Publications

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Annual Report 2001

THE RIGHT TO HEALTH

"Health" is defined by the World Health Organisation as a "state of complete physical, mental and social well-being and not merely the absence of disease or infirmity". The right to a reasonable standard of health is articulated in the Universal Declaration of Human Rights (UDHR), the International Covenant on Civil and Political Rights (ICCPR), the International Covenant on Economic, Social and Cultural Rights (ICESCR), the International Convention on the Elimination of All Forms of Racial Discrimination, and that against Women (ICERD and CEDAW respectively), and the UN Convention on the Rights of the Child (CRC).

Both ICERD and CRC uphold the right of everyone without discrimination based on race, colour, national or ethnic origin, to enjoy "public health, medical care, social security and social services".¹ CEDAW similarly bars discrimination against women and ensures the right of women to access adequate healthcare facilities. ²

While its Constitution does not explicitly guarantee the right to health, as a signatory the PRC is bound to standards of health enshrined in these Conventions. To this end, the PRC's Constitution lists the measures that are taken in order to advance and protect the health of its citizens, recognising the "right of everyone to an adequate standard of living, including a continuous improvement of living conditions," ³ including "the right of everyone to the enjoyment of the highest attainable standard of physical and mental health". ⁴ This right encompasses the creation of conditions that assure medical service and medical attention to all in the event of sickness. The State also purports to

develop medical and health services, promote modern medicine and traditional Chinese medicine, encourage and support the setting up of various medical and health facilities by the rural economic collectives, state enterprises and undertakings and neighbourhood organisations, and promote sanitation activities of a mass character. ⁵

The provision of healthcare within Tibet is found to vary widely between regions. Different regulations are found to be in force in each county, indicating a high degree of localised policies.⁶ What Tibetans commonly experience is racial discrimination in their attempts to obtain basic health services. Those escaping occupied Tibet report access to – and provision of – services as limited, and low-level or inadequate where available. The standard of basic health education also remains low. This is a serious concern, particularly in view of the escalating incidences of confirmed HIV/AIDS now acknowledged by China. Finally, a number of international studies have identified malnutrition and several life-threatening diseases as being prevalent on the Tibetan plateau.

The PRC’s November 2001 White Paper hails Tibet’s March toward Modernisation: “…Tibet has kept marching forward along the road to modernisation and made significant achievements that have attracted worldwide attention”.⁷ China may not, however, wish to herald the negative attention it has received this year particularly in the field of nutrition. Independent medical studies, and research inside Tibet by the US Embassy in Beijing, have made serious findings regarding the health status of Tibetans.⁸ Poor levels of nutrition were highlighted in the studies, along with the prevalence of certain endemic diseases. It was found that despite extensive central government subsidies, “…the region’s healthcare infrastructure still significantly lags behind the rest of China.”⁹

Statistics versus reality

It appears China is aware of the difficulties of providing a largely rural population with adequate standards of healthcare. China’s November 2001 White Paper states that pre-1959 Tibet was “extremely short of doctors and medicine, and most sick people lacked both money for medical care, and access to doctors”.¹⁰ Now, according to China, Tibet enjoys a comprehensive “medical and health network…covering all the cities and villages in the region” .¹¹ Despite injections of funds and such optimistic rhetoric, Beijing’s description of Tibet’s pre-1959 health infrastructure and services in fact accurately portrays the current situation. This reveals Beijing’s priorities when it comes to development in Tibet, particularly when compared to other rural areas inside China.

An independent medical study published in 2001 found that over 50 percent of the 2,078 Tibetan children assessed had moderately or severely stunted growth, well above levels found in China.¹² Severe stunting due to malnutrition occurs at a young age, as a consequence of numerous adverse conditions. These include the poor nutritional status of women, exposure to infection and other diseases, emotional stress, and possibly the effects of high altitude living.¹³ The proportion of children with stunted growth was found as greatest in non-urban areas, a conclusion that does not bode well for the estimated 80 percent of Tibetans who live in rural areas.

