This year, Surmang Foundation’s Dharma Sagara Clinic is isolated because of Covid-19.
So even the difficult travel to Qinghai Province and then 1500 km south at> 4000 meters, was made impossible due to the shutdown of air travel, not to mention the draconian measures such a social distancing and quarantine. Our Mother and Child programs which started in 2005, have been working well. This year the downstream effects of Covid effectively postponed the start of a second phase, a new health promotion program our foundation wanted to provide in 2020.
Despite our hubris as foreigners, since antiquity the region was also isolated. For Khampa Tibetans, social distancing is a traditional way of life. These peaceful nomadic yak herders, barley farmers and monks and nuns practicing meditation had never seen a foreigner until 1987, the year I arrived. This reason alone —the absence of primary care and mother and child health— ensured the sad reality that only returning visitors were death and disease.
That is, until the Dharma Sagara Clinic. Our clinic’s work was not just a plug-and-play health center, but a gradual elevation of the culture of health, to chip away at the very patterns of life that made having a baby and being a baby a kind of Russian roulette.
This year’s isolation has not impacted regular clinical operations — social distancing is a traditional way of life in this ethnic Khampa Tibetan region. Nor have there been outbreaks of Covid at Surmang. We are still treating about 1000 patients/month. In fact you could say that the last several months we’ve continued our work to the usual: full waiting rooms, pregnant moms, newborn babies, treating diseases like placenta previa, Hepatitis, high blood pressure, emergency medicine and trauma. Soon the snows, in this the Land of Snows, will return and Mother Nature’s winter will once again have the last move in social distancing.
[The Nuns Project]
Back in 2019, 2020 was the year we were to start a public health program among the nuns to eliminate the scourge of h-pylori, hepatitis, and TB. The idea is to eliminate these diseases and then make the nuns agents of change in public health in the Surmang region, since the nuns and monks enjoy very high status among the Khampa Tibetans. To the best of my knowledge, this way of leveraging our status at the Monastery to make the monastics agents of change in the community has never been done before. But this year’s Covid quarantine of foreigners and non Surmang Tibetans made these plans something we’ll have to do next year.
[What can be done?]
So what could we do? We decided to complete the interior, the clinic’s physical improvements. These have been furnishings and improvements such as the installation of a ceiling in every room on the 1st floor. The IKEA furnishings include 7 modern beds, sheets, quilts, pillows, nightstands, lights, cabinets for meds, a play area for children, a convertible sofa, a wingback chair, and finally Hunter-Douglas style window treatments to further insulate the building from the cruel East Tibetan winter. We also put the finishing touches on our new tiled toilet/shower. Last but not least is a washing machine —since water was installed two years ago.
[Wrapping it up]
When the furnishings are installed, we will have a clinic that is unparalleled in terms of function and taste. Although we have much further to go — a kitchen next year— I am very proud of this result so far. It will arouse the confidence and comfort of all guests who stay at the Dharma Sagara Clinic. I’m also hoping that in the future as eco-tourism grows for Surmang, that it will be a place of unparalleled dignity and comfort for those seeking to visit this extraordinary place. Please come!
Look --I’ll tell you something I discovered. By myself.
I’m not a doctor, not hospital administrator/designer and before Surmang, I had no background in Public Health. I’ve never been in clinic design/hospital administration before I woke up one morning and decided that we should have a clinic at Surmang. A very remote part of Tibet. And I never raised money for a cause before. The people at Surmang are very poor people.
That was 30 years ago.
I went to see the people I thought could help me. Actually I was dumbstruck.
I remember in 1992 or so seeing the head of UNICEF in Beijing. She was very friendly. She said “how do you know you can build a clinic at Surmang and it will succeed?” I asked her if she saw the movie “Field of Dreams.” Kevin Costner, the Iowa farmer, asked the ghost the same question and the ghost replied, “Build the field and they will come.”That’s what I told the UNICEF head.
A second event occurred a few years later when I met a woman who ran a rural clinic in Ladakh,India, a Tibetan region. Her advice was, “no matter what the cost, the patients must pay.”
[Should I bow to greater wisdom?] I thought I should bow to greater wisdom. But something in my gut told me that the advice I was given was a poor fit.
