Sean Hillman, 2011
M.A. (c) Religion (Buddhist Studies)/Bioethics
B.A. East Asian Studies
Department and Centre for the Study of Religion
Joint Centre for Bioethics
University of Toronto, CANADA
After going into exile in 1959, due to the heightening oppression of the occupying Chinese Communist regime in Tibet, His Holiness the Dalai Lama was followed to India by approximately 80-100 000+ Tibetans. According to the International Institute for Sustainable Development (IISD), “[t]he beginning years were expectedly the most difficult. Many Tibetans, coming from the high Tibetan plateau, succumbed to tropical diseases and heat. They were divided into road construction groups and lived in tented camps. With help from the Government of India and others, 54 agricultural and agro-industrial based refugee settlements were gradually established. The idea was to resettle the Tibetans in compact homogeneous communities where they would be able to preserve and perpetuate their culture and traditions, while at the same time enabling them to become self-sufficient in livelihoods.”[i] The majority of Tibetans settled in the Karnataka State of South India. There, the landscape is very flat, and this with the heat and drought make it as unlike their homeland as can be. Agriculture also proves to be quite difficult. The most significant of the many Tibetan communities throughout India, however, is in Dharamsala, a beautiful “hill station lying on the spur of the Dhauladhar range [of the Himalayas and]…wooded with oak and conifer trees and snow capped mountains [which] enfold three sides of the town while the [Kangra] valley stretches in front.”[ii] An environment much more suited to the Tibetans “lying 526-km northwest of New Delhi, Dharamsala[, it] is the headquarters of the Kangra District in the Indian state of Himachal Pradesh,”[iii] is the seat of the Tibetan Government-in-Exile, and houses the residence of His Holiness the Dalai Lama. The presence of the Tibetan leader and the region’s beauty, some parts so highly elevated (between 1250 m to 1550 m)ii that one is literally in or above the clouds, bring a myriad of Indian and foreign tourists every year. Birds of all kinds enjoy the area too, as it is a major migration route. Most of the settlement is built on steep inclines, and is subdivided into: (1) an upper region of Tibetan institutions (such as the Tibetan Institute for Performing Arts, TIPA), residences and markets called MacLeod Ganj which ends slightly further down the mountain at the main Temple complex and the Dalai Lama residence (surrounded entirely by a circumambulation route); (2) a mid-region even further down where the Central Tibetan Administration (henceforth referred to as CTA) offices (including the Paliament-in-Exile and Department of Health, henceforth referred to as DoH) and Library of Tibetan Works and Archives (LTWA) research library can be found; and (3) a lower region of Indian residences, offices and markets which splits off towards the Lower Tibetan Children’s Village school in one direction, and towards the Kangra Valley in the other. For the convenience of our purposes here we will subsume the entire area under the name “Dharamsala.”
What is provided collectively? What types of health care goods, other social goods & consumer goods?
Having provided some necessary background to the Dharamsala Tibetan settlement, we can now look at the goods available to the refugees. Let’s divide them broadly into the necessities of life (water, food, clothing, shelter, electricity), and essential services such as refugee intake and placement, health care, security, sanitation, education and transportation. Of course, many of these fall under Daniel’s categories of “[h]ealth-care needs…[which are] those things we need in order to maintain, restore, or provide functional equivalents (where possible) to, normal species functioning…[and which] can be divided into (1) adequate nutrition, shelter; (2) sanitary, safe, unpolluted living and working conditions; (3) exercise, rest, and other features; (4) preventive, curative, and rehabilitative personal medical services; (5) non-medical personal (and social) support services.” [iv] Looking at this list, we will add recreation to ours (including exercise and entertainment), and we will look particularly at medical (allopathic and traditional) health care and treat it separately.