The long-term effects of growth stunting have been linked to impaired development, lower intelligence and a reduced capacity for labour. These contribute to poor academic performance and limited employment opportunities, perpetuating the cycle of discrimination faced by Tibetans.¹⁴ Growth stunting reveals that the human right to adequate nutrition and access to healthcare has been denied. This will have a negative effect in Tibet for generations to come.¹⁵ The international study concluded with the observation, “The larger view is that as each day passes, the children of Tibet are suffering from a silent calamity that causes many to die and that inhibits the development of the survivors.”¹⁶

Tibetan refugees escaping to India from across the plateau testify to the bulk of funds that Beijing has allocated to Tibet’s health sector being channelled toward developing infrastructure, most commonly in areas where a significant Chinese population has settled

Contrary to the picture painted by Beijing’s statistics, Tibetan refugees escaping to India from across the plateau testify to the bulk of funds that Beijing has allocated to Tibet’s health sector being channelled toward developing infrastructure, most commonly in areas where a significant Chinese population has settled. This translates into the larger part of actual costs of medical treatment still being paid by the patient, while the often inaccessible hospitals and healthcare centres are improved.¹⁷

New arrivals in India are also sceptical about the utilisation of funds donated by international aid organisations. Dhimey, from Sog County, Nagchu Prefecture, “TAR”, states, “Any donation that is made for the people, the authorities will take in the name of the people and actually use it for themselves – they will buy a vehicle, or a generator. Donations for the people’s welfare actually does nothing for the people.”¹⁸

China faces logistical difficulties and resource constraints in attempting to provide comprehensive healthcare in Tibetan regions. However, there are some obvious steps to improve the situation, such as encouraging the education and training of Tibetan healthcare workers to serve their own communities, removing restrictions on foreign agencies working inside Tibet, and the promotion of health education campaigns — all of which would have minimum costs with substantial gain.¹⁹

The ability of individuals to exercise their human rights is directly related to their awareness of the rights to which they are entitled.²⁰ Thus the importance of health education for adequate nutrition and preventable, communicable diseases is paramount. Recent research inside Tibet “did not indicate that the PRC have made efforts to disseminate basic health and sanitation information to inhabitants of rural Tibetan regions.”²¹ The lack of information provided to pregnant women about health and nutrition are indicative of the absence of general healthcare education. Excepting one recent arrival from Saga County, Shigatse refecture, “TAR” the vast majority of refugees reported that no one gives health or nutrition advice to pregnant women.²²

However, the current HIV/AIDS debate within China may result in greater educative efforts, as indicated by the secretary-general of a recent HIV/AIDS conference within China: “Since there is no way to eradicate the HIV virus at present, everyone in cities and villages should receive health education.”²³

HIV/AIDS and the right to life

The growth of prostitution, a birth control policy that places all responsibility upon women, and a widespread lack of preventative education sets the scene in Tibet for an HIV/AIDS crisis. Inside China — with severe repercussions for Tibet — there appears to be a general reluctance to concede the potential consequences of an HIV/AIDS epidemic. HIV/AIDS is known to thrive amongst minority groups with a widespread lack of knowledge and protective life skills, a transient population, low socio-economic status, and inequitable gender dynamics.²⁴ Many areas of Tibet fit this UN definition, and combined with the borders Tibet shares with China, India and Nepal, there is strong evidence to extrapolate the existence of HIV/AIDS in Tibet.

Official 2001 figures published by Chinese authorities, widely viewed as conservative, have placed the number of confirmed HIV/AIDS cases across China at between 600,000 to 1 million, with a 30 percent annual rate of increase.²⁵ To date, Tibet is declared to have no confirmed HIV/AIDS cases.²⁶ In making this statement, the US Embassy in Beijing is referring to the “TAR”, excluding areas of pre-1959 Tibet that have since been claimed by China’s Yunnan and Sichuan. Both provinces register significant levels of confirmed HIV/AIDS cases, Yunnan recording the highest HIV/AIDS rate in China²⁷ . Inside the “TAR” there are no HIV/AIDS testing facilities, rendering it impossible to ascertain the level of the virus inside Tibet. The lack of confirmed HIV/AIDS cases must therefore be seen as reflecting these factors, rather than the status of health inside Tibet.

The future of HIV/AIDS within Tibet is heavily influenced by the actions the Chinese government takes in order to mitigate the epidemic, and if Beijing does not urgently begin comprehensive preventative education campaigns and establish testing and treatment facilities within Tibet, the chances of mitigating the crisis are slight.

Those exposed to HIV/AIDS are entitled to the right to life, to information and to accessing all the benefits of scientific progress. The ICESCR recognises the right of everyone to enjoy the benefits of scientific progress and its applications.²⁸ This right entitles people living with HIV/AIDS access to treatments and drugs which prolong life expectancy. All countries with poor health infrastructure face difficulties in providing these services, with China’s immense population also contributing to China’s inability to widely offer these provisions.

