Farewell

My time is over and I'm packing to leave Tianjin. I have had a wonderful experience these past 10 weeks. I found the people warm and friendly, welcoming me into their workplace and into their lives. They made me feel a little less like a stranger and a more like a friend. I will always cherish the memories of this time.

SARS

I have been talking to some people here about what it was like living in Tianjin during SARS. Tianjin was involved in the SARS outbreak of 2003. People living here were very afraid. Everyone wore a mask when leaving their homes. Streets and malls, usually packed with people, were deserted for months. If someone coughed while standing at the bus stop, people literally ran away. I haven't heard about food or any other shortages, though I would be surprised if none had existed. Universities closed their campuses. No one was allowed in. One of the epidemiologists here was completing her masters degree at that time. She left one day to visit her parents, who lived nearby. She was not allowed back in. All her books and clothes were in her dorm room, and she had no access to them for 2 months. She tells about how the students would congregate at the University gate and play badmitten with anyone outside. Another epidemiologist here was getting her masters as well. She did her studies for those 2 months by email.

Some good has come out of this time. Public health in China was placed in the spotlight. For the US, public health was strengthened in response to 9-11 and the anthrax mailings. In China, public health has been strengthened in response to SARS. I've been out talking (in a manner of speaking) to rural village leaders, as I've written about in previous blogs. They all know about communicable disease reporting. The oft-repeated statement from the leaders is "Before SARS, no one knows about disease reporting. After SARS, everyone knows."

We talk about and plan for a situation like this with pandemic influenza. China has lived it, and become stronger.

Friends

I was involved in a food-borne outbreak investigation last week. Unfortunately, I was on the wrong side of this investigation. Four of us in the epidemiology division became ill within 6 hours of each other last week. I was well cared for during my misery. Two non-ill epidemiologists came to my apartment to check on me that first day. They insisted on finding lunch. When they couldn't find an open restaurant (it was 10 AM), they went to a supermarket, bought the ingredients, and made soup for me in my apartment. I felt a little less miserable lying in my bed listening to my friends cook for me. This is just one more example of how far everyone here has gone to make sure I have a wonderful experience.

Doctor Education

We have spent a few days each week visiting rural doctors to evaluate communicable disease reporting (see blog of 11/16). The doctor in this picture (white coat) is 27 years old and has been working for 9 years. So, I asked how much education he could have if he began working at 18. This is what I was told.

He probably didn't have good enough test scores to get into high school, so he went to a vocational school where he learned to be a doctor. All doctors at the township level have this level of training. The next level up in the health care system is the county level. After graduating from high school, medical university is a 5 year program with a bachelors degree. This completes the training for the county level doctors. After the bachelors degree you can continue on to a 3 year masters program. Graduates from the masters program work at the provincial level hospitals. Finally, if you go on to get a PhD in clinical medicine, you are allowed to work at a national level hospital. If someone is truly ill, they do not go to the township level hospital. The township level hospital is for minor illnesses and routine visits, such as childhood immunizations and family planning. I was fortunate to visit all levels of hospitals during my stay here.

Confucian Temple

The Confucian temple in Tianjin was built in 1436. Unfortunately, it was closed because of damage to the structures inside. I was able to look inside, where workers were busy making repairs.

Mumps

I spent Thanksgiving day at a rural school investigating an outbreak of mumps. The school has set up a classroom in a house near the school to teach the students who are excluded from school with the mumps. In the first picture, 7 fifth grade children with mumps are seated around a table doing math. The second picture is of their classroom at school. You can see many empty desks. The boy in the front on the right has recovered from the mumps and returned to school. Interestingly, the empty desks are all clustered around him!

Survey

On Monday we visited another rural clinic in an effort to improve reporting from the rural doctors. 60% of the population is rural, and very little communicable disease is reported from the rural areas. We developed a questionnaire to determine the perceived barriers to reporting. There are 3 parts to the questionnaire. One for the village clinic doctor, one for the township hospital leader (where disease reporting into the computer system from the rural areas is supposed to occur), and the final part for the village leader. In the picture the CDC worker is administering the questionnaire to the village leader (seated on the bed).

Olympic Stadium

We visited Olympic Stadium on Saturday. Tianjin is the venue for soccer for the 2008 Olympics.

American Barracks

As I was returning from my favorite weekend coffee retreat, I noticed a sign on the wall at the side of the road. Apparently, these are the post-World War I US army barracks in Tianjin. Pretty nice buildings!

Tianjin, Dirty City?

Some people have asked me if Tianjin is a dirty city. I guess that depends on your definition of dirty. There is a lot of dirt. Everywhere. There is an amazing amount of construction (and destruction) everywhere you look.

