Tibetans in Nepal struggle to access health care

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Abstract

Thousands of Tibetans stranded in Nepal without any official status face bureaucratic hurdles to access health care and other basic human rights. Chris McCall reports from Kathmandu.
Near the plateau, the so-called Roof of the World, and in the shadow of their occupied homeland, thousands of Tibetans are in limbo, stranded in Nepal. They are citizens of nowhere and meeting their health needs is a challenge that their exiled leaders are officially banned from tackling.
In 2004, the Nepalese Government ordered the Dalai Lama's official representative out of Kathmandu. The office is still there, but its only official function now is to help a trickle of asylum seekers still arriving from China to find UN assistance to go on to India, which will still grant them a refugee card. For those who arrived in the past, or who were born there to Tibetan parents without any official status, life is a challenge. Officially these people cannot work, cannot study, cannot travel abroad, and cannot get a driving licence.
The community has serious health issues, and to tackle them it is constantly having to work its way around bureaucratic hurdles. It is largely dependent on donor money, often made available in a deliberately low-profile way, much of it ultimately from the US Government's Tibet Fund. Traditional Tibetan medicine still plays a substantial part in their lives.
And the community is ageing. Many of the younger Tibetans found roundabout ways to leave Nepal. But Tibetan officials in Kathmandu estimate that at least 13 000 Tibetans remain, possibly more. Only about a quarter have refugee cards. Their health problems include hypertension and type 2 diabetes, partly linked to the traditional butter and salt-rich Tibetan diet, exacerbated by change from a rural life of constant physical labour to the stresses of a foreign country and often an urban setting. Other problems include tuberculosis and respiratory disease, hepatitis B, and alcoholism, which is partly fuelled by unemployment.
In some remote mountain camps, where around a quarter of Tibetans live, there have been reports of malnutrition. “In Tibet most of them are farmers”, said Migmar Dorjee, secretary of the Tibetan Refugee Welfare Office in Kathmandu, which processes new arrivals from China. “In Nepalese border areas there is no good place for a farm and there is no good place to keep animals. Some of them are staying in refugee camps in border areas. Some are scattered and their living conditions are quite poor. Some of them live with a Nepalese landlord and work the landlord's fields. I have visited some remote areas. Some of them say they were not paid money, they had 0·50% of the crop or 0·25%. It would not be enough to eat.”
At the top of a flight of stairs in a Kathmandu old people's home sits Choekyi Dolma. She has lived to the ripe old age of 81 years, but her day is now spent upstairs in this home, part of a sprawling Tibetan camp. She cannot go downstairs without assistance. She is marooned upstairs. One of her feet is swollen and she is in constant pain. Around her neck is a portrait of the Dalai Lama, Tibet's ageing exiled spiritual leader who is not allowed to visit Nepal, even though he lives in India.
“I have to lean on my side. I tried Tibetan medicine but it did not help”, said Choekyi.
Jawalakhel camp was originally a cemetery. Local Nepalese thought it was haunted, so they let the Tibetans stay there. It has grown to resemble the surrounding suburbs but its small Buddhist monastery, where old people constantly turn prayer wheels, always clockwise, singles it out as Tibetan. So do its residents' clothes and faces.
Kelsang Dolma, a nun, was orphaned in 1959. Her widowed mother suddenly died trying to take her and a sister out of Tibet, after a failed uprising against Chinese rule. She was separated from her sister and does not know what happened to her. Aged 75 years, after years working as a servant and a carpet maker, she is finally learning to read and write. “I know these letters but it is difficult to join them up”, she said with a smile.
She has lived at the old people's home for more than 20 years. She used to like it, she said, but now many people have died. Also, moving in meant she lost her foreign sponsor, who used to provide her with 5700 Nepalese rupees (US$58) a month. She says she has diabetes and gets pains in her joints, which sometimes swell. Sometimes she uses acupuncture, but her small room shows clearly where her faith lies. The heat of a butter lamp keeps one small prayer wheel constantly turning clockwise. Inside it are written the words Om mani padme hung—Hail to the Jewel in the Lotus—the mantra of the Buddha of Compassion, whose present incarnation is the Dalai Lama.
