpine encampments. This is good news for any kind of sub-acute problem. But for problems that require evacuation it is difficult. But for women and children who need early intervention the clinics are closer than in the summer.
Higher skill levels for providers and early intervention. That is the key.
Increasing the skills of these providers in ways they can use, and linking up these folks –village health workers to village doctors, village doctors to township hospitals—that’s the way you create a system with synergy. That is why we are building birthing centers this summer with the help of the Danish Chamber of Commerce, China. But the hardware, the bricks and mortar only take us so far. We need support from you through globalgiving.org to pay for the training of these rural doctors, to enable them to use these facilities.
And that is the reason we’ll have a much bigger training of village docs and village health workers this summer than ever before. It sounds simple, but actually the directness and lack of jargon-driven agendas makes us outside the box of conventional development and public health approaches.
In the winter we too, at Surmang Foundation sit around our virtual fire, a period of regrouping, planning and strategizing. We can’t travel to East Tibet to oversee projects so we design for the coming year, we recruit the volunteers who will work on these projects, and we raise the funds we need for the whole year. So we must plan carefully to use our resources carefully. That’s where you, the donor come in.
In the November Beijing Fundraiser we auctioned off a “Tibetan Family” in the guise of dolls donated to our cause. The winning bid on the families represented the cost of providing medical care to a family. We were very successful, raising over $4,000 for each “family.” I encourage anyone who wants to participate at this level to make such a donation.
2014 promises to be a big year for us –we so far have 4 volunteer doctors including the return of our own esteemed Dr. Julie Carpenter. We’re going to visit once again the Shechen Orphanage and offer medical services there.
Suzanne Smith, a veteran of over 10 years in community organizing in Africa will join us as a project manager. Janis Tse yong-jee will return. The Chinese community is rising to the challenge – there will be a fundraiser in March. We are now registered in Qinghai Province. We are hoping for national registration by the end of the year.
It feels like our resources are gathering. Our calling is the stuff of life –and death—mothers and babies who carry the future of Tibetan families and Tibetan culture. So in the words of the poet, we have promises to keep and miles to go before we sleep. Please help.
Core Project and Government Partnership.
This year our clinic at Surmang saw over 12,000 patient visits for free, including meds. This year the clinic played a central role in the roll-out of our partnership with the Yushu Prefecture Public Health Bureau. The purpose of this partnership is to bring the Surmang model into the public health system as a sustainable prototype. Our clinic became user-friendly jumping off point for volunteer doctors, doing training at the 4 partner hospitals.
The awesome challenges of this project
It’s hard enough to create and run a private one-off project in remote Yushu Prefecture. But to leverage the qualities of that project and our good relationship with official China, to put it in the public health system, is something else again. No one else is doing that.
The challenges boil down to the fact that at our own clinic we control all the elements of HR, management and central supply, and zero of those in the 4 partner hospitals in the public health system. How we present our model depends on how we engage docs in the PH system. We have been selective in the sense of only training those who are focused on personal and medical excellence. Our job is to convince them that our foundation is the ticket to help them achieve just that.
Doctor Volunteers in 2013
This year we were lucky to have three volunteer doctors apply for our program. For reasons beyond us, one was denied a Chinese visa. Our two remaining volunteer doctors were Elizabeth Van Dyne and Rebekah Sands. Dr. Van Dyne had the excellent translation services of Mathilde Paturaux, and worked for us for about a month in June. Dr. Van Dyne came to us from the US and Mlle Paturaux from Brittany, France. They were able to travel to Surmang and all 4 of our partner township hospitals: Mauzhuang, Xialaxu, Xiewu and Longbao.
Here is an excerpt from her report:
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.
In September we hosted volunteer Dr. Rebekah Sands from New Zealand. Rebekah is a product of the international school of Tianjin and speaks flawless Mandarin. Her self-sufficiency was a first for our foundation –it’s not every day that we come across a person who has native-level Mandarin, to have a medical volunteer who does not need an interpreter. She spent more time on her own, a quality that bespeaks her true Kiwi grit and self-sufficiency. Drs. Sands and Van Dyne were great addition to our previous vintage of great volunteers.
Training Village Health Workers
As we know, Tibetan culture is under enormous pressures – cultural, political, and economic. Among those, probably the most unsung are those created by maternal and infant mortality. The death of a mother in rural Tibet often means financial ruin or the cratering of the family unit. This accounts for the high number of orphanages in ethnic Tibetan areas. That’s why we say, “if you want to save a culture, save a mother.”
