Medicine and health care along the silk road in China

MEDICINE, SCIENCE, AND SOCIETY

Medicine and Health Care Along the Silk Road in China TSUNG 0. CHENG, M.D.

STATE CHINA

OF HEALTH

AND EDUCATION

child care wards and 35.7-fold increase in beds in children’s hospitals. The ratio of hospital beds in urban and rural areas was 74.8 to 25.2 in 1949 and 38.3 to 61.7 in 1979. Eighty percent of Chinese live in rural areas. There are now 2,642,OOO doctors, pharmacists, nurses, and technicians; among them, the highly qualified ones including the doctors of Western medicine number 436,000; medical persons of intermediate qualification number 1,108,OOO. Graduates from medical college in the last 30 years number 388,000,40.8 times as many as the aggregate total between i 928 and 1948 [ 11. Peasants trained as barefoot doctors number 1,575,OOO (about one third of them are women), as health workers 2619,000, and as midwives 709,000. China’s current state of medical care and medical education perhaps may be better appreciated by noting the status of regular institutes of higher learning in China today (Table I). Although much improved since 1949, China is still quite backward in education as compared with the rest of the world; the proportion of students at schools of higher learning per 10,000 people is 11.4 in China, 58.4 in India, 106 in the Soviet Union, 210 in Japan, and 507 in the United States. The national census (July 1, 1982) showed the number of illiterates and semi-illiterates above 12 years of age in China stood at 235,820,002 or one fourth of the total population, but the Chinese are catching up fast and very eager to learn. All the bookshops in Xinjiang and Inner Mongolia are well stocked. As is true everywhere in China, the science and technology section is extensive and includes medical books and journals that lay persons can purchase or peruse. Most books are in Han or Chinese, although Uigur is the predominant language in Xinjiang and Mongolian in Inner Mongolia; some are in English. There are even bookstalls around the street corners and people line up before they open. The medical libraries I visited are adequately stocked with magazines, books, and journals on both traditional Chinese medicine and

IN MODERN

is past July, I accepted an invitation by the Chinese Medical Association and the Ministry of Health of the People’s Republic of China for a return visit to China for further exchange of medical knowledge and technological information. The invitation included also my wife who is a nurse. Although this was my sixth, and my wife’s third, visit to China during the past decade, it was our first visit to Inner Mongolia and Xinjiang (Sinkiang), two of China’s five autonomous regions,* places seldom visited by Westerners and rarely even by the Chinese. We retraced the Silk Road travelled by Marco Polo more than 700 years ago (Figure 1). Old China used to be called “the sick man of Asia,” a political epithet pointing out the plight of a country haunted by poverty, hunger, and pestilence. Much of this has changed in the last 34 years. What I saw in Inner Mongolia and Xinjiang suggests that these areas have progressed along with Peking and the rest of China. I should describe first the state of health, medicine, and education in China in general, and then the facts, figures, and life styles of the people along the Silk Road, which have an important influence on the health and diseases that affect these people. China now has 65,000 hospitals, 25 times as many as in 1949 at the founding of the People’s Republic [ 11. There is at least one general hospital in each of the nation’s 2,000-add counties including Xinjiang and Inner Mongolia. The whole country has 1,932,OOO hospital beds, 24.2 times the 1949 figure [I]. This includes a 5.9-fold increase in the number of beds in maternity and T

The native Chinese are Hans. Nearly 60 percent of China is inhabited by 67 million non-Han Chinese ethnolinguistic peoples, and the provincesin which they predominate are designated autonomous regions. l

From the Division ter, ldashington, inStOn

UniVerSit.V

of Cadioiogy, LXpartment of MM&e, George Washhgton Unhrsi~ Medical CenD.C. Requests for reprints shoutd be adaessed to Dr. Tsung 0. Cheng, Georgs WashMedical Center, 2150 bnnsytvank Avenue, N. W., Washington, D.C. 20037.

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modem Western medicine. I was pleasantly surprised to see several copies of Alex Haley’s Roots on the shelves of the medical library in the Shihezi Medical College; the book was used as a reference for the class in genetics. China is now more or less self-sufficient in medicines and medical appliances. The production of medicines is a nonprofit endeavor. The state has adopted a policy of low prices for medicines; after six nationwide price reductions, medicines are now 80 percent cheaper than in 1950. People in modern China not only are healthier but also live longer (Table II). As a matter of fact, it is not uncommon to see families of four to five generations living in the same household in Xinjiang. More will

Figure

TABLE I

1.

