Dinesh’s Song
By Dinesh Mistry, MD
Surmang, September 18, 2017
Dark, cold, rainy, muddy Tibetan September afternoons at 4000 meters (14000+ ft.) can carry a sense of foreboding. The spring and summer monsoonal rains from the Himalayas have ended a month ago. Winter’s coming.
A nomadic couple came to Surmang clinic with their 2-month daughter. One of Surmang’s few well-to-do families, they are benefactors to the monastery, and they were treated with deference. But that was then. Now, due to do alcoholism, they had lost most everything. And now, their baby girl was facing her own winter.
She was having difficulty feeding, difficulty breathing. The little girl had a fever and cough. She was pasty white, gasping for air. Her cries were often, but very weak and a temperature of 39.5C (103,5º F.) Her breathing had a whistling sound suggesting widespread pneumonia. Her pulse was greater than 200 bpm. This baby was at death’s door.
My initial reacting was to resuscitate and send the baby to the prefecture hospital at Yushu. Unfortunately, because of the family's financial constraints, it was out of the question.
We went ahead and started care for this very sick infant. I thought she might not survive. Dr. Phuntsok started the intravenous, but we had nothing to stabilize this vital access. So we got the father holding the foot and ankle to make sure that the fluids kept running, while the mother cuddled the baby. We started fluids to resuscitate the infant, and gave intravenous antibiotics. Over a period of two to three hours, the infants breathing became less labored, but was still indrawing, the temperature came down to 38ºC, the heart rate dropped below 200bpm.
We gently gave a sigh of relief. She survived the first two hours. We kept our fingers crossed for the next crucial 24.
We did not have the facility to keep the infant and the parents had chores to do at home. So
They went home with strict instructions to come back if the infant becomes worse, or to come the following day for intravenous treatment.
The following morning, it was my time to leave. We called Dr. Drogha, several times regarding the infant, but she did not answer, and we expected the worst. We tried calling again when we reached Yushu at about 1pm(it had taken us 4+ hours on some really treacherous and impassable roads because of some heavy rains, the night before).
Dr. Drogha answered and gave us feedback. She had gone to the patient's home to see the infant, where she gave the intravenous antibiotics again. The parents did not bring the child to the clinic because she was better than yesterday and they had chores to do.
postscript I.
Before Dr. Mistry got on the Beijing-Vancouver flight, we called the clinic. Phuntsok told us that the little girl had completely recovered –no fever, normal pulse.
Lee Weingrad
postscript II.
This is one very dramatic story and yet is it is but one of the more than 10,000 that occur at Surmang every year. It is a credit to the foundation that the clinic is there at all, and further that these two angels, bodhisattvas, Phuntsok and Drogha are there with their unbelievable skill and devotion to give the same care and compassion to all. Amazing. They are local heroes.
Dinesh Mistry, MD
Dinesh Mistry, MD has recently completed his second rotation at the Surmang Dharma Sagara Clinic in E. Tibet. He is a doctor from Calgary, Alberta. He is a member of Surmang Foundation Canada’s Board of Directors.
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There is a land that time forgot, hidden behind the highest mountains in the world. It's a place of yak-herding nomads, farmers, monks, nuns, moms and dads. It’s a place where there are no days of the week, no family names, no watches, no weeks, no months, no years and few cars. It’s a place where no one speaks Mandarin Chinese, and almost no one can read or write their own language, Khampa Tibetan. It sits apart from the rest of us cut off by 2 /16,000' passes, with very long snowy winters and short glorious summers.
It is Surmang.
But it is not a place that disease forgot. It is a place with no doctors, with world record-high infant and maternal mortality and also communicable diseases. It is a place whose culture grew in antiquity in isolation. For 25 years Surmang Foundation has operated quality public health, at clinic in this remote part of East Tibet.
With your help and that of GG.org, we've treated over 130,000 patients for free and reduced maternal mortality to zero in 2011 and kept it near there since. Now it's time to go further. Here is where we need your help:
Public Health. We are expanding our public health calling to include three infectious diseases:
They are all treatable. They are all nearly 100% prevalent in each and every Surmang Khampa Tibetan.
Capital Construction. In addition we’ve gone from being the only new building on the block to being one of the oldest buildings. So we are in the beginning stages of renewing our footprint:
In the shadow of the vast number of international foundations that have left China, we remain. Getting support from people like you who read this appeal, not being connected with a big School of Public Health, Medical School, foreign government or international foundation, we've gone about our work for 25 years.
We depend on your help. As we say "when you help them, the feeling stays with you."
