In Step with the Giant: China

In Step with the Giant: China

It's February 2008, and School of Public Health 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.

boultonBut zoning out would mean missing the incredible story that Boulton (at left, at the Great Wall) is telling. It is the account of a devastating Chinese earthquake and how the world came to learn about it: the 7.8-scale earthquake that struck the eastern coast of China in 1976, that is, not the 7.6-scale quake that would strike central Sichuan on May 12, 2008.

"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 in-troduced the economic reforms that continue to transform China."

"And it was right near here," Boulton exclaims, "in Tianjin!" A man of tremendous energy, he tells a story with intensity—especially when physically confined to a bus seat and left with nothing but narrative for expression. Many of the 30 SPH students he is chaperoning during this spring break field experience in Tianjin loll in states of exhausted distraction, except for a few rapt listeners.

Actually, the epicenter of the 1976 quake was a few miles north, in Tangshan, but a monument in Tianjin commemorates significant losses—and Boulton's point is well-taken. In its first year, the China Scholar Exchange that Boulton has established between SPH and the Tianjin Center for Disease Control and Prevention has expanded partnerships in a formerly closed part of the world. In fact, when the May 2008 quake struck, and the world marveled at China's newfound forthrightness, Boulton—who happened to be in China at the time—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. Working with his colleagues in Tianjin, Boulton and the SPH Practice Office he oversees in Ann Arbor 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.

students and chinese doctorsMOVING 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."

Think of those firework footprints moving through Beijing during the Olympic Games opening ceremonies in August: China is nothing if not a giant.

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.

water pipelineMOVING 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.

During their field experiences, one hard-working group helped sleuth reasons for Tianjin's recurring outbreaks of measles, which ranks sixth for incidence among the 37 notifiable diseases in China (more than 100,000 measles cases occurred countrywide last year). A 94-percent increase in cases was being experienced in Tianjin during the group's visit, and they were able to identify possible factors related to recurring outbreaks, despite China's program of free national immunizations that include measles.

Another group of students had firsthand experience with China's water treatment and supply issues. They visited a wastewater treatment plant that no longer pollutes by incinerating its sludge and now uses methane byproducts to generate electricity. In rural Tianjin, they observed purification of drinking water sourced from groundwater, to guard against fluorosis damage to the teeth and bones. One SPH student candidly told her hosts and fellow students about her family's struggles with minerals in their well water, and showed the telltale marks on her teeth.

Another group spent time observing acupuncture and reflexology and learning about a range of traditional Chinese medicine treatments. They noticed the proximity of traditional herbal pharmacies to Western-style clinics. After witnessing the resourceful care of postpartum women and their babies, some SPH students wondered if this was an area where the West could learn much from Chinese practices.

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.

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UPDATE: March 2012
Blog from the newest SPH projects in China

At UM SPH, several faculty members have Chinese ties. A sampling:

  • Through the Center for Managing Chronic Disease, Noreen Clark collaborated with the Beijing Heart, Lung, and Blood Vessel Institute and Capital Institute of Pediatrics to try Open Airways, a school program proven to have enhanced asthma outcomes for American children, in 21 schools in Beijing. Results showed marked improvements in asthma control for Chinese children.
  • Arnold Monto works on seasonal flu vaccines and strategies with the Chinese CDC, particularly Deputy Director for Disease Control and Emergency Response Yu Hongjie.
  • Brant Fries and the interRAI collaborative nursing home assessment programs have expanded their presence in China

To Learn More

  • July/August 2008 Health Affairs special China/India issue covers the rise of obesity in China, aging populations, and the effects of development on public health in both countries.
  • Wild Swans: Three Daughters of China (Touchstone, 2003), Jung Chang's memoir recounts her experience as a barefoot doctor. She documents the 1976 Tangshan earthquake and its role in unleashing Mao's brutal grip. Symbolic of a world apart: Growing up, she was told to eat all her food, because the starving children in capitalist countries had none.
  • Contagious Capitalism: Globalization and the Politics of Labor in China (Princeton University Press, 2007) , by UM political scientist Mary Gallagher. Analyzes the path to China's current strengthened economy and state, weakened civil society, and delay in political liberalization
  • Oracle Bones: A Journey through Time in China (HarperPerennial, 2007), by New Yorker China correspondent Peter Hessler. Changes post-Tiananmen, life in boomtowns, problems of float population, endangerment of Chinese traditions.


  • Half the water in China's seven biggest river basins is unfit for consumption; stress on aquifers is widespread.
  • China has the highest dioxin levels ever measured in urban air.
  • Paper masks commonly worn by Chinese commuters do not protect against ultrafine particulates of air pollution that cause the greatest health threat.
  • The New York Times cites 1.2 million annual Chinese deaths from smoking-related causes.
  • A Western-style obesity epidemic is emerging in China: more than 25 percent of its adults are considered overweight or obese.
  • Since 1985, deaths from diseases linked to poor diets in China have increased from 48 percent to 62 percent in urban areas and from 34 percent to 46 percent in rural areas.
  • By 2030, older adults are projected to account for two-thirds of the total disease burden in China.
  • Over half the world's female suicides occur in China, where a male-oriented society and access to potent agricultural poisons contribute to a ratio of female-to-male suicides that's unsurpassed in the world.
  • The "Latin Americanization of China" refers to the recent increase in economic disparities, wherein urban and coastal populations are generally six times wealthier than rural.


  • The environmental crisis is gaining attention, and the country can move quickly when motivated. Recent actions include a ban on plastic bags, the first national park designation, enhanced automotive fuel-efficiency standards, official support of alternatives to coal (such as modifying plants to run on natural gas and investing in nuclear, wind, and hydro power), and stronger water pollution prevention laws with specified penalties.
  • Progress on some infectious diseases has been significant, and education on chronic conditions increases. China proved its capability to mobilize when it built a 15,000-bed hospital in a week during the 2002 SARS epidemic.
  • Beginning in 2011, cigarettes carry health warnings on labels.