In Step with the Giant: China
The China Scholar Exchange brings the public health challenges of the world’s most populous nation into sharp focus for U-M faculty and students.
It's February 2008, and University of Michigan School of Public Health (SPH) Associate Dean for Practice Matthew Boulton is riding a bus on his fifth visit to China in the past year and a half. It's the kind of travel schedule that evolves when you're launching a two-way exchange program on the other side of the world.
Out the window behind him, a kinetic collage of zipping scooters and screeching trucks nearly ricochet off each other across unmarked lanes.
Rush hour on the fringe of Tianjin, an eastern city of 11 million, seems too impossible to be routine. Masses of bulky bikes float amid motor vehicles. Some are oversized trikes for elderly commuters. Many have dinner-time cabbages bulging below the seats. Repeatedly, the fastest cyclists spurt forward, stop at a traffic light, and pause to be joined by a few, and then many others—until the dark wedge spans all lanes. Scenes like this confirm that China has a different relationship between the one and the many. You could become mesmerized watching the panoramic mechanical ballet.
But zoning out would mean missing the story that Boulton is telling: the account of a devastating, 7.8-scale earthquake that struck the eastern coast of China in 1976 - and how the world came to learn about it.
"I remember how people slowly started to know something had happened, and how difficult it was to get the full story on the vast loss of life," Boulton says. He was in college in Nevada at the time, and not yet as attuned to disasters as he would be later as a public health physician, Michigan State Epidemiologist, and director of disaster preparedness and response initiatives at SPH.
The Western world in general learned of the 1976 quake when abnormal seismic readings traveled across borders, well before official reports emerged from Mao's China. Suppression of information about the deaths of probably 240,000 people and China's rebuff of international assistance are now considered to be part of what the New York Times called the final thrust "ending the decade-long Cultural Revolution and ushering in leaders who introduced the economic reforms that continue to transform China."
In its first year, the China Scholar Exchange that Boulton has established between SPH and the Tianjin Centers for Disease Control and Prevention has expanded partnerships in this formerly closed part of the world.
In fact, when a 7.6-scale quake struck central Sichuan on May 12, 2008 and the world marveled at China's newfound forthrightness, Boulton was invited by colleagues at the Tianjin CDC to join their Sichuan relief effort. It didn't work out logistically, but Boulton was willing—and honored.
In thousands of regional offices, China's CDC staff work on some of the country's greatest challenges. Michigan is the first Western school of public health to establish this level of partnership with China's CDC or any of its regional offices. Through the China Scholar Exchange program, U-M hosted eight Tianjin CDC scholars in 2009, with four more scheduled to arrive in Ann Arbor in January. More than 50 U-M students have spent time in China through the program, and Boulton will be leading another student trip to Tianjin in May.
Working with his colleagues in Tianjin, Boulton and the SPH Practice Office are on the front line of a cooperative strategy to combat global health problems. It could pay off not only in dealing with natural disasters like earthquakes, but also with contamination (both of food and the environment), chronic diseases in aging populations, and the specter of epidemics like avian flu.
By inviting its new partners into a public health infrastructure that includes water-treatment facilities, clinics, and schools, the Tianjin CDC is expanding the curriculum for SPH students as far as the globe can spin.
Moving into Power and Partnership
When University of Michigan political scientist Mary Gallagher was lecturing in the spring of 2008 about China's 100 million "float" itinerant workers who flee from resource-depleted rural areas to dirty jobs in boomtown cities, she called it the largest internal migration in the history of the world. With a wry laugh, she added, "Of course, almost everything you say about China is the biggest in the world."
Because it involves more than a fifth of the earth's people, population health in China is a daunting realm. For a truly potent mix, add China's specifics: emerging from a repressive authoritarian era, remaining under single-party control while encouraging private entrepreneurship, moving to capitalism by skipping democracy in an unprecedented way.
"China is the growing economic power in the world, and that has at least been partially manifest by their staggering, and very rapid, investment in building a public health system," explains SPH's Boulton. "The personnel and physical infrastructure of that investment and commitment is evident and overwhelming—especially when you consider it has been created since SARS. I find that mind-boggling."
Because he wanted to give SPH students, faculty, and their Chinese counterparts reciprocal experiences in complex and different environments, Boulton launched the exchange program —and even set up a satellite SPH Practice Office at the Tianjin CDC. SPH Dean Ken Warner attended the formal opening of the office and delivered the keynote address at a forum for Chinese health practitioners. He marvels at what Boulton has wrought with the China Scholar Exchange. He and Boulton envision using the new Tianjin CDC office as a home base for bringing SPH research expertise to Chinese health problems. SPH faculty were invited in the fall of 2008 to join 14 cooperative research projects with the Tianjin CDC, on topics ranging from multidrug-resistant tuberculosis and assessment of AIDS prevention education to lead, genetics, social status, and neurodevelopment in children.
