Part deux (project-related) of my previous post titled, "A long-overdue update," is long overdue as well. But, alas, here it is. So far, we've made two major trips outside of Xining. The first trip was to oversee the first round of vaccinations and the second trip was to help two filmmakers make a documentary of the project.
During the first trip, Yan and I were stationed in Ping An, but also traveled to Le Du and Hu Zhu (all of these are small counties within the district of Haidong, which is about an hour drive from Xining). First, we met with the head of the District CDC in Haidong and explained to him our plans for the trip. Our first goal was to observe a small sample of the first round of vaccinations. Our second goal was to hand out 6,500 pre-education surveys to a random sample of students throughout the district. Our third goal was to arrange for two filmmakers to come the next week to begin making a documentary of the project. Sounds simple, right? Actually, it was a feat explaining this to both the Xining and Haidong CDC heads (most of the explaining is usually accomplished by Yan, who is much more fluent in Chinese, specifically mainland Mandarin, than I am). Even more, each goal came with its own set of barriers. With patience and persistence, Yan and I accomplished goals #1 and 3, but goal #2 turned out to be an utter disaster.
Goal #1: Oversee the vaccinations. (I'll just write about the logistics here, and you can look at pictures to get a sense of what the schools look like.) Though it probably seemed like Yan and I were just taking a guided tour of random schools, we were in fact looking for specific things to ensure that the vaccinations were being carried out thoroughly and safely. (1) Every student must turn in a consent form signed by his/her parent. This serves as proof that the parents know what is going on, and also confirms that the students have not already been vaccinated so as to not waste resources on unnecessary vaccinations. (2) Every student must sign their names off on a chart, so that by the time the second and third rounds of vaccinations comes around, there will be a record of who needs to get a shot. It is very important that every student receives all three shots, otherwise they will not be protected against Hepatitis B for life. (3) Look for proper administration of the vaccination – most importantly, one needle per student. (4) Look for proper disposal procedure – i.e., all needles must be properly re-covered and thrown away in a special container separate from all other waste.
Overall, Yan and I were happy with what we observed at the schools. Unfortunately, it was quite a hassle trying to work out the timing of these site visits. In Xining, we were told that the vaccinations would be going on all month, so we expected that we could pick schools randomly and do surprise visits. When we got to Haidong, however, we found out that each county CDC has its own vaccination schedules and each of the health centers in the smaller counties within each county has its own schedules. Most of the vaccinations were going to be done by the end of the week, and the rest wouldn't start until near the end of the month. In fact, though we traveled to three schools, we only actually observed two vaccinations since the third was already over by the time we arrived at the school! Even more, we were not able to randomly pick schools to observe. Instead, the Haidong CDC took us to schools of their choosing, i.e., it was questionable whether the schools we observed were actually representative of the vaccinations going on province-wide. Nevertheless, the fact that everything was up to par at the schools we visited was enough, and the most we could do, to assume that at least someone somewhere in Qinghai knows how to properly administer these vaccinations.
Something that I've come to accept is that it is impossible for the two of us, Yan and I, to go to every school (crossing altitudes of 4500+ meters and encountering miles upon miles of dirt roads, if we're lucky to have roads) in every small county in every county in every district in the province of Qinghai to observe 500,000 vaccinations and teach 500,000 students in the time span of a few months. So, we have to depend on the local people here – the CDC workers and the teachers – to help us carry out this project and trust that it is getting done. People must be willing to help themselves in order to be helped. In any case, it is better that we are standing back as observers, working behind-the-scenes to organize the project and checking up on its progress every now and then to make sure things are going as planned. By handing over the brunt of the work to the locals, they are given the opportunity to help themselves and the ownership of making Qinghai the first province in China to vaccinate all of its children. More importantly, if funds suddenly run out at the Asian Liver Center, the Chinese will still have the knowledge to carry out this project and achieve similar results in other provinces. In fact, providing free vaccinations and making them readily accessible to all is important, but in some ways, education is even more powerful. Sure, getting three shots will protect you for life, but if you don't know what Hepatitis B is, then you will still fear the disease and discriminate against those who are infected. Without education, you will not encourage your friends and family to get vaccinated, and you will not know the options available to chronic carriers for delaying the onset of liver cancer and prolonging their lives. Hence, the slogan we came up with for our project: "Get vaccinated. Know more. Protect yourself for life."
Goat #2: Distribute the pre-education surveys. The purpose of pre-education surveys is to measure the level of Hepatitis B knowledge among the students before they are educated, as a baseline for comparison with data from post-education surveys. The idea is to get data like: "Before the Qinghai Vaccination and Education Project, only 10% of the students were vaccinated and only 30% knew what Hepatitis B is. Now, 100% of students in Qinghai are vaccinated and 90% know what it is, 85% know how it is transmitted and how it is not transmitted, and 92% do not fear the disease." Data like this will make Yan and I very proud. Otherwise, we will get fired. Just kidding. Still, pre-education surveys are crucial for showing just how much impact this project has had on Qinghai's health. Our goal was to hand out 6,500 surveys to 10% of the schools in Haidong to serve as a baseline for our study. (Haidong's student population is about 50% of the total student population in the five districts we're vaccinating this year.) Unfortunately, when we got back the surveys, the majority of the answers were clearly fabricated. Either one person, with the same pen (sometimes even with the same pen that was running out of ink), went through a stack of 50 and marked off the correct answers, or just marked off random answers (sometimes not even checking one answer, but rather the space in between two answers). Or a class of students all got correct answers, which most likely means that one kid, or teacher, knew the right answers and the rest just copied them down. In the end, we still graded 6,000+ surveys to prove to the Xining CDC that, indeed, they are useless. Most of the districts received a score of at least 95% correct on most of the answers. Ideally, these results would be exactly what we want – everyone already knows about Hepatitis B, so our work is done without even having started it! Realistically, having asked students in person about Hepatitis B (and usually receiving blank stares) and knowing that a "good" score would near 80 or 85%, we knew that we couldn't use the surveys. What a waste.
