by Pamela Logan

Sept 17, 2001

This report describes the observations of a small team that made unannounced visits to medical clinics and hospitals in Ganzi Tibetan Autonomous Prefecture in August, 2001. The team was led by Dr. Bruce Beattie of International SOS, who is an expert on health care in developing countries, and who has inspected medical facilities in (other) poor areas of China such as Qinghai and Shaanxi. He was supported by Martin Dunphy, also of International SOS; Fanni Fabnedey who operated the video camera; and myself, who was note-taker and interpreter.

All of the facilities we visited are on the Sichuan-Tibet highway, a major thoroughfare. It is therefore to be expected that conditions we saw are better than conditions at clinics in more remote townships and villages. This should be kept in mind when reading this report.

At each of the small clinics we visited, we had a warm welcome from whatever doctors happened to be there. At our request, they opened all the rooms for which there were keys, and they answered our questions patiently and thoroughly. They allowed Bruce Beattie and Martin Dunphy to open cabinets and drawers, switch on equipment, and nose through medicines and supplies. Before leaving each place, we gave them a doctor's bag worth about US$300, stocked with supplies and equipment.

Some generalities

Nearly all the doctors we met or heard about during the survey were graduates of the vocational school for medicine in Guza. (Guza is a small town at the eastern edge of the prefecture). The Guza school has three- and four-year programs, which is sufficient training to receive credentials and be assigned a job . People entering this institution are graduates only of junior middle school, which means that they have only nine years of prior formal education and are as young as 16 or 17. Scanty training is one of the biggest problems afflicting medical care in Ganzi, but it is not unique to Ganzi or to Tibetan areas - it is common throughout rural China.

Most of the hospitals/clinics we visited had a large staff - too large for the number of patients. This has several bad effects first, that wages must be kept low (US$110/month for a typical doctor) to accommodate the large payroll; and second, that staff seems to take the situation as a license to be absent for long periods. In only one clinic, Rongbatsa, did we actually meet the director. In the other places, the director was not around. Absence of the leader takes an obvious toll on care quality, organization efficiency, and especially morale.

In the past few years, across China, the government has been trying to trim the bloated civil service. A couple of years ago they were talking about eliminating one third of jobs. Yet this has proven politically difficult, and so far has not been achieved.

Except for the Dawu county hospital, hygiene at the clinics and hospitals we visited was poor. Rooms were dark and unheated, floors made of unsealed concrete, furniture battered and chipped, sheets washed and reused until they were only blood-stained rags. Ward beds had little padding. Staff housing is cramped and squalid. There was often no running water, either hot or cold.

Medical practice in Ganzi relies heavily on injections and IV drips - this treatment being preferred by many patients. I have seen people receiving IV drips at home and spotted them walking around on the street, a friend holding the bottle overhead. Antibiotics are, by Western standards, vastly over-prescribed, being thought to cure even the common cold or flu. This mistaken view is probably common throughout China. I have seen friends who, when ill, went down to the clinic, got a shot, and then clearly expected that they would now improve - which they did, so the attitude dies hard. In every clinic, we saw a large supply of injectable drugs. At least they do use disposable needles much of the time.

Rural doctors spend a great deal of time outside their clinics making house calls. Sometimes this involves travel of a day or more. At the better clinics, women will come in to give birth, but at less hygienic ones there is no advantage in this and a doctor will probably be summoned to supervise a home birth. Typically, a woman will go in for an ultrasound examination just once during her pregnancy. Many births take place without a doctor present, especially in remote areas.

One of our surprising findings was the government support given to traditional medicine systems. Many Tibetans - especially older, more conservative people - prefer traditional Tibetan medicines. One reason is that they are quite a bit cheaper. By contrast, I have also met Tibetans in rural Ganzi who, when a family member is seriously ill, have bankrupted themselves to send the patient to the finest western hospitals in Chengdu. Thus there is a wide range of preference in medical care.

As medical costs are prohibitive, poor families are discouraged from seeking care until the situation becomes desperate. Like elsewhere in China, Ganzi's health care system is far less accessible to ordinary people than it was ten or twenty years ago.

Here is a summary of what we saw at individual clinics.

Tagong.

The town of Tagong is the headquarters of a poor township of the same name, within the relatively prosperous county of Kangding. Altogether, the county has sixteen hospitals, clinics, and health centers. The Tagong clinic serves 6000 people. It is located about four hours' drive from the county seat, on high-elevation grasslands. Most of the local population are herdsmen. When we visited, a week-long festival was in progress; therefore the clinic was locked up and no one was there, but inquiries led to two doctors being summoned.

The clinic has six doctors total. Our hostess was Dr. Zhang Lin, one of the staff. She and the other staff members have three years of training each at the Guza medical school.

