Health Care in Tibet /Yushu

Dear Friends of Surmang,

It’s very meaningful to enter this year-end report, since it gives us the opportunity to reflect on 2014 and the years before.

2014 was a year that brought several things to fruition that had been cooking on the stove for the past 20 years. I often say that Surmang Foundation is like a rock and roll band that played small clubs in central California for 15 years and then one day became an overnight success.

Connecting to Tibetans

Maybe there’s a kind of inner Steve Jobs in me. When we were asked in the mid-90’s how we knew that the Tibetans would want a clinic, I responded in effect, “they don’t know they want it yet.”

Tibet is one of the most remote places in the world and Surmang sits at the center of that.

One of the marks of that success is risk taking connected with openness and communication with the Tibetan people of Surmang. Unlike the fans of the mythical rock and roll band, the Tibetans are not Californians. They lead traditional herding and farming lives are not into experimentation. So they are slow. There are few if any people wearing watches in Kham. In 1996 Tai Situ Rinpoche told me that going there would be like going back 500 years in time. He said, “For every 10 discursive thoughts an American has, a Tibetan has 1.”

So these are not people who are experimenting in lifestyle. The ideas that we had as a group came out of our admiration for these people as survivors, as people who are very warm, as people who are very genuine. I think that when you connect to people on that level, you can connect with your own warmth and genuineness.

When we opened full time in 2000, there was a question about how to charge for services, since these people make about US 12¢/day. It was clear that we couldn’t judge people based on their appearance since nomads who have 500 horses dress exactly like those who have 5. Also they didn’t seem to know they were poor. Was I going to be the guy who told them that?

 So we provided the services for free. And that’s the way it’s always been. It was only 10 years later that we found out –thanks to the Peking University assessment—that our cost of providing services per patient visit was about 1/7 that of the public health hospitals. In doing this, we stumbled across what is perhaps their #1 cultural value: jinpa, which in Tibetan means “generosity.” In about 2008 one of the high Tibetan lamas wrote a memorial, which declared our clinic a Medicine Buddha center.

 Another element of connecting directly to our beneficiaries is the lack of orthodoxy: neither medical, public health nor development. This means we, in essence, learned to cook from scratch, meaning we weren’t taking anyone’s word for it. In some ways this open view put our direct experience with Surmang on the front burner and as a result it became actually easier to take on appropriate public health, medical or development advice. It wasn’t always so natural or easy for me, like back in 2006 when Mauritz Van pelt told me that our foundation is about “empowering women.” I’ll never forget that. It was a defining moment; that advice would become our victory banner 9 years later, reducing maternal mortality in a place where it is the #1 killer and in writing a proposal about empowering women and girls in Tibet.

 It made it possible to hear the sage advice of Dr. Ray Yip, regarding Chinese PH policy during his many trips to Surmang. It made it possible to see that clinical delivery was the most advanced form of the assisted delivery our Community Health Workers were giving. But whatever we learned was based on the foundation of our own openness and experience.

2014

We had 4 very great medical volunteers: Board member Dr. Julie Carpenter, back for her third rotation. Drs. Laura Kimbro, Trudy Singzon and Sisi Zhao. Dr. Kimbro is an OBGYN who has done many such international rotations as is Dr. Singzon. Dr. S is also a teacher of an international OBGYN protocol, A.L.S.O.

 2014 was the year we became –with the help of the Chinese Government, Yushu Public Health Bureau—a registered charity in China. It was the year we began the journey with supporters and donors from inside China. Why not? We are a Chinese organization. It was the year of our engagement with the Danish Chamber of Commerce China, resulting in the construction of a birthing center on our Surmang campus and the installation of birthing centers at 4 partner township hospitals.

 So it seemed natural, after our 4^th Annual Fundraiser in Beijing, that we figure out how to use that birthing center to maximum advantage. The answer was articulated in a proposal written by Suzanne Smith and myself over a two-month period. The guts of the proposal lie in empowering women and girls in Tibet. And the means to achieving that goal is to reduce maternal and infant mortality. Dying in the process of creating life is the greatest challenge Tibetan women face. We proposed doing this through incentivizing mothers, community health workers and our doctors in pre-natal exams, birthing, post-natal and well-baby exams.