If you share my definition of dirty, which is garbage lying around everywhere, then Tianjin is one of the cleanest cities I have ever seen. Everyday there are thousands of workers on every street (at least it seems that way to me) sweeping the dirt to the side and picking up the garbage. These workers are even on the major highways, sweeping.

Tianjin has made it a priority to become greener. They are planting trees and shrubs everywhere. There are little gardens along most roads. I get the feeling that they think there is nothing they can do to stop the pollution, so the best thing they can do to improve their air quality is to plant trees. Another area of beauty in the city is the riverwalk. The Haihe River runs through Tianjin. Look at the pictures I have posted to see the improvement in the riverwalk from one side of a bridge, where the riverwalk is finished, compared to the other side, where they have some work left to do. Notice also all the construction cranes in the photo.

Field Studies

Wednesday and Thursday we spent out in the field investigating an unusual finding in dairy farmers which was identified on a routine survey. They have a cooperative type dairy located away from the village. Each family has 3-8 cows. They herd them to the milking barn then walk them back after the milking is completed. Unfortunately, the best time to find the farmers was at milking time. The best way to talk to them was to walk with them either on the way to the milking barn or on the way back (see picture-the girl on the left in the red coat is walking with the farmer and administering the questionnaire). The first evening we were at the dairy by 5 PM (milking time). It was cold and windy and dark by 5:30. Luckily, I had a flashlight with me, so I would hold it while others spoke to the farmers. Another problem we faced (besides the adverse weather conditions) was the dogs. Dogs in China are not vaccinated against rabies. China is second in the world (behind India), for human rabies cases, so I was told. Any time a dog barked at us we began a rapid retreat.

A few thoughts about this experience. First, many farmers were reluctant to give us their name. They didn't trust that we weren't from the government. I thought it quite sad that they fear their government and are not confident in their rights. Second, the health of the rural farmer appeared quite good. Very few physical complaints. We asked questions regarding their health for the past year, and had very few negative responses. Third, I don't believe there are any dentists in rural China. Very poor dentition.

Well, after 2 days of wandering through rural dairies, dodging dogs, cowpies, and the occasional stray poultry, we decided to return to Tianjin. This was truly an experience no one should be without.

Stone Mountain

Sunday we took a trip to Pinggu, a mountainous area north of Tianjin and east of Beijing. We travelled a beautiful road winding through many villages. Occasional mountain peaks had tall lookout pagodas perched at the top. One mountain had a giant gold Buddha seated at the top. Stone Mountain is really not very high, but the only acceptable way to climb it is straight up the stairs that are built into the mountain. Thousands of stairs (unfortunately, not an exageration). Some stairs were very narrow and steep, others were wide and shallow. You really had to watch every step as the size and steepness varied. It was a cold, windy day with occasional snow flurries on our climb! We didn't make it all the way to the top, I'm afraid. This picture was taken from our highest point. Note the path where we began in the bottom left corner.

No Water

Here is where I usually enter my apartment complex. Do you think this has anything to do with the fact that I woke up Wednesday morning to find out I had no water? Luckily water service was restored by Wednesday night. Trying to get back to my apartment at night when it's dark is very tricky. I'm glad I brought a flashlight!

Immunization Check

On Monday we went rural again! This time was for what they call an immunization recheck. A village is chosen at random, and workers from the provincial CDC go to that village to check children's immunization cards. The child's immunization card is compared to a log kept by the township hospital, where immunizations are given. This check has already been done by the local CDC, hence the "recheck". This is primarily a quality evaluation of record keeping, but has the added benefit of speaking to the villagers and reminding them of the need to immunize their children. We caught up with a group of villagers with their children at an impromptu clothes sale by the side of the road. The picture on the left shows the man handing over the immunization card for the child in his mother's arms next to him. The mother to the far left is being scolded because her son is behind on his immunizations. The picture on the right is of two CDC workers comparing the immunization card with the log book.

Starbucks!

By Friday I was getting a little cranky. 2 whole weeks without my Starbucks! I rarely go more than 12 hours without my Starbucks, so you can see the trouble I was in. Anyone who knows me knows I always carry a thermos of coffee around with me every day. So, I went to Starbucks.com to search for locations in Tianjin. There are 9! One appeared to be close to my apartment, so I decided to explore. Saturday morning I rose bright and early, did some laundry, cleaned my 2 room apartment, got groceries, then headed out on my quest. After walking about 1 1/2 miles THERE IT WAS!!! The familiar sign. It looks like a Starbucks anywhere in the US. Same menu (in ENGLISH!), same set up, same prices! The people behind the counter spoke English! I've decided this will be my weekend treat. In fact, it's now Sunday afternoon and I'm sitting in Starbucks drinking coffee and writing this. LIFE IS GOOD!

