February 21, 2011
Today I arrived in Guzhen, a small town in the south of Guangdong province about one hour from Guangzhou, to visit a community health program established almost 20 years ago for the prevention and control of chronic diseases. The Chinese government has heralded the program as a model for stroke prevention in rural China and has attempted to replicate the model in other impoverished regions of the country. Twenty years ago, the concepts of disease prevention and health promotion were foreign to China, as was the idea that investing in prevention up front would save money in the long run. A fortuitous combination of ‘right time, right place’ and the dedication of a team of neurologists from Guangzhou Medical University, however, have transformed the town of Guzhen into a truly impressive example of public health at its best.
When the program began, two neurologists from Guangzhou Medical University, Drs. Xu and Liu, who have been tireless champions of the community health effort, traveled regularly to Guzhen to educate local health and government officials on the health benefits of disease prevention, while at the same time emphasizing social and financial incentives, eventually convincing the provincial and national government to invest in the program. They brought their own supplies from Guangzhou, including refrigerators and other lab equipment, and traveled by bicycle down dirt paths to visit one community health clinic (or “hygiene station” as they are called here) after another, training local health workers on how to take a neurologic history and do a neurologic examination, how to take a reliable blood pressure, how to run a lipid panel, how to choose a blood pressure medication and, most importantly, how to educate patients on these same issues.
Drs. Xu and Liu were local fixtures in the community, showing up to town meetings, school functions and other events where they helped to shift the mentality of local residents to understand the benefit of coming to the hygiene stations BEFORE illness struck. At first, the entire team was available to train and supervise during makeshift clinics in hygiene stations. Later, only one team member was available per hygiene station. Eventually, local health workers were flying solo with one of the team members from Guangzhou only checking in every few weeks to months to field questions and ensure quality control.
Initially, the team from Guangzhou paid 1 RMB out of pocket to local health care workers for each patient they were willing to see, essentially buying the cooperation of the local health workers in the hygiene stations. Now, though, as the program has become established it is backed almost entirely by the provincial and national government. Health care is nearly free for the entire community, including thousands of local farmers, with an annual copayment of only 3 RMB, the equivalent of less than $0.50. This year marks the first year that the hospital has turned a profit which is largely attributed to reaping the benefits of 20 years of prevention efforts. Their current goal is to ensure every adult over the age of 35, estimated to be about 45,000 residents, is enrolled and seen annually in clinic.
Because the provincial and national government are extremely invested in this effort, resources have been set aside for health education, including written materials that are plastered on most walls of the local hospital and hygiene stations, along with community classes for “hypertension and diabetes clubs” which focus on nutrition, exercise and medication management. Each night, thousands pour onto the beautifully lit main square to perform exercises and traditional Chinese dancing en masse. Even sales of chicken livers and other cuts of meat that are known to be high in cholesterol and fat have fallen since the program’s inception.
The model has been effective in large part due to the dedication of the neurology team from Guangzhou Medical University who for years volunteered their time and resources to make the program work. Drs. Xu and Liu knew that in order for their efforts to be beneficial, not only did they have to train the local health workers in Guzhen to be able to stand on their own, but the relationship with Guzhen had to be a mutual collaboration, as it has been and continues to be to this day. The question, though, is how to translate this model into a more comprehensive program for all of China, including the most rural and difficult to reach regions of the country. Some of what made Guzhen such a success holds true for the rest of China, namely minimal emigration from rural areas and the power of the totalitarian Chinese government to set public policy that is actually followed by the Chinese people. (As one of the neurologists I worked with told me, “For better or worse, when the Chinese government sets out to do something, there is no question that it can be accomplished.”) What makes Guzhen unique, however, is the boom economy that has stemmed from a relatively new and thriving light manufacturing industry. Without this extra financial cushion, even Drs. Xu and Liu who were staunch supporters of Guzhen long before anyone could imagine the public health success that the community enjoys today, are skeptical about the ability to replicate Guzhen elsewhere in the country.