The lack of information currently provided to both Chinese and Tibetans surrounding preventative education constitutes a breach of the right to information for the protection of public health.²⁹ The UN Commission of Human Rights has urged states to

introduce protective legislation and appropriate education to…ensure the full enjoyment of civil, political, economic, social and cultural rights by people living with HIV/AIDS.”³⁰ UN officials continue to press China to take urgent measures, as “over the next two decades, what happens in China will determine the global burden of HIV/AIDS”.³¹

Disregarding the magnitude of the potential epidemic, China has failed to incorporate recommendations by the international community into domestic law, as well as breaching the Covenants to which it is party.

Absence of strategies targeted toward HIV/AIDS awareness and prevention are reflected through the testimonies of recent exiles. The majority of new arrivals from Tibet state clearly: “No one in our country knows about it, no one in Tibet has this disease.”³² The view is unanimously shared that: “We do not have AIDS in our village. It is said that there is a terrible disease in big towns. The people in the village are talking about it while the government and the hospital says nothing.”³³

In China, a delay of 13 years followed the first confirmed AIDS case in 1985 and the establishment of HIV/AIDS prevention or control centres, an example of China’s inability to respond to the impending crisis.³⁴ This reluctance has translated into barriers in accepting the seriousness of the epidemic, and obstacles in the implementation of preventative campaigns. The spread of accurate preventative information in the PRC is inhibited by the “traditional morality” that accords discrimination to people living with HIV/AIDS.³⁵

The prevalence of discriminatory attitudes are associated with a lack of awareness, and can be assuaged only by education strategies that appreciate HIV/AIDS as a complex social problem, connecting issues of conservative attitudes, gender dynamics, public health and strategies for long-term treatment. “Only recently has there been any official recognition of the problem; however, a small yet important trickle of documentation has begun to flow out of China regarding the significant HIV prevalence in both the rural and urban areas.”³⁶ Now that HIV/AIDS is entering into mainstream society, out of the “high risk categories”, attitudes and rhetoric around the issue are beginning to shift.

November 2001 saw China hold its first National HIV/AIDS Conference.³⁷ The conference was combined with the launch of a national campaign to raise awareness, and involved high-level officials, national and international specialists from China, and HIV/AIDS sufferers.³⁸ This is seen as an indication of the changing climate at the political level.³⁹ It seems the Beijing government has little choice but to begin programmes of education, policy review, project management and improving medical standards in testing, diagnosis and treatment. These measures, although promoted during the November conference, have not translated into initiatives inside Tibet.⁴⁰

Although the importance of a centralised education campaign is touted, local officials inside Tibet determine what kind of information is imparted. From Tingri County, Shigatse Prefecture, “TAR”, a farmer recalls a meeting held by local leaders to warn of the dangers of visiting prostitutes:

They said that if we have sexual contact with prostitutes we would get [AIDS]. They said if you get AIDS, not only you but also the next person with whom you have sexual contact will get transmitted with the disease…I don’t know whether [this information] is true or not.⁴¹

Any incidence of HIV/AIDS in Tibet will also have severe repercussions upon the already epidemic levels of tuberculosis (TB) on the plateau. As HIV/AIDS compromises the immune system, the danger of increased cases of opportunist infections such as TB is grave.⁴²

Accessing healthcare

Recent escapees from Tibet unanimously identify key problems contributing to inadequate healthcare services. These include the cost and quality of treatment, the distant locations of facilities, and the racial discrimination faced by Tibetan patients in the urban areas. The costs of attempting to access healthcare are cited by Tibetans across the plateau as a severe prohibiting factor. The array of costs includes hospital or medical clinic deposits, diagnosis and treatment costs, “bed-fees” for accommodation in hospitals,⁴³ charges for medicines and fees for “insurance”.