Practice is, after all, about applied research, connecting academia with the health workforce, and working to implement systems and solutions.
Although UM has a long history of affiliations with China, Boulton worked largely outside established channels. He relied instead on Dr. Jianli Kan, a colleague and friend from their years together at the Michigan Department of Community Health nearly a decade ago. Kan went back to China after the SARS epidemic, and is now director of epidemiology for the national China CDC in Beijing. Together, Kan and Boulton established the two-country partnership, in cooperation with Dr. Xiexiu Wang, director-general of the Tianjin CDC and a senior advisor on tuberculosis to the World Health Organization.
Tianjin, a landscape of multiplying skyscrapers, was the first city in China to offer free testing for HIV (a disease on the rise in China). It's still surrounded by rural areas, and thus it provides varied settings for Westerners' practice-based learning about environmental and health-related issues in China.
Along with the population it serves, the Tianjin CDC benefits from the collaboration in many ways. Its researchers get assistance and co-authorship on journal articles and opportunities to learn and present in Western settings. Dr. Guohong Jiang, director of non-communicable diseases at the Tianjin CDC, recently completed a three-month residency at SPH. While she was in Ann Arbor, she gave a Public Health Grand Rounds presentation in which she summed up China's problems with emerging diseases, an aging population, and barriers to promoting healthy lifestyles. "We need your help," she concluded.
"They want to learn how to do better practice and build their infrastructure, given all their significant public health challenges," Boulton explains.
SARS was an important turning point. The near-pandemic of severe acute respiratory syndrome that blindsided the world in late 2002 resulted in more than 770 deaths. Most occurred in China and Hong Kong, and China was internationally criticized for not being open with outbreak reporting. China later apologized to the international community for its slowness in dealing with the epidemic.
"SARS attacked us, and it exposed our weaknesses, such as the backward development of public health," a China CDC document states with disarming honesty. A "never-again" resolve led to an impressive Internet-based system that came online in 2003 and enabled ten times faster disease reporting.
Moving Forward
China has made gains in controlling the infectious diseases that plagued the country in the era when Mao's untrained "barefoot doctors" were guardians of health. But much remains to be done. China suffers from an inefficient and inequitable health care system biased toward urban areas. Health insurance is a foreign concept. Safety and product testing lack focus and enforcement.
Smoking is still an issue in China, where people (including doctors) puff away in hallways of many hospitals, cigarettes are inexpensive, and one in four people smoke. The restrictive "One Child" population-control program combines with low social status for women to produce mental health challenges for both genders. Decades of restrictiveness have produced a culture where people move cautiously, often avoiding hot topics like "the 3 T's" (Taiwan, Tibet, and Tiananmen). On the other hand, science and technology are on the march, and Americans increasingly go to China for stem cell treatments for cancer and other chronic diseases—treatments not legal here.
From infectious-disease outbreaks to the prescribed use of herbs, China offers a chance to work on health problems and solutions outside the domain of public health in the U.S. The 30 SPH students and the handful of staffers who spent their spring break 2008 in Tianjin saw immunization clinics of various sizes and styles, drinking-water testing, purification and delivery, and many interworkings of a public health system and culture unlike their own. A day might begin with a meal of pig ears and fire-dragonfruit, move to a colorful demonstration of tai chi sequences at a senior center, and end with exhaustion from frantic commuting on rough roads.
The spring break trip gave credence to the idea that if you're going to go to all the trouble of setting up an exchange in the furthest of foreign lands, you might as well do it somewhere interesting, with history, infrastructure, challenges, and strengths very different from what you know. Sorting through assumptions makes for fruitful learning.
The leader of one SPH group in Tianjin, SPH Adjunct Associate Professor and alumna Eden Wells (who's also a senior medical epidemiologist with the Michigan Department of Community Health), believes such participation, discussion, and exploration justifies all the logistical difficulties behind a program like the China Scholar Exchange. "I don't think we should make conclusions from such a trip," she said. "We're only beginning the questioning process. I leave with many impressions, lots of information to draw upon. China is too large to capture in simple conclusions."
Too large, and too full of momentum—for better or worse. China's problems may seem impossibly massive, but the long history of the culture gives reason for hope.
It's like those wide wedges of cyclists ebbing and flowing through every rush hour, seemingly at the brink of capacity at each stoplight, but always moving forward to the next. Domestically and globally, China, like the U.S., struggles now for economic and political credibility. The issues and path behind the struggles aren't the same, but the benefits of collaboration and trust are clear, today and in crises to come.
By Mary Beth Lewis
Photos by Dina Kurz, Mary Beth Lewis, and UM SPH students.