Drying food

Here is a picture of corn and sunflower seeds drying on the road. This village had wide streets with plenty of room to drive. Some villages we drove through covered the entire road, making driving a challenge!

Rural Doctors Clinic

Here's a picture of one of the rural clinics we visited. Note the drying corn outside.

Hospital Visits

I spent Wednesday, Thursday, and Friday visiting various hospitals in the Tianjin District. The visits were to learn how communicable disease surveillance works so that we can come up with a plan to improve reporting. For a little background, Tianjin is on of four municipalities in China that answers only to the National Government. Tianjin Municipality consists of the city of Tianjin with a population approximately 6 million, and the surrounding rural area, with a population of about 4 million. First we visited a children's hospital in Tianjin City. Another thing you need to understand is that there are very few private doctors. If your child is ill, you take them to the children's hospital for outpatient evaluation. No appointments, just masses of sick children arriving and waiting to be seen. The outpatient department at this hospital sees about 3,000 sick children each day! On Thursday we travelled to a district about 70 km north of Tianjin City. There we visited a county hospital, a traditional medicine hospital, and a township level hospital. Friday we went VERY rural and visited a township hospital (no inpatient or lab services) and rural clinics in a district about 30 km south of Tianjin City. A few things struck me in these visits: 1. The complete lack of documentation. As far as I can tell, other than an occasional outpatient log, no paperwork is filled out unless the patient is admitted to the hospital. 2. There is no standardization to diagnosis. As lab confirmation is rarely performed, the diagnosis is purely clinical. I was amazed that in a rural clinic with no labs the doctor could diagnose shigellosis. Does this just mean dysentary? How does he know it's not campylobacter? 3. The drying food everywhere. Corn and sunflower seeds were laid out on roads everywhere to dry. Imagine a 6 lane road (3 lanes each direction) with 2 lanes on each side covered with drying corn and sunflower seeds. Who owns all this food? How do they pick it all up when it's dry? Just sweep it up with a broom? I watched cars run over the edges, children run through, dogs squat in the middle, flies and spiders crawling through the food. Do they wash it later? Then we went to lunch and everyone started eating sunflower seeds. I have to say that I had a very difficult time eating the sunflower seeds. I certainly didn't use my teeth to crack open the shell!

A Chinese Wedding

Sunday was another eventful day. First I went to Xu Wenti's home to learn to make chinese dumplings. While my dumplings were certainly as tasty as any other, they were not nearly as decorative looking. I couldn't seem to master the art of folding and pinching the dough closed in a visually appealing manner.

In the afternoon we went to a wedding. The bride is a colleague of Wenti's husband, both working in public health education. I thought the wedding would be very different from US weddings, but it was much the same. It was kind of like a combination wedding and reception. While we all sat around the dinner tables, the wedding was performed. The ceremony involved the exchange of vows and rings. Then the ceremony leader asked the bride and groom questions about how they met, the first time they held hands, things like that. Influential people in their lives (their fathers, bosses at work, teachers) came forward and gave them advice. They cut the cake, drank some wine together, and that was about it. During the dinner the bride (and groom too I think) changed clothes 6 times. The original wedding dress was typical western. 2 of the subsequent outfits were traditional Chinese. I don't think the bride and groom ever sat down to eat. They circulated and changed clothes the whole evening!

While the bride and groom circulated and changed clothes, we feasted! An amazing amount of food. It is tradition to continually toast the bride and groom at your table. They had some special "white wine" to toast with. I choked on the first toast, making everyone laugh. The "wine" was 50% alcohol, 100 proof. As you can well imagine, it was a very happy reception!

Laundry, Crabs, and Grapes

Friday night I decided it was time to tackle laundry. I have a new washing machine in my apartment, and the only instruction I was given was to move it into the bathroom when I wanted to use it. So, I opened to the lid and found a variety of parts and instructions NOT in English. I managed to screw a grate on the bottom (no screwdriver, I used a table knife), attach the water hose to the faucet, and the drainage hose to the drain in the floor (once again, no screwdriver). I have to say it was one of the proudest moments in my life when I started the first load and NOTHING leaked and EVERYTHING worked as it was intended. Amazing. The only thing missing from the instruction sheet was the happy woman with the laundry basket.

