Health
 China
Project #5500

Health Care in Tibet /Yushu

by Surmang Foundation
Vetted
Drs. Kireet Tauh and Tonia Berg
Drs. Kireet Tauh and Tonia Berg

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.

a patient
a patient
Community Health Worker Training
Community Health Worker Training
Young Khampa Girl examination
Young Khampa Girl examination
"I will fight 6000 maternal mortalities"
"I will fight 6000 maternal mortalities"

Links:

A young patient
A young patient

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. 

  • Meds inventory. Although it's boring to say this in a GG report, the 10 days I was there were spent setting up a meds inventory system. We had to do this since we were the recipients of a $12000 donation from a Chinese pharma company. 
  • Water. We are moving ahead in setting up a water system for the clinic. At this point we visualize that it will cost about $20,000 to deliver the water from upstream to a tank in the Clinic building. 
  • Relations with the monastery. This year the Abbot of the Surmang Monastery gave his unqualified support for the clinic.  We welcome the increased marriage of our two worlds. 
Patients.
Patients.
Donated meds.
Donated meds.
Phuntsok and Lolo in Jiegu
Phuntsok and Lolo in Jiegu
Preparing the inventory software
Preparing the inventory software

Links:

putting up the building
putting up the building

You wake one day, both your children are in college, your black hair is silver and your fledgline Tibetan health care project is 20 years old

This summer we celebrate the 20th anniversary of the Surmang Dharma Sagara Clinic.

It was 1992 and I though, "who would ever give us money if we don't have permission from the Chinese Government to build in Tibet?  What started out as a dream became a contract with the Qinghai Government, with the help of Gov. Huang Jing Bo. Not so long after we signed the contract we got the construction funds -- our only big grant. We broke ground in '93, and completed the work in the summer of '96. There have been 20 brutal East Tibetan winters in between, and and devastating earthquake in 2010 that took down the 400 year-old monastery on whose land we sit. But it didn't scratch the clinic. 

And come they did. In the past 10 years alone, over 140,000 patients. Over 150 volunteers. I have to admit that some of the success was driven by naive luck. I was told by several experts in international development and public health that, like Rodney Dangerfield, we'd get no respect if we didn't charge for services. But for the life of me I couldn't figure out how to do that. By looks alone, I couldn't tell the difference betwen a nomad who had 200 horses and one who had 20. The dressed the same and looked the same. The only thing that made sesnse was to charge everyone the same and for me and the foundation to do the work to get the funding elsewhere. So since then we've never charged for services or meds.

We took a place with among the highest maternal mortality rates in the world --3.000/100,00 live births-- down to zero in 2010 and kept there near there ever since. 

In '95 when I spoke to the ehad of Mother and Child Health at UNICEF in Beijing, she asked me, "how do you know that anyone will ever come to the clinic?" I asked her, "did you see the movie, "Field of Dreams?" Kevin Kostner's character is told to build a baseball diamond in his Iowa cornfield. "What makes you think they will come to play?" he asks the ghost. "Build the field and they will come," was the answer. That's what I told her. Now she's at Ford Foundation and when I contacted her 20 years later, her first words, on hearing my voice, were, "build the field and they will come."

years after completion, patients line up
years after completion, patients line up
patients waiting to see one of our docs
patients waiting to see one of our docs

Links:


Attachments:
waiting room
waiting room

Wintertime is when the nomadic yak herders return to their winter homes with their families and livestock: yak, horses, goats. The winter quarters are permanent structures in villages with names like Modi, Jerikhe, Rijie. There is a reason why Tibet is called “the land of snows.” As precious as the fragrant wildflower displays are in the short alpine summer, that is how brutal the weather is at 4300 meters (13000’). It will snow heavily and continuously for months with no snowplows. If they are anything, the Tibetans are survivors and there are few among us outsiders who could take winter’s full measure at Surmang.

With the villages full, is the busiest time of the year at the clinic. Phuntsok has told me that some days they will see 300, 400, 500 patients and work from early morning to late into the night. It is difficult to describe the grit of our two doctors, Phuntsok Dongdrup and So Drogha. So I’d like to take the opportunity to salute their efforts. They are local heroes.

They operate one of the few private clinics in Tibet that are focused on mother and child health. Phuntsok has been with Surmang Foundation since 2000. Drogha since 2001. 2016 is his 16th year, Drogha’s 15th. What makes the Surmang Dharma Sagara Clinic unique is the dedication and professionalism of these two Khampa Tibetans. For each and every one of those 15 and 16 years, they have received hands-on training by foreign volunteer doctors who have high renown in their fields. 2016 will be the first year that all 5 volunteer doctors will be returned volunteers.

For our patients, the result has been quality health care and free meds with no questions asked, no bureaucratic hoops for the patients to jump through, with an emphasis on early intervention and local access in a place with few roads, fewer cars and little electricity or phone connectivity. It’s user-friendly health care.

