On December 26th 2008, at a restaurant near the Amity office, four university students and Amity staff were gathering for a reunion. The students were special guests of Amity – “children” from the polio project. Tan Lei, a second year medical student at Nanjing Chinese Medical University, was telling everyone how he had managed to get here by taxi with a wheelchair: “The taxi driver stopped when I waved, I got into the car on my own and he helped to put the chair in the back.” The boys and girls were very happy to see each other and exchange their experiences in the new city. Amity staff had brought old photos from the time 10 years ago. Looking at the pictures taken when they were still children with crutches, the young people started to recall the old days. Time flashes by. Everything seemed to have happened only yesterday.

In 1992, Mr Zhang, the retired deputy director of the Pizhou Public Health Bureau, came to Amity for help, after a request of his to help polio-infected children had been turned down by the Provincial Public Health Department and the Red Cross. The 60-year-old man informed Amity that there were 648 children infected with polio, aged between 1 and 3, scattered around different villages in the Pizhou area. Amity staff immediately took action and paid a visit to Pizhou. The scenes were shocking. The children were crawling on the floor. When their parents picked them up, the children’s legs were limp as noodles. These children had got infected during the polio epidemic of 1989. Most of their parents were farmers, lacking both money and knowledge to help a paralyzed child. Some parents had traveled around China and spent all their savings in search of help, but came back disappointed. Moreover, the local government at the time lacked the experience and financial means to help them.

The Amity polio project, with support from the Norwegian Mission Alliance (NMA), started to meet the needs of these families. The project lasted for 13 years. During a 3-year period it was run as a pilot project; two 5-year phases followed when the project was officially implemented. A resource center, called the New Hope Center, was established for all the “polio children” and their families. Amity cooperated with both local and provincial-level hospitals in Nanjing to provide surgery, physical therapy and occupational therapy for the children.

Even more importantly, a Community Based Rehabilitation (CBR) team was established to offer orthotics services, including the manufacturing and repairing of braces, wheelchairs and other mobility aids. The rehab workers visit every family at least twice a year and offer services accordingly. Scholarships of RMB 200 (US$ 29) per year for 522 children in financial need were part of the project, too. 96 seriously paralyzed children received 9 years of compulsory education right at the center. The other 552 children all attended local community schools. The project helped the community primary schools to set up barrier-free facilities and organized trainings for teachers. In October 2008, the project underwent a final evaluation. A group of experts assessed it from medical, educational, sociological and NGO-managerial perspectives.

During the final evaluation field trip in October 2008, Tan Lei’s mother happened to be one of the interviewees. She tried to recall the name of the local CBR worker: “Xiao Wang something,” she speculated, “it’s been too long, I cannot remember his full name. He came quite often while Tan Lei was still at home.” The project provided support to Tan Lei’s family so they were able to pave the front yard with cement for easy access by wheelchair. Tan Lei’s mother is now very proud of all her children, three of whom went to university. “Tan Lei set up a very good example for his sisters. His younger sister used to ride her bicycle to take him to school every day.”

The family’s situation kept improving during those 15 years. Besides the scholarship for Tan Lei, the family received a microloan through this project. The annual amount of CNY 5,000 enabled them to start a chicken raising business, which has been growing ever since. A second big hen-coop for 2,000 chickens was built last year. Asked about other disabled children in the community, Tan Lei’s mother wasn’t aware that her own experience with Tan Lei could be an important resource for her neighbors. But whenever somebody came to ask her about disability, she would tell them to turn to the New Hope Center.

All the children have grown up by now. Among the 648 “polio children” in 2008, 5 were university graduates, 105 university students, most of the others were in high school, vocational school or middle school. At present the biggest challenge is finding employment for these children – the final test of social acceptance. The center organized trainings for “polio children” with different interests, including music, art and sports, etc. In 2008, 10 athletes from the New Hope Center participated in the Beijing Paralympics and won 6 gold medals, 2 silver medals and 1 bronze medal.

In order to help more children to become independent, microloans are now given to the children themselves. Mao Yanyan opened her own barber shop with the help of such a loan. Liu Erhu happily showed everyone his electric motorcycle repair shop and demonstrated his swift moves. Another group of 11 children, lead by Cao Hailiang, started their own handicraft business. They rented a big studio, where they work together. Cao Hailiang said that even though the sales were not going so well in 2008, they were still hoping to continue their business by seeking other opportunities. Cao describes his own experience with changes in people’s attitudes: “Before, the people in my village thought that I was a burden, bringing bad luck to the family. But now, when they see me work in town on my own, they say that this boy is very capable.”