The Tibetan refugee community in India almost entirely depended on the kindness of the Indian government when they first arrived in 1959, physically and emotionally destitute. “With help from concerned governments, the UN High Commission for Refugees, humanitarian organisations, and philanthropic individuals on the one hand and the sheer tenacity of the Tibetans themselves on the other hand,”i over the next 50 years an infrastructure has been built on the basis of a “democratic administration in exile…to manage the affairs of the Tibetan refugees” i to the point where the Tibetan community in Dharamsala has become autonomous and self-sufficient to a very high degree. Some of the goods mentioned above are provided/regulated by the Indian Government, some are collaborative between the Tibetan and Indian communities, and some are entirely provided by Tibetans for Tibetans. Some of the necessities of life are only available through the Indian governmental agencies, such as those which regulate water and electricity/gas distribution. A certain amount of land was initially given to the Tibetans, but building in other areas requires both permission from the government and collaboration with Indians since non-Indians cannot own land in India. An exmple of such a negotiation is the process of acquiring land in an area close to Dharamsala for another important Tibetan religious leader, His Holiness the 17th Gyalwa Karmapa. Although the mountainous terrain of Dharamsala prevents the Tibetans from engaging in much agriculture, they do produce their main staple from ground barley, known as tsampa. Many goods are also brought from Tibet, such as bricks of tea, yak jerky and dried cheese. As expert crafts people, the Tibetans make much of their own traditional clothing, and sell them, as well as generating income by way of tourism and hospitality, crafts such as carpet weaving, wood and metal carving and sculpture, thangka (religious iconography) painting, book publishing, and traditional Tibetan medicine. This income allows for the purchase of food and clothing they cannot produce themselves, individual roof-top water tanks (beyond that which is available communally, such as the water that comes from local water-pumps) and electricity/gas supply.
As for essential services, the only areas where the Tibetans are for the most part dependent on the Indian government are security and transportation. Although there is a private security force surrounding the Dalai Lama at all times, which is reasonable for someone who is considered to be like a head of state (despite there being a democratically elected prime minister and parliament of Tibet-in-exile), the police and military are Indian-run. Although many Tibetans own private vehicles, including a great many motorcycles for their convenience and cost-effectiveness, the bus services (save some Tibetan-run tourist buses) and taxis are state-controlled. The remaining essential services, refugee intake and placement, health care, sanitation, and education, are collaborative overall, but Tibetan health care and education are predominantly internal within the Tibetan community. When Tibetans arrive from Tibet, exhausted, impoverished, frost-bitten from walking over snowy mountains and sometimes at death’s door, the Tibetans have everything in place to assist them (including a Tibetan Torture Survivors Program, TTSP, a “multi-disciplinary program…[to] reduce physical, psychosocial and psychological problems as a result of violence and politically motivated torture in prisons in Tibet”)[v], but eventually the new refugee will need to get permission to stay from the local police superintendent. There are identity papers that a Tibetan may acquire from the Indian administration, but they are not the equivalent of our landed immigrant documents. They may potentially be sent back to Tibet, but this does not happen as frequently as in Nepal since India does not relent to bullying by China whereas Nepal is heavily influenced by the regime. Tibetans even have the freedom to protest the Chinese occupation in India, but in Nepal it is forbidden (which I learned the hard way when I was arrested in Kathmandu in 1996 for being on a bus that was merely heading towards an Amnesty International sponsored rally). As for education, “[w]ith assistance from the Government of India, Tibetan schools were established to impart modern secular education to the Tibetan children while also emphasising the learning of Tibetan language and literature, history, culture, religion, arts and crafts,”i and now it is safe to say that there are no Tibetan children not attending one of the Tibetan Children’s Village schools (which also serve as orphanages). In theory, the Indian government schools are open to Tibetans, but that option is not usually taken. Tibetans also have the option to attend secondary and post-secondary institutions, such as the College for Higher Tibetan Studies (where I had the fortune to studied logic and philosophy in the Institute of Buddhist Dialectics division). It is important to note that monastic community life and education is available as well, with more monastic colleges for males but still enough available for nuns to pursue such training also. Sanitation is an ongoing struggle for both the Tibetan and Indian administrations and communities. Both have made attempts to slowly develop recycling and garbage pick-up programs and install public washrooms in key locations, such as the main religious hub of the Temple complex of the Dalai Lama. Open sewers remain, as does the phenomenon of outdoor human waste elimination at the side of the road, or even during mass gatherings with the side of a hill demarcated in lieu of porta-potties. Garbage is still thrown into the environment, and collected waste is brought to open dumps at some distance from residential areas. Tibetans must pick up the slack in areas where the Indian government falters, and their recycling in the Tibetan institutions is quite admirable. The stray dog overpopulation problem, with rabies and mange quite rampant, is dealt with either by removing them to other areas, isolated sterilisation projects (such as volunteer Danish vets brought in the early 2000’s) and a relatively new animal welfare association. Lastly, touching briefly on recreation will suffice with mention of basketball courts being an essential part of every Tibetan school’s yard, and a public swimming pool built by the regional authorities at the site of a natural spring, which keeps the pool constantly full of fresh (and bone chilling!) water.
