A Tale of Two Hospitals

I’m falling terribly behind with these posts; a week of last-minute preparations followed by a week without internet can do that to you. So despite the fact that I just returned from a week one of two of carrying out rural screenings, this post is about a VHW “pre-training” session that occurred three weeks ago.

I’ve got loads of stories and pictures but I’m about to head off into the internet-less pit of rural China again. Please be patient.

July 28: VHW Pre-Training at Yun’an and Yu’nan

There was never a pre-training session in the original game plan. A brief lecture about commonly-seen eye diseases followed by a practicum in vision screening should fit comfortably into the time span of one morning. But given the fact that I had yet to meet the 25 VHWs we recruited at each hospital, I thought it might be a good idea to sit down with them face-to-face prior to the real thing scheduled for early August.

And so, our mid-July pre-training.

The schedule consisted of:

1. Drag the most important people in the hospital up front to say a few pre-scripted words, with a giant red banner waving behind you;

   

2. Have a ZOC doctor with a knack for storytelling lecture about the importance of eye health (“See this beautiful woman? Now imagine if you had cataracts.”);

   

3. Try to convince the VHWs that using SMS to refer patients is a good idea;

4. Then break the VHW into discussion groups so they can figure out how to house and feed 5 volunteers in return for their free labor.

   

Our first stop was Yun’an County People’s Hospital (YPH). Despite the red banner treatment a words of welcome from the hospital director, things start going downhill from the lecture. I look around the room and am alarmed to see some of the VHWs starting to doze, and a few already out cold. The discussion that was supposed to run for 30-40 minutes ended after about 15, with VHWs heading out the door to hurry home and our volunteer reps desperately trying to interrogate the few stragglers.

     

“There will always be some resistance when you introduce something new,” I say as I try to reassure my demoralized crew on our way back to the hotel. But in truth I’m a little fearful of what we’ll discover when we reach our second hospital the next day.

The following day we arrive (somewhat apprehensively) at Yu’nan County Traditional Chinese Medicine Hospital (YTCMH). It’s during the morning lecture that I notice something hopeful. The VHWs here aren’t falling asleep; in fact, some are even taking notes. During lunch, two of the volunteer reps sit down at a table of VHWs to strike up conversation, and as I eavesdrop I hear the one volunteer ask what they could eat in the villages, followed immediately by a chorus of consent from the VHWs to eat with them… The rest of the afternoon goes unbelievably smoothly, as we engage the VHWs in active discussion and it’s only at the hospital director reminder that we wrap up and send everyone home.

   

Why this stark different across two hospitals, both with long-term relations with the ZOC, and both located in the same geographical city?

Two theories. The first (and probably the more likely of the two) has to do with the method of VHW recruitment. When we outlined instructions for recruiting 25 VHWs to both hospitals, we specified that VHWs must be randomly selected to give a sample representative of the wider population. However, we also didn’t want to force VHWs who were unenthusiastic to participate (not to mention issues of informed consent). So we assigned each of the 200-some VHWs in each county a number, generated a random number sequence, and asked each hospital to go down the line, calling each VHW and asking whether they were interested in participating. If they were, great, they were in. If not, no big deal.

YTCMH did just that.

YPH had different plans. Instead of calling each one by one, they had the local Health Bureau send a mingling to the top 25 VHWs on the list, asking for them to come participate in a training. In ancient China, a mingling was the order sent by an emperor which you disobeyed at the risk of execution. It has adopted a less draconian but equally significant meaning in modern China. These VHWs couldn’t not come.

The second theory is that VHWs at YTCMH was served tea throughout the entire session.

Three interesting things to observe here:

  1. Despite the fact that the Health Bureau is now paying 10,000 RMB per year of income to local VHWs in return for their cooperation on matters of public health, five VHWs at YPH still failed to show up—a higher absence rate, in fact, than YTCMH where they were asked to voluntarily participate. This just goes to show that the power of top-down commands based on hierarchy has its limits.
  2. Brute force of command often leads to less-than-optimal results. I relayed my discovery of the recruitment method used by YTCMH to Dr. Wang as we headed back toward Guangzhou. He didn’t seem surprised. “That’s the way things are done in China,” he remarked with an air of bemusement. “The government orders things done and they do get done…but often in less-than-satisfactory manner.”
  3. Despite the voluntary recruitment method used by YTCMH, very few of the VHWs contacted actually refused. Of the 9 contacted who couldn’t come, 4 were because of wrong numbers, and 2 were sick.

There are likely other reasons at play here that I am currently unaware of, such as the VHWs’ understanding of blindness prevention and their relationship with their respective hospital. (Although if history of cooperation is a factor here, VHWs at YPH should have been more enthusiastic since YPH had already established a VHW network.) But for now, it seems reasonable to conclude that despite the allure of relying on mingling in China, taking the time to ask for consent may lead to a much better working relationship.

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