B. Access to Healthcare

The PRC claims that '[t]he government provides free medical care for all Tibetans.' We found, however, that in practice two principal factors limit Tibetan children's true access to healthcare: the absence of adequate healthcare facilities, particularly in rural areas; and the high cost of healthcare even where facilities exist. Several Tibetan physicians whom we interviewed emphasized that children's ability to obtain quality healthcare in Tibet frequently depends on their parents' social and economic status, the cost of treatment and the geographic location of the family (urban or rural). Some evidence suggests that only Tibetan children whose parents have the 'right' background - a government position or some connection within the CCP - receive subsidized healthcare. In our interviews, geography and treatment costs emerged as the two primary concerns that seem to restrict Tibetan children's access to healthcare.

1. Availability and Quality of Hospitals, Clinics and Physicians

Farmers, villagers and nomads, in contrast to urban residents, often live in regions without adequate health facilities. Based upon her experience with recently arrived Tibetan refugee children, Dechen Tsomo, a nurse in Dharamsala, told us that in rural regions of Tibet 'no one has access [to a hospital].' In an emergency, nomads or farmers who live in remote areas of Tibet may well be unable to reach a hospital in time to avert fatality. Several experts told us that, as a consequence, rural Tibetans who 'get really sick' often die, despite the availability of effective treatments in urban centers. Dr. Alo, for example, a Tibetan physician who practiced medicine in Lhasa as well as regions of Kham and Amdo, estimated that Tibetan villagers often must walk as much as forty kilometers to reach the nearest healthcare clinic, and outside of the cities most facilities do not have modern medical equipment. In emergencies, he said, they most likely will have died before they reach an appropriate facility.

Several children related instances in which they (or relatives and friends) sought hospital treatment but could not obtain it because the hospitals were too distant. For instance, one girl from Kham explained that the closest hospital was a full day's journey by car. In the event of an emergency, it would have been difficult to find someone with a vehicle to drive her there. Similarly, the child who had been mauled by Chinese police dogs told us that his father took him to the nearest hospital, which turned out to be a Chinese facility located two days away by yak. A nomadic boy from Kham similarly told us that, at the age of five, he suffered from a 'disease with pimples all over my body and fever,' probably chicken pox. He did not receive medical care, however, because his family did not have the means to take him to the closest healthcare facility, a Chinese hospital located about five hours away by vehicle.

Urban access to healthcare is reportedly better. Large hospitals in Lhasa are open twenty-four hours and out-patient facilities are available during daily office hours. 'The equipment,' according to Dr. Alo, tends to be 'good - most of it comes from Japan and the United States -but the doctors are not well-qualified.' Another anonymous source added that, today, European and Chinese manufacturers also produce much of the hospital equipment. The largest hospital in Lhasa, Dr. Alo said, has roughly 600 staff members and 100 doctors. In the whole region of Amdo, by contrast, he estimated that there are about 221 doctors, of whom more than half are Tibetan.

One physician from Amdo, who fled Tibet in 1998, reported that most district health facilities in his region were administered by Chinese officials. These officials, he said, instituted regulations to prevent Tibetan doctors from providing treatment to their patients without authorization from their Chinese supervisors. In response to what he perceived as an abysmal lack of medical care for Tibetan villagers, he established a private clinic in his village, which otherwise lacked a medical facility of any kind. While in Tibet, he operated this private practice and provided free medical care to all patients who were unable to pay.

2. Healthcare Costs

This highlights the second major barrier to medical treatment for many Tibetan children: the substantial - often prohibitive - costs. Many children and Tibetan healthcare workers reported that the large hospitals charge excessive 'security deposits,' without which they refuse to treat patients. Larger hospitals generally require a 1,000 yuan security deposit for admission. The size of the deposit may vary depending on the hospital's location (urban or rural), as well as whether the patient has connections to the Chinese government. According to a former medical aide at a Chinese clinic in central Tibet, security deposits range from 1,000 yuan at the village level to 2,000 yuan at the larger Chinese hospitals. In practice, he said, the Chinese hospitals generally require no (or very minimal) security deposits from Chinese patients, as well as from Tibetans who work for the Chinese government. Another anonymous source told us that the standard entrance fee at a Lhasa hospital is now 3,000 yuan.

