BBORDERS WWITHOUT DDOCTORS
THE COMMUNITY HEALTH WORKERS PROGRAM FOR TIBETAN REFUGEES
Emily Cohen August 15, 2004
Dr. Tara Doyle
Emory-IBD Tibetan Studies Program Dharamsala, India (Spring 2004) ACKNOWLEDGEMENTS
I would like to express my deep gratitude and appreciation for the people who helped me with my research in Dharamsala.
First, to Dr. Tara Doyle, for helping me to connect with the CTA and gain access to study this program. To Kalun Lobsang Nyandak la, whose directive opened the door for me to explore the CHW program at every level of the Tibetan community. To Secretary of Health Tenpa Samkhar la, whose friendly and encouraging guidance made my research both informative and enjoyable, and whose recommendations allowed me to enter Tibetan communities with great ease. To Mr. Sonam Hara la and Jamyang la, who so graciously hosted me during my visit to Bir and made every effort to address all my questions. To the Community Health Workers, Dawa Tsamchoe, Tsering Wangmo, Dolma, Tenzin Dolma, Jamyang, and Sonam, for working so diligently to maintain the health of their communities and so graciously allowing me to have interviews with them. To Dr. Arri Eisen in the Biology Department at Emory, for advising my research and providing me guidance. To Tara Plochocki and Meghan Shearer, for their guidance and friendship And finally, to the members of the Gu Chu Sum Movement of Tibet, with whom I lived during my research period, for many hours of conversation, reflection, and support.
1 TABLE OF CONTENTS
Executive Summary...... 3
Introduction...... 4
Methods...... 12
Results ...... 16
The Creation of the Community Health Workers program ...... 16
The Operation of the program...... 19
Training...... 19
Implementation in the Settlements ...... 22
Discussion...... 35
Works Cited...... 39
Appendices...... 41
2 EXECUTIVE SUMMARY
The Community Health Workers (CHW) program, sponsored by the Department
of Health of the Central Tibetan Administration, was created in 1981 by the Tibetan
Delek Hospital in Dharamsala, India. It recruits residents of all Tibetan refugee
settlements in India and Nepal to attend a three-month training at the hospital in primary healthcare methods. The trainees then return to their home settlements and create or work for primary health clinics.
In the following paper I explore the CHW program as it operates in three Tibetan settlements in India: Dharamsala, Bir, and Tashi Jong. I focus on how the program was created, how the CHWs are trained at Delek Hospital, and examples of how the CHWs utilize their training to improve the health of their communities.
With the CHW program, the Tibetan government-in-exile has successfully created a web of health clinics with the use of very few doctors. It is a creative and unique approach to healthcare that reflects the nature of the Tibetan situation in exile and the field of community-based health interventions.
3 INTRODUCTION
Imagine you are a Tibetan living in Tibet. After years of hardship under the
Chinese rule, you decide to escape to India, where you’ve heard there is more opportunity for Tibetans and you will be able to see His Holiness the Dalai Lama. Without telling most of your family, for fear of their reaction and getting them in trouble with the
Chinese police, you leave home in the middle of the night. You travel to Lhasa, where you find a guide and a group of other Tibetans who want to leave.
You pay the guide almost all the money you have and, together with the rest of the group, you set out in a truck for the Nepalese border. It takes days of sitting in the truck, in constant fear of being stopped and searched, before you reach the foothills of the mighty Himalayan mountains, over which you are to escape. Carrying with you only some food and the clothes on your back, you set off in the middle of the night on your journey. It takes your group almost a month to get over the snow-capped mountains, trekking only in the night and sleeping in the day so as not to be seen by Chinese border police. It is painfully cold in the snow, and the only covering you have is what you can carry on your back. Towards the end of your journey, the group runs out of food. For the last few days of the trek, you survive only on a small amount of yak butter, which you make into tea. Sometimes the hunger is so severe, you are forced to eat grass.
Finally, your group arrives at the Nepalese border, weary and sick. You take a bus to the Refugee Reception Center in Katmandu, where you can finally relax for the first time since you left home. You can rest here, and you are given enough food to gain back a little bit of your strength. You can sleep deeply enough to dream here, and it’s
4 your dreams that bring you back to the reality of what your future holds. You dream of your family, and when you awake you realize you will probably never see them again.
You dream about farming and herding, the simple life to which you were so accustomed.
Will you have the same lifestyle in India? How will you begin a life in India with no family, no education, and no money? You are now alone in the world, save for the group with whom you traveled over the mountains, and soon you will be separated from them, too.
Your time in Nepal you spend waiting, recuperating, and wondering how long it will take for your refugee registration to come from India. It takes months. You have nothing to do with your time but sleep, pray, and reflect on the life you left and the life you are beginning. You are now a refugee.
Finally, your new registration papers come from India. You are not a citizen there, but at least you have some papers which give you legal permission to exist. Had you been caught at any point in your journey so far, you would have been arrested (unless you had enough money to bribe the police) because it is illegal to travel without any documents. Now you at least have proof of your identity, which will allow you passage into India.
The Reception Center puts you on a bus, which brings you to Delhi, to another
Reception Center. When you arrive, you spend one night there while your new papers are processed. You have arrived in your new country with no knowledge of the language, culture, or any idea what your future holds. All you have for support is your fellow Tibetan refugees and a Refugee Identification Card. When your papers are finished processing, you get on another bus. This one will bring you to Dharamsala, the
5 “capital of Tibet-in-exile”. The bumpy 15-hour bus ride ascends into the foothills of the
Himalayas, those beautiful mountains which remind you of home and your journey from
it. There is much more vegetation on this side of them, though. Tibet is a high plateau,
which supports very little growth and stays cold for most of the year. What you’ve seen
of India so far is much lower in altitude and home to many strange plants you’ve never
seen before. It’s also remarkably hotter than your home.
You get off the bus in McLeod Ganj, a busy little town bustling with Indians,
Tibetans, and white-skinned tourists. You bring your few belongings to yet another
Refugee Reception Center, where you will begin the process of acclimating to life in your
new home. You are greeted there by the Reception Center’s small staff and the Tibetans
who arrived before you did. You spend a month in this place, getting your first
introduction to Tibetan life in India. You learn a little bit of English and a little bit of
Hindi, the two languages which will help you survive here. At the end of the month, you have your first audience with the Dalai Lama. It is better than you imagined. You heard only small bits of information about him when you were in Tibet, so all you knew was that your hope could rest on him fighting to get your country back from the Chinese.
He knows what you’ve been through. After all, he was the first of all your people to make that trek into exile in 1959. He tells you that you’re safe here, that you must keep yourself healthy, and that you came here for a reason. He assures you that the fight is going strong; one day your people will go back to their homeland.
Now that you’ve had your introduction to life in exile, you move on to be educated. You lived in a rural area of Tibet where there were no schools, so you have never been educated beyond what your family taught you about farming and herding.
6 You cannot read or write. You move to the Tibetan Transit School (TTS) to get some
education. Because you are over 18 years old, you cannot go to one of the many primary
schools for Tibetans in India. The TTS was established to help people in your position; it
gives you the opportunity to study English and Tibetan language for two years before you
move on to a settlement. It is located just down the mountain from Dharamsala in the
Kangra Valley which, at an elevation much lower than Dharamsala’s, boasts a much
higher temperature.