Status of lnstltutes

The Silk Road, inner Mongolia,

of Higher Learnlng

Total unlwrsitles Polytechnic institutes Agricultural Institutes Institutes of forestry Teachers instltutes Language lnstltutes Institutes of finance and economics Institutes of political science and law Institutes of physical culture Art institutes Medfcal universities Institutes for nationalities l In addition to these 112 medical In the enrollmant figures.

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be said of these nonagenarians and centenarians in the subsequent section. One reason for longevity is eradication of infectious diseases in modern China. Among the infectious diseases common in old China, smallpox has been totally eradicated; the plaque, cholera, kala-azar and venereal diseases have been basically eliminated; typhus and recurrent fever are occasionally found in some places; polio is also under control; the incidence of measles is markedly low; that of tuberculosis, too, has been greatly reduced. More than 80 percent of the people infested with schistosomiasis, a disease that once prevailed in the nation’s 11 southern provinces, one autonomous region, and one municipality, and threatened the health

colleges,

and the rest of northwest

in 1982

715 32 206 56 10 194

454,614 51,627 163.630 36,720 4,031 125,444 4,396 9.207 920 4,904 2,951 25,964 4.616

10

36 9 13 27 112’ 10 there

are five faculties

The American Journal of Mmfklne

China.

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of medicine

79

in general

1.133.494 125,200 405,619 70,162 7,966 261,626 11,431 37,247 9,225 6,349 4,957 161,669 9,601

311,620 35,239 106,366 19,963 2,260 94,676 2,647 11,267 2,595 2,363 1,731 29,314 2,935 universities,

but their

students

are not included

MEDICINE.

TABLE II

of 100 million, have been cured. With infectious diseases gradually brought under control, cardiovascular disease and cancer have become the main fatal diseases in many parts of the country, especially in Inner Mongolia and Xinjiang.

SCIENCE,

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Average Llfe Expectancy

United Stales Japan England chha Yeer Male Female Male Female Male Female Male Female 197970.60 75.46 1951 42.74 46.76

68.20 75.90

71.18

76.31 67.80 73.80

HEALTH OF NONAGENARIANS AND CENTENARIANS IN NORTHWEST CHINA

One of the most interesting segments of my recent China trip along the Silk Road was the opportunity to visit and examine several nonagenarians and centenarians in Turpan, Xinjiang.7 I was fortunate to have the able assistance of Professor He Bing-xian from Xinjiang Medical College who is a cardiologist transplanted from Shanghai in mid-1950 and knows many of the minority languages. The opportunity to visit several of the very elderly people in Xinjiang came more by serendipity than by preplanning. One day, during my visit to the Xinjiang

Medical College, Professor He asked me about Dr. Alexander Leaf from the Massachusetts General Hospital and told me that he had accompanied Leaf several years ago on a trip to the mountainous area near Turpan to visit people of extreme old age. Unfortunately, my tight schedule in China did not permit me to go there, as it would extend my stay for at least one more week owing to the less than ideal means of transportation in that part of the country. It happened that my local tour guide overheard our conversation and suggested that perhaps I would like to visit her great grandmother who was “not very old but only 108 years of age” and lived in a nearby village (Flgure 2, left). On our way to her village, we met a 92-year-old Chinese traditional doctor who lived not far from a 95-year-old-man who in turn introduced me to his tea parlor friend, a 99year-old man

7 Xinjbkg has the hi@est number of centenarians in China. According to the latest statistics, there are 865 centenarians-536 males and 329 females-In Xinjiang; one of every 15,123 Xinjiang reskknts lives beyond 100 years of age. In all china there are 3.770 centenarians. Therefore Xinjiang, with about 2 percent of China’s population, has nearly 25 percent of China’s centenarians, many of them of the Uigur ethnic group.

F@~re 2. A woman of 108 years of age strolling age (rfght) in Turpan, Xinjiang.

(Figure 2, right).

All four were Uigurs and appeared to be healthy and happy. Their blood pressures were 140/80, 130/80,

with her &miiy (fen) and a man of 99 walking behind a man of 95 years of

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135170, and 130/75 at 108,99,95, and 92 years old, respectively. None showed an earlobe crease or a heart murmur. The most surprising finding was that all had normal electrocardiograms (Flgure 3). None smoked or drank. Their diets consisted principally of vegetables and fruits. When I asked the 108-year-old woman the secret of her longevity, she could offer none but looked at me disbelievingly when I kept inquiring into possible