Despite all the trouble this has caused, Yan and I have learned a lot from this failure. First, our job is not to vaccinate nor is it to educate, as explained earlier. These jobs are for the local people to accomplish. Instead, our job is to organize, observe, and assess. Regarding the latter of the three tasks, it is absolutely crucial that we obtain accurate data. This means that we will have to personally go to each school, go to each classroom, hand out the pre- and post-education surveys, watch the students answer the surveys without outside help, collect the surveys and compile the data. Thankfully, after having dusted off the statistics sitting in the back of our brains (and receiving a lot of outside help and advice), we discovered that we actually don't have to get 10% of the students to take the survey (which would have meant going to about 150 schools). Instead, we only need about 400 responses to get data that is accurate with 95% confidence and a 5% margin of error (i.e., only 4 to 5 schools). The key to getting data that is representative of all five districts, though, is random sampling. This will be tough, but everything else in our project has eventually worked out, and I have faith that this will, too.
Goal #3: Help film the documentary.The Asian Liver Center has hired two filmmakers to make a documentary of this project. I mentioned this in an earlier post, but to recap, one filmmaker is British and the other is American, and both have previously worked on other documentaries for the Asian Liver Center (one is on youtube – search for "another life hepatitis b"). Anyway, Yan and I were tasked with a simple job: notify the Xining and Haidong CDC that they will be coming to film a documentary. Again, this was tough. In fact, making this documentary a possibility has been the most incredible feat Yan and I have accomplished thus far.
First, nobody in China really knew what was going on with this documentary, much less that plans existed to make a documentary. And, of course, it's difficult to make a documentary of any kind in China with all the censorship. The censorship multiplies when you want to film vaccinations, interview people in villages and rural areas (God forbid they say anything bad about the government or mention that they are not receiving equal access to healthcare services), and interviewing government officials (God forbid we have on tape officials saying incorrect things about Hepatitis B). Even more, everything works very, very hierarchically in China. To get any one task done, it must be approved by the people at the top and relayed down the chain of command. Tasks will not get done if you just go directly to the people you need to work with to get it done. In China, efficiency must be abandoned and headaches must be suffered. This means that to get this documentary approved, we have to talk to the people at the Foundation in Beijing, have them call the Xining CDC, who then has to call the Haidong CDC, who then has to call the county CDC, who then has to talk to the doctor at the local health center and the principal at the school. And that's not enough. Someone from the Xining CDC has to accompany us at all times to make sure that the local CDC workers will listen to us, and someone from the local CDC will also have to accompany us to make sure that the rural people will recognize us. (Actually, it's more likely a step to keep us foreigners in line and make sure that we're not snooping around and causing trouble.) To top it all, as I said before, timing things here is impossible – the filmmakers were arriving during a week that there was going to be no vaccinations…so what were they going to film??
Of course, Yan and I are incredible and everything worked out impressively in the end. We fought to film at a school, and not just any school, but the perfect rural school with documentary-worthy scenery. We fought to follow the lives of 4 children, go into their homes, interview their families and film a typical day in the life of a rural person. We translated from English to Chinese and Chinese to English (and sometimes even requiring a third translator to translate from the Qinghai dialect to Mandarin Chinese and back). We were the middle-(wo)men between the filmmakers and the CDC workers and between the filmmakers and the interviewees. And, we scheduled for the filmmakers to come back in time to shoot the second round of vaccinations and the teachers getting educated about HBV by the CDC workers. Yan and I should get a gold star.
Since Yan did most of the translating, my job was to be the Sound Engineer, though at times I was promoted to the positions of Associate and Executive Director. Actually, it was an amazing experience to learn about the process of filming and making a documentary. Obviously, we went through the painstaking trouble of working through the logistics of this documentary. But the best part is that we were always behind the camera when the kids were playing in the playground and learning in the classroom, when the parents were talking about their lives and how this project has affected their lives, when the CDC officials were talking about Hepatitis B as a public health problem in Qinghai and how this project is helping to resolve this problem. And it was great to watch two professionals working in the field – to observe how they plan what to shoot, who to shoot, and how to shoot it, and try to understand why their decisions will most assuredly look great on film.
Anyway, this post is getting incredibly long, but YES, I have been working!! Kind of. I feel like I have to convince myself sometimes that I am employed now. As always, pictures to accompany this post are available at http://www.flickr.com/photos/12460644@N0 3/.
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