Health Care in Tibet /Yushu

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.

Links:

• first person narratives about traveling to Surmang

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.

Links:

• Surmang Video --new!