The Surmang Tibetans were/are so poor I couldn’t never figure out how to charge them for meds and for services. Based on their appearance, I could not tell the difference between the man who has 500 horses and the man who has 5.
The only thing I could do is administer a means test, and given 95% illiteracy in Tibetan, they could not fill out a form and also, I was not about to have them admit to a fellow Tibetan how rich or poor they were. In fact, their culture doesn’t work that way --they have no idea of “being rich or poor,” which is to say they never ever think about money. So why should I be the one to make that change in their culture? They don’t think of themselves as poor. So what I ended up doing was to not charge them. I raised the money for their services and their meds. We paid for their health. It was one of the greatest decisions I made in my life. Ever.
[The structure of a hospital. The structure of our clinic.] It took me a while, but I realized that when you go to a hospital, a good deal of the charge is for the largish administrative function of the hospital: the building maintenance, the computers, the payment scheme, the purchasing of equipment and meds. So many hands to pass through and somehow we think of that as the norm. Hospitals have become health cash cows in America: at each door was someone with their palm extended in order to be paid.
With Surmang, the administrative wing was and is me, 2000 km away in Beijing. I raise the money to pay for the meds; I raise the money to pay for the equipment. I pay the docs' and assistants’ monthly salary. Originally, I thought this was a funky home-grown mistake. Now 30 years later, I have seen that ghost baseball team come to our field to play on Kevin Costner’s farm.
I soon figured out that our model was very very cheap to run compared with even the rural clinics of the Chinese government. Peking University computed it on an all-in perpatient visit cost. For a Township Chinese Municipal Hospital it’s $38 per patient clinic. For Surmang Foundation it’s $7.
So you might say it’s socialized medicine we practice. But there’s more. About 10 years ago one of the high lamas from the monastery told me that because we give everything away, because we treat people kindly, that our Clinic embodies the highest ideals of Buddhism: “jinpa,” or generosity, the hallmark of the health element of Buddhist wakefulness, personified in Medicine Buddha. So by some stroke of luck we’ve tapped into the heart, the core of Surmang Tibetans’ culture.
Is it any wonder they support our clinic as their own? Please help us go further with this work. Support the clinic as your own. Every pfennig, Loony, nickel, yuan RMB, shekel, helps.
In 2019 the Dharma Sagara Clinic at Surmang Dutsi til has treated over 12,000 patients, for free. Including meds.
In particular, we have elevated the status of women by focusing on maternal and infant mortality and morbidity. We have worked in an area that had sub-Saharan-level maternal and infant mortality rates. We lowered the former to zero by 2011.
2019: What we did with your help
With your generosity
In 2019 we achieved Revenue Canada nonprofit status for Surmang Foundation Canada. (cf our website for details)
We want to bring health to the 90 nuns of the Surmang Dutsi til Monastery. As monastics, they are community leaders. They are are celibate and they have high status. But as women that status is threatened by infectious disease, issues of personal hygiene and environmental issues, such as unsanitary food preparation, the presence of helicobacter and tuberculosis and most importantly, lack or access to proper gynecological care. They share the plight of women in rural ethnic Tibet.
We will change that in 2020.
In connection with our goal of international hygienic standards for the clinic and for the community, the 90 Nuns of Surmang play a leading role. We will provide not just primary care, but also have the nuns serve as a model of what the community can achieve with clean clothing, bedding and food preparation.
1. The Nuns Project.
Extending health services to these leaders of the community —the 90 nuns of Surmang— we will be extending health to the community as well and improving the status of these women and girls.
The nuns have very high status in the lay community. We will eliminate helicobacter, TB and Hep A and C with a pro-active program that will not only create sanitary conditions for the nuns, but also use their example as a means of influencing the lay community.
2. Incentivized visits
We have successfully extended medical resources to women who are in their child-bearing years through a network of 40 Community Health Workers, In 2020 we will be even more pro-active. We will incentivize pregnant women and community health workers to come to the clinic for pre-and post-natal examinations. We will pay them to come to examinations.
Providing robust pro-active health services to a very poor area will show ourselves, China and the world what we are capable of accomplishing. We will be one of the high capacity health care clinics that will operate on international standards.
In cooperation with United Family Foundation, we are planning on doing cervical cancer screening at our clinic in the summer of 2010.