The accommodations at TTS are small buildings made of tin sheet metal. The
roofs leak when it rains, and the heat brings many bugs into your living quarters. Your
new diet consists mostly of dhal and rice, both of which you had never eaten in Tibet.
The heat is worse than any you’ve ever experienced and you find it difficult to
concentrate in class. Before long, you find yourself seriously ill. You are running a
constant fever, vomiting and having diarrhea, and experiencing severe stomach pains.
Many of your classmates have the same symptoms. The pain and heat are so intense, you
cannot think of anything else. You regret ever leaving Tibet, where this kind of fever
would never have befallen you. Every day, more of your classmates fall prey to this
illness and you fear that you will die if you’re not treated soon. There is no doctor at TTS
to treat you all; one by one, you and your classmates must be taken to the nearest
overbooked hospital, where you’ll receive just enough treatment to keep you alive. The
experience leaves your body considerably weakened before you even start your new life
in a refugee settlement. Your opportunity for schooling lost, you must now find a way to
support yourself with almost no education and little strength left for manual labor.1
1 This story is a compilation of the accounts of many Tibetan friends and classmates in Dharamsala. Although it is fictional, it is based on real experiences of Tibetan refugees.
7 *****************
Tibetans have been escaping Tibet since 1959. In total, approximately 120 thousand Tibetans are now living as refugees in India and Nepal. In the 45 years since the first group of Tibetans fled with His Holiness the Dalai Lama to India, great strides have been made to provide for the well-being of this population. A Government-in-exile called the Central Tibetan Administration (CTA) was established in Dharamsala, India, to organize and provide for the steady stream of Tibetans escaping Tibet and their offspring born in foreign countries. Still, the Tibetan refugees living in India and Nepal face many problems. Among the most urgent of these is maintaining the health of these displaced people.
The Tibetans are a noteworthy group of people for many reasons. First, they have spent 45 years in India as refugees, establishing a semi-permanent state of transition.
Second, the Tibetan community in exile experiences a low degree of assimilation into local culture. Third, Tibetan refugees are often especially susceptible to illnesses in their host countries.
As refugees, the Tibetans in India and Nepal do not carry citizenships. However, they have been living in exile for 45 years and, as of yet, see no hope to return to their home country in the near future. Thus, they are fixed into a semi-permanent state of
“liminality”, as Margaret Nowak discussed in her book Tibetan Refugees: Youth and the
New Generation of Meaning. She wrote, “In a more formally structured liminal condition… In the case of the Tibetan refugees, neither the de facto leaders of the community nor the inexperienced youth can be confident that such ‘reintegration’ [back
8 to Tibet] will in fact occur.”2 Given this political structure that lacks definition and direction, many Tibetan refugees become distraught. A growing number of Tibetans turn to substance abuse as a way of escaping the reality of their situation. Steven Venturino, a
diaspora scholar, wrote, “The survival as migrant is not, in the Tibetan case of forced
exile an end in itself, but a means to an end.” 3 However, many of those who live in exile
lose hope after seeing no change in their political condition. In this struggle that has
lasted for generations and will continue for generations to come, it is essential that
Tibetan communities in exile provide an adequate support system for their members.
As part of the political goal to remain unified and return to Tibet, the Tibetans in
exile have experienced a low level of assimilation into their host countries. As Bhuchung
Tsering, an older Tibetan living in exile, wrote, “The young Tibetans are very conscious
of their identity. No matter where they live, they realize the fact that they do not belong
to that society.”4 In India and Nepal, most Tibetans live in settlements which support
their uniquely Tibetan identity outside of Tibet. These settlements experience varying
degrees of involvement with local Indian culture, but none can exist being isolated from
the world. The Dalai Lama wrote of his experience as a refugee, “In some ways this is a
source of sorrow, but the positive result is that I and many of my compatriots have had to
become citizens of the world.”5 Thus, although Tibetans make an effort to preserve their own identity within a foreign context, they are influenced by their surroundings. This unique situation of being a Tibetan refugee in a foreign nation also serves to bind the community together.
2 Nowak, page 45. 3 Venturino page 99 4 Tsering, as quoted in Venturino, page 104. 5 His Holiness the Dalai Lama, as quoted in Venturino, page 110.
9 Tibetans are especially susceptible to certain illnesses because of their
circumstances. For Tibetans who were born in Tibet, the trauma and hardship of their
escape over the Himalayas presents a significant psychosomatic stress. Also, the severe
change in altitude and climate between Tibet and India is a challenge to their immune
systems.6 No immunizations are given inside Tibet, which leaves Tibetans especially
susceptible to common infections in India, to which their bodies are not accustomed.7
The Tibetans’ diet also differs significantly from their Indian neighbors’. Radiologist
Kieran Murphy noted during his stay in a South Indian Tibetan monastery that the monks’ diet was a “traditional Tibetan diet of tea made with butter, salt, tea, and milk, and bland food rich in salt, fat, and noodles.”8 This may explain why cardiac problems and Cirrhosis are among the leading causes of death for Tibetan refugees in India. Other leading causes include Cancer, Tuberculosis, and accidents.9
The political, geographical, and health conditions of Tibetan refugees in India and
Nepal necessitate an effective and efficient medical system that is specifically intended
for this population. Thus, the CTA Department of Health has generated many programs
to meet their needs.
*****************
In the Spring of 2004, I set out to explore one avenue by which Tibetans in exile
provide for their own health and well being. The Community Health Workers (CHW)
program, established in 1981 as part of a Tuberculosis Control Project of the Tibetan
Delek Hospital in Dharamsala, trains Tibetan residents of all settlements in India and
6Bhatia, et. al. “Tuberculosis among Tibetan Refugees in India.” 7 Interview with Nurse Jamyang, Bir settlement Community Health Worker, April 22, 2004. 8 Murphy, Kieran. 9 Bhatia, et. al. “A Social and Demographic Study of Tibetan Refugees in India.”
10 Nepal in the provision of primary medical care. These trainees then return to their settlements and operate primary care clinics or otherwise work for the health of their neighbors. The result of this program is a primary care system for all 120,000 refugees that operates with very few Medical Doctors.
I sought to understand the program because I saw it as a miracle of public health.
How could this huge group of refugees, scattered all over India and Nepal, provide for their own health care with so few doctors? The Tibetans do have a well-established, successful medical system of their own, but the Community Health Workers program operates independently of the Tibetan medical system, providing only allopathic care.
Thus, I set out to answer three basic research questions:
(1) How and why did the Community Health Workers program start?
(2) How does the program work, in both the training of health workers and their
implementation of health care programs in their settlements?
(3) Why is this program appropriate to the Tibetans in exile and how does it
reflect their unique position and the philosophy of community-based health
care?
The following paper addresses these three questions. It concludes with a discussion of my findings and suggestions for further research.
11 METHODS
The Community Health Workers program is multi-faceted. It includes administrative planning, training of health workers, and implementation of health programs in the settlements. I utilized three primary research methods to explore all facets of the program, as well as the philosophy behind it. These included interviews, both in-person and via e-mail; participant observation; and a review of literature that included publications by the Department of Health and Delek Hospital, as well as published books and journal articles on community-based health care and the Tibetan situation in exile.