Next we come to health care. India has, in general, a two-tiered health care system. Both Indian government hospitals and private clinics exist, the latter including physicians, labs, diagnostic imaging, oncology and so on almost endlessly. Tibetans have access to both, but would sooner visit a traditional Tibetan doctor who approaches health with a 3-humours model, placing emphasis on pulse and urine analysis and including religious explanations and activities in response to health concerns. They may also simply buy herbal remedies, or blessed substances such as ‘mani pills,’ from the Tibetan Medical and Astrology Institute (TMAI, Men-Tsee-Khang). Both Men-Tsee-Khang and the Tibetan Delek Hospital are located mere steps away from the Central Tibetan Administration complex, and the hospital would be the next place to visit when addressing more serious conditions. The “45-bed…hospital provides general medical care with a special focus on Tuberculosis, the single most serious infectious disease that threatens the Tibetan population and new arrivals from Tibet. Delek also has strong maternal and child health care programs, a service sorely lacking in the area.”[vi] Since Delek’s “hospital services are limited to primary health care…as we cannot provide advanced medical facilities in our settlement hospitals due to lack of qualified and duly skilled staff and also because of financial constraints” patients are sometimes sent for “advanced…treatment in referral hospitals in various parts of the country…[hospitals] that cover major surgeries and other allied health services, which are currently not available in our settlement hospitals.”v The hospital does have a single, small ‘ambulance,’ a converted van of the type used by local taxi drivers. A co-ed old age home for the Tibetan elderly, Jampa Ling, is located behind the residence of the Dalai Lama, strategically placed because it is on the circumambulation route around the residence and older Tibetans are quite fond of circumabulating for health and social chatting, in addition to the karmic merit that is thought to be accrued. At any point in the development of health concerns, from the most minor to the most major for oneself or a loved one, a Tibetan may also consult a religious professional (either monastic or not). In addition to astrological advice that can also be accessed at the Men-Tsee-Khang, a client may ask for: a divination (by dice, tsampa balls, or drum); an assessment for potential spirit harm as the cause of disease or obstacles; or even an exorcism (though this is less frequent in contemporary India, or kept more quiet). The Central Tibetan Administration’s Department of Health is “working towards the integration of traditional system of Tibetan medicine with the allopathic Primary Health Care system in order to avail maximum benefits. The two systems of medicine run in parallel to each other and are used equally by the people; increasing the frequency of referral process between the two health care systems.” v It has also, over the years, implemented programs for: potable water, improved sanitation, substance abuse rehabilitation, helping those with disabilities and special needs, and health education including HIV/AIDS campaigns.v
The nature of the provision for each of these types of goods.