Many children reported that their families could not afford required hospital care. One boy, for example, told us that his family had to sell all of its possessions to pay for his mother's four months in the hospital. She passed away despite this treatment. Another boy said that when his mother became very sick, his father could not afford her medical treatment. The father agreed to serve as a porter in a Chinese hospital in Lhasa for one year in lieu of payment. Lawyers for Tibet asked a twelve-year-old girl from Kham, who said she suffered from 'eye and heart problems,' whether her parents ever took her to a clinic for treatment. 'No,' she replied, 'because the hospital is Chinese. They take too much money. They demand 10,000 yuan as a security deposit.' While 10,000 seems improbable - a figure between 1,000 and 3,000 yuan would comport with the majority of our interviews - her response epitomizes the perception of many Tibetan children that Chinese hospitals and clinics charge far more than their families can afford.

Children also reported high treatment costs. For example, a nomadic boy from Kham estimated that a single injection costs 150 yuan. After he injured his knee, he recalled that the staff at the nearest Chinese clinic charged high fees for his stitches, which his uncle paid. Soon after, his knee became infected, and he had to travel to a large Chinese hospital in Lhasa, which charged him 200 yuan for a two-hour intravenous treatment. The next time he required treatment - for a frostbite-related gash on his foot - he sewed his own stitches because he could not afford to pay hospital fees again. Another girl from Kham, who believed that she had a 'jaundice problem,' reported that treatment cost her 450 yuan. Describing the hospital, she said that '[i]f you don't give money, they won't treat you.'

Like education, access to healthcare for Tibetan children may sometimes depend on themto. Children born in excess of family-planning quotas imposed on Tibetan families do not receive themto (or must obtain it by bribery, which their families cannot always afford). In some regions of Tibet, without themto, state healthcare facilities charge children much higher fees for treatment. Without a themto pass, said one fourteen-year-old girl from Lhasa, she could not receive housing and food rations. A twenty-four-year-old Tibetan, a former Chinese medical aide who arrived in exile in 1997, told us that village-level clinics do not always require themto. In cities and towns, however, a patient without themto documentation would be charged more than double the cost for a patient with themto.

Misuse of state and foreign funds may also contribute to the high cost of healthcare for Tibetan children. Dr. Alo, for instance, alleged that widespread corruption mars the disbursement of government and foreign funds. The Chinese government, he said, asserts that it spends hundreds of thousands of Chinese yuan every year on the welfare and development of Tibetan people in Lhasa. Actually, . . . all the money is being spent on the salaries and the families and the houses and the benefits of the Chinese officers or the Tibetan staff working for the Chinese officers in Lhasa. [The same applies to] donations from foreign agencies.

Some prior reports have likewise suggested this kind of misuse or improper allocation of central government funding.

3. Access to Traditional Tibetan Medicine

In the face of these obstacles, it appears that many Tibetans, particularly in rural areas, choose to visit traditional Tibetan physicians, as an alternative to the (largely Chinese-administered) clinics and hospitals. In general, children appeared to prefer treatment by Tibetan physicians, whom they said were kinder and more attentive. Many also expressed the belief that Tibetan medicine had cured their ailment where allopathic Western medicine, as practiced by Chinese physicians, had failed. Accounts suggest that Tibetan physicians are generally more accessible than Chinese doctors and likelier to charge lower fees (or to waive fees altogether for very poor children). For example, one child from central Tibet broke his arm and required a cast. But instead of traveling two hours by car to the closest Chinese hospital, which he said he could not afford anyway, he had a Tibetan man from his village wrap and set the bone for him at no charge.