 And why not? Already our salaries to community health workers are 1/3 of their family income. Since the government has stopped the collection of cordyceps sinesis (“worm grass”) due to possible extinction, it makes sense that increasing income would make clinical delivery more attractive.

Through the help of Director Chris Devonshire Ellis, 2014 was the year that we partnered with Dezan Shira to get the benefit of their expertise in financial reporting. Not only that, they did 3 articles for us in their 40,000 member "Asia Briefing." 2014 was the year that our website, www.surmang.org, was redone largely with the help of the marketing firm, Shanghai Jungle. In our last reported week our requests for pages went from an average of 3500/week, pre-re-do, to 15,000 a week, post.

In addition  Did I mention that 2014 is the year when our Surmang Clinic achieved status as a government clinic? That means that we are the beneficiaries of meds, supplies and can register births (and deaths).

 Part 2 of the proposal is the creation of an income stream –a weaving co-op so we can re-introduce traditional yak cashmere blankets and shawls, a skill lost during the cultural revolution. Usually in the NGO business success is monitored according to measurable outputs and indicators. But for this project –as well as mothers and babies not dying in birth—the non-measurable outputs are really the strongest. These are: how a woman feels about having a baby. Joyful or life threatening? And how a traditional sacred craft like weaving reassures Tibetans of their place in this world. In a book on Balinese weaving, someone said, “the patterns in this cloth are the lens which brings the power invisible world into the visible.” I hope that the cloth of our foundation could as a whole could have a similar wholesome impact, as we enter 2015.

I welcome you to join us.

Lee Weingrad

Director

Links:

• Search for us on Google

East Tibet 2010.

Our team was doing an emergency assessment of Yushu Prefecture township hospitals following the disastrous 2010 earthquake. The way was muddy and rutted. We had to get out of the Landcruiser often to push.  On the way to the Mauzhuang hospital, I saw a bunch of our Community Health Workers (CHWs) by the side of the road.  It was very unexpected. They were having an informal meeting, right there in the open.

I got out of our 4x4, in the thin air near Rijie village. About 10 Surmang Foundation Community Health Workers (CHWs) were waiting. No training program, no money, no pregnant women. Just us. Khampa Tibetans are very straightforward so I asked them: “Look there's no one here except us. Just speak to me directly. If you could change anything about our work, what would it be?”
 
One, Palmo, stepped forward and spoke, shouting, almost crying. “You should have started 10 years earlier! So many mothers and babies who died would be walking the earth with their loved ones now!”
 
I was speechless.

I think until that point I was pretty proud of our achievements -- after all, we'd not just lowered maternal mortality and infant mortality rates (mm to zero 2010 to 2013), but there  was a sense that we'd been able to change the way medical care works for women and overcome a great deal of the cultural inhibitions among Khampa Tibetans, such as no one ever getting undressed in front of another person, ever, or women giving birth with the animals.

But in this case I realized how profoundly these women pay the price and bear the burden of maternal and infant mortality and pay the price mainly alone, by themselves. And also I saw that no matter how stoic we think these nomads and farmers are, it was clear to me right then, how deeply these women carry their history and their struggles with them every day into the present. And Palmo's remark made it clear to me that they now had some other reference point, that it's possible to have children without rolling the dice to determine if you live or die.

It made me see how deeply the work that we are doing affects not just each woman we help, but the entire cultural landscape. It also made me see how totally vulnerable these woman are, not just physically, but emotionally and spiritually as well.

So yes. It's a failure that we didn't start earlier. But in a sense her remark was a kind of Zen koan. It is impossible to return to the past. But in a sense I saw that we have to be open to the wounds that these women carry and not just expect that our optimism and our accomplishments combined with Tibetan grit are some kind of balm that wipes the slate clean. When you bring that much hope and change to people, you have to also own the despair and solidity that arises from the past.

Links:

• Shining Through, Surmang's new video
• Surmang website

As our summer ended, our training season also came to a close. This year we’ve had a very successful training program. With the oversight of (tri-lingual) Project Manager Ojen Tsering, we were able to make a quantum leap in our work. This year, with the kind assistance of the Danish Chamber of Commerce, China, we’ve taken the extraordinary step of completing building a birthing center at the Surmang Foundation Dharma Sagara Clinic and the installation of a birthing center at the Xiewu Prefecture partner Hospital.

