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,
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.
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.
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?
By Janis Whang Tseyong-jee, with Drs.Phuntsok Dongdrup, Sonam Drogha
Our partnership calls for exporting our Surmang Prototype to the rural public health system. One part of this is provider training in the township clinics. Another is the exporting of our Community Health Worker (CHW) project. Within the rural public health system there is an incipient system called Village Health Workers. Training VHWs was the main work we accomplished this summer.
The 2012 VHW training started early in July, three training sessions were conducted. One in Xiewu Township, one in Rongbo Township, and one in an ecological migration village of Rongbo, where people from three former villages have been moved to. The village is about 30 km from the township.
13 new VHWs were recruited in total. One was added to the Xiewu VHW team and 12 from Rongbo, basically we have 2 VHWs from each village of Rongbo. Now there are 19 VHWs outside Surmang area. Making our total corps of CHW/VHWs 59.
Thanks to the support of Yushu Prefecture Public Health Bureau, Yushu County Health Bureau, and Rongbo Township government, the whole VHW training project this summer was very successful. The help we got from the township clinics was extremely important, for without it the trainings wouldn't have been so successful.
Xiewu VHW Training
The first training was done in Xiewu, one of the eight townships of Chengduo County, which is about 46 km to the northeast of Jyekudo. The training took place on the fifth of July; the original plan was to start in June. However, it was postponed till July due to the fact that it was the season for digging caterpillar fungus (cordyceps sinesis) the main income local families rely on for living. The training was done in a conference room at the Xiewu Township Clinic building, which was a kind offer from the director of the clinic.
Who were trained
Out of the 7 VHWs from last year, 6 attended the training. For the seventh, the clinic director tried to contact the other one to inform her about the training, but unfortunately couldn't reach her. It seemed no any other VHW knows anything about her; we didn't even get her name. However, instead of her we had a new VHW this year. Songcho, a 63-year-old village doctor who has been practicing medicine in the community for more than 4 decades. She has shown great interest in learning, and her rich experiences were shared with the other village doctors throughout the training. We had her to demonstrate many times in the training how to help delivering a baby, how to do CPR, and etc.
The training design
The training in Xiewu was designed a bit differently from our previous training. for all the other VHWs are literate and 6 of them were trained in Jyekundo (Yushu, Chn.)for 6 months by the Jinpa Project, a local NGO in that is also dedicated to health related issues in Yushu. It was different in a way in that the training was more detailed and included more medical terms and professional skills. After the training by Jinpa, they returned to Xiewu and interned at the township clinic for 1-3 years respectively. Some of them didn't return to their own community after their internship due to the fact that there weren’t yet village clinics. However, they are still paid by the government annually, and each of them received 3,000 Yuan since last year. According to the clinic director, 3 new clinics are being built in the villages where there had never been clinics. They are Bamba, Adroronba, and Xiasayba, hopefully the new village clinics will be in use this fall.
Problem with Meds supply from the Township Clinics
At the village level clinics, they will be providing a few kinds of vaccinations for newborns, including TB, Measles, DTP, and Hepatitis B, if power isn’t a problem. Another interesting thing we heard was that the village doctor got the medicine to use at their clinics from the township clinic, and then they decide the price of the medicine when they prescribe the medicine to the patients. However, Zuncho told us that they don't make profit out of it, because the price of the medicine they get from the township clinic is higher than the retail pharmacies.
The record forms they were given last year to keep track of their work was collected, however the main four columns, including place where the births took place, the mother’s condition, the baby’s condition and the number of visits, were left blank probably due to miscommunication last year. They kept the record of newborns that got vaccination, not necessarily the deliveries they attended. We explained how to record and the beneficiary of keeping not only a record of the newborns and mothers, but also for all the patient they see, hopefully it will build up their interest and confidence in keeping patient records which might contribute to the electronic records keeping in the future.
Donation of Equipment
At the end of the training, each one of the VHWs received birthing kits, soups, eye ointments, and Surmang caps. They were all very satisfied with the training, and they request that we offer more training in the future and they wish to learn more about gynecological problems. They were also suggesting that providing gynecological books might also be very beneficial since they are all literate and will able to use the book as reference.
Rongbo VHW Training
Rongbo is about 70 km from Jyekudo, and it was the second most seriously damaged town during the April 14, 2010 earthquake. It was estimated that the earthquake killed around 100 people and most of the houses here were destroyed. Therefore, the whole town Rongbo was reconstructed, and many houses are still under construction.
The training began on the 13th of July. The training in Rongbo couldn't be organized right after Xiewu, because of the damage the township clinic suffered from the earthquake in 2010. The new building was completed early this year, but it was not yet ready. It was decided to give the first training be given in the township, because three villages of Rongbo are located near by and it was within walking distance for most of the VHWs. The second training was given in an ecological migration village that is about 30 km from the township. There lives 617 families from three former villages of Rongbo Township, that’s why the community is called ‘617.’
All the VHWs from Rongbo were illiterate except for one, which is similar to our CHW in Surmang area. Both of the training sessions started in an awkward atmosphere, all the VHWs were shy to speak and became embarrassed easily when talking about pregnancy. However, the whole situation changed on the second day, probably because they started to realize that there’s nothing to be embarrassed about when comes to life and death. Addition to the regular neonatal care we often do in Surmang, we included information about HIV/AIDs and basic CPR in the training at Rongbo this year. In fact, one of the reasons for that is that there is confirmed case of HIV in Rongbo, however no further information was known.
Gayjee Zongkou Village
According to the VHWs, Gayjee Zongkou had the highest maternal and child mortality among all the six villages of Rongbo, and the accessibility of the village still remains a problem for the year around. Unfortunately, we were not able to get anyone from that village. New VHWs from this village should definitely be recruited in the near future.