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2016 Surmang Foundation Clinic Report
1) Case data
In 2016 Surmang clinic registered patients totaled 10790 people, or about 900 patients per month. Of those were 17 were women who gave birth, 1527 patients received ultrasound, including 288 ultrasound for pregnant women. 61 patients had to be transferred to other hospitals due to dystocia and various serious illnesses. We did 193 house calls or a little less than 4 per week. One patient died at the clinic (cerebral hemorrhage due to a traffic accident).
2) Treatment
According to the basic symptoms of the patient this year to analyze the majority of patients Surmang offering from
o influenza,
o hypertension,
o cerebral hemorrhage,
o arthritis,
o fracture hyperplasia,
o fractures,
o appendicitis, cholecystitis (gall bladder inflammation),
o gastric ulcer,
o gynecological diseases,
o trauma,
o dystocia (slow, or difficult childbirth),
o dysentery,
o Tuberculosis and
o hepatitis B and other symptoms of different diseases. in the past two years, tuberculosis and hepatitis, diabetes, have especially become more prevalent.
In addition to tuberculosis and hepatitis, acute appendicitis and cerebral hemorrhage and other difficult diseases, the vast majority are patients are those who are treated for rehabilitation, that is to say, those have been previously treated for chronic problems and who return for treatment.
In a change from previous years, are males or female from the age of 30 present a suffering high blood pressure. We attribute high blood pressure to dietary causes. Our experience is that the illnesses arising from diet most are: high blood pressure, tuberculosis, and hepatitis. A similar situation has been recorded as well in city, prefecture and state hospitals.
3) Hours of operation
In accordance with the regulations; our normal working hours: 9:00 am to 12:00 pm, 2:00 pm to 6:00 pm. But in many cases, we have to use off-hours as well to diagnose and treat patients. Sometimes patients were treated late at night traversing tens of miles of dangerous dirt mountain road to go to the patient's home for medical treatment. Most of our patients have no means of transportation beside horse or yak and so we do what we can while they are in the clinic and otherwise make house calls.
When we encounter a poor family suffering from serious illness in need of being transferred to a hospital for treatment, we ourselves will drive the patient free of charge about 150 kilometers to the prefecture hospital.
Starting in 2016, the policy of the Government requires all newly born children to have birth certificates. The result is that most of the mothers now go to the city hospital to give birth, since the government hospitals are the places where birth certificates are provided.
There are other reasons, such as reimbursement via insurance requires city or prefecture hospital delivery. In addition, due to the limited conditions of our clinic, some maternal diseases, (pregnancy-induced hypertension, nephritis, premature birth, dystocia, bleeding) and other reasons they need to go to the prefecture to get treatment. In addition, this year, many mothers presented high blood pressure and nephritis and other comprehensive diseases, diseases mainly produced by eating habits and lifestyle and life pressure. This is a great change from the past.
3) Community based training
As in years past, highly qualified foreign doctors worked volunteer rotations. Volunteer Doctors carried out a full range of medical training.
These Include:
o the use of antibiotics,
o hypertension,
o heart disease,
o tuberculosis,
o hepatitis,
o arthritis,
o digestive diseases,
o community health etc.
What we have learned is to train the 40 CHWs, the Community Health Workers, to deepen and expand their knowledge and to trust them as people who have deep roots in their villages. That is the way we increase our survival --building a culture of strong healthy mothers and girls.
CHWs are actively involved and very grateful for their role as teachers among their communities, spreading knowledge of disease and disease prevention. On one level, basic knowledge of the causes of disease and related work and the importance of community health is one part of their role. Another is to identify what kinds of social and cultural changes –such as washing of hands and surfaces connected with the preparation of food— are a necessary component of a healthy community. After many years in this very traditional society, the small changes in behavior have had a sea change impact on the largest threat everyone can see: virtual elimination of maternal mortality and morbidity and vast reductions infant mortality and morbidity. This gives the clinic and the Surmang Foundation increased credibility working alongside their friends and neighbors for the protection of health and life and ensuring strength for women and girls, resulting in the sustainability of Tibetan culture.
Dharma Sagara Surmang Clinic
December 30, 2016
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Looking back on 25 years in Tibet
Steve and me
In the mid 90’s Steve Jobs went to New York to meet with some New York venture capitalists to fund the iPod. They asked him, “What kind of focus groups did you run?” Jobs replied, “What kind of focus groups did Gandhi run?” They asked again, “how do you know they’ll like it?” He replied, “They don’t know they want it yet.”
While I’m no Steve Jobs, I faced exactly the same kind of questions in establishing healthcare in E. Tibet. What kind of capacity do you have? What are the established needs? I was not a public health professional and while I knew none of the answers, I was confident we would succeed. And succeed we did.