Remoteness and geographic challenges are as serious as any other cultural challenges – keeping women and children far away from services and in the cross-hairs of maternal and infant mortality. There is no doubt that to cure maternal mortality, hospital delivery is the key. However with poor dirt roads, no village cell phone service, no public transportation and no private ownership of cars, infrastructure is the primary obstacle to realizing that goal.
Since it’s beyond our capacity to build roads or an ambulance service connecting the villages to the township hospitals, we must provide assisted delivery in the remote villages as we’ve done at Surmang through the Community Health Worker project.
This year we trained over 50 Village and Community Health Workers, under the direction of Janis Tseyong-jee, MPH. What made this year’s training unique was that the trainers were all Khampa Tibetan women: Janis, Dr. So Drogha, and Pema tso, one of our Community Health Workers. We have moved a step into training other trainers –TOT.
While there are government paid Village Health Workers, they are an under-utilizied, and largely untrained resource.
But, as we’ve shown over 20 years, these health challenges are amenable to change. In fact, compared with other challenges, especially political and economic, we can make a real difference. We are on the cutting edge of what people can do in such challenging conditions, and have instilled confidence among rural women that there is something they can do about their own situation. Our unique contribution is that we are not extra-system.
We want to transplant this model inside the public health system. In late July, we met with the government – they support our work, just as we support putting our model in the public health system. At our summer meeting with the Director of the Yushu Public Health Bureau we received a standing ovation when I said, “if you want to save a culture, save a mother.” Please join this cause.
Surmang Foundation has become legally registered in Qinghai Province as the, The Qinghai Nomadic Health Promotion Assn. Registration was done with the active help of the Qinghai Government, and our two most pro-active supporters, Mr. Deng Haiping and Dr. Xiao Jiugha. Dr. Xiao is a Khampa Tibetan and retired head, Yushu Prefecture Public Health Bureau.
We stand for healthy families. But how can you have a healthy family and a healthy culture when the mothers and children are dying in record numbers? Yes, it’s true that Tibetans and other minorities in China live in very low population density. But there are over 40 million of them in China –including Uighurs, Kazaks and Mongols-- who have lack of access to quality health care. That's more people than live in Spain.
There’s a direct correlation between the dramatic health levels –especially the world-record-high infant and maternal mortality stats-- and access to quality health care in places like Qinghai. A nomadic or farming mother in Yushu Prefecture stands a 1-in-15 chance of dying during pregnancy or delivery. There are a lot of orphanages in Tibetan areas, makes sense, because the mothers die and orphanages are downstream results of maternal mortality. Our goal is to up-end that through creating greater access to health services and increasing the quality of the services that are already there. This is the heart of the Surmang model.
We have changed the odds for mothers and babies, by eradicating maternal mortality in our own catchment and significantly lowering infant mortality. What is the cost? Our estimate is about $225/birth. I think you could say ‘this is the cost of not having children and mothers die. But what is the cost when then do die?’ It can’t be photographed; it can’t be quantified. This is where the international community of supporters comes in.
As a health care strategy, building local capacity is the answer. This spring, Janis Tseyong-jee, with help from Surmang Foundation, graduated from Tulane University with an MPH. Janis is now one of the very few Tibetans with an MPH. Janis has volunteered for our foundation every year for the past 6 years. This year she made the transition from one of the principal assistants in the CHW (Community Health Worker) program to a vital role as a designer and implementer.
The CHW program is one of the two pillars of our Surmang Prototype – creating assisted births through home-based health care. This July and August, Janis trained over 30 Surmang CHWs, and paid their incentives for training, assisting in birth, well-baby checks and referrals to our clinic. In addition for the second year, we were able to extend CHW training in the townships and villages in our government partnership catchment. Our goal is to have over 400 CHWs. It’s hard to put into words the real-world challenges that Janis, Dr. Drogha and Dr. Phuntsok face when a program like this is implemented. Just getting all these CHWs in one place for training is one such challenge. Getting to the place where we do the training is another –roads are not paved, and in the summer monsoon season, frequently washed out. But the support and determination on the part of our staff and the CHW trainees more than compensates for these obstacles.
As we know, Tibetan culture is under enormous pressures – cultural, political, and economic. Most we cannot do much about. Remoteness and geographic challenges are as serious as any – keeping women and children far away from services. But, as we’ve shown over 20 years, these health challenges are amenable to change. We are on the cutting edge of what people can do in such challenging conditions, but we are not extra-system. We want to transplant this model inside the public health system. In late July, we met with the government – they support our work, just as we support putting our model in the public health system. At our summer meeting with the Director of the Yushu Public Health Bureau we just about received a standing ovation when I said, “if you want to save a culture, save a mother.” Please join this cause.
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.
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:
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,
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