The county hospital would never treat any patient, no matter how serious the condition, unless they paid an advance of 2,000 yuan (US$235)

In some regions, “security” may be deposited in the absence of sufficient funds. From Sado Township, Chamdo Prefecture, “TAR”, families have been reported to leave precious coral or turquoise as “security”.⁴⁶ Security deposits in Chinese hospitals are consistently reported as waived or reduced for Chinese patients or those working for the government.⁴⁷ The lack of regulations to establish admission fees has resulted in widespread discrimination over access to healthcare between counties and prefectures in Tibet. Individual clinics, centres, or doctors reportedly use their own discretion in fixing the fees for their area, thereby contributing to the difficulties involved in holding the state responsible for such practices.⁴⁸

A themto (Ch: hukou), or identity/birth certificate, is also required prior to admission into most medical centres. This practice discriminates against those who are born “above quota” of the permitted number of births, and therefore are denied a themto. Ineligible for assistance to healthcare, the family must bear the full cost of any treatment for such a child, or attempt to gain a themto through illicit means.⁴⁹

Interviewees describe “passes”, or “cards”, as a further obstacle for those attempting to access medical treatment. Passes of different colours were publicised as entitling holders to subsidised, or free medical care.⁵⁰ A man from Yanag Township, Nagchu Prefecture, reported that “This year, again 20 yuan was collected from each person in the name of medical insurance (for which a card is also given). Nobody has benefited from this arbitrary collection of money”.⁵¹ Tibetans therefore attempt to evade this payment.⁵²

A government official collected 20 yuan from each person and said that we would receive a permit card for the hospital. In 2000, they collected 20 yuan from each person as well. We were supposed to get a green card but so far no one received one. They said that if you get the permit card, you don’t have to pay medical fees.⁵³

Once a deposit is paid, costs for treatment can range from 1,000-3,000 yuan (US$117-235). To put this in perspective, a recently-exiled forestry worker reported his average annual wage was 3,000 yuan.⁵⁴ A man from Chungpo Township, Tengchen County, Chamdo Prefecture, “TAR”, felt that “If poor people get sick they cannot get treatment from our hospital …if a poor person doesn’t get well on his own, he will have to die.”⁵⁵

The distance factor

Refugees from across the plateau testify to the lack of health facilities at village or township levels. Medical institutions are largely confined to county capitals and larger towns, which can be substantial distances for the estimated over 80 percent of Tibetans living in rural areas. This renders the Chinese assertion that “nowadays, medical institutions can be found everywhere”⁵⁶ a myth of bureaucracy.

Difficulties in accessing remote medical facilities is compounded by the lack of roads or transport for many rural Tibetans, even in the case of emergencies. In Tengchen County, Chamdo Prefecture, a former agriculturist said, “There is no motorable road to our village. You have to ride a horse for two days to reach a hospital. Then, if there is a vehicle, you have to drive for about two hours.”⁵⁷ A man interviewed from Malho “TAP”, Qinghai, reports that if a person in his area is seriously ill, he is taken on the back of a motorbike to the closest clinic, even if the condition is serious.⁵⁸ Similarly, for a man from Ngamring County, “TAR”, the closest medical facility was a six-hour walk.⁵⁹

Obstacles of race

The International Convention on the Elimination of all forms of Racial Discrimination (ICERD) guarantees the right of everyone, without distinction as to race, colour, national or ethnic origin, to enjoy “the right to public health, medical care, social security and social services”..⁶⁰ China continues to cite improvements in healthcare and services as evidence of the social progress in Tibetan regions. However, the newly-established medical services are perceived by Tibetans as discriminatory, due to a lack of Tibetan healthcare workers or Tibetan medicine.

Escapees from Tibet report the allopathic style of medicine practiced in hospitals as unfamiliar, and the absence of Tibetan employees exacerbates the confusion and unease felt by many patients. One testified, “Those Tibetans who cannot speak or write Chinese face big problems in hospitals. Filling out the forms and every other process is through the Chinese medium.”⁶¹ An exile from Serzhung Township, Saga County, “TAR”, recounts that in the hospital in her township, “Besides one Tibetan doctor and three Tibetan medical workers, the rest are all Chinese.”⁶² With few Tibetan employees, communication is also difficult. The lack of Tibetan interpreters raises concerns about the possible absence of informed consent when Tibetans require, or request, medical operations.

Chinese racial imperialism continues in the professional sphere. A graduate of “TAR” Tibetan Medical College in Lhasa reported his inability to contribute to an international meeting entitled “The Discussion of Tibetan Medicine in the World”. The proceedings of the seminar, attended by representatives from India, Russia, USA, Japan and France, were conducted in Chinese. “They all talked on Tibetan medicine…Chinese was the main language. Not much could be understood, so later we did not attend.”⁶³ Clearly China enjoys promoting Tibetan medicine to an international audience, endorsement that does not extend to the Tibetan community.