Because our patients can recognize kindness and quality care, 2015 saw over 18,000 patient-visits to our clinic.

In 2015, Surmang Foundation faced challenges from a tightening official environment. We are one of the few international foundations in Tibet. Yet, in the face of these challenges, we were able to be gifted $15,000 in medicines, and another $51,000 in our Annual Appeal. So, like climbing Everest or Meru, the question isn’t so much a question of the environmental dangers, such as weather, crevasses and vertical ascents so much as it is our own preparation, fitness and grit to fulfill our promise. And our own openness. We took a region that had among the highest maternal mortality rates in the world and by 2011 reduced it to zero. And it’s stayed close to there ever since. Infant mortality has declined significantly too. We have that commitment. We have that grit.

The challenges for 2016 are: construction of a water system and a training center. For the first we need $25,000. For the latter $60,000. This is our clinic’s 20th year of operation. Let’s join in the celebration and ensure continued success!

Please join us. Tibetans say “repay kindness with kindness” and this is certainly true with those who contribute to this project. The feeling stays with you.

Dr. So Drogha
Dr. So Drogha's resolve
3 patients
3 patients
Feeling Stays with you
Feeling Stays with you

Links:

 

 

 

2015 is 23rd year of our providing medical services in Tibet. It’s been an interesting year. But then again we are working in Tibet and at 4000m, (13,000’ +) it’s bound to be interesting.  

 

In terms of patient visits it was another over-the-top year for our clinic. About 1400 patient visits per month. This means that each patient returns about once. To give a reality check about our work and compare it with the much larger PHS county hospitals:

 

 

Number of doctors

Monthly patient visits

Surmang Clinic

2

1400

Township Hospitals

12

100

 

This means for an all-in budget of $150,000/year, our per-patient visit cost is about $9. This includes births and well-baby visits. I think that’s something.

 

The statistics above show what kind of model, what quantifiable outputs we want to contribute to the rural government hospitals. Actually the phrase “rural Tibetans” is a kind of joke, since most Tibetans live in far-flung farming or nomadic regions. Tibet is 1/5 of the Chinese landmass with .5 of her people. Before 1959 there were no roads, since the Tibetans didn’t use the wheel and thus no carriage or car (wheel is a sacred object), and there were no cities, except for Lhasa.

 

We continued our training of our two Surmang Clinic docs, Phuntsok and Drogha, as well as the training of docs in Yushu PHS hospitals in accordance with our government partnership.  We had a very great collection of 4 volunteer doctors, each doing a one-month rotation. 3 from Canada, 1 from Australia. Great people. Unbelievable what luck we had to get them and also for the people we serve great luck. One of my enduring observations is that from nomads to farmers, monks to businessmen, all Tibetans know quality and all Tibetans know when someone is there to help them out, without expecting anything in return.

 

The challenges we face are management, financial and legal.  By management, I mean that the project design is not from a school of public health, nor from a medical school, nor from a big foundation or foreign government. Our expertise is on-the-job training, which ensures that, if we pay close enough attention, it will be possible to learn lessons from our patients, doctors, and other stakeholders. I think that sense of pure vision is not lost to our Chinese government counterparts, because we have the blessing of being virtually the only international foundation in Tibet.

 

Financially we have always operated on a shoestring and always lived hand-to-mouth. I believe that there is strength in this approach, even though it is difficult. Our weakness is our strength and our strength is realizing that you don’t have to be big to get big results. This is the story of David and Goliath, and according to Malcolm Gladwell, about 40% of all military victories are where the winning side was smaller or less well equipped than their adversaries. When you win that way, the victory is sweeter because it’s come out of your playbook, your experience, not out of a tradition or a textbook. This is definitely our story and what contributes to what Dr. Ray Yip, recently retired Director of Gates Fnd China described as our pre-eminence as experts in the field of Tibetan health care.

 

Now we enter the cold weather in Tibet and the season when our patient visits and births will spike. I ask you to continue supporting our work as you’ve done in the past.

 

We still have a ways to go

 

·      Our priorities are home delivery with Community Health Worker assistance. But we need to maximize the clinical visits by pregnant women. For the ones that seem more difficult, we need to have clinical delivery or in the worst case, be taken to the prefecture hospital for delivery. We can do this.

·      We need to install a water system. We have the pumps. We need to raise the funds to do this. A water system will bring our clinic to the next level

·      We need to re-boot our sat dish so that we can effectively do remote consultation and diagnosis using blood diagnosis and ultrasound

·      We need to build a training center so that the PH service doctors we train will have a proper venue.

 

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Organization Information

Surmang Foundation

Location: Boulder, CO - USA
Website: http:/​/​www.surmang.org
Project Leader:
Lee Weingrad
Founder
Beijing, Beijing China

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