648 children, 648 stories. The polio project has built up a complete rehabilitation network, offering the beneficiaries holistic services including medication, education and social integration. Changing people’s attitudes, though, is a long-term effort. The working model of this project proves that combining community-based rehabilitation with institutional assistance – a people-oriented project – can be successful. The experience of being of help to “polio children” now enables the New Hope Center to reach out to children with cerebral palsy. As the name indicates, there is new hope for the disabled. Communities do not just cooperate in a project – through the work of the New Hope Center the whole of society is invited to completely accept disability. For now, the project is still only an experiment, but it was a successful one. It’s time for policy to change and time to apply this model on a bigger scale.

Becoming a village doctor had never been one of Chang Xi’s childhood dreams. There was no calling and no aging parent to urge him. “I did it,” he explained, “because I didn’t want to be farming all my life or become a migrant worker.” Chang Xi, a young ambitious man in his early thirties from a small village in Gansu Province near Wuwei, could well have chosen some other occupation to escape a life of harsh physical labor but he picked medicine.

Young people of his age belong to the so-called “post-80s generation” of China. They grew up when the Chinese countryside experienced a major shift in production and living standards from 1979. The people of this generation have fewer siblings and their lives are not so much influenced by political campaigns, food shortages and communal production but rather by a more liberal economic system and a promise that things will become better – even in the countryside. Chang happily took up the challenge to work himself out of a farmer’s life.

First, he managed to secure one of Amity’s scholarships for medical training that enabled him to study at a local health college. When an old village doctor, ready to retire, offered the young graduate to take over his clinic, Chang agreed. Together with his wife, a nurse he had met at college, Chang set up business. During the first three years, everything seemed to work out fine.

When patients stay away

Problems began when modernization arrived at the village and a better road was built. “Our clinic was located at some distance from the new road in a dip,” says Chang, “people didn’t want to take the extra turn.” As Chang and his wife worked hard to keep the clinic running, the number of patients dwindled. The better road, of all things, had cut them off from being able to make a living.

The reason for this sounds like a paradox: The wealthier patients were driving the young village doctor out of business. But the explanation is simple. Living standards around Wuwei had been improving slightly over the years. As more and more farmers earned their incomes as migrant workers, some of the more fortunate ones bought motorcycles. If a clinic looks run down or is inconveniently located, motorized patients ignore it and go on to the next one, which looks nicer or is easier to reach, even if a little further away. As a result, off-road village doctors lose their financially sound patients.

In a way, this looks like healthy competition – but if village clinics close, all the other patients, those who cannot afford a motorcycle, go without any healthcare.

Yet, it is vital for rural communities that all residents enjoy good, hygienic and easy to access medical services. More than anybody else, in fact, it is the people in the countryside who are in dire need of better healthcare. There are huge inequalities between rural and urban areas. The 37 million people living in Guizhou, one of the poorer western provinces with a big rural population, can expect to live 13 years less than residents of Shanghai, according to official reports. One reason is the lack of proper healthcare.

Moreover, rural areas sustain a much higher proportion of ill-health than the cities because of migrant labor. Villagers who move to the cities as migrants tend to be young and strong, leaving behind the children, members of the older generation and the sick. Migrants stay in the cities as long as they are healthy and strong, only to return when their strength and health deteriorates. They are thus exporting health and re-importing ill-health into their home villages.

Even though village doctors like Chang are no doctors in the proper sense of the word but really paramedics or health workers, they are none the less badly needed to treat minor ailments like the flu or stomach aches, to help with emergencies, vaccinate people, watch out for signs of an epidemic and give advice to pregnant women. In order to be able to stay in the game, some village doctors need outside support.

Where is the money?

To help Chang stay on as village doctor and provide basic healthcare for all the villagers, Amity supported his plans to build a new clinic on a patch of land next to the main road granted by the government, which costs RMB 80,000 (US$ 12,000). Around 10% of the cost was covered by Amity but the biggest chunk of the investment Chang needed to raise himself. The banks would only lend him one fifth of the amount he needed. “The rest I borrowed from family members and friends at high interest rates,” says Chang. Interest rates of 25% are not unusual in such private transactions. Moreover, Chang never knows where and when his creditors want their money back:  “They come any time and ask me to pay them on the spot.” Chang has sometimes trouble sleeping at night because of his debts. What he needs is a stable income.

The financial situation of village doctors has slightly improved in recent years. The local government in Wuwei has experimented with innovative healthcare schemes that have shown some good results. Under a basic health insurance scheme, the authorities pay a fixed annual sum of RMB 1200 (US$ 176) to every village clinic. Doctors can now count on this small but stable income. This is not sufficient, though, to keep a clinic running.