My primary research was conducted in three different Tibetan settlements in
Himachal Pradesh, a state in northern India in the foothills of the Himalayas, from March
31 to May 12, 2004. Most of my research was performed between April 17 and May 12,
2004, in McLeod Ganj, the Tibetan area of Dharamsala. I also researched the
Community Health Workers’ programs in the settlements of Bir and Tashi Jong.
Data collection in Dharamsala included:
(1) Interviews with:
♦ Kalun Lobsang Nyandak, Minister of Health and Finance, Tibetan
Government-in-Exile, March 31, 2004
♦ Mr. Tenpa Samkhar, Secretary of Health, Tibetan Government-in-Exile,
March 31, 2004; April 2, 2004; April 9, 2004; April 17, 2004; May 10,
2004
♦ Mr. Dawa Phunkyi, General Secretary, Delek Hospital, March 31, 2004;
May 4, 2004
12 ♦ Mr. Yusuf Naik, Joint Secretary, Tibetan Government-in-Exile, via e-mail
received August 6, 2004
♦ Dr. Dolma, Community Health Workers trainer, Delek Hospital, May 3, 2004
♦ Nurse Dolma, Community Health Worker, Lha Keri Nursing Home,
May 5, 2004
♦ Nurse Wangmo, Community Health Worker, Lha Keri Nursing Home,
May 5, 2004
(2) Participant Observation at the Community Health Workers’ training, May 3, 2004
(3) Gathering of written materials from the Department of Health and Delek Hospital,
including:
♦ Delek’s Community Health Workers Training Program Evaluation (From 1981-
1987). Mr. Dawa, Delek Hospital, 1987.
♦ Tibetan Health. Volume 17, Issues 1, 2, and 3. Department of Health.
♦ Training information on pregnancy for Community Health Workers. Dr. Dolma,
Delek Hospital.
♦ Health Care of Tibetans-in-Exile. Department of Health, CTA
♦ A Manual on Drug Dependence and Alcohol related Problems. Department of
Health, CTA.
♦ Various pamphlets from the Department of Health including “Hepatitis B
Prevention & Control”, “Women & HIV/AIDS”, “Tibetan Torture Survivors’
Programme”, “Want to Quit Smoking?”, “Features of Mental Disorders”.
13 From April 21 to 23, 2004, I traveled to the settlements of Bir and Tashi Jong. In
these settlements I utilized the following research methods:
(1) Interviews with:
♦ Mr. Sonam Hara, Director of Bir Primary Health Clinic, April 22, 2004
♦ Nurse Jamyang, Community Health Worker, Bir Primary Health Clinic, April 22,
2004
♦ Nurse Dawa Tsamchoe, Community Health Worker, Tashi Jong Clinic, April 23,
2004
♦ Mr. Phourgya, member of Bir Disability Care Committee, April 22, 2004
♦ Mr. Shaga, member of Bir Community Health Committee, April 23 2004
(2) Participant Observation of Bir Primary Health Clinic, April 22, 2004
I chose these research methods for a number of reasons. First, I wanted to compare the philosophy behind the program and its intended structure with the way it actually functions. Second, I wanted to hear the opinions of people in all parts of the program: the administrators, planners, trainers, and health workers themselves. Third, I gathered materials on the health of Tibetans in India and Nepal to understand the health issues facing Tibetans in exile.
I did not utilize the same research methods for all three settlements in which I studied. The reason for this discrepancy is that the way Community Health Workers operated in all three varied significantly. For instance, Dharamsala’s proximity to Delek
Hospital made a community clinic unnecessary for most of the population, and the community clinic that did exist in McLeod Ganj was not operated by Community Health
14 Workers. I did not utilize a participant observation method at Delek Hospital because, although it staffs two CHWs, they operate as nurses. In Bir, I did find it appropriate to utilize a participant observation method because the Bir Primary Health Clinic is the single healthcare source for the settlement and it is staffed by CHWs. In Tashi Jong and at Lha Keri Nursing Home in Dharamsala, I did not utilize participant observation because the clinics were empty on the days I interviewed their CHWs.
Although I was able to gather a great deal of information from the aforementioned methods, my research was limited by the time and opportunities I had while in India.
With only three weeks in which to focus on my research, I was unable to interview as many people as I would have liked. Because Tibetans in India often do not have telephones or e-mail addresses, scheduling interviews was very difficult. Also, because the medical system for Tibetans in India is severely understaffed, interviewees often had to cancel interviews with me in order to attend to their patients. In a few cases, interviews had to be continually rescheduled and ultimately could not be performed before I left India. In one case (Mr. Yusuf Naik, Joint Secretary, Tibetan Government-in-
Exile) an interview was continued via e-mail after my return to the United States.
In the following paper, references are cited where I have used a direct quote or information taken directly from a certain source. Specific interviews are not cited, due to the fact that many interviews generated similar information.
15 RESULTS
Since 1981, the Community Health Workers program has been creating and
sustaining and network of healthcare providers in the Tibetan refugee settlements that
effectively brings healthcare to every Tibetan refugee who needs it. In a population that
is so mobile, spread out, and susceptible to disease, this is quite a feat. As the training
component of the program is now at its end after twenty-three years, it is appropriate to
reflect on the program’s origin, its methods for training health workers, the CHWs’ own
methods in their home settlements, and the underlying philosophy of the program.
The Creation of the CHW Program
In 1979, Delek Hospital established the TB Control Project, a community health program for the Tibetan settlements in Himachal Pradesh. Tuberculosis is a notoriously prevalent disease for Tibetan refugees in India and Delek held one of the best facilities in
Himachal Pradesh for treating it. However, the treatment facility was not enough to stem the edpidemic. Delek administrators felt the need to expand their efforts, so they brought their knowledge to the settlements around them, creating prevention education programming. By 1981, they felt the program needed more staffing. There was a shortage of doctors and nurses in the settlements, and it was impractical for Delek staff to travel around the state. Thus, they decided to train members of the settlements to run the health programs themselves.
16 Delek staff felt strongly that there was not enough healthcare available to the
people “at their doorstep.”10 As a democratizing society, they emphasized the importance of grassroots action to make healthcare accessible to all. They also espoused the World
Health Organization’s Alma Ata Declaration, which states:
Primary health care is essential health care … It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process…It requires and promotes maximum community and individual self-reliance and participation in the planning, organization, operation and control of primary health care, making fullest use of local, national and other available resources; and to this end develops through appropriate education the ability of communities to participate.11
Thus, the model of community empowerment they used was exceptionally appropriate to
their situation. Soon after they implemented the CHW program, they expanded it to
improve Tibetans’ access to primary healthcare, in addition to Tuberculosis control.
