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.