Village doctors usually make money by selling medicine and treating patients. But money tends to be in short supply. Many patients are too poor to afford even a package of pain killers. Dearth of cash in the countryside cripples business of all kinds and doctors have not choice but to adapt. Chang’s colleague, Yan Ruinian, who runs a clinic in a neighboring village, has specialized on Chinese medicine, because this is what people can afford. Instead of pills and drops, he prescribes herbal concoctions or a blend of mushrooms, collected in the wild and dried by his wife. This, at least, provides him with a monthly salary of RMB 600.

Still, getting any money from patients remains a problem. It is nothing unusual that patients try to avoid paying for medicine and services on the spot. Instead, they prefer to sign an IOU, paying later when money is at hand. In the past, many village doctors had no choice but to become migrant workers themselves because their patients couldn’t pay. Chang has but one chance a year to call in his money. Before Spring Festival, employers hand out the annual salary to their workers. Then, for once, it is payday for the village doctor. At least around 70% of his patients repay their loans at that time. But Chang has still to stop by their houses personally to settle the matter.

Village doctors in Wuwei operate on very narrow profit margins. Chang and Yan – like all the other village doctors – continue to do farm work on top of their medical duties to feed their families and send their children to school.

Since village doctors are on duty at least 12 to 18 hours a day – not counting the emergency cases – they have little time left for further training. Even though it is increasingly recognized that village doctors need more training, courses come at too high a price for them. “I cannot close my clinic for several weeks to attend a training course,” says Chang. The financial loss would be to high. To compensate for missed opportunities to learn about medical innovations, some village doctors collect cut-outs of local newspaper articles on medical issues. This is the best they can do.

Staying on

Still, village doctors struggle hard to stay on. So far, Chang’s investment has been a success. Today, his new 90-square-meter clinic is in good shape. A chatty group of patients and their kin occupy the treatment room, an airy space with two clean beds, IV drip stands, bright windows and carefully chosen pictures on the wall. A wood-stove in the middle of the room oozes warmth and a living-room atmosphere. On one of the beds, a 50-year-old woman farmer receives an IV in order to get rid of a tenacious case of the flu. She and her husband have come down from another village by motorcycle despite the biting November cold to visit Chang Xi’s clinic. “The price is fair and the service is excellent,” they say. They would rather be here than at another clinic.

While Chang’s wife is changing the IV drips, swiftly and carefully, Chang pokes the fire. He wants his patients to feel at home. He and his wife have a good reputation in the area. “People respect me,” says Chang, “I can sense it when I am on family visits.” It looks as if Chang will stay on despite all the troubles.

You will never find Majiang in a tourist guide to China. Indeed, you would need a very detailed map to locate it. And yet this poor rural country in eastern Guizhou province is the quintessential Chinese landscape of steep limestone hills cut by fast-flowing rivers, terraced farmlands and wooden houses, water buffaloes sloshing through rice paddies, women working in the fields with babies strapped to their backs, all surrounded by interminable eerie swirling mists.

I have just spent a week in Majiang, researching opportunities for our students to travel there in a group. The service group that I lead at the College, GCAT (Global Concerns Action Team) has just raised the funds to sponsor the construction of two medical clinics in Majiang in support of a campaign by the Amity Foundation to build 100 medical clinics in this very poor, deprived, rural area.

Majiang has been classified by the Chinese government in Beijing as a ‘Poverty County’. Indeed, the whole of Guizhou is one of China’s poorest provinces – as the saying goes, Guizhou is a land where there are “no three days without rain, no three kilometers without a mountain, and no three coins in any pocket”.

The focus of my visit was to study the health care needs of Majiang. It is hoped that the first of the two GCAT-sponsored clinics will be finished at that time. In order to gain a clear understanding of the program, I joined a team from Amity’s headquarters in Nanjing headed by Zheng Ye, supported by Tong Su from Amity’s Hong Office and Anthony Tong, LPCUWC Board Chairman, in a meeting with local health officials of the Majiang County Health Bureau. This meeting was a very useful opportunity for me to gauge the enthusiasm of both the local officials and the Amity Foundation for the medical clinics project – the enthusiasm of both sides was infectious to say the least.

The next morning, in steady rain, we visited Dachong village in Majiang County. Our visit began in the old clinic, and once we saw the leaking roof, bare earth floor, open cabinet used for storing medical supplies and damp, unhygienic conditions, we quickly appreciated the need for the new clinics. Fortunately, that building had been replaced by a newer, temporary building after the snowstorms, and although inadequate, it was a vast improvement on the old clinic. The clinic was staffed by a husband -and-wife team, which worked well as many of the medical issues dealt with at village level are gynecological, and women always refuse to be seen by a male doctor.

