What Can Student-Run Free Clinics Do for Rural Ethnic Villages in China ? The Sunshine and Love Free Clinic Rural Medical Trip Initiative to Dimen Village

The Sunshine and Love Free Clinic is China’s first and only student-run free clinic. Two successful outreach projects to a rural ethnic village, Dimen, by the volunteers of the clinic took place in 2015: a pilot project focusing on women’s health, and a larger medical service trip focusing on record building and clinical visits. While the indigenous healing is a great recourse, four major health-related issues were identified through these projects: women’s health and reproductive health; chronic illness care; a lack of formal medical training among the village clinic staff; and a lack of patient record system. This article proposes that a summer service trip model can be utilized by student-run free clinics in China to tackle these issues, and provide sustainable intermittent long term health care for the rural ethnic China in a culturally sensitive manner.


Sunshine and Love Free Clinic (SLFC)
Established in 2010, the Sunshine and Love Free Clinic (SLFC) is affiliated with Peking University Health Science Center (PKUHSC) in Beijing, China, and is run by medical students from PKUHSC.The model of SLFC was based on the concept of student-run free clinics (SRFC) in the United States.In the absence of family medicine, especially for the less fortunate in China, SLFC serves not only as the first and only SRFC in the country, but also one of the first attempts to provide primary care for the underserved.
SLFC has over 100 regular medical student volunteers, most of whom are in their preclinical years.Currently the clinic has 38 patients, and each patient stays with the clinic for at least a year.Patients can remain enrolled with the clinic for longer if they so choose.Most patients of SLFC are between the ages of 40-60 years and are rural migrant workers who work on or near campus.Migrant workers are the engine of China's enormous economic growth over the last several decades, but they are largely marginalized and subject to institutionalized discrimination.As a result, although the majority are insured by the New Rural Cooperative Medical Care (NRCMC), they have very limited access to health care.Established in 2003, NRCMC is a voluntary insurance system aiming to make health care affordable for the rural poor. 1 The most common conditions at the clinic are hypertension, diabetes, musculoskeletal complaints, and joint pathologies.
Each patient is assigned a medical student volunteer as their student provider.Patients communicate with student providers via texting, phone calls, or face-to-face conversations whenever convenient.This allows patients to be seen even on the days when the clinic is not operating, and provides continuity of care for those with chronic diseases.Other roles student volunteers can take on include clinic management, fundraising, public relations, patient education organization, etc. clans and 584 households of the Dong ethnic minority Dimen's population today is around 2,600.Dimen is among the few communities in China that still largely practice traditional agriculture and ways of living.The Feng Shui Master, who is also an herbalist, provides health care to the villagers using both herbal medicine and rituals.For example, in a National Geographic article, Amy Tan describes how a sore throat of one patient was attributed by the Master to her ancestor's ghost possessing her body.An exorcism was prescribed as the treatment. 2n addition to the Feng Shui Master, a small western medicine clinic with three staff members was established in 2009, providing simple medications for common diseases.The staff received basic medical training at technical schools in nearby towns.The pharmacy supplies mostly antibiotics, aided by various Chinese patented medicines.Other western medicine options outside of the village are clinics in two nearby towns, and two county hospitals in the nearby city.Most villagers are ensured under the NRCMC. 3Dimen is 5km away from the local small hospital, and 45km away from the municipal hospital, where most women deliver their babies.There are 3 buses taking people outside of Dimen village each day.
A cultural eco-museum was established in 2005 in Dimen through cooperation of the county government and the private sector to foster the preservation, inheritance and development of indigenous Dong cultures.In 2014, after learning about the service-oriented nature of SLFC, Huang, the information manager of the eco-museum reached out to Zha, the founder of SLFC, proposing a possible service trip to Dimen by the student volunteers.Through the collaboration between two organizations, they hoped to assess and understand the complexity of administering effective health care in an area where local populations have great faith in traditional and non-medicinal forms of healing.The main concerns at the time were the limited access to modern medicine in the village and the lack of awareness in women's health issues.We hope the results of the project bring forth the ways in which modern health care and health education can be strategically implemented in rural communities like Dimen in a sustainable and culturally appropriate manner without diminishing the long existing indigenous healing recourses.