In 2001, exiles have reported a number of Tibetan-run clinics that do not operate with any support from the PRC government. A monk from Ngaba County, Sichuan, reports that the clinic at his Ganden Choephel Ling Monastery provides service to the community, and “…it is accepted if you pay the medical fees later.”⁶⁴ A nomad from the Derge County, Chamdo Prefecture, “TAR”, spoke of the Tibetan clinic in a nearby village, where “…you can give money if you have, and you can also not give money. They don’t ask you for medical fees.”⁶⁵ The service received from traditional Tibetan-run clinics is said to be more accessible and affordable, but it appears to only receive support from Beijing in light of its ability to cut expenses from the PRC healthcare budget.⁶⁶

This approach contrasts to the testimonies reporting Tibetans dying outside health clinics due to their inability to pay.⁶⁷ The increasing use of – and trust in – Tibetan medicine is indicative of its accessibility and utility to those who are unsatisfied with, or incapable of accessing, Chinese treatment. Increased training and support for Tibetan doctors and healthcare worker is crucial to increase the number of Tibetans who are able to receive adequate healthcare. Unless Tibetans are involved in the delivery of healthcare to their own communities, it is unlikely that their health conditions will improve.

Uncertainty in treatment

The 8,984 health employees claimed by China to service 80 percent of Tibet’s townships⁶⁸ may exist on paper only, according to a December 2000 fact-finding mission by Beijing’s US Embassy.⁶⁹ Authorities have admitted to difficulties in training and providing salaries. This leads to poor service and low levels of trust in alleged “health workers”.⁷⁰ Exiles escaping to India are reporting a lack of confidence in the treatment received through the Chinese healthcare system.⁷¹ One informant from Chungpo Township, Tengchen County, Chamdo, “TAR”, explained that “if there are well qualified doctors then the public has faith in them. Some of the doctors are not well qualified”..⁷²

Although the Chinese government claims over 8,000 healthcare workers, many employees are Tibetan villagers who may not be paid for their work and are often inadequately provided with facilities or medicine, operating rather as unskilled pharmacists. A refugee from Pomda County, Chamdo Prefecture, “TAR”, told of a man in his village who “gave outdated medicine that helped very little, and not for free. He doesn’t have any medical training…and is paid 30 yuan (US$3.50) per month by the government.”⁷³ International agencies noted this lack of training and low skills of healthcare workers as early as 1997.⁷⁴

Trust in the healthcare provided is integral to establishing a cohesive system, but cannot be achieved without substantial improvement in services. Without trust in the system, Tibetans report an unwillingness to seek services that are found to be lacking in quality treatment, available medicine, and with poorly-trained staff. This sentiment is shared by the US Embassy delegation report: “Given the risks of transportation, and uncertainty of the quality of the treatment upon reaching a hospital, many potential emergency patients end up taking their chances at home.”⁷⁵

Recently-exiled Tibetans have cited the cost, availability and effectiveness of medicines as a major complaint. They report malpractice in the treatment of semi-literate, or illiterate patients. As doctors know that such patients are unable to read their prescriptions, out-of-date, or incorrect medicines are given⁷⁶ . Main county hospitals are found to pass on their expired medicines to the rural areas.⁷⁷ Medicines are sometimes found to be ineffective, or to worsen conditions.⁷⁸

It is also alleged that under-funded medical centres elevate the prices of medicines to boost their income.⁷⁹ Hence, expensive or optional medicines are portrayed as life-saving: “If you are seriously ill and almost dying they will say that you will recover if you buy such and such medicines, and it is up to you whether you buy them. So when the person is almost dying he will buy medicines.”⁸⁰

Within Tibet, diseases such as tuberculosis (TB), Kashin-Beck disease,⁸¹ leprosy and hepatitis are alarmingly common. One source estimated that in some areas in Tibet, TB levels are as high as 20 percent.⁸² Other common ailments on the plateau include chest conditions, diarrheal diseases, stomach disorders, rickets, goiter, eye infections and complaints of the heart, lungs and liver⁸³ . The prevalence of these common and preventable diseases indicates that China’s health treatment, or education campaigns, do not effectively extend beyond the urban centres.