The highlight of our visit to Dachong was the laying of the foundation stone of the first Amity clinic. This was quite a prestigious occasion by the standards of a remote rural village, with speeches, presentation of banners, ceremonial turning of the earth, fireworks and so on, all under steady rain that I was told was a very positive omen – in springtime the farmers need rain for the seeds to sprout, and the rain meant that the seeds of the new clinics would sprout and blossom in the times ahead.

No bed for an IV

Our next stop was Xuetou. This was a larger village with a population of about 13,000 people. The current clinic was abysmal, being so small that there was no room even for a bed to handle intravenous drips (which seem to provide the entire foundation of Chinese rural health care). Consequently, the doctor in Xuetou does most of his work as house calls, carrying with him a Cultural Revolution era Barefoot Doctor’s kit box. Because of the clinic’s location, some of the doctor’s house calls require a walk of up to 5 kilometers, which can take about 3 hours in the difficult terrain of Xuetou.

Like many of the villages in Majiang, and indeed Guizhou province, Xuetou is depopulating as young men leave in search of work in the coastal cities. This means that more and more women have to do the farming work, and it also creates a potential problem of the spread of AIDS when the men return.

Paying with IOUs

We traveled to another village called Gubing. The clinic in Gubing is one of the busier rural clinics, seeing up to a dozen or so patients per day. Like the other clinics we visited, the level of equipment was extremely basic, including a coat hanger on the ceiling to hold the intravenous drips. The doctor’s monthly salary was just 400 Renminbi Yuan per month (US$56), comprising 120 RMB (US$16.90) per month from the government, the balance being on the profit made on medicines sold – all visits for basic medical issues are free to the patient. Even so, many people in the village cannot afford treatment (because of the cost of the medicine), so the clinic works on an IOU system. Over the course of a year, the debts can amount to about 5000 RMB (US$700), which is more than the doctor’s annual income!

Working 24 hours a day

The doctor in Gubing seems to be fairly popular. She does not keep regular hours, but works 24 hours seven days a week. If patients come at meal times, they join her family for lunch or dinner. The most common problems she deals with are arthritis, high blood pressure, hepatitis B, tuberculosis and gynecological issues.

Logs propping up the walls

Another village we visited was to Daping, a cluster of several hamlets spread over several square kilometers. In that village, we witnessed taps that still have no water in them, and many of the village residents carrying buckets of water on shoulder poles from a water source an hour and a half’s walk away.

The visit to Daping also included the medical clinic. Although this clinic was a little larger than some – it did have enough room for a bed – the building was in a sorry state following the snowstorm, and the walls had to be propped up by two logs to prevent the building falling over. The clinic was extremely basic, but the young doctor, trained with financial assistance from the Amity Foundation, was remarkable for his optimism.

A cleaner village

Our final stop for the day followed a long drive to a Han nationality village called Nabai. Nabai is the centre of a biogas project sponsored by the Amity Foundation, which is trying to encourage sustainable environmentally-friendly energy use. A total of 52 underground tanks were built in the years following 2004 in which a mixture of pig manure and human excrement was fermented to produce biogas to fuel small gas stoves and household lights.

The tanks need cleaning out every two years or so, but the sludge is a very useful fertilizer for the fields. Several members of our team noted how the biogas project seems to have resulted in a much cleaner and tidier town than many of the others we had visited.

As you have probably gathered, I was deeply impressed with my experience in Guizhou and the work of Amity Foundation there. I am really looking forward to working with Amity to develop the trip for my students in November this year, as I think they can learn a great deal as well as contribute a great deal in this economically needy but culturally rich and sensationally hospitable little-known region.

Most people in the countryside of Guizhou Province have only one choice when they need to see a doctor: visit a small village clinic run by a rural health worker. These health workers often live in the same rooms where they deliver their services. They provide check-ups and treatment of patients on the same bed where they or their family members sleep at night. The clinics often have mud floors and wooden walls. This is not what one expects from hygienic treatment facilities. Working conditions of village doctors have been so poor that many of them have left their villages to work in cities, where they can realize much higher incomes.

The importance of infrastructure

We at the Amity Foundation are convinced that with the proper infrastructure – clean and hygienic clinics which are separate from health workers’ living quarters – health workers will be able to serve more patients, feel less vulnerable from infections, take more pride in their work, bring in higher incomes and feel motivated to stay in their villages, serving their communities in the long run. Villagers, too, will directly benefit from more hygienic surroundings and enjoy better care.