The Tagong hospital has five rooms an examining room, ward, labor and delivery, pharmacy, and office. They have an ultra-sound machine for monitoring pregnancies and diagnosis of abdominal conditions. Bruce tried the machine and found that it produced a poor quality image. The technician who operates it received only one month of training and can do only simple procedures. The clinic also has an oxygen concentrator for delivering oxygen to acutely ill patients.

A facility like Tagong is obviously unable to take on complicated cases, or perform surgery. Such patients are sent to the county hospital in Kangding town. They do deliver commonplace medical services, notably vaccinations. We saw the vaccines--they were not refrigerated, and Ms. Zhang admitted that they would have to be thrown away. Vaccines are sent in from the county seat and normally used right away. The clinic uses disposable needles when giving immunizations in villages and encampments, and reusable, sterilized needles when vaccinating in town.

Bruce commented, "This is one of the worst clinics I've seen. They need everything equipment, training, medicines. But a major overhaul is inappropriate because the skill level of the staff is insufficient."

He suggested that we find money to buy for them a refrigerator, set of scales, disposable syringes, stretcher bed, and delivery bed. In addition, the clinic asked for a chemical analysis machine, X-ray machine, delivery bags, ward beds, surgical equipment, and training.

Dawu County Hospital

The Dawu County Hospital was completely different from the clinic in Tagong. When we arrived, we found the building full of workmen laying new tile on the floors and painting the walls. The place was clean, bright, and very lively. We learned that they had recently received one million yuan from the government, which they were using for building improvements, equipment, and training.

The hospital has fifty beds and sixty doctors. (I am using the word "doctor" as a shorthand translation of the Chinese "yisheng" which includes not just doctors, but also nurses, dentists, technicians, and specialists in Tibetan and Chinese medicine). It is by far the largest of the county's ten medical facilities.

We were taken around by a deputy director. He seemed rather proud of the place, It has two buildings, three or four stories high, and many rooms. The hospital has quite a bit of electronic equipment, including a machine for analysis of blood and urine, an ultrasound, and an electrocardiograph.

Of the sixty professional staff, forty are trained in Western medicine. They have two doctors trained in traditional Tibetan medicine, and a pharmacy of traditional Tibetan medicaments. They also have a Chinese medicine department and pharmacy. Of all these doctors, none has attended medical school for more than four years.

The hospital has a special delivery room with two beds, and an incubator for premature babies. They deliver about ten babies per month. Their operating room is used for simple surgeries, such as appendectomy and gall bladder surgery, once or twice a week. They can also do Caesarian sections.

At this hospital we learned something about the Tuberculosis problem in Ganzi. On the road coming up to Kangding, at a construction site, Bruce had observed a worker with characteristic signs of TB lymph nodes draining from his neck. The disease is problematic throughout poor rural areas. It is diagnosed by means of a chest X-ray and a skin test. The Dawu hospital sees 50-60 cases a year.

China has a national program to combat TB, but the doctors in Dawu said that this is having only a small effect. One major hindrance is, it's hard to diagnose the afflicted people unless they voluntarily go in for testing. Since many Tibetans don't go in - either because they live too far away, or they are too poor, or too stoic - there are many, many unreported cases.

Overall, the Dawu hospital was a very well-run place. I told them, if I ever get sick in Ganzi, I'm coming straight here, and I meant it! Bruce concluded that our resources are better spent on small, struggling clinics than on wealthy facilities like Dawu. Nevertheless, they did have a request a new light for their operating room. We looked at the existing light some bulbs (or circuits supplying power to them) didn't work, but it wasn't quite junk and Bruce didn't think replacing it should be high priority.

Mazhi

The Mazhi clinic is one of the satellite facilities in Dawu County. It is located only 9 km west of the county seat, and connected to it by a good highway. We were hosted by the director, Tashi (or Zhaxi), and a 20-year-old doctor Wang Xiaoxue.

The facility serves a population of between one and two thousand, mainly farmers. They see seven or eight patients a day. It was a nice, clean little clinic. Morale seemed good. They do not have to deal with difficult cases - they just send them down the road to the county hospital. The services they provide are therefore very basic.

I did notice that the clinic director, Tashi, was unable to write his name in Chinese; he had to ask Dr. Wang to do it for him. Probably, Tashi belongs to the generation that couldn't attend school because of the Cultural Revolution. Ignorance of written Chinese does not necessarily mean that he is a poor doctor, but it was nonetheless a disturbing observation. The team was, however, rather impressed with Dr. Wang, who seemed very bright and capable.