A David and Goliath Story.

You don’t need a lot of money or a big organization to help Tibet's mothers and children. You just need to pick your battles, and have a good relationship with everyone involved: mothers, babies, nomads, farmers, monks, and our partners in the Yushu Public Health Bureau. It doesn't hurt to have a sensitive project design and sensitive volunteers to train the providers of Tibet:  the doctors and community health workers. According to WHO, the greatest threat to life in this region is non-infectious disease and the greatest threat among non-infectious diseases, is from mother and child mortality and morbidity. Why are there so many orphanages in Tibetan regions? Because the mothers die in such great numbers. Why do Tibetans have such low life expectancy? Because 1 in 5 babies will die before the age of 2. 

In this region maternal mortality rates are as high as the highest rates in the world. That's where we work. 

The problems in this region are manifold:

• Poverty
• Lack of assisted births; lack of clinical delivery
• Lack of infrastructure: no roads, phones
• Lack of access to health care
• Lack of access to quality health care – poorly equipped local hospitals and poorly motivated and trained local providers.
• Lack of timely intervention for critical care.
• Women bear most of the responsibility for the family. The impact of the mother’s death, on the society is the cause of families cratering, bankruptcy, the downward spiral of poverty and children entering orphanages. 

All the above are both caused and effected by high maternal mortality and morbidity and infant mortality and morbidity (mmm/imm) rates.

The great numbers of mothers whose health is ignored, who give birth alone in the cattle bier, are witness to the most pernicious and silent form of violence against women: maternal mortality.  Because of their remoteness, it's a quiet killer. There are many many thousands of women who will bleed to death in poor farming and nomadic areas in China --yet there are no, as Laurie Garret pointed out, marches down 5th Avenue for them. 

David and Goliath

You might think that such a big problem demands a big foundation, big money and a big project. But it's not about big money. It's about smart money. 

The view that throwing big money at a problem is what Billy Bean in “Moneyball” called “financial determinism.” But actually with our small resources, we’ve been able to find the right weapon --not the most expensive one-- to laser-in on the cause of the biggest problem: lack of access to care and lack of quality care. This is how our David asymmetrically slays the Goliath that threatens Tibetan culture. And it all begins and ends with connecting the warmth and openness of our Tibetan beneficiaries with our own warmth and openness.

For the 3^rd year in a row, we’ve reduced maternal mortality to zero, and infant mortality to rates similar to Denmark’s.

And now with your help we've come this far and we can go much further. This summer was our most ambitious training project so far. We had 4 doctors, 3 experts in rural mother and child health, one a trauma and emergency medicine expert. These were not common people. They were docs who have done rural training all over the world. They were

• Drs. Julie Carpenter, USA
• Laura Kimbro, USA
• Trudy Singzon, USA
• Sisi Zhao, Australia.

And our local staff:

• Mr. Ojen Tsering, China, Project Manager
• Dr. Phuntsok Dongdrup, China, Clinic Director
• Dr. Sonam Drogha, China, CHW Director.

Intern:

• Iana Weingrad, interpreter.

They worked at the Surmang Clinic, and then traveled to 4 partner township hospitals. A thousand or so miles at 13000 ft. It’s not exactly like traveling on I-80 in the US. It’s rural E. Tibet. They were able to continue the training of doctors in patient examination, delivery, gynecology, and emergency medicine. They trained over 15 doctors in a period of 3 months. There is no way we can repay our debt to these volunteers.

Although the doctors were unpaid volunteers, your contributions paid for their ground transportation in Tibet, their care and “feeding,” Your contributions also paid the expenses of Community Health Workers to receive training, including clean delivery kits and training materials.

Let’s go further.

According to the head of the Beijing University Graduate School of Public Health, there are at least 40 million people in China who live just like the Surmang Khampa Tibetans. Remote places with incomes around 1¥RMB/day. The problem is no one ever sees them. Surmang Foundation is changing that.

But if the need is so great, why are other donors and foundations not working in this remote place? It is a difficult place to work, as the dearth of foreign organizations will attest. Grandfathered in since 1992,  Surmang Foundation has the ability to commit for the long haul. The region has great challenges. This is why, among some other reasons, Surmang Foundation is one of the few if not the only international charity working in a Tibetan region.