Tibet's Government-in-exile in India is not allowed officially to undertake any activities in Nepal. Ironically, though, many Nepalis have Tibetan ancestry. Unofficially, ways and means are inevitably found. But Nepal is very much in the shadow of China. It has had a succession of weak governments. Many of its political parties have loose Communist affiliations.
Nepal is not a signatory to the 1951 UN convention on refugees, and in 1989 it announced it would cease issuing new refugee cards to Tibetans. Since then, only once has this policy been briefly relaxed. Amid an increasingly harsh stance by China, the flow of new asylum seekers has slowed to a trickle. Those that arrive now are quickly moved on to India. But until 2008 several thousand a year still came, and not all were so fortunate. One thing most do have is a green card issued by the Tibetan Government-in-exile, which identifies them as Tibetan. This identification allows them to access a network of Tibetan schools and health clinics around Nepal, all run at arm's length from the Tibetan Government-in-exile.
Most basic health services to the Tibetan community are provided through Snow Lion Foundation, an organisation registered in Nepal. Its health coordinator, Tenzin Nima, a 29-year-old nurse, says it is a constant struggle to work around bureaucratic hurdles. It needs to find organisations that are willing to help, and donors who are willing to pay the cost. “It is a bit difficult to conduct the health programme”, she said. Snow Lion Foundation runs clinics in the main cities of Kathmandu and Pokhara. There are also smaller clinics in remote mountain camps. Not all the staff have even a nursing diploma, although they may be giving injections and administering intravenous fluids. Snow Lion Foundation has to organise its own training programmes, with the help of Nepali sympathisers. Tibetans needing urgent surgery can benefit from a special fund, but they still have to pay the cost initially up-front. Fortunately, at least in hospitals Tibetans are not required to show a refugee card to get treatment. There is a nutritional supplement programme. With some help from Nepali organisations and the UN, a tuberculosis screening programme is underway, involving directly observed therapy when needed. Another major problem is hepatitis B and health workers say why it is so prevalent is not exactly clear.
In Jawalakhel camp, the Tibetan clinic operates to some extent like health clinics elsewhere, handing out regular drugs for hypertension and organising public health awareness activities. But its means are restricted and it caters to around 900 people. Tashi Dolma, also aged 29 years, is one of the nurses. She recently trained in India. The doctor is a Nepali and many of the older patients don't speak Nepali, so the Tibetan nurses have to translate. Treatments available generally include cheap drugs. Amlodipine is a mainstay for hypertension. Salbutamol is available for asthma, but only as a tablet, not as an inhaler. One of the most important health awareness campaigns has been for children for simple handwashing, a key issue in Nepal where hygiene is often not good and the water supply may be contaminated. Once a month, the clinic opens its Tibetan traditional medicine service, which is much in demand from the older members of the community.
In Tibet itself, Tibetan medicine is one specialty that the Chinese Government has left largely untouched. Tibetan medicines are expensive and are highly sought after in China. Whether they actually work in a scientific sense is hard to say, but many Tibetans believe they can. Tsewang Rigzin, a traditional Tibetan doctor in Kathmandu, said that there were some illnesses, such as tuberculosis, that would be more appropriately dealt with through western medicine. However, he said that in other areas, such as digestive disorders and mental health, traditional Tibetan medicine offers an effective alternative. “Tibetan medicine is a holistic approach. We don't have any specialisation into one part of the body”, he said.
Its roots go back more than 2000 years, he said, and despite many differences, there are some similarities to western medicine, including the need for a history and examination. Tibetan doctors do not undergo a university-style education, but they require 5 years of basic training followed by a 1-year internship, he said.
Many traditional remedies are based on plants, particularly Himalayan plants, and many of the ingredients still come from Tibet. Its theories are based on maintaining balance between three humours, often translated as wind, bile, and phlegm. Men-Tsee-Khang, the Tibetan Medical and Astrological Institute, oversees the practice of Tibetan medicine from India. Tsetan Dorji, a senior Tibetan doctor based in India who is trained in western medicine, said that traditional medicine offers a reasonable alternative for many chronic issues. But for trauma and other urgent cases, Tibetans would normally seek doctors trained in western medicine.

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