Zhu-a

This is a health center (weisheng suo) in Luhuo (Trango) County. It has ten professional staff, including two nurses, two dentists, and two ob/gyns. Their two dentists were trained in Chengdu, the rest were trained in Guza. We were hosted by Dr. Yang Xiaoping, age 25.

The center serves five villages and about 2000 people. It sees roughly thirty patients on an average day. For serious emergencies, an ambulance (Iveko minibus) can be summoned from the Luhuo County. seat.

Overall, this was a well-equipped and well-run facility. They had quite a bit of equipment, including an X-ray machine.

Nima's TB clinic and old folks' home.

This place was not one of the clinics we surveyed formally, but it's worth mentioning as an example of an NGO providing needed social services and medical care. It was founded by Lobsang Nima Soghatsang (lonima@bluemail.ch), a Tibetan living in exile in Switzerland. The clinic is located in his home town of Ganzi. We bumped into him and a volunteer Swiss doctor at the county guest house, and they invited us to visit the following day.

In Tibet/China, childless elderly people are, like orphans, a pitiable group. There is no Social Security or Medicaid to provide for their needs. Many end up as beggars, and certainly their life expectancy is less than it might be. For this reason, Nima established an organization called "NIMA- Social Projects in Tibet" to care for the aged in Ganzi. With Swiss money, he built a beautiful Tibetan-style facility costing US$50,000 to house ten people. Certainly, the seniors we saw - sitting on the veranda spinning prayer wheels - seemed very happy and to be rejoicing over their good fortune at being taken in.

With the help of Swiss medical expertise, he has also undertaken care for a few TB patients. TB is curable if medicines are available and the patient can stick to the regime; however, impoverished Tibetan often cannot meet these requirements without outside help.

We were taken to see a TB victim named Deshi, a 28-year-old woman. She was near death when Nima took her in. Careful nursing and medication had improved her condition quite a bit, however she was still seriously ill. When I saw her, she appeared very weak, and was coughing up phlegm.

I have to say that I was frightened to be in the same room with Deshi, as TB is quite contagious. Bruce told us that, 24 hours after a TB patient coughs, the active virus can still be found in the air of the room. It is often spread to family members living with the sick person. Nevertheless, Nima went up to her and helped her by holding up a jar for her to spit into. This kind of courage and compassion is saving lives on the Tibetan plateau.

The TB patients are housed in a different wing from the senor citizens. Yet another wing contains a small, Tibetan-style hotel. We were rather doubtful of the wisdom of housing TB patients on the same grounds as seniors and tourists. The hotel so far does not seem to have many customers.

Rongbatsa

Rongbatsa is a district in Ganzi County, with its headquarters located 32 km and one hour's drive west of the county seat. Rongbatsa's hospital is the largest of four clinics in the Rongbatsa district. Altogether, the district has twelve doctors serving a population of 20,000.

The hospital director is Shamba (Xiangba), who received four years training at the Guza medical school. His specialty is traditional Tibetan medicine. He has been a doctor for fifteen years in Rongbatsa. He was an extremely intelligent and articulate man who has traveled widely, including trips to Germany and Switzerland.

The Rongbatsa hospital was well-kept and tidy. They had no refrigerator for vaccines. They had an X-ray machine but could not use it at full power due to limitations on the electrical supply, a problem that Shamba said could be fixed with a 2000-yuan wiring job. They did not have any means of performing a TB skin test. Shamba said they do have "lots" of TB in Rongbatsa. High blood pressure is another common malady.

They have a surgery where they can perform Caesarian sections but not appendectomies because the place isn't clean enough.

Shamba requested equipment and training. He also mentioned that the living conditions for doctors are really very bad, which means that doctors stay only one or two years before moving elsewhere. Although Shamba was the only person who mentioned this problem, we suspect that it afflicts rural clinics in all remote areas. We saw quarters at the Rongbatsa clinic that were shared by two doctors, a married couple. They had two rooms in an old building - old and dingy and hard to make clean.

Shamba then offered to take us next door to a new Tibetan medicine hospital that he was building with German and Swiss donations. It was a beautiful building, very clean and bright. I particularly remember a bathroom fitted with running water and a sit-down toilet - exceptionally rare in these parts. Although it wasn't finished yet, already they were seeing patients. Some rooms were being used to dry herbs later to be ground into medicines.

We were concerned about a potential conflict of interest arising from one man running one hospital with public funds, and another with private money. Bruce thought he spotted some things in the new place that could only have come out of the old. On the whole, however, it seemed that Shamba is serving his community very well, and that is the most important thing.

Manigango Hospital

Manigango is located in Dege County at a fork in the Sichuan-Tibet highway, where a branch road goes up to Qinghai province. It is high, with a cold, harsh climate. The local residents are virtually all herdsmen, and very poor.