Delek recruited CHWs initially by asking the settlement directors to nominate
promising members of their communities for the health worker position. The nominees
would then send applications to Delek, where administrators would choose candidates
based on the settlements that needed health workers, as well as the applicants’ maturity,
educational attainment, and interest in health work. The applicants chosen for the
program would spend three months at Delek, with room and board provided free of
charge, to be trained in basic health care methods. They would then return to their home
settlements where, by agreement with the settlement directors, they would “promote
health education to ensure the administration of preventive care, to provide curative
10 Dawa, page 1. 11 World Health Organization. “Alma Ata Declaration.”
17 service for simple ailments and to refer more complex cases to the health centre or hospital at the higher level.”12
The program gained momentum very quickly. They secured funding from the
Tibetan Aid Society, under the Bret Vocational Training Fund. Because they provided jobs to a populace that struggled with unemployment, by 1982, Delek staff was training three batches of CHWs per year. They set out to train at least one health worker from each settlement in Himachal Pradesh, and accomplished this goal by 1987. They also aimed to provide continuing education for working CHWs in order to keep their skills fresh. In 1984, the hospital began running one-month refresher courses annually.
Eventually, responsibility for the CHW recruitment process was transferred to the
Department of Health (DoH) of the Tibetan government-in-exile. The DoH changed its system to focus on settlement residents, rather than settlement officers. They advertised in the settlements via posters, pamphlets, and word of mouth (for an example of a CHW program pamphlet, see Appendix A). They invited any interested Tibetans to apply for the CHW position, and chose from the applicant pool based on educational attainment and interest in healthcare. Beginning in 1990, the DoH held sole responsibility for choosing health workers and coordinating the administrative side of the program. Delek continued to accommodate and train the CHWs at its facility once they were chosen.
In 2004, Delek trained the 24th and last batch of new CHWs. From that point on, the hospital planned to facilitate only refresher courses for working CHWs, since the program met its goal in 2001 of training at least one CHW from each Tibetan settlement in India and Nepal. Delek recruits working CHWs for refresher courses, but the funding for the courses continues to come from the DoH.
12 Dawa, page 3.
18 The Operation of the CHW Program
In its twenty-three years of operation, the management of the CHW program has
gone through many changes. Some, like the changing of hands from Delek Hospital to
the DoH, were quite dramatic. Others, like the modification of the CHW training
curriculum, were less major but still impacted the efficacy of the program. My analysis
of how the program functions is in no way thorough enough to serve as an evaluation;
however, many people with whom I spoke about the program offered suggestions for its
improvement and, where appropriate, I have included those suggestions in this section.
The section is divided into the training aspect of the program and its implementation in the settlements.
Training
It is 2 pm on Monday, 3 May 04. Mr. Dawa, the Secretary of Delek Hospital and CHW training coordinator, brings me to a building just up the hill from the main hospital building. We enter a room where thirteen young people are seated at three tables, in horseshoe formation in front of a small blackboard. The class, consisting of seven laywomen, four monks, and two laymen, is filled with the sound of students’ chatting and laughter. When Mr. Dawa and I arrive, the class quiets down. He introduces me to the class, and after he leaves I take a seat in the back of the room. The chatter rises again as soon as he departs. As are most rooms in Dharamsala, this classroom is small and made of cement. The floor is covered with chalk dust and the walls are lined with cabinets holding piles of books and papers. A old painting of His Holiness the Dalai Lama hangs over the blackboard. The three tables and the chairs around them are the only furniture in the room. All of the students look young – most look under 20 years old to me. The women are all dressed quite nicely in traditional Tibetan chubas.
19 The atmosphere is like that of an American high school class, with students making jokes and laughing with one another before the teacher arrives. A few moments before Dr. Dolma, the teacher for the day, reaches the doorway, the students alert each other to her presence and the room reaches an immediate silence. As is customary for Tibetans, all students rise as their teacher enters the classroom. Dr. Dolma is clean-cut, dressed in a chuba, and has a no-nonsense attitude about her. She explains to me that she must teach the class in Tibetan, because it is easier for the students to understand medical information in their native language. After all, they are learning all this information for the first time. She talks very fast as she teaches. Today, Dr. Dolma is giving a lesson on pregnancy. She first goes over the signs and symptoms of a pregnant woman, and teaches students how to identify how far along a woman is in her pregnancy. She focuses primarily on when to refer a patient to a hospital for a caesarian section, what medications to give a pregnant woman and which to avoid, and how to record a visit with a pregnant patient properly (for the complete class notes from this day, see Appendix B). In the middle of class, Dr. Dolma’s cell phone rings. As she goes outside to answer it, the class takes a default break – the commotion from before she arrived rises up almost immediately as she steps out. She returns after a few minutes, covers the rest of the lesson, then dismisses the class before 4 pm – an early dismissal, which allows her to get back to her heavy workload at the hospital today.13
The training for CHWs is designed to introduce them to the basics of healthcare.
It lasts for three months and consists of learning in the classroom and practice in the clinic. Students spend their mornings shadowing doctors and nurses at Delek, learning
13 Participant Observation, Delek Hospital, recorded May 3, 2004.
20 the methods of diagnosis and treatment. They practice their skills as well, giving treatments such as injections, dressing wounds, and feeding sick children, all under supervision. As their skills develop, they attend to patients at Delek Hospital, the
McLeod Ganj Clinic dispensary, and the Tibetan Children’s Village Dispensary.
There are two primary texts used in the training. The first is Where There is No
Doctor, a manual for rural primary care providers which instructs how to diagnose, prevent, and treat common medical problems and diseases. It also covers nutrition, healthcare for children and the elderly, first aid, and details about how to use medications.14 The second primary text is a CHW manual, compiled by Delek staff, including notes from all of the class sessions. The curriculum is developed by Delek administrators, who compile a list of subjects for CHW trainers to cover. The doctors teaching the CHWs decide among themselves who will teach each subject. This year there were four doctors serving as CHW trainers: Dr. Dorje, who coordinates the training;
Dr. Dolma; Dr. Peter, a visiting physician from Scotland; and Dr. Marie, a visiting physician from England. Each doctor teaches on approximately ten topics.
According to the evaluation of the CHW program performed in 1989:
At the end of the training, students will be able to:
1. Set up and run a primary health centre in his/her own community with the help and continuing support of community members and Delek Hospital staff.
2. Recognize and manage correctly the most common diseases in the community, namely TB, malnutrition, acute respiratory infections, ear infections, lice, diarrhea and dehydration, scabies and skin sores, etc.
3. Be able to recognize when a child or adult is too sick to treat him/her and so to send that person for medical attention.
14 Werner, et al.
21 4. Maintain a strict emphasis on the importance of preventive rather than curative medicine and therefore to concentrate particularly on: a. Teaching the community, both formally and by example, about the importance of health, hygiene, and nutrition. b. Child health vaccinations.15
Although the 3-month training is a wonderful introduction for budding health professionals, many working CHWs in the settlements reflected that the training could be improved with additional time spent in practical work at the clinics. Those working
CHWs who independently run clinics almost always received additional training outside the CHW program (for the background stories of working CHWs, see Appendix D).
Many remarked that they found the trainings beneficial for work in a health care setting, but felt inadequately prepared by it to run their clinics independently.
Implementation in the Settlements
There are over fifty Tibetan refugee settlements in India and Nepal, ranging in population from 500 to 10,000 people. Their sources of livelihood range from agriculture to handicrafts to small businesses. Some settlements contain mostly monks and nuns, while others are comprised mainly of laypeople. Given such variety, it is no surprise that the health programs implemented in each settlement vary significantly between them. As of yet, there is no complete compilation of the health clinics and programs implemented in the settlements. However, the DoH is currently developing a full-scale evaluation of the CHW program.