Objectives
This article aims to describe a pilot project focused on women's health in Dimen initiated by SLFC and its follow-up medical trip.In doing so, we hope to provide information on how SRFCs can help address health issues and provide care sensitively to the residents in rural ethnic villages in China.

Pilot Project and Women's Health in Dimen
A pilot project focused on women's health screening took place in January 2015.The target population was women of childbearing age.Women in this age group not only make up the main labor force in the village, but also determine domestic nutrition of the community.We surveyed 100 women regarding their general, obstetric, and gynecological health (Appendix 1).All 100 responded.We also shadowed the Feng Shui Master and observed how he managed patients.And, we spent time with the local clinic staff while conducting brief health screenings for patients visiting the local clinic.
Ninety-four participants were younger than 50 years old.The majority were of normal body mass index.When asked what bothered them the most, most women answered gynecological diseases, chronic pain and arthritis related to repetitive physical work, and reproductive health.Several women's health issues were identified (Table 1).
All the participants were married, including the youngest at the age of 21 years.While family planning policy in China only allows two children per household, most of the women we surveyed had two to three children.Two had no children and one expressed concerns about infertility.The two main contraceptive methods utilized were vasectomy and tubal ligation (Table 2).These procedures are performed mostly in the municipal hospital.Barrier and oral contraception were unfamil-  iar to most.While 32 reported use of no contraceptive method, only four were planning to have more children.
We spent one morning with the Feng Shui Master, Wu Xuezhen, and observed three patient encounters at his home.In one case, an elderly woman who presented with headache, insomnia and recent significant weight loss was found to have an enlarged cervical lymph node on exam.Master Wu explained that the pain was caused by the spirit of an unmarried and desperate great uncle occupying her body.The Master performed a ritual where he put a handful of rice grains into water while saying a spell, and waited for the one grain of rice to float to the surface.That floating grain of rice was identified to be the vessel through which a cure would be delivered.The Master then instructed the patient to tape the grain of rice to her skin until she felt better.After the ritual, the patient was invited to have lunch and wine with us.This is a common theme: free therapy sessions with an invitation to eat as a house guest.We were deeply moved by the warm and empathetic presence of the Master in his patients' lives as a counselor and spiritual mentor.The Dimen clinic staff also highly respect Master Wu. "Traditional herbal and western treatments are complementary to each other here, and patients will go for the most suitable method to their symptoms," said Wu Yuancheng, one of the clinic staff.
In summary, this pilot project confirmed our primary concerns regarding the lack of modern medicine in Dimen and the lack of understanding of women's health and reproductive health.