Upon arrival to India as refugees, the Tibetans lived in tent camps and the basic necessities of life were provided for by the Indian government. Since then, the Tibetans in Dharamsala have become organized enough to not have to rely entirely on the generosity of India and can afford the costs of individual household water-lines/tanks (although some families still access local unfiltered well-water via pumps, which are unreliable at best but available at no cost) and electricity, food and clothing (so much so that new refugees can be taken care of by the community) and land beyond the areas initially given to the Tibetans. Although private taxi-drivers and tour buses abound, generally bus and taxi transportation service and fees are regulated by the government which makes for low ticket prices and reliable schedules. The extra efforts to improve sanitation in Dharamsala are borne by the community and donations from abroad. Almost every area of Tibetan society is in some way touched by international financial support, but predominantly it is found in support of: refugee services, education, environment (sanitation, roads, building), monasteries/nunneries and health care. As mentioned earlier, Tibetans can access free education and health care provided by the Indian government but mostly opt out in favour of Tibetan-run services. Education and health care are two areas where needy Tibetans can get what they need at no cost, but, in addition to international donations, the Tibetan community itself bears the financial burden to some degree.
The Tibetan Children’s Village is a case-in-point regarding the Tibetan community investing in education to ensure access and quality. “On 17 May 1960, fifty-one children arrived from the road construction camps in Jammu, ill and malnourished. Mrs. Tsering Dolma Takla, the elder sister of His Holiness, volunteered to look after them. Initially these children were assigned to members of the Dalai Lama's entourage, but before long the Government of India offered its assistance, renting Conium House to accommodate all the children together… Originally, the Nursery for Tibetan Refugee Children provided only basic care for children. When they reached the age of eight, they were sent to other residential schools established by the Government of India. But eventually this arrangement could not be continued as all the residential schools filled to capacity… A massive re-organization plan was set into motion. This included seeking help from private donors and international aid organizations. A period of hectic construction work ensued to provide for more houses and classrooms for children. The Nursery slowly took the shape of a small village with its own school and homes… [Started in the 80s during a great influx of refugees, t]oday, TCV School Lower Dharamsala is a high standard school with both primary and secondary school. It is entirely funded by Tibetan parents in exile.[vii] Initially the Government of India provided both land for refugee orphan housing and access to Indian schools, but proving inadequate, the growth required depended instead on international support and eventually the Tibetans could support their main school themselves. The monastic life, too, is invested in by both international supporters and the Tibetans-in-exile such that any Tibetan who can follow the discipline can be assured of a lifetime of support by the institution. This includes the necessities of life and extensive religious (and some secular) education.
Health care is another example of a good invested in by both international supporters and the Tibetans-in-exile themselves to ensure access and quality. It is free for both Tibetans and local Indians who cannot afford the low fees. “In its basic health care policy, the DoH has adopted the goal of ‘Health For All,’” v and as an example, Delek Hospital is a charitable institution where “[u]ser fees are kept exceptionally low so that the poor can afford treatment in this hospital.”vi The CTA is responsible for maintaining free access to health care for the poor: “Under the guidelines issued by the Kashag (Apex Executive Body), the Central Poverty Alleviation Committee has conducted an intensive survey on poor and needy among the exile Tibetan Community… As per the Kashag’s policy and guidelines, the Department of Health is providing monthly stipend and bearing all the medical expenses of all the needy and poor Tibetan people identified by the Central Poverty Alleviation Committee.” v An Emergency Medical Relief Program allows for Tibetans to pay what they can (even if it is zero), and to buy into health insurance: “advanced treatment…can be classified into two categories: emergency medical relief for the staff members of Central Tibetan Administration who make a monthly contribution of 1% of their monthly gross salary towards CTA medical fund. The other category is the poorest of the poor who are selected and duly registered by the three concerned CTA Departments, i.e. Department of Home, Education and Health. We look after the health of the poorest of the poor category and bear cent per cent of their medical cost including medical services, surgery and other operational cost. As for the remaining category of patients, the percentage of DoH medical relief assistance is based primarily on the scrutiny and recommendation of the settlement heads, camp leaders and the DoH hospital Executive Secretaries of various settlements.” v
What types of health care goods are and are not provided collectively (or where the type of provision is different)?