I have presented here my observations of the CHWs’ work in the settlements of
Bir, Tashi Jong, and Dharamsala. These are only examples of programs implemented by
15 Dawa, page 2.
22 CHWs and are in no way representative of the diversity of such programs in India and
Nepal. However, the three communities are vastly different from each other. Thus, the variations between their programs highlight the ability of the CHW strategy to target its healthcare to the local conditions of each settlement.
Bir
April 22, 2004. 9 AM. I arrived yesterday evening at the Bir Primary Health Clinic after a six-hour bus trip from Dharamsala. I was welcomed inside by Mr. Sonam Hara, the director of the clinic here. He showed me to my room – a large, clean room with two beds and a sink, located inside the clinic compound and sharing a bathroom with the rest of the clinic. This is the “doctor’s room” – it is vacant because there is no doctor here. I emerge from my room in the morning to find the compound empty and quiet. It is a beautiful clinic: a courtyard surrounded by twelve very clean rooms. The walls of the buildings are decorated with informative posters in English and Tibetan (for photographs, see Appendix C). Across the courtyard, I hear a voice call out to me: “Good morning! Come inside!” It is Jamyang, an older CHW, who is inside the dispensary preparing it for the day’s work. She brings me to a nearby café to get breakfast just as the morning’s first patient arrives. As we walk, she tells me she’s been a health worker for 34 years. “I started when I was young, and then I got so old!” she exclaims. When we arrive at the café, she orders breakfast for me and then returns to the clinic to meet her patient.
23 Her demeanor is so kind and comforting, I think I wouldn’t mind to have her take care of my health.16 The Tibetan settlement at Bir was established in 1966 under the Tibetan
Industrial Rehabilitation Scheme.17 It currently houses approximately 2,300 Tibetans,
about one third of whom are monks at Bir’s four monasteries. The settlement’s major
source of income is carpet weaving, and many of Bir’s residents travel to other Indian
cities to sell sweaters and other goods in the winter. The Tibetan Primary Health
Center in Bir is located on the main commercial road in the town, about one block from
the settlement’s branch of Men Tsee Kang, the Tibetan Medical and Astrological
Institute. Before 1990, Bir had a smaller, four-room medical facility. In 1990 it
expanded with support from a group of Swiss Tibetan residents and the Swiss Zonta
Club. The land used by the clinic was donated by Dzongsar Khentse Rinpoche. The
clinic has a staff of four CHWs (one of whom is the Clinic Director), one driver, one
lab technician, and one sanitation worker. 18 The annual cost to run the clinic is approximately Rs. 320,000 (~ US $7500).
When I return to the clinic, Jamyang welcomes me inside the dispensary, where she and another health worker are processing patients as they come in. By 10 AM, they have seen 19 patients. Jamyang shows me the patients’ files – ¼ page-sized booklets filled with blank pages that the patients keep at home themselves. She complains that patients often forget to bring their files with them when the come to the clinic, so the “doctors” don’t know their medical histories. She refers to Mr. Sonam Hara as
16 Participant Observation, Bir settlement, part one, recorded April 22, 2004. 17 The TIRS was a CTA program intended to provide jobs for Tibetan refugees. It was later regarded as an unsuccessful program, but it resulted in the creation of settlements that remain today. (Information on TIRS is from Nowak, page 122). 18 Central Tibetan Administration. “Bir Primary Health Centre.”
24 “the doctor”, although he does not have an M.D. Jamyang scolds patients heartily for forgetting to bring their record books. The patients seen so far have come for reasons including TB medication (the clinic dispenses TB meds according to the WHO’s DOTS strategy)19, fever and cough, leg pain, boils, ear infection, and dental care. Today is the one day per week that a dentist comes to the clinic from the nearby Tibetan Children’s Village, Suja. Jamyang records each patient and his or her reason for visiting in a log book. She explains that the clinic sees an average of 30 patients per day, which is roughly equal to the number seen by the Men Tsee Kang branch down the road Some of the patients today have come to see the doctor or the dentist; others come only for medication. Jamyang tells me that the health workers often refill patients’ prescriptions without requiring that they visit the doctor again. This saves the patients Rs. 10 (US $0.23) for the doctor’s visit. The medications in Bir’s dispensary are either donated (mostly from donors) or purchased from Indian chemists. The clinic has no charge for donated medications, and for the others they charge only what they paid for them. Jamyang emphasizes that no profit is ever made in the sale of medication. She then takes me on a tour of the clinic.20 The facility consists of eight rooms that are utilized for patients: the dispensary, doctor’s room, dentist’s room, inpatient room, delivery room, women’s health room, laboratory, and health education room. In the dispensary, the health workers register patients, settle finances, and distribute medications. The doctor’s room is used by Mr.
Sonam Hara to see patients individually. The dentist’s room is open weekly when the
19 DOTS is the WHO’s internationally-recommended treatment method for Tuberculosis (from WHO, “What is DOTS?”). 20 Participant Observation, Bir settlement, part two, recorded April 22, 2004.
25 dentist from TCV Suja is on call. The facility can keep patients overnight in the inpatient room, and give them an IV if necessary. This room is rarely used, since patients in critical condition are taken to the nearest hospital, 28 kilometers away. Jamyang delivers all of the babies in the delivery room, where women can stay for 3-4 days after they give birth. If there are complications during childbirth, women are taken to the nearest hospital. Jamyang uses the women’s health room for consultation with pregnant and non- pregnant female patients. She distributes condoms and gives prevention education in this room. She also performs checkups on pregnant patients, testing them for HIV and
Hepatitis B and C and giving them vitamins and minerals that are distributed by the DoH.
Part of the clinic’s expansion includes the laboratory, which until recently could only perform simple tests (urinalysis, stool tests, etc.). Just two weeks before my visit to
Bir, the clinic hired a lab technician who is trained to perform all necessary lab tests on the premises. He can also operate an x-ray machine, which the clinic is about to receive second-hand from Delek Hospital.
Finally, the health education room is used to hold meetings with community members about health issues in Bir. The clinic holds monthly meetings with the leaders of all four monasteries to discuss disease prevention. The monasteries house many newcomers from Tibet, who are often more susceptible to communicable diseases, such as Tuberculosis. The clinic staff also gives women’s health lectures in this room. Most of Bir’s health education happens outside this room, however. Four times per year, the clinic staff holds large health education talks in all three parts of the Bir settlement. They also go to the four monasteries and schools to discuss health with Bir residents. On
World Health Day every year, they organize a community-wide sanitation project.
26 The Bir Clinic is able to offer many essential health services at its facility.
Because of its connection to the Tibetan DoH, it receives supplies for DoH’s Maternal and Child Health program (also known as the Reproductive Health program). Under this program it can dispense immunizations for Hepatitis B and MMR (Measles, Mumps,
Rubella) to mothers and children, free of charge. It can also test pregnant women for
HIV and Hepatitis B and provide medications for children if their mother has Hepatitis.
Every Tuesday afternoon, the clinic performs antenatal checkups. Pregnant women can attend these sessions as often as they choose – weekly, biweekly, or monthly. Children under five years of age are given monthly checkups as part of a DoH early childhood program. Every month, the clinic checks their weight and gives necessary immunizations. Records for all of Bir’s 90 children serviced by this program are kept at the clinic.