The Amity Foundation has therefore committed to the building of 100 clinics in rural Guizhou Province as part of the Clinton Global Initiative (CGI). This commitment is designed to improve the level of health services offered in villages in the Chinese countryside. The clinics will be constructed through a public-private partnership arrangement. Amity hopes that the clinics will serve as a model for the state to consider for replication. 170,000 villagers, many of them from ethnic minority groups, will benefit once this commitment to action is completed. More than half of the beneficiaries are women and children.

The clinics we are planning to build take account of the current government standards and can effectively meet the needs of the villagers. Moreover, following our commitment to ensure sustainability, Amity focuses on supporting those health workers who have already received medical training by the Amity Foundation in the past.

Proof of concept

Guizhou is one of China’s least economically developed provinces and under the country’s decentralized fiscal system, the provincial government does not have sufficient resources to build all the clinics in rural areas in the foreseeable future. The Amity clinics will serve as a proof of concept, demonstrating how affordable health services can be delivered even under very difficult circumstances. We hope that in the longer term, our model will be taken up by the government to provide better primary health care in the whole province.

This is the first time for Amity to build clinics in clusters. In the past, we responded to requests from various provinces. While this has worked well for individual villages and Amity has had plenty of opportunity to gain experiences in this field, there is still room for improvement in terms of long-term and comprehensive impact.

Partnership

Amity has chosen the three counties of Majiang, Jianhe and Cenggong because of their acute needs and their proactive approaches in solving primary health care problems. Local authorities have been very forthcoming and are willing to engage in meaningful, long-term cooperation with the Amity Foundation.

The Health Bureau of Guizhou Province is helping to identify the locations according to the relative needs of individual villages. The design of the clinics is both based on national standards and has benefited from the expertise of Hong Kong practitioners. Amity will put up the equivalent of US$ 6,450 for each clinic, while the local communities will top this up to the full cost of constructing clean and hygienic clinics.

Implementation strategy

During the first stage of the clinics project (April to November 2008), Amity’s Hong Kong office focused on the raising of initial funds and planning. Construction of clinics and fundraising will go on through 2013. Estimated total project costs are US$ 645,000, with first-year costs at US$ 129,000. The Amity Foundation’s Hong Kong office has so far raised funds totaling US$ 90,300. We hope to be able to raise the remaining funds by 2013.

That health checkups for women can prevent diseases is widely unknown in today’s rural China. Now, time has come for preventive healthcare to be introduced to women in some rural communities in Gansu Province. Amity has provided funds and expertise for over 16,000 women in Lintao County to be screened for health problems and treated, mostly free of charge, if irregularities are found.

During the first phase of the project, local health personnel were trained. The check-ups followed in the second phase. Getting out the word to the women turned out to be a challenge in itself. Banners had to be hung up in towns and villages, and health workers were sent out to the villages to speak at public meetings.

The efforts paid off. Almost half of the women screened were diagnosed with women-specific health problems.

Most of them received treatment afterwards, among them Sun Yilan (picture above), an 80-year-old woman from a village near Lintao. “I didn’t know before that there was a cure for my problems,” said the mother of four children when asked why she had never gone to see a doctor. She feels much better after undergoing surgery last June. All she had to pay was RMB 150 for an operation costing RMB 2500 (US$ 365).

Whether the women of Lintao County will continue to get check-ups in the future remains to be seen. Ideally, the health authorities will continue to invest in preventive healthcare services. But local health experts already say that people in the area are often too poor to pay their medical bills, let alone preventive measures.

Jatropha is a hardy plant which grows on sandy grounds and even saline soils. Because it thrives under inhospitable circumstances, it does not compete with edible crops for soil and water.  Crushed, the seeds eventually yield a high-quality bio-diesel which can be used in cars, trucks or even airplanes. Jatropha is highly efficient. One hectare produces alsmost 2000 liters of bio-fuel (ten times as much as maize) and one tree can yield crops for up to half a century. What is left after processing the seeds can be used as fertilizer.

Amity forged a cooperation between the German Evangelischer Entwicklungsdienst (EED), the Finnish Evangelical Lutheran Mission (FELM), Yunnan provincial authorities and the China National Petroleum Company to help poor farmers in Huaping County and other areas near Panzhihua fight erosion, raise the tree coverage in the area, earn a living despite the low quality of their farmland and contribute to the global effort to substitute for fossil fuel with CO2-neutral substances. Amity’s efforts to encourage farmers in Huaping to grow Jatropha and other plants compatible with the local exosystem is part of a large-scale integrated project in Yunnan – the biggest ever implemented by Amity.