At the same time, our good relationship, the Yushu Prefecture Public Health Bureau has thrown down the challenge to us, to really do something. And I believe with your help, we have risen to the occasion. But there is much to do and we must finish the job.

That’s where this project comes in. The building and installation of these birthing centers is driving not only the patients to the centers for care, but it is also the focus of quality training resulting in quality care, for years to come.

But the job is not done. We need to complete the work, and install 3 more birthing centers next year. Your continued help will continue to train doctors both in our own clinic and in the township hospitals. I believe we’ve demonstrated the need, the opportunity and the management delivery system to get this job done. Now we just have to continue the work. Please help.

Links:

• Surmang Website
• Shining Through, Surmang's new video

As the highland barley shoots start to greet the sun, when the snow melts off the hillsides, fields abound in fragrant wildflowers, the rivers are in spate, days are long, and the nomads and their yaks, goats and horses move to their highland pastures. Suddenly it’s June in East Tibet.

It’s our active season and our projects move into high gear. With the snow gone, we too have mobility and access to most of the region we serve.

In this region, most women give birth by themselves. And when there is a problem, they or their babies die by themselves. Low access to services is common. And the services they get are of poor quality. We did something about that. We zero-ed out maternal mortality in our catchment and now in partnership with the Yushu Public Health Service, we are expanding that to 4 other hospitals.

With world-record high maternal and infant mortality and low access to quality health care, there is no greater threat to Tibetan culture than those that those impact the mothers and babies of Tibet. That’s why there are so many orphanages in Tibetan areas. Despite the romanticism about Tibetans, the women endure under a “tsampa ceiling,” with great responsibility for their families and even greater risk to their own lives.

We are not a big foundation and we operate on a kind of David and Goliath strategy. With your help, our focused efforts have outsized, assymetric, results. In our own area our Community Health Workers have stanched maternal mortality. If you want to save a culture, save a mother.

And now we are expanding that work to 4 other regions.

Construction of a Modern Birthing Center.

We are taking it to the next level. With the cooperation of the Yushu Public Health Bureau, and generosity of the Danish Chamber of Commerce, China, we begin the season building two modern birthing centers – one at Surmang and the other are a partner clinic in Xiewu, just an hour north of Yushu/Jiegu.

This is not just bricks and mortar, for on the back of this added capacity we are teaching doctors how to save the lives of mothers and babies through safe delivery and fast intervention through our network of Community Health Workers. When you support our CHWs, you support safe delivery and when you support safe delivery, you support the baseline of hope for Tibetan culture: the survival of their mothers.

Volunteer Doctors

We bring 4 world-class volunteer doctors to train our own doctors and those in the four townships we work with: Maozhang, Xialaxu, Xiewu and Longbao. Julie Carpenter is one such doctor.

Julie Carpenter is an iconic doctor from Boulder, Colorado. Just ask anyone from Boulder. A senior Board member Julie served on two prior volunteer rotations: 2001 and 2003, for three months at a time. She is the one who asked the question that changed our entire project: “how come,” she asked, “there are no women and children in this clinic?” Now we have 40 Community Health Workers who answer that question. We’ve put two of them in the photos below. This year Julie is coming back for over a month.

We are also hosting Suzanne Smith.

Suzanne is a seasoned development professional who has worked her whole adult life in places like Zimbabwe and Kenya, rolling out health promotion projects and analyzing their results. She is one of the most senior development professionals in our foundation’s history.

We have three other doctors volunteering their time: Drs. Ray Yip, Director of Gates Foundation, China; Laura Kimbro, and Trudy Singzon both senior OB-Gyn providers and trainers.

In addition we have the help of Ojen Tsering, who is adding his awesome project management experience and tri-lingual capacity (Chinese; English Tibetan; he also is fluent in 3 Tibetan dialects). This is his 5^th season of working for us.

Training Schedule

• Training in the use of the new birthing centers at the Surmang Clinic and Xiewu Hospital.
• Training in the connection between village doctors and township hospitals.
• Training in the well-baby care.
• Training in patient examination best practices.

Please join in our effort.

Links:

• Surmang's new website

• interview with 2 Community Health Workers (PPT)
• NASA sat image with arrow showing our clinic (PDF)
  

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.

Links:

• Surmang Website
• Surmang Video: Promises to Keep