The DoH also encourages certain populations to utilize Tibetan medicine, rather than allopathic, because of its cost effectiveness. The Bir clinic is impacted by these choices, and participates in the process of evaluating Tibetan therapies’ effectiveness for pregnant women. The DoH no longer provides the clinic with Iron pills for pregnant women, instead encouraging them to get their iron from Tibetan medicine. The clinic takes a hemoglobin count during antenatal checkups to test the efficacy of the Tibetan medicine to provide pregnant women with enough Iron. The DoH also encourages
Hepatitis B patients to use Tibetan treatment rather than allopathic which, at a cost of Rs.
12,000 (~ US $280) per week for two years, is an impractical option for Tibetan refugees.
Bir’s clinic is also connected to the Indian government, which provides it with additional resources. It can give immunizations for Polio, Diphtheria, Tetanus, DPT
27 (Diphtheria, Pertussis, Tetanus), BCG (Tuberculosis), and Measles. Also, because the clinic is considered a health sub-centre of the Himachal Pradesh government, it receives
Iron pills, Vitamin A pills, and condoms from the Indian government. It also purchases additional pills and better quality condoms to distribute to patients.
Bir’s community is especially well-organized in that they have two community groups to monitor and improve healthcare and prevention in the settlement: the
Community Health Committee and the Disability Care Committee. The Community
Health Committee discusses public health issues in Bir and consists of representatives from all parts of the settlement who are interested in health. Past issues have included an insufficient number of toilets (after the community’s report, the DoH donated a toilet for each family in the settlement), Tuberculosis prevention, ways to help the poor in Bir, and the water shortage in Bir (the DoH has sent representatives to investigate this problem, but as of yet no solution has been implemented).
The Disability Care Committee consists of Bir residents with a special interest in caring for the disabled and a CHW who guides them. The group discusses best practices for caring for the disabled, as well as advocates for more resources. Currently, the group is advocating for a facility in Bir in which all disabled residents could be watched by a professional.
23 April 04. In return for Phourgya giving me an interview yesterday, Jamyang takes me to Phourgya’s home so I can visit his daughter. She is 37 years old and has been severely mentally and physically handicapped since birth. She must be spoonfed and cannot urinate on her own. Yesterday he told us his concerns about her: first, he and his wife were both aging and he worried about what would happen to her after they passed away. Second,
28 she almost never gets visitors. Phourgya and his wife take care of her in their small home. For both these reasons, Phourgya stressed Bir’s need for a facility to care for the disabled, where they could enjoy social interaction and be assured the care they need. The walk to Phourgya’s house goes up a road with rows of very small one-room houses on both sides and one of Bir’s monasteries at the end. There is trash lining the street on both sides. Jamyang and I walk slowly up the road and she tells me about the development of the area. On the way, everyone we pass greets us warmly. We pass an elderly couple with whom she stops to talk. After some conversation, she takes out her wallet and hands the man some money. Afterwards she explains to me that the man carries her gasoline tanks for her stove (due to a bad leg, she can’t do it herself) and in return she gives him money “for milk and fruit”. She tells me there are many Tibetans in the area who struggle for money, especially those with medical problems like Phourgya’s daughter. When we arrive at Phourgya’s house, he is thrilled to greet us. He brings us inside to meet his wife and his daughter, who is in a wheelchair. His wife makes us tea and tells us about what it’s like caring for her daughter. She explains why her daughter is wearing a nice chuba with a wedding apron and many necklaces: “She loves to be dressed pretty”. Phourgya and his wife both thank us for visiting their daughter. It is the first time in a while she has had a visitor.21 Bir’s health programs sustain a highly beneficial vehicle by which the community
can address its health problems. However, the settlement still struggles with public health issues. Unemployment is a major problem for the community, and many young people
21 Participant Observation, Bir settlement, recorded April 23, 2004.
29 without jobs turn to substance abuse. Since 2001, the clinic has taken 15 drug users to
Delhi for rehabilitation. Although the problem cannot be completely eradicated, Bir’s health education programs and community mobilization have helped to decrease the number of addicts in the past three years. Common health problems for Bir residents include Tuberculosis, Hepatitis, gastric problems, and skin infections. These problems are treated at the clinic, but residents are still susceptible to them.
Infrastructural deficiencies also create public health problems in the settlement.
For instance, Bir never received land from the Indian government to be used for burning garbage (the predominant method of garbage disposal in India). Thus, garbage collects along the streets in Bir because residents often have no where else to put it. Infection spreads quite easily in this type of environment. Settlement leaders and the clinic have appealed to the Indian government and Tibetan DoH for help with this problem, but as of yet it has not been addressed. Additionally, the settlement has a shortage of water. Two water lines supply the entire camp, and one of them is unsuitable for human consumption
(Mr. Sonam Hara noted that Bir residents drink the water anyway, because they have no other option). Settlement leaders are also trying to obtain another water line, but the process has been difficult.
Tashi Jong
Tashi Jong is located about 15 kilometers from Bir, but the settlement and its clinic operate in a very different way. The settlement was established in 1966 by the late
Ven. Chokling Rinpoche. Approximately 500 Tibetans live in Tashi Jong, about one third of whom are monks. The location is also home to a nunnery for Western nuns,
30 which technically is not part of the settlement but participates in the community and utilizes the health services. Tashi Jong’s livelihood is earned mainly through carpet weaving, barley farming, and traveling small businesses during the winter. The clinic in
Tashi Jong was originally operated by one of its monasteries, but was then taken over by the Department of Health. 22
The small community makes it much easier for Tashi Jong’s two CHWs to serve the community. They often make house calls for their patients, and even serve many local Indians in the surrounding area. Dawa Tsamchoe, the director of Tashi Jong’s clinic, knows all of her patients (both Tibetan and Indian) personally, and so is able to treat them with more individualized care. The CHWs make an effort to treat their patients kindly, so as to create a comfortable atmosphere for healing. The clinic treats
30-40 patients per day, offering all the basic primary health services necessary (for pictures of the clinic, see Appendix C). It costs approximately Rs. 50,000 (~US $1150) per year to operate the clinic facility.
Tashi Jong is similar to Bir in that it offers DoH-sponsored health programs. The
Maternal and Child Health program operates the same way there as it does in Bir. The program in Tashi Jong is much smaller, however, because the settlement only has eight children under five years old. Tashi Jong also has a facility for inpatients to stay overnight with an IV if necessary, but more often one of the CHWs will bring their patients to a nearby hospital. Twice per year, Delek Hospital sends a group to Tashi Jong to provide medical care. Once a month, Men Tsee Kang sends a representative to the settlement to see about 25-30 patients. Major health problems in this settlement include
22 Central Tibetan Administration. “Tashi Jong Health Centre.”
31 arthritis, gastric problems, and diabetes. Only one resident of Tashi Jong has
Tuberculosis.
Tashi Jong’s clinic differs from Bir’s in that it buys all of its medications from
Indian chemists and only charges patients 50% of the cost to the clinic. Thus, the clinic actually loses money by dispensing medicine, but the cost is mostly covered by the DoH.
However, the clinic does sometimes face a shortage of medications, in which case the
CHWs appeal to the DoH, the settlement office, or visiting Westerners for monetary donations.