The ICESCR⁸⁴ has recommended that in order for states to realise the highest standards of health, “The prevention, treatment and control of epidemic, endemic, occupational and other diseases”, is paramount; this encompasses the need for immunisations. For many diseases, China’s reported domestic immunisation levels are close to 100 percent.⁸⁵ Tibet’s children, despite a centralised PRC policy, do not receive comparable immunisation. As with many health service, newly arrived exiles report varying levels of immunisation in different areas. Throughout most regions of Tibet, however, it seems the vaccinations — where they exist — consist of annual injections for babies or toddlers, and are not given to adults unless they display serious symptoms.⁸⁶

A now-exiled doctor reports that while hospitals in larger townships routinely administer immunisations, rural and nomadic children are the responsibility of health workers who have an aversion to travelling into outlying areas.⁸⁷ Judging by the testimonies of new exiles this year who hail from rural areas, vaccinations in Tibet are rare: “The government does not give preventative vaccinations.”⁸⁸ In other areas, “When children are two or three years old, Tibetan doctors are sent up from the county to give the preventative vaccinations. They are sent once a year, and do not charge medical fees.”⁸⁹ These exceptions suggest that the medical neglect facing rural children may be less a matter of state policy than one of effective implementation.

The well-being of women

A variety of international laws guarantee women special protection in regard to their health, particularly reproductive rights. The Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW) makes it clear that birth control policies should be based not on coersion or force, but on choice, education and economic security. ⁹⁰ China has been a signatory to CEDAW for over a decade; in ratifying this Convention, it is bound to uphold its provisions and, under Article 2 of its constitution, agrees to condemn discrimination against women.

China contravenes the CEDAW Ccommittee’s view that coerced or compulsory sterilisation and abortion are acts which adversely affect women’s physical and mental health, and are therefore considered forms of violence against women.⁹¹ The PRC has moreover failed to implement CEDAW’s Article 10(h), which requests States to take appropriate measures to provide educational information to ensure health and well-being of families, including advice on family planning. By contrast, exiles from Tibet describe China’s family planning measures as one of the most serious problems facing Tibetan women, and subsequently the Tibetan community as a whole.⁹²

Article 25 of the PRC Constitution maintains that the State “promotes family planning so that population growth may fit the plans for economic and social development”. ⁹³ China states that “The family planning policy in place in Tibet…[is] encouraging few and healthy births…[and] full respect should be shown to the Tibetan cultural tradition.”⁹⁴ However, the tactics employed in Tibet depart from this ideal. Testimonies from recent exiles reveal that while the present policies may fit the plans of the Chinese government, the economic and social development resulting from the current policies in Tibet does not accord with the needs — or the rights — of Tibetans.

According to the UN Convention on the Prevention and Punishment of the Crime of Genocide, any act which is committed “with the intent to destroy, in whole or in part, a national, ethnic, racial or religious group” constitutes genocide. This includes the imposition of measures intended to prevent births within a group.⁹⁵ The outcome of China’s birth control policies, in tandem with Beijing’s ongoing population transfer of Chinese onto the plateau, has already reduced Tibetans to a minority within the three regions of Tibet. Whether the “intent” to destroy Tibetans as a group is the official motivation for these policies remains to be established. It cannot be refuted, however, that both policies are widely viewed by Tibetans as part of a deliberate means to limit and control the Tibetan population.⁹⁶

Beijing’s Family Planning Policy varies greatly between regions; however, women in Tibet uniformly suffer extreme regulations and strict — if not forced — compliance. The family planning methods involve contraceptives, (oral tablets, Intra-uterine Devices, and slow-acting forearm implants) and the use of abortive and sterilisation operations.⁹⁷ In different areas families are subject to specific regulations which require women to reach a certain age before marriage, obtain a permit prior to conception, comply with an enforced waiting period between births, monitor their menstrual cycles and submit to periodic examinations to determine pregnancy.⁹⁸ In some regions women are also required to display a certificate detailing their status (number of children, spacing between children and whether a sterilisation operation had been performed).⁹⁹ Due to the treatment endured through family planning measures, Tibetan women are often reluctant to seek medical assistance for their own or their family’s basic health needs.¹⁰⁰ This is explored at length in the Case Studies in the Appendices.¹⁰¹

In their attempts to meet their quotas for numbers of women sterilised and children born with “correct” spacing, officials are found to use any means necessary to achieve their targets, including psychological pressure, economic penalties and force. If these targets are not met, officials may be penalised or lose their jobs.¹⁰² These measures are imposed despite Tibet being one of the world’s least populated regions with population figures well below the target growth rate set by China for the region.¹⁰³ This runs counter to Bejing’s rationale for imposing stringent family planning measures.¹⁰⁴

