High in China’s western Qinghai province is a small village where project DROLMA is based. The population consists of 2,800 nomadic people who move twice a year, to and from their summer encampments which reach 15,420 feet into the sky. The conditions are harsh with short growing seasons; their traditional diet consists of roasted barley flour mixed with yak butter and salted tea. A centrally located monastery with 52 monks in residence provides the spiritual guidance for this community. It was the wisdom of one of their spiritual leaders that made the project a reality. He reached out for assistance, seeking new ideas for problems that have challenged his people for decades.
Project DROLMA was initiated in 2004 and is a comprehensive community effort encompassing health, education and economics. Due to local concerns of increased maternal mortality, efforts are focused on community health improvement with a focus on women’s health. Dr. Nancy Chin co-directs the project with Dr. Becky Loy. They bring fundamental public health principles to their approach: local community participation, capacity and infrastructure building, local adaptation of evidence-based interventions, engagement of regional experts and a commitment of a minimum of 10 years to help bring forth transformational change1.
Each summer they recruit an interdisciplinary team that is based on the project needs. Pediatricians, family practitioners, public health experts and even high school students have made the long journey to this remote community. In the 4 years since inception, the project accomplishments have been remarkable, especially considering the limited field time and the harsh conditions they are working in. Dr Chin shared with us some of her notes from the summer of 2007. It’s a close and personal look into the realities of field work; the successes and challenges that make this work so rewarding.
“Day one: We arrive at the Gompa at lunch time. Nothing is ready. The clinic which was supposed to have at least two rooms finished so that we can see patients is still under construction. Workmen are mixing a batch of cement on the floor of the waiting room.
Every building at the Gompa is also under construction. They were not expecting us. How is that possible? Nothing is ready. Pancho, the Gompa Dru-In or manager, opens room after room in the guest house to reveal floor-less rooms filled with debris. One room with a floor is so filled with garbage — a broken cot stand, boxes, a motorcycle under repair — that it would take us hours to clean it out. At 14,000 feet, this is not an easily accomplished task. Finally, behind the last door, there is a room with a floor and very little debris. The workmen balk; the monks persist, we have a room for all 8 of us on the second floor. Mattresses are placed on the floor. We unroll our sleeping bags.
Day two: Once settled into the monastery guest house we tentatively begin work amidst all the monastery activity. Fourteen of the monks are sitting in a 45 day puja or prayer session and are not available to do other monastery work or to help us with our project. Unfortunately this includes Tenzin, one of my most reliable drivers. Fortunately my other ace driver, Day Ching Tarsing, whose father and brother are village leaders, is available, and, as always, very willing to help out.
It rains every day, sometimes all day. Conditions are sub-optimal for getting any medical or public health work done. [If you are interested in sounds effects, place an audible ‘groan’ at this point.] All my responsibilities to donors, team members, my university and to the health of the community loomed before me. The weather is horrid. When it isn’t raining, we are being pelted with hail stones the size of quarters. (When we marveled at the size — and quantity — of the hail stones the Abbess merely shrugged. Sometimes, she claimed, we get hail stones big enough to knock a yak out cold. I never want to be in a hail storm that size.)
The important thing to remember is that you are never the sole decision maker; that if you really believe in community-based participatory research all the responsibility is shared. Give the problems back to the community. They will find the solution. It works. But not before my affect gives me away. I forget how crabby I must look to the monks. Several of them come to me independently of one another to reassure me that they are glad to see me, and that we are doing good work here. I am ashamed of myself. They live such hard lives all year ’round. We pop in on them and expect them to drop everything to help and meet our needs. I need to buck up a bit. They shouldn’t have the responsibility of encouraging me. Kert’ing, the tough guy, shyly asks me not to be angry. I am not angry, Kert’ing. I am scared. I can’t do this work without the monks’ help. He laughs. You have it.”
1. These principles are derived from the works of Dr. Carl Taylor and Dr. Paul Farmer.
Nancy P. Chin, PhD, MPH is the Associate Chair for Education and Associate Professor, Department of Community & Preventive Medicine at the University of Rochester Medical Center.
For our readers:
It’s common for the “helpers” to feel frustrated (or even outraged) when the “locals” do not live up to our expectations. What lessons can we, and MUST we learn?