One girl from Kham told us that, due to the cost of Chinese hospitals and medications, most of the Tibetans in her village visited 'herbalists.' A Tibetan physician, another child explained, was located only half an hour from her home. The nearest Chinese hospital was a full day's journey. A fourteen-year-old Tibetan farm boy from Ngari likewise reported that he generally went to a Tibetan doctor, for similar reasons. The Chinese hospital took two and a half hours to reach by truck, and it refused to treat patients who could not afford the fee. By contrast, the Tibetan doctor lived only about half an hour from his home.

According to the ICJ, after the Cultural Revolution subsided, traditional Tibetan medicine enjoyed a general revival. In fact, it now seems to receive active support from the Chinese government. This may be because, like the PRC's encouragement of local funding of primary schools in rural Tibet, it saves the central government money. A traditional Tibetan medicine aide, who arrived in exile in 1997, confirmed that far more traditional Tibetan physicians exist today than did fifteen years ago. In 1997, an estimated 1,200 practitioners of traditional Tibetan medicine treated patients in the TAR. Many others practiced in Amdo and Kham. Our interviews suggest that today, Tibetan medicine serves as one of the few - and the only widely available - alternative to distant and expensive Chinese facilities.

4. Availability of Vaccinations

According to the PRC's 1992 'white paper,' Tibet Its Ownership and Human Rights Situation, 'a planned immunization program has been widely implemented in Tibet since 1986. Over 85 percent of children have been inoculated.' Yet as Dr. Alo commented, 'in reality, [healthcare workers] don't immunize kids in the villages because they don't want to travel so far.' UNICEF's statistics show that the percentage of fully immunized children in China for many diseases approaches one-hundred percent. But our research suggests that this number does not accurately reflect the reality in Tibet, particularly in rural regions. A physician who practiced in Amdo before arriving in exile in 1993, told us that he administered vaccinations to children at his hospital, which devoted a division to child immunizations. In remote villages, however, he reported that few children received vaccinations, a situation that he, like Dr. Alo, ascribed to the general aversion of healthcare workers to serve in these regions. In our interviews, several urban Tibetan children (typically from Lhasa) recalled childhood shots, but those from rural regions outside the vicinity of a Chinese hospital or clinic generally did not. Despite some efforts to remedy the problem in the past decade, the situation seems to be improving slowly, if at all.

The remarks of most physicians and healthcare aides who treat Tibetan refugee children on a regular basis confirmed this general pattern. Dr. Tsetan Dorji Sadutshang, Chief Medical Officer at the Tibetan Delek Hospital in Dharamsala, said that vaccinations are rare to non-existent in rural areas of Tibet. Dechen Tsomo, a nurse at the Tibetan Children's Village school in Dharamsala, likewise reported that most refugee Tibetan children do not arrive with a 'TB mark,' which indicates the standard 'BCG' vaccination that reduces the chances that an infant will contract tuberculosis. Kelsang Phuntsok, Health and Education Project Officer for the Tibetan government-in-exile (TGIE), noted that, due to the presumptive lack of vaccinations in most regions of Tibet, TGIE immunizes all newly-arrived refugees with the 'six standards' established by the World Health Organization, which include polio, tuberculosis, tetanus and measles.

The Chinese government may be seeking to remedy this problem. One Tibetan, a former medical aide who worked for a Chinese medical facility from 1994 to 1997, described participating in a widespread immunization program for rural Tibetans. Each year, he said, he and other medical aides would travel to remote villages and, working from home to home, administer vaccinations to infants for the six most common diseases, including TB, whooping cough and polio. Adults would receive injections only if they showed signs of a developing illness. Still, if they did receive such vaccinations as infants, few rural children seemed aware of it (and, as noted, few refugee children today show signs of having been vaccinated as infants). In fact, only one rural Tibetan whom we interviewed recalled receiving vaccinations from government healthcare workers. A boy from a remote region of Kham said that, until the age of ten, he received immunization boosters every year, which were administered by Chinese officials who traveled to his village for this purpose. These exceptions suggest that the problem for rural Tibetan children may be less a matter of state policy than of the willingness of individual healthcare workers to carry out vaccination programs in remote Tibetan regions.