There is a difference in the distribution of Tibetan traditional medicine and the operation of freelance religious professionals that address health concerns by way of traditional medicine or by religious methods. The Tibetan Medical and Astrology Institute (TMAI, Men-Tsee-Khang) supports their own staff and their families, and students from funds generated by their services and from international support. “To involve children in the community of TMAI, housing, child care and other resources are provided to staff and their families. To ensure that the children of staff receive adequate medicine, food, clothing and school supplies, we seek individuals willing to sponsor a child… As part of its charity work, Men-Tsee-Khang also provides free education for its medical and astrological students.”viii Additionally, the elderly, new refugees, the poor, monastics and students are granted special consideration: “Charitable Health Care: As a registered charity, it is Men-Tsee-Khang policy to provide free medicine to Tibetans over the age of seventy, to new Tibetan refugees for the first six months, and to poor or desitute Tibetans (the respective Settlement/Welfare Officer in the refugee settlement determines whether a Tibetan is poor or destitute). Concessional medicine is provided to monks, nuns and students.”[viii] It is noteworthy that the last category of Tibetans are not given free medicine, but rather that which is “concessional” (some degree of subsidy), likely because the institutions to which they belong provide on-site medicine and basic nursing care, monetary support for health care external to the institution, and monetary stipends. It is also worth noting that the elderly are given free medicine regardless of their financial standing.
As freelancers, religious professionals control the distribution of their own services. As they may or may not be monastics, they may or may not be receiving financial support from a monastic institution or individual lay Buddhist devotees. As a dependent themselves, it would be difficult for a monastic to deny helping someone who could not afford their services but as there is no regulation of their vocation as a healer, herbalist, diviner, astrologer, exorcist or ritual specialist, their own discretion determines how they deliver services. If they are a graduate of the Men-Tsee-Khang, as many monks are in fact trained traditional Tibetan medical doctors, there may be some systemization of their delivery of service despite having their own clinic. This requires further investigation.
What rationale(s) is provided (or implied) in all of this? What appears to be the nature of the entitlement(s)?Here we have several types of distribution: the Indian governmental support of the Tibetan refugee community, Tibetans helping other Tibetans, Tibetans investing for entitlements for themselves and the younger generation, Tibetans helping the impoverished regardless of their ethnicity, and Tibetans giving special entitlements to certain groups within the Tibetan community: new refugees, the elderly, the destitute, students, and monastics.
As for the initial and ongoing Indian governmental support of the Tibetan refugee community, I think there are several layers of rationalization behind it. The first could be the particular situation of the Tibetans as refugees. As such, they are particularly needy, disadvantaged and unprotected. Not only this, they are a neighbouring people who consider India as their spiritual homeland from which their religion has come, as the majority of Tibetans are Buddhists who practice Indian Buddhism (as opposed to Chinese Buddhism). Plus, India is sympathetic to the Tibetan cause in opposition to the Chinese communist viewpoint that Tibet is a part of China therefore their occupation is legitimate. This is shown by 50 years of India not bowing to Chinese pressure to not host the Tibetans, and could be reinforced by the fact that India has had its own troubles with China where their borders meet. For both the Indians and Tibetans who are in a position to help new refugees, both can see them as special claimants, and be motivated to meet their needs because they are especially needy. They may also be motivated to prevent harm, and also driven by charity and beneficence. The reasoning of fulfilling the needs of others by virtue of their being special claimants can also be behind the Tibetans’ demarcation of certain groups: the poor in general, and the elderly within their own community. These groups are vulnerable and especially needy, and so helping them can be motivated by the same reasoning as for helping refugees (harm prevention, charity, beneficence). Alternatively, the students and monastics would not have special entitlements because of being especially needy and vulnerable, but rather due to their particular lifestyle requiring them not to work and the value placed on these groups by Tibetan society. Students, in order to fully participate in society as a