Among China’s family planning policies are measures that equate to eugenic control over the population. “Improving the quality of the population” is seen by China as a legitimate goal, as are measures attempting to ensure this outcome. Under China’s Mother and Infant Health Care Law, people with “serious hereditary diseases, legal contagious diseases or relative mental disorders”, are prohibited from bearing children.¹⁰⁵ Although internationally the PRC has been subjected to strong criticism for these policies, the state has not retreated from their push toward “racial purity”.¹⁰⁶ This adds another uncertain element to the oppressive family planning practices already levelled at Tibetan families.

Gender bias in birth control

Accounts given by exiles arriving in India, and Chinese official reports, reveal no information concerning family planning strategies is aimed at male family members; women bear the full brunt of China’s birth control measures. All measures employed to limit Tibet’s population are directed toward women, including attendance at birth control meetings, fines and penalties imposed for non-compliance.¹⁰⁷ In 1999, CEDAW’s Rapporteur for China brought this concern to Beijing’s attention: “...in light of the fact that vasectomy is far less intrusive and costly than tubal ligation, targeting mainly women for sterilisation may amount to discrimination”, to which China has made no response either in policy or action.¹⁰⁸

Evasion of State responsibility

China’s family planning measures also absolve the state of responsibility for any children born without the consent of the authorities.¹⁰⁹ This causes discrimination against children as a matter of law. The child will not receive a birth certificate, and is therefore precluded from assistance with education, housing, rations, subsidised child day care, or medical care.¹¹⁰

The ICCPR articulates that “Everyone shall have the right to recognition everywhere as a person before the law”. Every child shall also “…be registered immediately after birth” as part of his or her right to protection accorded due to being a minor.¹¹¹ By discriminating against Tibetan families, China also contravenes the ICESCR, as China clearly does not provide “protection and assistance [for] all children and young persons without any discrimination for reasons of parentage.”¹¹² While the PRC has incorporated these ideals into its Constitution,¹¹³ in practice they are far from being realised.

China asserts that its family planning policies take precedence over Article 6 of the Convention on the Rights of the Child in its instruction for States to “…ensure to the maximum extent possible the survival and development of the child.”¹¹⁴ China’s downgrading of this Article imposes an inferior legal status on the child, placing a burden on the child’s family to provide all services for the child, as well as enduring heightened surveillance and public criticism. Those families who do adhere to the regulations are said to receive preferential treatment in a number of fields, including placement in schools and consideration for employment.¹¹⁵

In September 2001, a new arrival spoke of families who “…if they have more children than the imposed limit, the additional child cannot go to school. If a family has an additional child they do not tell the government.”¹¹⁶ Through hiding the birth of a child born above “quota” from government officials, the family may evade a fine at the expense of the child’s health care, education, employment potential and other social benefits.

In further violation of State responsibility to ensure the maximum development of the child, the vast majority of interviewees from Tibet reported that the government does not provide support or advice to pregnant women. Regarding medical advice or health and nutrition education, “No one is there who gives guidance to the pregnant women. They have to take care of themselves.”¹¹⁷

...if they have more children than the imposed limit, the additional child cannot go to school. If a family has an additional child they do not tell the government

Limiting births

Through Beijing’s birth control programme, Tibetan families have lost the autonomy to determine the size of their families. China defies CEDAW’s Article 16, which stipulates the right of women to freely determine the number and spacing of their children. A recent exile, a former employee of Xinghai County Nursing Hospital, Tsigorthang, Tsolho “TAP”, Qinghai confirmed reports of Chinese authorities setting limits on the number of children permitted per family, dependent upon a family’s location and occupation. She further verified that a minimum gap of two or three years between children is strictly enforced.¹¹⁸

Penalties as prohibition

Interviews with recently-arrived refugees reveal the range of penalties suffered by women, their families and potentially their Work Units for non-compliance to the family planning regulations. These include fines, denial of benefits for children who exceed the “quota”, confiscation of land or animals, loss of employment, reduction in pay and public criticism. The penalties work as prohibitive disincentives for Tibetan women who breach the regulations.¹¹⁹