Despite the fact that almost none of the VHWs has been to school, they are mostly quick learners and they were all very active in the role play during the training and asked lots of questions regarding assistance in deliveries. Besides, they required to be trained in blood pressure measuring and the use of pregnancy testing sticks. And the VHWs from an ecological migration village, where using thermometer wasn’t included in the training, asked to add it in the training next year.
Having our Surmang CHW, Dadren, from Surmang, at the training this year was helpful, because people tend to listen more carefully when it’s based on first-person accounts, their own true stories. She shared her own experience about the deliveries that attended before and after she became a community health worker. Some of the stories were very sad, one of them was about her daughter lost her baby when she was seven months pregnant.
She also shared a story of how she saved one of her grandchildren, who was not breathing, when he was born by using what she had learned from the training.
She emphasized many times how much she appreciate that she was trained as a CHW, and told how very important it is for a woman to be able to assist deliveries. She said that almost every woman has sisters, and will probably have daughters and granddaughters. Being able to help them in risky moments like giving birth makes you not only a better sister, mother or grandmother, but also a life saver.
Last year we reduced infant and maternal mortality to zero in a region that has some of the highest in the world.
For our foundation, we believe that when you have something that works –share it. That was the inspiration behind our post-earthquake government partnership. We want to expand our network of Community Health Workers to the 4 most severely damaged township clinics in Yushu Prefecture: Mozhang, Xialaxu, Xiewu and Longbao. So this summer so far, we concentrated on this.
We began our government partnership project in June under the auspices of Janice Tse-Yongjee. Janis is a Khampa Tibetan who has worked for us every summer since 2004. She is entering her second year as an MPH student in the US, and when she graduates next May we hope she will be able to add her expertise on a full time basis. She is fluent and literate in Tibetan, Chinese and English.
Together with Drs. Phuntsok Dongdrup (Surmang Clinic Director) and So Drogha (Associate Director), and one of our senior Surmang Community Health Workers (CHWs) Palmo, they trained 20 new CHWs. Xiewu is 40 km north of Yushu/Jiegu and 4 hours north of Surmang. Longbao at 4500m, was near the epicenter of the 2010 earthquake, and is about 8 hours from our Surmang Clinic and 4 hours from Yushu/Jiegu. It is very difficult to describe the logistical and environmental challenges they had to overcome. To set up the training in these areas, you don’t exactly call to make an appointment. Most of this region is without telephone or electricity. In most of June most women were gone, collecting “worm grass,” cordyceps sinesis. The roads are unpaved, and wet from the summer monsoonal rains which come over the Himalayas from India. Even for Tibetans, it is still Tibet.
Our biggest accomplishment was not just that our foundation trained new CHWs, but that they –Janis, Phuntsok and Drogha, and Palmo-- did it by themselves. This is the first time any foundation has had accomplishments such as these, without any foreign oversight. They did it on their own. This impressed our senior public health consultants and me. It was this kind of dedication and grit that was the reason we have so many patients and why we treated so many mothers and children last year at Surmang. Now is our chance to expand this work 4 times. With your help we can succeed. If you read the news, you know the difficulty the current situation and how lucky we are to still be operating in a Tibetan area at all...and are one of the few International foundations to do so. I feel confident that with your continued support, we will continue to help the women and children in our catchment.
Charlene Chan is an In-The-Field Representatives for GlobalGiving. She is visiting projects throughout China. Here is her most recent "postcard" from Yushu, China:
Recently, Mari and I visited the project site of Surmang Foundation, a clinic in the remote Tibetan plateau providing free medical services. The project also aims to train local women to become midwives or as the clinic calls them, CHWs (Community Health Workers), with the objective of reducing infant and maternal mortality.
Upon arrival, we were warmly greeted by the two doctors running the clinic, Dr. Phuntsok Dongdrup and Dr. So Drogha, as well as a translator, Janis Tseyongjee. The two doctors live at the clinic, housed in temporary housing after the devastating earthquake that hit the region in 2010 destroyed their homes. The clinic itself was established in 2000, and while the CHW project is relatively new, the two doctors have been treating patients from all over the Tibetan plateau for a long time.
The next day, Dr. Drogha very kindly allowed Mari and I to observe while she treated patients. She saw about 20 patients that day, with ailments ranging from arthritis to tumors. Throughout the day, Dr. Drogha patiently answered all our questions and her patients kindly consented to us being in the room while undergoing treatment. I was most impressed by the patience, warmth and dedication the doctors displayed toward their patients despite their busy schedule - their patients were like family to them, and many of them stayed after receiving treatment to chat and play with Dr. Drogha's young daughter. When asked, they expressed fondness and gratitude for the clinic. Besides the free medical treatment, the clinic provided a more effective alternative to the traditional Tibetan medicine that most Tibetans resorted to when sick. Many patients had also traveled from afar to seek treatment, some as far as four hours away by motorcycle!
While we were not able to observe the CHW project in action, we managed to see a patient who was under the care of a CHW, and had come to the clinic for her free ultrasound. Dr. Drogha explained to us that each CHW was expected to perform 3 prenatal visits, deliver the baby and perform 3 postnatal visits to check on both the mother's and the infant's health. The CHW would be paid 200RMB (about 30 USD) per patient. There has been great demand for CHWs in neighboring villages, and while Surmang Foundation is looking to expand the program, funding has become their main obstacle.
Both Mari and I were sad to leave the clinic, its beautiful surroundings and the warm and wonderful people that run the clinic. We hope the clinic will be able to obtain more funding to expand its program and operations, to improve the lives of the inhabitants of the Tibetan plateau!
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