wage-earner, need to spend a certain amount of time focusing on their studies and not working. Similarly, but in an ongoing way, monastics need to focus on their religious studies and practice and in observing the ascetic discipline they do not do wage-earning work in that trade or commerce increases attachment to wordly activities and possessions. Highly revered in Tibetan culture, the role of a monk is in reciprocity with the Buddhist householders: the monastics offer teachings and guidance, and the householders support them by providing the requisites of food, shelter, clothing and medicine (either directly or by way of making donations to the monastery/nunnery). It would be remiss to not mention that Buddhists see any help offered to monastics as one cause for the accumulation of meritorious karma that will benefit the practitioner in this and future lives, so religiously-oriented motivations also influence entitlements granted monastics. Lomasky’s statement that “[e]ven on coldly economic grounds, it is irrational not to invest a sum that will be returned many times over in a life of increased productivity” [ix] can apply to the entitlements given to refugees, students and monastics. Even though wage-earners and non-wage-earners have different outputs from their training and development, both are valid and valued by Tibetan society for their contributions. As well, both refugees and students will eventually, it is hoped, no longer be at all dependent on special entitlements and so their initial and limited supported can be seen as the fair equality of opportunity principle in operation.
According to these policies and practices, is health care different? How is health care different?
Buchanan’s approach of using the “combined weight of arguments…[as] justification for an enforced principle guaranteeing a decent minimum of health care to everyone…[rather than a] universal right to a decent minimum of health care”[x] might give us a glimpse at the reasoning behind the Indian government and the Tibetan community in India treating health as paramount in refugee support. The first are the “Arguments from Special Rightsix where “[s]pecial right-claims…restrict the right in question to certain individuals or groups."[xi] One type of these arguments is "from the requirements of rectifying past or present institutional injustices… on the grounds that these injustices have directly or indirectly had detrimental effects on the health of the groups in question...[from a] history of unjust treatment by government or other social institutions."x The Tibetans as new refugee claimants escaping from an oppressive regime certainly makes them an especially needy group health-wise, suffering from such things as: injuries, malnourishment and post-traumatic stress from torture, underlying illnesses exacerbated by not receiving proper care in Tibet, frost-bite from the trek to India and so on. The legitimacy of the claim is strengthened by India’s first-hand experience with China’s strong territorial movements to surrounding areas. In this case, the rectification would not be because of injustices perpetrated by India, but rather those perpetrated by the occupying Chinese and recognized as such by India. Another line of reasoning comes from Buchanan’s “Arguments from the Prevention of Harm” which will "protect the citizenry from certain harms arising from the interactions of persons living together in large numbers… Examples include sanitation and immunization. The moral justification of such measures, which constitute an important element in a decent minimum of health care, rests upon the widely accepted Harm (Prevention) Principle, not upon a right to health care." x Since the Tibetans have, at various times (particularly 1959 and the mid-80s), come to India in droves, such a principle would inform the actions of the hosting nation in relation to refugees to ensure not only that the Tibetans would not be harmed by being put together while their susceptibility to illness is high (taking as a given that the majority will not be in good health upon arrival), but also so that Indians in the surrounding areas will also not be harmed by the spread of disease out from the refugee community.
Earlier it was shown that education and health care are the two social goods that Tibetans buy into for themselves: Lower TCV school is entirely funded by Tibetans, and some Tibetans have the option to give a percentage of their income as health insurance. Health care is approached differently in that it relies on support from the CTA and donations both local and abroad and a sliding-scale based on the ability to pay because (1) the needs are so great and, because (2) the Tibetans are committed to providing health care to every Tibetan. It cannot be said that the Tibetans ensure that every Tibetan gets an education, since it is only for Tibetans of schooling-age that this is done. But it can be said that the Tibetans ensure access to health care for every Tibetan.