The 4000 m alpine summers of Surmang are short and glorious, aromatic deep green fields abundant with wildflowers and wildlife. Snowcapped mountains glistening with sunlight rising on their horizon frame the scene.
In 1991 we made out first trip with volunteer doctors to Surmang. It was 4-wheel drive country, with no roads and rivers and with no bridges. But the local response was breathtaking. No one had ever gone to so much trouble before to take care of them. Hundreds of people would come to our tent to be treated. Every day. While their personal response was very warm, none of them had ever seen more than one foreigner before. Me.
One of our doctors, David Dubin, said, gesturing to a Khampa warrior with long braided hair and a sword, “I feel like I landed on another planet.” I responded, “Imagine how they feel when they see us!”
We continued. In 1992 we signed a partnership agreement with the Qinghai Prefecture government to build a clinic. Within 6 months we had the funding from Caritas. Three years later 1996, the clinic was finished. By 2000 we had a local Tibetan who completed 3-year-post-HS training as a doctor. By 2001 we had a second, a female. That summer our overseas volunteer doctors began a journey that continues today: training our two doctors.
Throughout those first years of the 2000’s volunteer doctors like Julie Carpenter of Boulder, CO, would ask, “Why are there no women and children in this clinic?” That question was a game-changer. As a result we shifted our focus to mother and child health.
In ’94 we penned an agreement with the Yushu Prefecture Government to do a mass-data survey of 400 nomadic mothers. This is China and foreigners don’t run around surveying the locals. It had never done before, hasn’t been done since.
We found out that the region has one of the highest maternal mortality records on earth, on the level of Uganda or Somalia. I found out later that WHO estimates 6000 women die each year from childbirth or pregnancy. And they didn’t count Qinghai or Sichuan. The biggest threat to Tibetan health was facing death in the process of making life. The next year, 2005, with the cooperation of the government, we began to train 40 Community Health Workers, women embedded in their villages and nomadic camps to pro-actively remove the sword of Damocles hanging over the neck of every Tibetan mother and girl.
By 2011 maternal mortality in our area went to zero. And stayed close to there.
This year, 2016.
This year’s report will come at the end of November. Anecdotally I can report that among our clinic’s 9000+ patients treated for free and the region’s 95+ births, there were only 2 maternal mortalities and 1 infant mortality.
In the early 90’s Suzie Jolly, then with UNICEF asked me when we were building our clinic, “how do you know you will get any patients?” I asked her if she saw the movie, “Field of Dreams.” In that movie Kevin Costner’s character is asked to build a baseball field in his Iowa corn field so that the ghosts of the corrupt Chicago Whitesox (the “Blacksox”) could play an honest game and redeem their souls. He said, “How do I know they will play if I build the field?” The ghost said, “build the field and they will come.” I repeated this story to Ms. Jolly.
Two years ago I was re-connected to her through the late Maurice Strong. He said, “Call her up.” And so I did. When she answered the phone and I identified myself, she said, “build the field and they will come.”
Our work is to save Tibetan culture. If you want to save a culture, save a mother. We get no funds from foreign governments or churches or big foundations. We are driven by individual donations. There is one big takeaway for our many small donors: the feeling stays with you. Help us. See what happens.
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Winter exits the stage late at 4000 m., and summer comes even later. This year we once more had the expert services of two volunteers -- Drs. Tonia and Kireet of Vancouver, Canada. They work side-by-side with resident docs Phuntsok and Drogha. Dr. Kireet, a 4th year resident in cardio surgery, was particularly interested in the ultra-high salt intake among Khampa Tibetans. On a healthy side, salt helps keep fluids inside the body and this is particularly useful on the high plateau. This is because, without much atmosphere to speak of, there is little atmospheric pressure and when there is less atmospheric pressure, the liquid in one's body basically flies into space. This is why volunteers often experience chapped lips during an all-day rain fall.
The downside for many Tibetans is very high blood pressure and also the resulting chronic arteriosclerosis and heart disease. The problem when we treat this sympomatically, by giving BP meds, is that it doesn't go after the heart, so to speak, of the problem, which is salt intake that is 5 to 7 times that recommended.
Dr. Tonia, a 4th year Radiology Resident, was interested in cario-applications of our ultra-sound to Dr. Drogha. As usual Dr. Drogha is a great student and picked up moved year's lessons to a new high.
In August, Dr. Ron arrived -- his 3rd volunteer rotation. Everyone was happy to see him back again. All three volunteer docs were received with typical low-definition Khampa warmth and smiles.
This year, we've had the services of manager/interpreter Lobsang. Lolo, as he is known, adds a kind of off-handed tri-lingual fluency and humor to the project.
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