All with your help. Please continue this important journey with us.
Before our clinic started its work, the maternal mortality rate at Surmang was higher than that of Sierra Leone, Africa, the place with the world’s highest maternal mortality rate. The heart of our work is the 1300 patients we have treated for free --including meds-- every month for the past 23 years, focusing on mother and child health and keeping the maternal mortality rate at zero or very close to zero.
This is how we work for the empowerment of women.
Since 2007, the last three years at Surmang have been dedicated to expanding the clinic’s capacity to serve its immediate community as well as the larger catchment. Strictly speaking this region is within a 20 km radius of the clinic. But we frequently have patients that come from as far away as Chamdo, in the Tibet Autonomous Region to the south and Sichuan Province to the East. Both these regions are strictly Khampa Tibetan regions, despite their being in different political entities. For the most part all these people more or less speak the Khampa dialect of Tibetan, a dialect that is impregnable to a Tibetan speaker from Lhasa.
The infrastructure changes started in 2007, when we put a metal roof over the clinic. Tibet is known as “the land of snows,” and the accumulation of snow over the winters of the past 25 years had challenged its existence. Back then, in 2007 an engineer told us we had three choices: put up a roof, rebuild the current roof every three years or do nothing, in which case the building would collapse in 5 years. We chose “A,” put up a roof. My wife immediately contacted Chinese patrons and within two hours we raised $9000.
Do you think it’s hard to get a plumber in Denver or San Francisco? Try getting one in Surmang!
Last year we installed a water system, connected to the monastery’s line, a system installed by the government after the locally constructed lines failed 3 times. The work was mainly designed and executed by staff member Joseph Weingrad, with assistance from a Master US plumber, Russel Iser.* That took over a month, but it worked.
The next step was to replace the tile with flat black marble and install waiting room chairs and burn the wooden benches that had served us well since 1997. The Clinic is a high-gain passive solar building, which means that it can absorb the sun’s heat during the day and disburse it to the building at night. There is no connection between the floor and earth below.
[2019. The beat goes on]
This year’s work was far more ambitious. It was to
[Why the big fuss?]
We definitely have the trust and love of the people we serve, our catchment. That took a long time to accomplish in this very traditional region. I can feel it when I go there.
Now that that trust is established, we should be able to raise the clinic service level according to international hygiene and medical standards. While it’s not that difficult to do, neither is it easy. As I’ve said before, Surmang is not in the middle of nowhere, it’s on the edge of nowhere.
To that end, we’ve engaged and partnered with United Family Hospitals and Clinics in Beijing, the largest international-standards hospital group in China. They will assist us to create a further miracle in this remote, beautiful, sacred, under-served region of China.
*name used by permission
There is a history, a unique history in the very beautiful, sacred, far away place, Surmang, East Tibet.
History has often been unkind to Surmang. After I arrived in 1987, there was a spate of construction at this 400 year-old monastery. The bad news was that the 2010 Yushu earthquake destroyed most of these newly reconstructed buildings. The good news was that our clinic survived intact. In the last few years there’s been a second spate of monastery construction making our clinic the “gray lady,” compared to the newer buildings.
Our work has introduced medicine to remote SE Qinghai, China, aka East Tibet, Kham. We remain of of the few foreign foundations in any Tibetan region, thanks largely to the acceptance of the people we serve and the cooperation of the government (and us proactively seeking their partnership). Our aim is neither political nor religious. It is empowering women and girls by reducing maternal and infant mortality and morbidity. The arc of our work has been to first get these traditional people used to our clinic, Then based on that trust, raise the gaze of these Khampa Tibetan men, women and children.
It’s worked out well — we —out two local Khampa Tibetan MDs, Phuntsok Dongdrup and ?Sonam Drogha, and a staff of 5, treat about 1100 patients a month for free, and in the process lowered maternal mortality to zero in 2011 and it stayed there ever since.
This summer we will complete a 3 year cycle of construction at the clinic. We will:
it’s been a very interesting journey. We’ve grown. I’ve grown.
I will go there in a couple of weeks and hope to return with new photos to share.
Please continue your generous support of our effort in this year’s re-do, creating further proof, of “build the field and they will come.”
Director, Surmang Foundation
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