The community involvement in healthcare and prevention in Tashi Jong also differs significantly from Bir’s community-group model. Because the population of
Tashi Jong is so small, patients can express their concerns directly to the CHWs. The settlement’s youth group often helps with the care of sick people. For health education, the clinic holds community-wide meetings once every three months. Employees from the settlement office go door-to-door to gather residents for these sessions, which include such topics as nutrition, vaccinations for children, and Tuberculosis prevention. Young people get HIV prevention messages in their schools as well. In addition, the CHWs give daily prevention and heath maintenance messages to those residents gathered at the clinic. They often advise patients on healthy nutrition, because many Tashi Jong residents visit the clinic with gastric and blood pressure problems.
Tashi Jong’s CHWs did not report the same infrastructural public health problems as Bir’s did. The only concern they expressed was the street dogs that gather around
Tashi Jong’s monasteries because the monks feed them. Although the monks keep the dogs clean, many of the Western tourists who visit Tashi Jong for its spiritual life are
32 concerned about their safety with the street dogs. At the time of my visit, the CHWs were investigating ways to rid the settlement of its dogs.
Dharamsala
Dharamsala is a settlement whose lifestyle and healthcare system are entirely different than those in Bir and Tashi Jong. Its Tibetan neighborhood, McLeod Ganj, is home to approximately 10,000 people, and its atmosphere is much more like a small city than a rural village. Home to His Holiness the Dalai Lama, Dharamsala attracts thousands of Western tourists per year. With a fairly dispersed population and its to
Delek Hospital (only 15 minutes by foot), McLeod Ganj does not have a strong need for a community-based clinic. However, there is one branch of Delek in McLeod Ganj which dispenses medications, sees psychiatric patients, and holds open clinic hours on certain days of the week.
Given this structure, there is not much need for CHWs in Dharamsala. However, the settlement employs six CHWs, two of whom work at the hospital, two at the settlement’s nursing home, one at the Refugee Reception Center, and one at the Lower
TCV School. These sub-communities are residential and thus merit separate clinics.
Below I have included information on the clinic at Lha Keri Nursing Home, whose medical program functions similarly to the Reception Center and TCV’s.
Lha Keri has 157 residents, assigned to the facility by the CTA Department of
Home. Health problems for the clinic’s patients include Hepatitis, high blood pressure,
Arthritis, Asthma, heart problems, gastric problems, Cancer (especially Stomach Cancer),
Tuberculosis, Epilepsy, deafness, and blindness. The clinic dispenses medications to
33 residents three times per day and provides first aid when necessary. Doctors from Delek
Hospital visit the facility twice per week, seeing anywhere from 32 to over 40 patients,
and a doctor from Men Tsee Kang comes once every two weeks, often seeing over 50
patients. The CHWs travel to the hospital and Men Tsee Kang to collect all medications
prescribed by the doctors. The clinic at Lha Keri sends most patients to Delek Hospital if
they require more treatment than first aid. All treatments provided by the clinic and
medications dispensed are given free of charge. Funding for the clinic comes from both
the DoH and the Department of Home.
Although most of Lha Keri’s residents are treated by Delek doctors, the CHWs
play an important role in their daily care. Often, the elderly residents experience bouts of depression and express physical pain which is easily treated with care and a small amount of medication. In many cases, CHWs remarked that patients simply need gentle care and attention in order to feel better. Some minor aches can also result from their diet, in which case the CHWs advise a change in eating patterns.
34 DISCUSSION
The CHW strategy is a unique approach to healthcare that appropriately meets the needs of the Tibetan refugees in India and Nepal. The program, established by the
Tibetan Delek Hospital in Dharamsala and continued by the CTA Department of Health, brings primary healthcare to all Tibetans living in settlements without needing doctors to provide the care. In doing so, it reflects the uniqueness of both the Tibetan situation in exile and the philosophy of community-based healthcare.
As discussed previously, the Tibetan refugees living in India and Nepal exist in a semi-permanent transitional state, with a low degree of assimilation into their local cultures. Thus, the need for programs, practices, and causes to unite the population is strong. Psychologically, these community exercises serve to give young Tibetans a sense of identity which is easily lost in their transnational existence. Practically, they help the community focus on supporting its members to thrive in exile.
There are a number of ways in which the exiled Tibetan communities unite themselves. Political activism and cultural preservation are two of many avenues by which the community stays distinctly “Tibetan” within an Indian and Nepalese context.
Through avenues like the Tibetan Youth Congress, whose goal is “the creation of a free and independent Tibet,” young Tibetans utilize grassroots activism as a tool for political empowerment.23 In the process, many youth find a sense of identity with Tibet. Thus, by announcing their cause to the rest of the world, Tibetans also unite themselves with a common identity and purpose.
23 Nowak, page 144.
35 Efforts to preserve Tibetan culture also serve this aim. Ever since he established
the first settlements in India, the Dalai Lama has stressed the importance of preserving
Tibetan culture outside of Tibet, while inside Tibet the ability of Tibetan culture to
survive is less hopeful. The CTA has an entire department devoted to the preservation of
Tibetan culture. The Department of Religion and Culture restores monasteries,
nunneries, and other cultural organizations in exile that were destroyed in Tibet. As the
department’s mission states, “These institutions play a very crucial role as the corner
stone for the preservation of this rich living religious and cultural tradition of not only the
people of Tibet but a priceless common heritage of the human kind.”24 By keeping alive
religious traditions, performing arts, and other cultural practices from Tibet, the Tibetans
in exile unite themselves in memory of their common past.
The CHW program also brings together Tibetans in exile towards a common
cause. It provides employment and volunteer opportunities for Tibetans to work for the
health of their communities. In doing so, it utilizes the Tibetan cultural importance of
service to others. Compassion is a central value to Tibetans, the majority of whom are
practicing Buddhists. As Samdhong Rinpoche, Prime Minister of the CTA, said in a
1995 speech, “All people born in the spiritual land of Tibet have a universal
responsibility to all beings, and the fulfillment of that responsibility is a duty that we all
incur simply by the fact of our births.”25 Thus, the CHW program gives Tibetans an avenue by which to practice compassion. Many of the CHWs I interviewed expressed a desire to help their fellow Tibetans as one of their reasons for entering the health field
(see Appendix D for the CHWs’ accounts of how they came to their current positions).
24 Central Tibetan Administration. “Department of Religion and Culture.” 25 Rinpoche, as quoted in Venturino, page 109.
36 The CHW program also reflects the uniqueness of community-based strategies to provide healthcare. An increasingly popular approach in communities across the world, community-based healthcare utilizes cross-sector collaboration, empowerment, and community participation as its primary tools.26 Rather than encouraging government programs which meet the needs of underprivileged communities, this strategy builds on the assets of communities to help themselves. As John Kretzmann and John McKnight, two leaders in the American community-building field, wrote, “It is clear that even the poorest neighborhood is a place where individuals and organizations represent resources upon which to rebuild.”27 They argue that by capitalizing on the internal assets of communities, those who seek to give aid can reduce the need for external support, increase the effectiveness of interventions, and instill a greater sense of empowerment in the community.