A major influence on the Tibetans treatment of health as special comes from the Buddhist conception of suffering and its alleviation as the fundamental human challenge. When Daniels says that “[s]ome might say health care in a direct and simple way reduces pain and suffering,”[xii] the Tibetans would belong to this group. There are many principles from Buddhist doctrine and practice that might influence Tibetan decision-making: generosity, the wish to benefit others, the wish to become fully developed in order to be most effective in helping others do the same, love (the wish for others to have happiness), compassion (the wish for others to be free from suffering), the technique of imagining taking on other’s suffering and giving them happiness in return, and so on.. All of these can be engaged in with the idea of accruing karmic merit for oneself or, alternatively, with no hope for reward, purely for the sake of the other. With these as a foundation, an “enforced beneficence argument for a decent minimum of health care”[xiii] might not be seen as interference in a person’s autonomy but rather as a co-ordinated effort to act in accord with Buddhist principles as a group which must necessarily lead to a positive outcome.
It might be said that Tibetans overemphasize health. This, however, might be perceived by an observer as due to the Tibetans’ not holding to a “ ‘biomedical’ model of disease and health…[where health is the] absence of disease…[and illness is from] deviations from the natural functional organization of a typical member of a species.”[xiv] Tibetans, rather, adhere to a bio-psycho-spiritual view of health, which means that many things are included that would not be typically seen as falling under the binary of health/disease, such as very subtle conceptual positions and emotions. Also, contrastingly, because the end goal of the Buddhist path is seen as total mental health (which will necessarily be coupled with perfect physical health), a heavy emphasis is placed on mental development to the detriment on some crucial components of health, such as exercise.
Are these policies and practices appropriate?
The historical support of the Tibetans-in-exile by the Indian government in providing refuge, the necessities of life and essential services up to the point where the community could support themselves, to the detriment of the country’s relationship with China, is very admirable and garners ongoing gratitude from the Tibetans. Treating refugees as a special group, especially when most have been subject to abuse, is appropriate, as is harm protection for the Tibetans as a group and in relation to pre-existing neighbouring communities. The Tibetans utilize these two principles (special entitlements and harm protection) themselves when dealing with new refugees. The only problem is see with this is in finding the threshold where a new refugee is no longer ‘new’ and has achieved a certain level of stability where his entitlements should change because they require less dependence. The Tibetans make this distinction, but I do not know how they come to the determination that a refugee is no longer ‘new.’ I also am not sure how or if the Indian government makes the distinction between a new or more settled refugee. My concern extends to the support given by international donors and fundraisers. For example, in South India some monastic institutions receive monetary support beyond their needs and, in the expressed opinion of the Dalai Lama, it is wasted on buildings that are too big to fit all of their monks and would be used more effectively if given to the local farmers who struggle with drought. Also, in every Tibetan community in exile there will be some who try to retain multiple sponsors, on the basis of being a refugee and each without the knowledge of the others, and resulting again in there being resources beyond needs. The potential to subsume new refugees with those that are more settled, and the accumulation of benefits and donations from multiple sources, can endanger entitlement claims as well as charitable assistance.