Follow-up Medical Service Trip
To further understand other health care needs in Dimen, a week-long medical service trip to Di-men took place in June 2015.The team was composed of 21 medical student volunteers from SLFC, one undergraduate student, and one high school student.A general practitioner, a pediatric nephrologist, a registered nurse, and a hospital staff member from Beijing also joined the team during the second half of the week.Three students from Guizhou Medical University served as local liaisons and ten high school students who are fluent in the Dong language served as interpreters.The recruitment of the above team members other than the SLFC student volunteers was through word of mouth.Since SLFC has a very positive reputation on campus and nationally for its medical volunteerism, there was an abundant influx of volunteers.
This trip had four parts: patient visits and patient record building, cultural events, visits with the Feng Shui Master and local clinic staff, and a lifestyle survey.One hundred twenty patient encounters took place, 344 paper-based health records were established and stored in the village clinic.Three major cultural events took place: welcome and farewell dinners and a traditional a cappella performance.More importantly, genuine friendships and partnerships were established despite of cultural and language differences.This broke ground for future collaborations.
Each patient encounter lasted approximately one hour: 15 minutes of history taking, 20 minutes of physical examination, and 25 minutes of closure and lifestyle counseling.A detailed health record was established for each patient and others who are willing to participate.The three most commonly reported chronic diseases are hypertension (21.4%), chronic low back pain (7.78%), and arthritis (6.61%).
Two hundred fifty-seven surveys regarding lifestyle and health care access were collected to further aid the understanding of cultural norm in Dimen (Appendix 2).According to our data, about 71% of the villagers consume a low salt diet, 80% are never smokers, and most live a physically active life.However, according to our data on food composition (Appendix 3), 20.24% villagers consume rice wine frequently, and other alcoholic drinks such as beer and herbal wine are also common.The majority are at least social drinkers.In terms of health care access, although 81.82% villagers are insured by the NRCMC, only 5.45% of those surveyed have recently visited a medical facility outside of the village.Further inquiry revealed that oftentimes when people fall ill, they do not seek medical attention.When prescribed medication by outside facilities, many do not pick up their prescriptions.Less than 50% of villagers who have been diagnosed with chronic illnesses are currently on any treatment.These trends are largely attributed to the lack of ability to pay even with the help of NRCMC.Of note, the average income in 2014 in China is $7,593.9per capita and on the rise, 4 while more than 70% of the Dimen villagers have an annual income of less than $3,000.
Through this trip, we discovered that chronic diseases such as hypertension and back pain were of concern to villagers but rarely treated or followed up on.Via spending time with the clinic staff, the Feng Shui Master, and the eco-museum staff, we learnt that a paper-based patient record system would be helpful, and further medical training of the staff members was much needed and desired.

Future Planning: the Summer Service Trip Model
Based on the experiences and data described above, several health issues can be identified in Dimen: 1) women's health and reproductive health are under-addressed; 2) there is a lack of continuity of care for chronic illnesses; 3) the clinic staff are not sufficiently updated on the current guidelines for diagnosing and treating acute illnesses; 4) there is no patient record system prior to our projects.Future plans to provide care for Dimen should not only address these issues, but also do so with respect for the cultural heritage.
PKUHSC requires every medical student to complete at least one summer service project. 5We propose that the SLFC should extend the length of the Dimen medical service trip to 4-6 weeks, and make the trip a summer service project available for all its volunteers.The volunteers will be divided into four teams: Female and Reproductive Health, Chronic Disease Management, Acute Care, and Cultural Affairs.Each team has the responsibility to help educate the Dimen clinic staff.
The tasks of the Female and Reproductive Health team are patient education in contraception and gynecological health.By providing an open and safe space, topics around contraception, abortion, sexual behaviors, and treatment for dysmenorrhea will be addressed.For those who are sexually active but undecided on whether to have children, or those who have new or multiple partners, condoms will be provided with instructions.Our data shows that the most utilized method of contraception is sterilization.In an almost western medicine naïve culture, the wide use of this extreme method is surprising.In fact, since China's one child policy was implemented in the late 1970s, forced sterilization has been practiced in many regions of the country. 6The target of this aggressive measure is mostly families who have already had two children, which is the majority of families in Dimen.Therefore, barrier contraception can not only help families with family planning, but also help avoid premature or potentially harmful surgical sterilization and its complications.Since education is the main task in this part, preclinical medical students can staff this team.
Chronic Disease Management is the team that will most heavily utilize the patient record system.The team will focus on the management and education on hypertension, low back pain, and arthritis.In terms of management, over the counter medications such as aspirin, other non-steroidal anti-inflammatory drugs, and heating pads can be purchased and distributed by the team.Prescription medications and the adjustment of such should be made by physicians.Counseling for lifestyle changes should be done in a culturally sensitive manner.For instance, many behaviors are identified as risk factors of hypertension. 7But according to our data, diet, smoking, and exercise might not be the major risk factors of hypertension among the Dong people.Alcohol consumption, on the other hand, could be a major risk factor of hypertension, which was also hinted by the Dimen clinic staff.Since alcohol consumption is a cultural phenomenon, counseling on this subject should be given after confirming excessive drinking with a thorough social history.
The Acute Care team can use the model for patient visits during the 2015 summer medical service trip.The team must be prepared for emergency situations where patients need hospitalization.An emergency protocol should be in place.Both the Chronic Disease Management and the Acute Care divisions should utilize mostly senior medical students and physicians for patient encounters, while preclinical medical students can provide patient education.
The Cultural Affairs team can be composed mostly of preclinical medical students or nonmedical volunteers.Besides participating in significant cultural events, including welcome ceremonies, visits to the Feng Shui Master and elders of the village, end of trip celebrations, and other rituals, volunteers can assist the eco-museum and the local clinic in storing, organizing, and utilizing the medical records so that the new practitioners can come in and access the patients and their history.
During the one week medical service trip, 120 patients were seen.If we assume this is the average number of patient seen each week, during the 4-6 week summer service trip, 480-720 patient encounters can take place.This means that at least one member from each household can be seen.The summer service project requirement by PKUHSC and the abundance of volunteers in SLFC ensure participation.The connection and organizational skills of the SLFC team make fundraising an easy task.And both the pilot project and follow-up summer medical service trip have laid a solid foundation for further visits.This is a practical and sustainable model to provide intermittent long term care for Dimen.