On Saturday we went to Hangu District to pick grapes and catch crabs (see map of Tianjin) . What a lot of fun we had. This trip was planned in coordination with the influenza conference on Friday. There were 2 buses full, about 100 people, on the trip. It took about 1 1/2 hours to reach our first destination. It was a place to catch crabs. We sat around a pond dangling pieces of pork in the water. When the crabs started to eat, we caught them in a net. It was somewhat difficult to pull the line up, scoop a gyrating crab into a small net, and not fall in the pond all at the same time. I think I caught about 8 crabs (see picture) although I threw them all back. After lunch we went to a vineyard to pick grapes. They were delicious! I paid 12 yuan (less than $2) for about 8 bunches of grapes. A fun day out in rural Tianjin. Tomorrow I have been invited to a wedding!

It's Friday!

What a busy first week of work. I thought it might start slow, but that was not to be. My assignment Monday was to put together a presentation on surveillance in the U.S. and compare it to surveillance in China. Wenti and I have been working together on this. Then on Tuesday at 4:30 PM I was asked to talk about influenza surveillance in the U.S. for a meeting they are having today to kick off influenza surveillance season. So, I have managed to pull together two presentations quite quickly. Thanks to all you at home who sent me information and slides. Hopefully I will do justice to both topics.

In the midst of all this I have been trying to get registered at the police station. The law states that all foreigners coming in to work must register within 24 hours at the local police station. We have been trying, but every day it seems they need something else. Thank goodness Tina came with me the first day. No one spoke English there, so I couldn't possibly have done this myself. She has spared me most of the problem which means she has been going to the police station every day trying to accomplish this task. Hopefully today is the day it will be done!

The epidemiology division is a wonderful place to work. Everyone speaks English quite well! I'm very impressed. Everyday someone brings me some different foods to try. My favorite was something they said was a new species of date. It was the size of a large nut, and tasted like an apple. Very delicious! I have also been given cookies, cakes, roasted chestnuts, and sweet potatoes to eat. And it's only been 4 days!

The CDC is a large campus of at least 8 different buildings. The newest one that I am working in is just 1 year old (see picture). To the right and behind my building is the rest of the CDC buildings. On the grounds there is a tennis court, basketball court, and some various exercise equipment. Every morning when I come in people are out playing and exercising. There's usually a group playing what we call hacky-sack, although their bag has 3 feathers on the top. My epi group does yoga after work. I have not stayed for yoga yet because I want to make sure I can find my way home before it's dark. Maybe next week.

Picture Day, Tuesday, October 9, 2007

We had our picture taken today. Here is the epidemiology section I am working with. A very fun group of people who have made me feel so very welcome.

My Apartment

This is my apartment building in Tianjin. I am the third door down on the left (behind the red vehicle). I am on the fourth floor.

Shopping, Sunday, October 8

Wow! Now this is a Supermarket! It's about a 10 minute walk from my apartment. It is a very interesting walk with one paved lane shared by the mostly one-way car traffic along with two-way bicycle and pedestrian traffic. There is packed dirt on one side, but it had rained early this morning so there were many puddles to navigate around. We explored three floors of shopping. The ground floor has individual shops with various items such as jewelry, home decor, clothing, and specialty foods (such as a tea shop). The second floor held housewares, clothing, toiletries, and toys. The third floor was groceries. Think of a small mall on the ground floor with a Meijer's stacked on top. Moving ramps allowed you to take your shopping cart from one floor to the next.

I had thought shopping would be difficult as I would have difficulty deciphering labels and prices. This was not the case. While some labels remained a mystery to me, most of the time I could figure out what the product was (of course, I had Tina there to translate for me). All prices were written in numbers, not chinese characters, so that was also not a problem. Because I spent a certain amount, I took my receipt to a station where I could get either 6 eggs or a 2L of Coke for free! I took the Coke :)

Tomorrow (actually today as it's 2 AM) I'm off the the police station to register and then on to the CDC!

Arriving in China, Saturday, October 6

I have arrived in China! The flight from Detroit to Beijing (with a quick stop in Tokyo) took about 18 hours. Navigating through the airports in both Tokyo and Beijing was very easy. There were no lines at either quarantine, immigration, or customs. I waited maybe 3 minutes for my luggage. We landed at 9:15 PM and I was out the door at 9:40. I have never had that kind of service at Detroit Metro! Tina from the Tianjin CDC was waiting for me right outside the door with a driver and a bottle of water. An EXCELLENT welcome. Only very important people get picked up from an airport 2 hours from their destination with a driver.

We arrived in Tianjin close to midnight. My apartment is very nice with all new furnishings. Someone had stocked the refrigerator with some food and bought all the toiletries I could possibly need. All in all, an incredibly generous and thoughtful welcome. Well, it's 2 AM and I'll try to get some sleep. Tina will be here at 10 AM to take me shopping!