My first inkling that this wasn’t going to be a routine village visit was when I noticed that our coach had a police escort. Then when we arrived at the village of Lianghu in Shanxi province in China I saw the huge, highly decorated arch that is the entry to the road to the village. But it was the drummers that made me realise that this was something very special.
The 50 or so drummers, all women, lined the approach road to the village. They were dressed in the most elaborate scarlet and gold costumes with hats that could have belonged to emperors. A woman in an even more elaborate, more yellow, costume led the drumming. The music reached a crescendo as we marched between them.
At the end of the road we could see what looked like the entire village, perhaps 400 people, gathered to meet us. They stood and sat between bright red banners announcing in Chinese and English “The China rural health salt reduction programme.” In addition, two giant red balloons, filled with helium and highly decorated, flew above them. Red is always the predominant colour because red means good luck. Behind the villagers was a huge poster, perhaps 90 feet by 30 feet, with maps of the village.
From the moment we stepped off the bus about eight photographers snapped hundreds of pictures of us. As we marched up to the meet the villagers I felt like Barack Obama or Lady Gaga. “This is a bit different from a community development project in East London,” said an Australian Colleague.
We, about 25 of us, were there to see in action the China rural health initiative, which is a pragmatic complex cluster randomised trial to control hypertension. There are two interventions: training of “village doctors” (the former barefoot doctors), and education about salt reduction and provision of salt substitute. There are 120 villages in the trial in five provinces, and some villages get both interventions, some one or the other, and some neither.
Hypertension is a big problem in Northern China, partly because of their high salt consumption. The mayor told us that salt consumption in the village was 17 gm per person per day when WHO recommends no more than 6 gm. “How many mayors,” said an American colleague, “know the salt consumption of their citizens?”
When we moved into the very welcoming crowd we were offered seats. Six of us in the group were Westerners and were of special interest. We sat down, and the village leader began to read a speech explaining the programme. Nobody seemed to be listening. They were much more interested in us and in the small girls, all dressed the same, who were being led forward to dance for us. The smallest girls, who were probably 3 to 4, had blue skirts, white tights, pink shoes, gold tinsel wrapped around their wrists, and bizarre teashirts that featured a woman who looked like a cross between Nana Mouskouri and Barbie. They were made up with green eye shadow, and clearly a lot of work had gone into getting them ready. The bigger girls, who were probably 5 to 7, had equally bright costumes.
The village leader ploughed on regardless and was followed by a district health official. The girls were jumping around in front of us, keen to get going. After the health official came the community health educator, who explained the dangers of salt, which foods contained it, how to reduce salt consumption, and how to buy salt substitute. Her talk was punctuated by a lottery draw with the winners receiving bags of salt substitute. If we, most of the rest of the village, the drummers, and the dancing girls had not been there, the community health educator would no doubt have done better in getting her messages across—but people were too distracted.
Eventually it was time for the dancing. The smallest girls began with “Two tigers,” and very good they were. They did two dances, and the bigger girls also did two, with the finale being “I love my country,” a very energetic dance. We clapped each dance with great enthusiasm, and the photographers continued to snap our every move.
After the dancing it was time for the serious picture taking. The girls came and stood in front of us, and mothers handed us their babies to be photographed on our laps. It had been a while since I’d held a baby, and I loved the astonished look on their faces as we held them, waiting for them to burst into tears as it all became too much.
Next a large red book and a thick black pen were produced and we had to sign our names and write a comment. I looked shamefully at my illegible scrawl beside the Chinese script, which to me always looks beautiful.
Then we began a tour of the village. It has 10 temples for its 450 families and 1526 people (remember the one child policy), and some of the temples are a thousand years old. Indeed, many of the houses are that old, most in a dilapidated condition but with exquisite carvings still easily visible. Most of the houses are of brick and are built around courtyards with huge, carved wooden doors giving access to the courtyards. Many have upper stories, and I couldn’t help but think that this was like a small scale and run down version of the Forbidden City, the beautifully preserved home of the emperors in the centre of Beijing. The most spectacular building in Lianghu is the home of a marshal of China from the Ming Dynasty. It has the big doors, the carvings, an upper floor with a balcony, and the large hall for receiving guests.
But people still live in many of the ancient houses of Lianghu. We went into one house that was a thousand years old, once had a drawbridge, and is now the home of an elderly women. She lived on the middle floor with a trap door to a floor below and a long ladder to the floor above. She had a large picture of Chairman Mao, but this was not a comfortable place to live. It felt not so different from living in the ruins of a Norman castle, with bare stone and dust. The toilet was outside, and she had to cook outside.
Some 550 million people in China live on less than $2 a day, but this is not one of the poorest parts of China. Nevertheless, many of the people are living in relative poverty in the decayed but still beautiful splendour of ancient dynasties. We saw too an elderly woman with bound feet. This practice ended in 1911 but lingered into the 30s.
All over the village there were posters about the dangers of salt (perhaps put up that morning for our benefit), and we went into a shop to see the salt substitute. The shop did, we were glad to see, include lots of fresh fruit and vegetables, but at the moment it is 1.5 yuan (about 15p) for 500 grams of salt and 2 yuan (20p) for 350 grams of salt substitute. One of the arms of the trial will include subsidy to make the two the same price.
Our visit ended with a tour of the clinic of the village doctor. It shares a richly decorated new building with the police station. Entering the clinic is like entering a shop with a counter containing all the drugs available, some of them Western drugs and others traditional Chinese medicines. A list on the wall gave the price of all the drugs, and most expensive was a course of amoxicillin (3.5 yuan, 35p).
The village doctor told us that he had been there for 30 years and how from this year 70% of the cost of his consultation and drugs was now reimbursed. Last year it was 40%, but the government is keen to promote rural health care. (China spends three times more per person on urban care than on rural care.) I asked what happened if people couldn’t pay. He told me everybody could pay, but colleagues told me later that people probably didn’t come if they couldn’t pay.
I asked then about immunisation, and the village doctor produced beautifully kept records that showed that every child in the village received every vaccine. Confidence in the village doctor means that he achieves 100% immunisation.
After the visit to the village doctor it was time to go. We climbed into our bus and waved goodbye as the band drummed us out. This was not a typical Chinese village, but it was certainly a remarkable one.
Competing interest: RS is the director of the UnitedHealth Chronic Disease Initiative, and UnitedHealth—together with the National Heart, Lung and Blood Institute and others—is funding the China Rural Health Initiative.