The clinic in Manigango, like many, is a set of low buildings arranged in a square around a central yard. When we arrived, it was several minutes before a doctor could be found. The total medical staff is fifteen, yet it seemed that few were actually in residence. The director was away, and he had taken quite a number of keys with him. Dr.Guo Jun showed us around, but there were several rooms that he could not open

This clinic serves 2000-3000 people. Two of the fifteen staff are Tibetan medicine specialists who have their own department. The western medicine department was very well equipped with an oxygen concentrator, ventilator, ECG monitor, and X-ray machine. They had an incubator new in the box, not ever used. There was one critical lack electricity. The town has been blacked out for 7-8 months, and the clinic's generator was out for repair.

The clinic has a surgery where they perform occasional Caesarian sections and appendectomies (two each this year).

Overall, the place was very dark, cold, soggy (it had been raining), and grim. It is hard to imagine a doctor wanting to stay here if he or she had other options.

Keluotong (Khorlondo)

Keluotong is a district located about 40 km and one hour's drive east of the Dege county seat. When we visited, they had not had any electricity for three months and didn't know when it would be restored. The clinic director, Nyima Tashi, had gone to the county seat to see a sick friend. The person who showed us around was a young woman staff member who was quite inarticulate (mumbled a rural Sichuan dialect), and seemed nervous. She was unable to show us the emergency equipment because it had been locked up by the director.

This place was the worst clinic we visited. The morale seemed at about zero, as evidenced by the totally decrepit, unsanitary, and dangerous condition of their toilet. It was about to cave in. There are supposed to be five doctors here, but, like most clinics, it seemed that few were actually physically present in the clinic. Bruce judged that their most important needs were a kerosene lantern, a basic equipment set, and a diagnostic set.

Other facilities

In the course of traveling and working in various towns of Ganzi, Kham Aid Foundation has toured a number of hospitals. We have had several field workers treated in these places - for dog bite, infection, and altitude sickness (all made a 100% recovery).

In Kangding town, for example, there are two hospitals - one at county level, the other at the prefecture level. They are both as well equipped as the Dawu hospital. The prefecture hospital was recently renovated and we haven't seen it since its facelift. The county hospital is a bit dowdy, and some of its equipment is broken and doesn't work. Last year Dana Isherwood toured the Danba County hospital, and found it quite grim, without even an X-ray machine. Some might recall that last year a prominent young man died at the Dege county hospital following emergency exploratory surgery.

Kham Aid Foundation Action

Our charity bike tour has raised a modest sum which can be used to purchase the most needed equipment. International SOS has pledged $10,000 worth of training for two doctors, who will be flown to Beijing for a seven week program. With help of David Altman, who is a volunteer in our wheelchair program, we have found a source of discounted medical electronics and recently provided an EKG to the Dege County hospital. Other participants in our wheelchair program have been bringing out medical supplies such as bandages.

Ways that you can help

Unfortunately, it's not possible (yet) for foreign doctors to stay at these places for long periods. They are considered too sensitive by the Foreign Affairs Bureau, which will not issue a permit for long-term residence. The one exception is Kangding, which already has the most advanced medical care in the prefecture. We are monitoring the situation and will recruit volunteer doctors if it opens up.

Bruce Beattie made one excellent proposal, which is to get together a truckload of paint, linoleum, draperies, and tile, and go from clinic to clinic sprucing up rooms. In addition to obvious hygiene considerations, I feel that it's important to improve the physical appearance of these clinics so that staff will take pride in them; its no less important to improve staff quarters so skilled doctors will want to stay. Such a program will need a lot of volunteers with home improvement skills, and some cash for buying materials and transporting them. If there are any handymen out there who'd like to volunteer to recruit and lead such a team, please contact me.

If you have medical supplies or equipment to contribute, please contact Bruce Beattie, Bruce.Beattie@internationalsos.com, tel 86 10 6462-9112 x279. We much prefer if the items can be transported by the donor to, or are already in, China, because import duties and customs paperwork have proven to be prohibitive.

To donate in Hong Kong, contact James Law, james.law@hk.pwcglobal.com, tel 852 2289 2501

To donate in the U.S., contact the main office, khamaid@khamaid.org, tel 1 626 449-7505.

THANK YOU to the many organizations and individuals who supported the project International SOS (www.internationalsos.com), especially Mark Jackson and Lisha Ma; employees at Price Waterhouse Cooper, Hong Kong; Bohdisattva Bicycles (www.bohdi.com), Shanghai; The Sichuan Holy Love Foundation, Chengdu; Carol's by the River, Chengdu; The Big Apple, Beijing; and last but not least, organizer David Oliver.