Why and How Can This Model Be Utilized in Other Parts of China?
Since the implementation of NRCMC, 99 percent of rural Chinese are said to have health insurance in 2013. 8However, considering the voluntary nature of the NRCMC and the difficulty in tracking rural-to-urban migrant workers, many are skeptical about this number.Other well identified barriers in the rural areas in the literature include patient avoidance of outside care, resource limitation, concerns for confidentiality, provider travel, training constraints, and language differences. 9ccording to the 6th national census in 2010, the Chinese population is 1.33 billion; about 52% live in the rural area, and 8.4% are ethnic minorities.Five percent of those 6 years or older have not received any education.Among ethnic minorities, this number increases to 8.3%. 10 Theoretically there are over 4.8 million uneducated ethnic minorities in the rural area.Many reside in geographically isolated areas, such as the Dong people in Dimen.Since NRCMC leaves out at least 1% of rural population, 48,000 or more are in need.
Intermittent long term care with community empowerment and education using a summer service trip model (SSTM) can address these issues, as demonstrated above.And if the SSTM is adopted by all medical schools in the country, the gap of rural health care can potentially be bridged: there are over 70 nationally accredited medical schools in China, and all require at least one medical service trips for each class.Fifty thousand patient encounters can take place each year.

Conclusion
It is SLFC's plan to continue to promote SRFCs in China.Its vision is to have SRFCs become a national student movement, where a culture of medical volunteerism and outreach projects is cultivated.The two projects described have demonstrated that the SRFC-led SSTM can successfully provide community-centered intermittent long term care for Dimen.If wide spread, the SRFC-led SSTM can be one of the means to provide such care for other rural ethnic communities, potentially bridging the gap of health care in rural ethnic China.

Disclosures
The initial pilot project was funded through individual and organizational donations by faculty members of Dartmouth College.These supporters include: Dr.Richard Chou, Dr. Amrose Cheung, Dr. Liming Bao, and the Geisel School of Medicine.There was no personal or organizational gain of those donated through this project, nor were the trip's objectives influenced by those mentioned above.
The housing of the volunteers in Dimen was provided by the Dimen cultural eco-museum, whose staff also provided help with coordinating both trips.

Table 1 .
Women's Health Issues Identified

Table 2 .
Means of Contraception among the Surveyed Women Journal of Student-Run Clinics | What Can Student-Run Free Clinics Do for Rural Ethnic Villages in China?If you could get more education on health maintenance, what would you like to learn about?Food Composition among the Surveyed Villagers journalsrc.org | J Stud Run Clin 3;1 | 8