causes and theories. When I asked the three elderly men the same question, all responded that they never went to a doctor and married younger spouses. Although it is true that their wives were much younger than they were, I tend to think that marrying younger wives was not the cause, but rather the consequence, of their longevity. As they outlived all their wives, each subsequent wife naturally would be younger than her predecessors. The fact that they never went to a doctor could mean that they were so healthy that they did not need one or that they avoided all the iatrogenic diseases by not going to a doctor at the drop of a hat as millions of Americans do [2]. Although absolute proof, such as birth certificate or census records-neither of which existed in China until recent years-was lacking, I had no reason to question the validity of their claimed ages. First, there was no incentive, financial or otherwise, for these elderly people in northwest China to exaggerate their ages. Very few Westerners ever visit this part of China, unlike the Ecuadorian village of Vilcabamba in the Andes where “wealthy Americans would fly down for a weekend of longevity” or American entrepreneurs could start “a business to bottle and sell water from Vilcabamba’s stream” [3]. Second, the way the Chinese keep track of their age is by adding a year every time they celebrate Chinese New Year. Therefore, the stated age is the minimum, and actual age may exceed the stated age-as the 95-year-old man told me, if he did not keep close tabs he might forget to add a year with each passing New Year. Third, by reconstructing the genealogy from their family members and close friends, I was able to come pretty close to their claimed ages. There is no physiologic function that “ages” at the same rate in all persons; some “age” faster than the others. Perhaps a method for chemical dating of age could be found. Recently, Helfman and Bada [4] reported a method using aspartic acid racemization in dentin as a measure of aging. Unfortunately due to the scarcity of teeth among the very elderly, this method has not yet been used to test claimed unusual longevity among the populations of Georgia in the Soviet Union, Hunza, and Vilcabamba, Ecuador. To date, in the absence of a more scientific and objective method, one can only rely on the best available subjective means of ascertaining human age [ 51. Electrocardiographic changes are said to occur “normally” with advancing age. Some minor changes of advancing age reflecting physiologic changes attending growth, changes in anteroposterior diameter of the chest and lung volume, and degenerative changes in the conduction system of the aging heart have all been accepted as normal. Therefore an abnormal electrocardiogram in an aged person who is otherwise free of cardiovascular disease is said to be a far less reliable independent marker of heart disease than in a

FIgwe 3. Electmcardio9rams of the lO& (fop), 99- (middle) and 95- (bottom) year-ohi people in Twpan, Xhjiang.

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young person. The finding of a completely normal electrocardiogram in these Chinese nonagenarians and centenarians certainly casts serious doubt on these presumptions. The same criteria for normal electrocardiographic results should be applied to both the young and the old; even minor changes such as “nonspecific T wave changes, ” “left axis deviation,” and “atrial prematuure beats” should not be considered normal in aged patients and may be associated with increased mortality [6]. As people live longer, objective noninvasive methods of assessing the presence or absence and the severity of heart disease assume an ever-increasing importance. As a noninvasive laboratory procedure, electrocardiography is without equal and provides a simple, noninvasive, universal, and reproducible method of assessing the cardiovascular status in elderly people. INTEGRATION OF TRADITIONAL CHINESE AND MODERN WESTERN MEDICINE

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and early ambulation immediately after operation, thus eliminating the necessity of intravenous infusion and reducing the complications of atelectasis and pulmonary embolism; avoidance of discomfort, pain, or hoarse voice caused by intubation; and absence of depressant action upon the respiratory and cardiac functions or other more serious side effects from the use of inhalant or intravenous anesthetics or drugs. Although the exact mechanism of acupuncture anesthesia is not completely understood, there is increasing evidence that the

MEDICINE

Although Xian, the ancient Chinese capital and the eastern terminus of the Silk Road, has gained world fame for the recent archeologic finds of the grave of China’s first emperor, Qin Shi Huangdi, with its 7,500 life-size armored soldiers, horses, and chariots buried 22 centuries ago, it impressed me medically as a typical example of successful integration of traditional Chinese medicine and modern Western medicine in modern China. In the Xian Medical College, I saw patients being treated for angina pectoris with Chinese herbal medicines and subjected to treadmill electrocardiographic and twtiimensional echocardiographic tests to assess the efficacy of the treatment. In the field of cardiovascular surgery, acupunctural anesthesia, which was first used for intracardiac surgery with extracorporeal circulation in 1972 in the Shanghai Third People’s Hospital [7] and Shanghai Second Medical Colleget and now employed successfully throughout China, represents the ultimate success of integration of traditional Chinese medicine and modern Western medicine [7,6] (Figure 4). Acupuncture is an ancient Chinese therapeutic modality for treatment of painful disorders and other ailments, but acupunctural anesthesia is relatively new [9]. The obvious advantages of acupunctural anesthesia in open heart surgery are: less interference with the patient’s physiologic, homeostatic, and hemostatic functions; active participation of the patient and constant cooperation with the surgeon during the operation; feasibility of oral feeding

Ffgura 4. Acupuncture anesthesia induced by fine need/es placed in the boy’s left ear for sugical &sure of a congenital ventricular septal defect under total cardiopulmonary bypass.