Fines imposed may exceed a family’s annual income, with recent exiles reporting sums ranging from 1,000-5,000 yuan (up to US$588).¹²⁰ The fines may also mark the beginning of ongoing discrimination, such as public criticism, a permanent reduction in salary and increased job insecurity.¹²¹

For the Chinese authorities, the birth control fines imposed on Tibetan families create a significant income. Contrary to China’s claim that encouraging new birth control concepts will “help families become richer”,¹²² it is Tibetan families who face financial hardship due to the regime, and Chinese officials who receive cash benefits and bonuses for implementing government quotas.¹²³ Bonuses include incentives offered for informing the government of any woman who disobeys the family planning regulations. An interview with an exile from Sangchu County, Gannan “TAP”, Gansu, reveals the authorities are offering 300 yuan (US$35) as a reward for reporting a woman in comtempt of regulations.¹²⁴ For the many families facing financial hardship, such a cash incentive may prove more valuable than community cohesion.

Abortion and sterilisation

As stated, China is in direct breach of CEDAW’s General Recommendation 19, which considers compulsory sterilisations and abortions as acts of violence against women.¹²⁵ Across Tibet such practices are frequent and show no signs of abating. Official documents from China refer to the “remedy method” as the best method of contraception – a euphemism for an abortion.¹²⁶

In October 2001, an exile recounted cases of women who had been forced to abort their pregnancies at seven or eight months. In Kolug Township, Nagchu COunty, “TAR”, an ex-party Secretary testified that orders from the county required 100 women to be sterilised: “The doctors came to the doorsteps of the women…saying that they had to undergo the operation. In one week doctors operated on 10-15 women per day, including women up to seven months’ pregnant.”¹²⁷ In March 2001, an exile told of his experience in Drayab County, Chamdo Prefecture, “TAR”. The two-child policy was being strictly enforced in the area and to this end 50-60 women were operated on in one day. He claims 700 were operated on in one instance in Drayab County alone. The operations were reportedly performed free; non-compliance resulted in a fine of 1,600 yuan (US$188).¹²⁸

A woman from Tsolho “TAP”, Qinghai, told TCHRD that she did not know of any cases where a woman consented to an abortion out of free will; all were undergone due to pressure from the authorities, or as a measure to avoid crippling fines or other penalties.¹²⁹ From Do-wi Salar Autonomous County, Tsoshar “TAP”, Qinghai, comes areport of women who were forcibly taken for the operations by army vehicles:

Such a thing happened twice in our village. In the night, when the people were sleeping, they came [to take the women] for the operation. All the women in their thirties’ are already operated on. After the operation they charge you the cost of the vehicle, medical fees and everything.¹³⁰

In Tsolho "TAP", Qinghai, an exile described the family planning policy targeting single mothers: “If a single mother has borne a child, she is at once taken for a [sterilisation] operation.”¹³² In Derge County, Karze “TAP”, Sichuan, single mothers are currently fined 3,000-4,000 yuan (US$350-470) for bearing a child.¹³³ All women, including those who have not yet borne a child, are included in sterilisation “lotteries” that take place in Pang Gongma Township, Gade County, Golog “TAP”, Qinghai. Five women every year are required to undergo the operation:

The names of all the females in our area are collected and drawn in the lottery. Whoever’s name is drawn out has to undergo the operation. All the females above 20 years are put in the list for the lottery.¹³⁴

Refugee testimonies recount cases of women suffering permanent disabilities and death as a consequence of involuntary and inferior procedures of sterilisation.¹³⁹ An informant also referred to cases of women who had their wombs removed without consent whilst undergoing abortion, causing severe pain and trauma.¹⁴⁰ Cases this year have also been described where women have given birth after undergoing sterilisation operations, or find they cannot conceive after having what they believed was an abortion.¹⁴¹ Unsanitary conditions and lack of subsequent care contribute to medical complications.¹⁴²

The need for justice

Tibetan women suffer untold psychological damage by complying to birth control measures that are unwanted and, in many cases, violate cultural and religious beliefs. China’s laws relating to the Protection of Women’s Rights and Interests bans the use of violence against women and girls with regard to their reproductive rights.¹⁴³ However, while NGO’s and concerned bodies may call on the Chinese government to take effective measures to ensure that officials who perpetrate, encourage or condone such human rights violations face punitive measures, as yet no cogent action or response has emerged. Until enforcement mechanisms are attached to relevant laws and conventions, any remedial action taken by — or on behalf of — Tibetan women may remain largely ineffectual.