Apart from state-sponsored vaccination programs, a few Tibetan children in rural regions may receive vaccinations from local physicians who assume the responsibility on their own. For instance, a fourteen-year-old boy from Ngari reported that he received a vaccination from a Tibetan doctor in his village, who called the children together to administer it. A girl from a small village in Kham reported receiving one shot, at a cost of 5 yuan, for 'lung problems and small pox.' It is unclear how many local Tibetan doctors and healthcare workers undertake this responsibility. But in this regard, Dr. Alo commented that '[s]ome of the villages have health workers who are Tibetan, and they really do it [vaccinations] very well.'

5. Availability and Access to Medications

Access to medications for Tibetan children seems dependent on factors similar to those that affect access to healthcare generally. Here too, 'connections' may play a major role. Medications in Tibet tend to be dispensed through the hospitals, often at considerable cost. Poor Tibetans and those who live in rural regions rarely can obtain them. Dr. Alo reported that, unless a child's parents work for a Chinese government office or have other connections with Chinese officials, they must pay full prices for medications. Similarly, in another physician's experience working in Tibet, the 'common people' had to pay for medicines, while individuals working in, or with connections to, Chinese offices, received medicines for a lower cost or free of charge. These medicines are frequently expensive. For instance, a former medical aide who arrived in exile in 1997 estimated that at that time treatment for TB would cost between 1,000 and 2,000 yuan. To put this into some perspective, he noted that the average annual salary of a construction worker is about 3,000 yuan. Another anonymous source estimated the overall cost of out-patient drug treatment for TB at approximately 800-1,000 yuan.

A Tibetan physician who requested anonymity ('Dr. Norbu') said that Tibetan doctors - by which he seemed to mean those working outside of Chinese hospitals - cannot obtain medicines directly from pharmaceutical companies. According to Dr. Norbu, drug companies provide medicines only to Chinese government workers and to 'officials with connections to the Chinese.' Tibetan villagers' access to medications is therefore generally poor. The only medications they can obtain, he said, are often 'outdated, four or five years old, not appropriate to be given to the patients.' Similarly, Choegyal, a TGIE employee at the Refugee Reception Centre in Dharamsala, told us that several recently-arrived refugees reported that Chinese doctors sometimes dispense expired medicines to their Tibetan patients. The upshot of this trend, according to Dr. Norbu, is that many Tibetan children, even if properly diagnosed, may be unable to secure the safe and effective medications required for proper long-term care. By way of qualification, however, another source noted that some 'outdated' medicines remain effective for between five and ten years after their official expiration. At times, organizations abroad donate 'outdated' medicines because they can be helpful, particularly absent any alternative.

Again, Tibetan doctors reportedly compensate for the shortage of modern medicines by at times dispensing Tibetan medicines as an alternative (typically at low or no charge for very poor patients). One anonymous source noted, however, that in rural regions Tibetan physicians increasingly face shortages of the herbs required to prepare traditional medicines. On the efficacy of Tibetan medicine, Dr. Sadutshang commented that modern medicines tend to be more successful for the treatment of infectious diseases, while Tibetan medicines tend to be particularly effective for chronic or degenerative disorders. A former Tibetan medical aide said that his treatments with 'medicinal herbs' worked well against certain stomach problems. For serious diseases, however, he referred patients to the larger Chinese hospitals. Yet he, too, emphasized that in most cases these hospitals were located too far away from rural Tibetans to avert serious permanent injury or fatality in emergency situations.

C. Common Illnesses Among Tibetan Children -->