$ ShanghaiSecond Medical College is my alma mater, as I was graduatedin 1950 from PennsylvaniaMedical College, St. John’s University, Shanghai, China, which was the predecessor of Shanghai Second Medical College. On July 23.1983, the Shanghai Second Medical College conferred upon me the lifelong title of Vislting Professor of Medicine.

F&we 5. Demonstration of a nuclear cardiac probe by Henry Wagner of Johns Hopkins University (on left of patient) to S. C. Liu (at head of patient) at Fu Wai Hospital, Cardiovascular Institute, Chinese Academy of Medical Sciences, Peking.

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Application of the nuclear campmbe using inciksn 113m by Dr. Liu to clinical evaluation of left wntricular tMcttoW response to higenamine, a Chinese herbal drug. Ejection fv rose from 46 percent before treatment (left) to 72 percent atler treatment (rtght).

central endorphin system and opioid receptors play an important role [ 101. What impressed me the most was that I saw in Peking, the modern capital of China, a similar but more sophisticated example of the integration of traditional Chinese and modern Western medicine, as in China’s ancient capital of Xian. In 1979, I led the first American College of Physicians Teaching Delegation to China [ 111, one member of which was Dr. Henry Wagner from Johns Hopkins University who brought along a nuclear cardiac probe (Bios, Valhalla, New York). This is a highly portable device that can provide information on left ventricular function much faster than any other nuclear technique. It was just introduced in the United States at about the same time it was demonstrated by Wagner in the Fu Wai Hospital, Cardiovascular Institute, Chinese Academy of Medical Sciences, Peking, during our 1979 China trip (Figure 5). Now our Chinese colleagues have employed the cardiac probe in serial radionuclide evaluation of left ventricular function response to var-

ious drugs including known beta-adrenergic stimulating and blocking agents [ 121 as well as many Chinese herbal drugs [ 131 (Figure 6). The adaptation of the cardiac probe by our Chinese colleagues to its use with indium 113m is important, because this agent is more available than technetium 99m in developing countries. One of the advantages of Chinese herbal medicines is that they are not as potent as Western drugs and thus have fewer side effects. However, until recently, it was dlfficuit to ascertain if and how these herbal medicines work in the patients, although their efficacy has been well demonstrated in animal experiments [ 141. invasive methods of human investigation are not very popular in China. Modern technology that employs noninvasive means of evaluating left ventricular function, as exemplified by the nuclear cardiac probe, makes this possible. It is a true representation of successful integration between the traditional Chinese medicine and modern Western medicine.

REFERENCES 1. Cheng TO: Medical educatkrn ln modem China: an update. Ann Intern Med 1980; 92: 702-704. 2. Halsell G: Los Viejos: secrets of long life from the sacred valley. Emmaus, Pennsylvania: Rodale Press, 1976; 175. 3. Leaf A: LonglIved populations: extreme ok! age. J Am Gerlatr See 1982; 30: 485-487. 4. Helfman PM. Bada JL: Aspartic acid racemisation in dentine as a measure of ageing. Nature 1976; 282: 279-281. 5. Leaf A: “Every day Is a gift when you are over 100.” National Geographic 1973; 143: 93-l 18. 6. Fisch C: Electrocardiogram in the aged: an independent marker of heart disease? Am J Med 1981; 70: 4-6. 7. Chena TO: Paul D. White lecture: Cardiokw In the People’s Republic of Chlna. In: Russek HI, ed. New horizons in cardlovascular practice. Baltimore: Unlverslty Park Press, 1975; l-27. 8. Cheng TO: Cardiology In People’s Republic of China In 1977. 9

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9. 10. 11. 12. 13. 14.

Chest 1978; 74: 209-211. Chang To: Medkine in modem China. J Am Gsriatr Sot 1973; 21: 289-313. Han JS, Terenius L: Neurochemical basis of acupuncture anafgesfa. Annu Rev Pharmacol Toxkol 1982; 22: 193220. Chinese show interest In US medicine. Bull Board Am Co8 Physicians 1979; 1: 2. Liu SC, Wagner HN, Chen W, Wang SH: Monitoring left ventricular functkw with indi1~1+113m and a cardiac probe. J Nucl Med 1980; 21: P88-P89. Jiang WQ, Liu XJ, Tao SC, et al: Clinical study of the effect of hlaenamine on electlcn fraction and bradwrhythmia. Chin; Mod Dev Tradlt Med 1981; 1: 6-8. Yu GR, Wang BY, Zheng DS, et al: Effect of hlgenamine on action potential of ventrkx~far myocardfal cells. J Electw carxtiol (In press).