In the field of healthcare, we often assume that experts are necessary to provide aid. Doctors and nurses are the cornerstone of the allopathic health industry, which relies on extensive training and advanced knowledge to treat patients. In environments that face a shortage of doctors and nurses, it would seem that the ability to provide care is severely limited. However, the community-based process utilized by the CHW program accomplishes the delivery of primary healthcare without the use of doctors and nurses.
By capitalizing on the assets of the Tibetan community – the men and women who aspire to be health workers, the tight-knit communities in the settlements, and the Tibetans’ desire to be help others – the CTA found the basis for a healthcare program that could operate successfully on its limited budget. Also, by increasing the capacity of settlement
26 Minkler, page 10. 27 Kretzmann and McKnight, page 5.
37 residents to provide health care, the program empowers the communities to help themselves, rather than depending on external resources.
A great deal more research could be performed on the effectiveness of community-based improvement strategies for the Tibetans living in exile. For instance, it may be beneficial to look into the possibilities this model presents for community development. As one CHW noted, although she could teach her community about
Tuberculosis prevention, the disease still spread easily through the population because their crowded living spaces did not allow for them to isolate infected individuals. It may be worthwhile, then, to explore community-based avenues by which Tibetans in settlements could improve their infrastructural conditions. In addition, it may eventually be useful to explore whether the community-based model of primary care provision significantly improves the health status communities. If proven evidence of the program’s effectiveness can be found, it can then be used as a model for other communities to follow.
Although a full-scale evaluation of the CHW program has not been completed, it is clear that the program is successful in bringing primary healthcare services to the
Tibetan settlements in India and Nepal. The unique program is suited particularly well to the Tibetan refugees in these countries, and takes advantage of the assets in the settlements to provide for their own welfare as much as possible. It is one of the many avenues by which the Tibetans in exile have miraculously preserved their cultural identity and strong community, accomplishments which may one day help the population to return to their home country.
38 WORKS CITED AND USED
Bhatia, Shushum, et al. “A Social and Demographic Study of Tibetan Refugees in India.” Social Science and Medicine. 54 (3): 411-422. February 2002.
Bhatia, Shushum, et al. “Tuberculosis Among Tibetan Refugees in India.” Social Science and Medicine. 54 (3): 423-243. February 2002.
Central Tibetan Administration. “Bir Primary Health Centre.” Web page available http://www.tibet.net/health/eng/hospitals/north/bir/
Central Tibetan Administration. “Department of Religion and Culture.” Web page available http://www.tibet.net/religion/eng/
Central Tibetan Administration. “Tashi Jong Health Centre.” Web page available http://www.tibet.net/health/eng/hospitals/north/tajong/
Dawa. Delek’s Community Health Workers Training Programme Evaluation (From 1981-1987). Dharamsala, India: Delek Hospital, 1989.
His Holiness the Dalai Lama. “On Turning Sixty.” Tibetan Review. 30 (9): 11-13.
Kretzmann, John and John McKnight. Building Communities from the Inside Out. Chicago, IL: Northwestern University, 1993.
Minkler, Meredith. “Introduction and Overview.” Community Organizing and Community Building for Health. Ed. Meredith Minkler. New Brunswick, NJ: Rutgers University Press, 1997.
Murphy, Kieran. “Recharging the Batteries.” British Medical Journal. 313:1644-1646. 1996.
39 Nowak, Margaret. Tibetan Refugees: Youth and the New Generation of Meaning. New Brunswick, NJ: Rutgers University Press, 1984.
Rinpoche, Samdhong. Satyagraha. Dharamsala: Tibetan Parliament in Exile, 1995.
Tsering, Bhungchung K. “Looking at the Tibetan Struggle.” Tibet: The Issue is Independence. Ed. Edward Lazar. Berkeley: Parallax Press, 1994.
Venturino, Steven. “Reading Negotiations in the Tibetan Diaspora.” Constructing Tibetan Culture. Ed. Frank J. Korom. Quebec: World Heritage Press, 1997.
Werner, David, Carol Thuman, and Jane Maxwell. Where There is No Doctor: A Village Healthcare Handbook. Hesperian Foundation, 1992.
World Health Organization. “Alma Ata Declaration.” Alma Ata, USSR: 1978.
World Health Organization. “What is DOTS?” Web page, available http://www.who.int/gtb/dots/whatisdots.htm
40 APPENDIX A CHW Program Pamphlet (not available electronically)
41 APPENDIX B CHW Training Notes on Pregnancy and Antenatal Care, May 3, 2004 (not available electronically)
42 APPENDIX C Photos from Bir and Tashi Jong (not available electronically)
43 APPENDIX D Background Stories of Working CHWs Jamyang, Bir CHW When she was in school, Jamyang’s mother became very ill. She dropped out of school to take care of her, and as she did the local doctor taught her about healthcare. She aspired to help the community and to take care of her mother. In 1968, she joined the medical team, and acted as an apprentice to her doctor friend. In 1983, she was trained at Delek Hospital. She also sought training from the Kangra Mission Hospital and the Government Health Center in Bir, where she took a course in midwifery. Since then, she has attended many refresher course trainings at Delek. Nowadays, she misses trainings because of her own deteriorating health and the care of her son.
Dawa Tsamchoe, Tashi Jong CHW Dawa Tsamchoe went to school in Mussoorie. In 1977, she went to Delhi and worked in a hospital for four years. She has a brother and sister who both live in South India. She married a man from Tashi Jong, so she moved there with him and worked for two years as a carpet weaver. Then the settlement officer told her to go to Delek to be trained as a CHW because she had medical experience and she liked to help the community. She especially likes to help people who are old and poor and have no children.
Dolma, Lha Keri CHW Dolma was an army nurse from 1973 to 1976. For that position, she had a 9- month training. Then she got married and didn’t work for 20 years. She lived with her husband in Ooty, Tamil Nadu, in South India. After her husband died, she came to the North and did the CHW training at Delek Hospital in 1996 to review from her army training. She was working at the Soga school, and she heard about the CHW training from the Department of Home. She would rather work at Lha Keri than anywhere else, because old people need a lot of care.
Wangmo, Lha Keri CHW Wangmo has been a CHW for four years. She went to TCV Ladakh in 1972. After that she worked as a nurse at Men Tsee Kang in Ladakh for five years. She then married a man who works for the Department of Health and moved to Dharamsala. She attended the CHW training in 2000. Then she did the refresher course in 2002. She had wanted to be a nurse since she was young, because she wanted to help patients. She heard from the Department of Home that Nurse Dolma needed an assistant at Lha Keri, so went there to work for her.
44 APPENDIX E Contact Information for Research Contacts
Mr. Tenpa Samkhar, Secretary of Health, CTA Department of Health Ganchen Kyishong, Dharamsala Phone: 01892 223408 Email: [email protected]
Mrs. Dawa Tsamchoe, Tashi Jong Clinic T.C.C. Tashi Jong P.O. Tara Garh Distt. Kangra, HP India Phone: 951894 242920
Mr. Sonam Hara, Bir Clinic T.P.H.C. Deptt. Of Health CTA Chowgan P.O. Bir 176077 Distt. Kangra, HP India Phone: 951894 268510
Mr. Dawa, Secretary of Delek Hospital Delek Hospital 01892 222053/223381
45