In my opinion, the biggest concern with the reasoning behind health care provision in the Tibetan refugee community in Dharamsala is the lack of some degree of personal responsibility affecting distribution. As Gutmann states, when we consider the various “choices of lifestyle among the population[xv]…[a]n equal access principle seems to neglect the distinction between voluntary and nonvoluntary health risks…”[xvi] The Tibetan community is notorious for certain types of behaviour statistically leading to certain health outcomes: a diet relying heavily on butter and salt, leading to high prevalence of diabetes; snuff usage, even (maybe even especially) in monastic community, leading to nasal problems and cancer; long periods of meditation while immobile in meditation retreat boxes causing crippling joint problems; lack of exercise in monasteries leading to obesity and heart problems;
and some may point to almost perpetual usage of incense as a risk for sinusitis. Not unique to the Tibetans, of course, but alcohol and drug abuse are problems particularly among new and young Tibetan refugees. Like Gutmann, in this community where access to health care is guaranteed for all, I would “…ask whether it is fair to provide the same level of access for all people, including those that voluntarily adopt bad health habits, and who quite knowingly and willingly take greater-than-average risks with their lives and health.”xvi The question is: are Tibetans all able to recognize certain activities as health risks? I agree with Dworkin (1979), quoted by Gutmann, who states that it would “not be unfair to force individuals to be financially liable for voluntarily undertaken health risks, but only under certain conditional assumptions…[the] ability…1) to determine…causal role of voluntary versus nonvoluntary factors in genesis of illness; 2) to differentiate between purely voluntary behaviour and…compulsive; and 3) to distinguish between genetic and nongenetic predispositions to illness.”[xvii]
If it is determined that a behaviour that is a risk to health is voluntary, the question then becomes: what health care entitlements are owed to this Tibetan by the Tibetan community, as decided by the CTA DoH? This is a difficult question in the context of a community committed to “health for all.” I would, however, suggest some new methods of health education and some deterrents to behaviours that pose health risks. Until now, according to the DoH, health education has been limited to “various health awareness programs in the settlements, schools and monasteries…[by way of] newsletters…pamphlets, books, comics, posters and films.”v What education is done by health professionals at the bedside or in clinics? And do foreign volunteer health providers have the freedom to explore approaches to health that may have never been broached with a Tibetan before? As for risk behaviour deterrents, since threats to access would not fit the Tibetan “health for all” model, providers could discourage those who consciously engage in behaviour that risks health by: increasingly burdening them with accountability exercises; providing explicit reference to the strain on the community, caregivers and resources (cost per visit or procedure); and making them aware of the increasing barriers to their own ability to access health services that would come with deteriorating health (such as not being able to make it to the hospital in time when in crisis).
Notes
[ii] Department of Tourism & Civil Aviation, Government of Himachal Pradesh, Shimla (2008); Himachal Tourish: Unforgettable Himachal; http://himachaltourism.gov.in/post/Dharamshala.aspx
[iii] An Informative, Travel and Community Website of Dharamsala, Mcleodganj and Kangra Valley (2011); http://www.mcllo.com/mcleodganj%20%5BMcllo.com%5D.html
[iv] Daniels, N. (1981); Health-care Needs and Distributive Justice. Philosophy and Public Affairs; Spring. 10(2): p. 158.
[v] Central Tibetan Administration Official Website (2009); http://www.tibet.net/en/index.php?id=25&rmenuid=12
[vi] Friends of Delek Hospital (2010); http://www.delekhospital.org/index.htm
[vii] Tibetan Children’s Village (2004); http://www.tcv.org.in/
[viii] Men-Tsee-Khang: Official Website of the Tibetan Medical and Astrology Institute of H.H. the Dalai Lama (2011); http://www.men-tsee-khang.org/
[ix] Lomasky L. (1981); Medical Progress and National Health Care. Philosophy and Public Affairs. 1981; 10(1): p.85.
[x] Buchanan, Allen E. (1984); The Right to a Decent Minimum of Health Care; Philosophy and Public Affairs, Vol. 13, No. 1, Princeton University Press. p. 66.
[xi] Ibid.; p.67.
[xii] Daniels 1981; p.169.
[xiii] Buchanan 1984; p.76.
[xiv] Daniels 1981; p.155.
[xv] Gutmann A. (1981); For and Against Equal Access to Health Care. The Milbank Memorial Fund Quarterly. Health and Society; 59(4): p.553.
[xvi] Ibid.; p.554.
[xvii] Ibid.; pp.554-555.
References
An Informative, Travel and Community Website of Dharamsala, Mcleodganj and Kangra Valley (2011); http://www.mcllo.com/mcleodganj%20%5BMcllo.com%5D.html
Buchanan, Allen E. (1984); The Right to a Decent Minimum of Health Care; Philosophy and Public Affairs, Vol. 13, No. 1, Princeton University Press.
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