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Safety Shot

Three young Americans stop at nothing to halt one of Asia’s biggest killers

In the far west of China, tucked away to the north of Tibet, lies the province of Qinghai.

When Jonathan Chen, a sophomore at the University of California-San Diego, first searched for information about the region, he found images of its namesake high-altitude lake and references to its long, freezing winters, and he learned it was China’s equivalent to Siberia — a destination for the banished.

“I had a conflict imagining this place. Was it full of hardened criminals or was it a desolate, beautiful place?” Chen wondered.

At 19, Chen was to be the pioneer program officer of a massive project to oversee the vaccination of Qinghai’s half-million children against the deadly hepatitis B virus. The province’s residents are impoverished and bear the burden of a particularly high rate of infection with the virus. The Qinghai Vaccination and Education Project is the brainchild of surgeon Samuel So, MD, director of Stanford’s Asian Liver Center and the Lui Hac Minh Professor of Surgery. He has raised $1 million for the $3 million project and the Chinese government has committed the rest.

As a young surgeon specializing in liver transplantation, So began to notice a disturbing trend. Many of his patients, particularly those of Asian descent, came to him when it was too late. Their livers were damaged by years of infection with hepatitis B, an infection they never knew they had. The virus often leads to liver cancer and the loss of liver function from the scarring of cirrhosis. Something had to be done, he thought.

So’s grand plan, which he dubbed the Jade Ribbon Campaign, is to eradicate the virus from the planet. In 2001, the Asian Liver Center launched the campaign in the San Francisco Bay Area to spread awareness among those of Asian descent about hepatitis B and liver cancer. Since then, the campaign has spread across the country and the world. The campaign’s muscle and soul are young people like Chen who carry So’s vision to the far reaches of Asia.

Hepatitis B is 100 times more infectious than AIDS and about 10 times more prevalent worldwide. It runs rampant in Asia. Without the protection of a vaccine, nearly one in 10 people in China will become infected with hepatitis B. The dormant virus can hide in the liver for decades, then emerge and cause damage that is unnoticed until it’s too late. Without treatment, a quarter of those infected will die from liver failure caused by cirrhosis and cancer.

Those statistics blew Chen away when he first heard them. As a high school sophomore in San Jose, he had signed up for a youth leadership conference begun by So to expose students to the realities of the deadly yet preventable infection. “People don’t realize what a serious issue it is, especially when you grow up in America,” says Chen. “You don’t hear anything about it your whole life and then you find out that among the Asian community — my own community — it is such a problem and really nothing is being done to solve it.”

People most commonly catch the virus from their mother, either in the womb or soon after birth. But they can also be infected later through unprotected sex, by direct contact with blood and even from sharing toothbrushes or razors.

Fighting back

Chen became intent on spreading the word. In his later high school years, he took the message on the road locally with the Asian Liver Center’s youth council, providing ethnically sensitive information and organizing public screenings in community centers in the Bay Area.

Then in 2005, Chen had the opportunity to take the message on a much different road: a dirt one, skirting a cliff, without a guardrail — in Qinghai. The Jade Ribbon Campaign was launching its massive effort to eradicate hepatitis B in Qinghai, starting with a single district. With Chen coordinating the effort, the campaign provided the faculty, training, staff, lab equipment, educational materials and vaccines.

Out of China’s population of 1.3 billion, 30 to 40 million Chinese people will eventually die from this preventable disease, So points out. He laments that although an effective vaccine has been available for more than 18 years, China began to provide free hepatitis B vaccination for newborns only in 2002. Government health officials have been attempting to catch up older children who missed these infant vaccinations, but not for free. In remote, rural areas where babies are often born at home and many are served only by an occasional “foot” doctor who wheels a cart of rudimentary medical supplies from village to village, countless children remain unprotected.

Through the Qinghai Vaccination and Education Project, the province will become China’s first to vaccinate all grade school children against hepatitis B virus. Qinghai is the largest in area of China’s 22 provinces, and the smallest in population, with just over 5.3 million inhabitants. So hopes that the success of this project will encourage other provinces in China to follow suit and put an end to the hepatitis B epidemic. But why place a 19-year-old in a position of such responsibility?

So wants to inspire youth to consider careers in medicine or public health. He needs volunteers who can think innovatively. He seeks project leaders who will come across to the Chinese as supporting officials there, rather than dictating new protocols. And the cornerstone of his plan is to reach the minds of schoolchildren. “For all these reasons, what better way than to use young people who share our passion and determination?” he says.

Chen went there in 2006 to help launch the effort. His role was to oversee the project. “Not many people have heard of this place; I certainly hadn’t,” says Chen, who was born in the United States but grew up speaking Mandarin at home with his native Taiwanese parents. “It was kind of scary to be going there, but not a bad scary. I knew as long as I didn’t have to eat bugs, I’d be OK.”

Over the course of nine months, he never did have to eat bugs. He did, however, ingest some “really weird things,” he says, including yak-butter tea, cooked over burning lamb droppings. The tea is salty and greasy and has barley wheat at the bottom of the cup, which the drinker kneads into dough. “I hadn’t washed my hands in who knows how long, and it was really hard to finish it as I was picking lamb hairs out of the dough,” says Chen, “but it was awkward for me to refuse.” In the end he developed a taste for it.

By the time Chen left Qinghai, he had traversed more than 7,000 miles in the province, and more than 50,000 schoolkids were vaccinated.

“The kids felt relieved and safe knowing that they would be protected from this intimidating virus,” says Chen. “Many of the teachers would come to me after I gave a class on hepatitis B, asking about getting a family member or a friend vaccinated. By touching the students, we had also touched the community.”

Reaching every child in Qinghai

In September, the Stanford Asian Liver Center sent two new volunteer program officers to carry out the program’s next stage: expanding the scope to include every elementary-school-aged child in the province. All 500,000 of them.

Julie Len, 22, and Yan Pu, 23, had both been to China before on vacations and grew up speaking Mandarin at home. Len, who has Chinese ancestry, was born in the United States. Pu was born in China and came to the United States at 9. The two hadn’t met before they were accepted to work on the project. “However, the situation could not have turned out better,” says Pu. “Our individual skill sets and personalities really complemented each other’s very well,” adds the recent Claremont McKenna College graduate. “My role was more big-picture strategy, while Julie managed all the schedules and kept track of everything.” And luckily they hit it off.

Upon arriving in Qinghai in September, Len and Pu observed some of the vaccination sites, chosen randomly, as Chen had done. They wanted to ensure that the doctors used a clean needle for each child, that the vaccine was kept cold and that records were kept to help assure each child would receive all three of the shots in the series. A full series is the key to lifelong immunity.

“Sounds simple, right?” says Len, who graduated from Stanford in June 2007 with a joint degree in international relations and biology. In actuality, she says, it was a quite a feat to negotiate all of the layers of bureaucracy — not to mention that all of their dialogue was in an unfamiliar dialect. Visiting a school a few miles away, for example, required no less than eight phone calls, beginning with a call to the Chinese public health officials in Beijing. There were the physical barriers as well.

“Something that I’ve come to accept is that it is impossible for the two of us to go to every school, crossing altitudes of 4,500-plus meters and encountering miles upon miles of dirt roads — if we’re lucky to have roads — in every small village 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,” says Len.

They concluded that the key was educating the local people — the public health workers and the teachers — to help them spread the word and carry out this project.

Providing free vaccinations and making them readily accessible to all is important, they say, but in some ways, education is even more powerful. The vaccine protects people for life, but if they don’t know what hepatitis B is, then they will still fear the disease and discriminate against those who are infected, they won’t encourage others to get vaccinated and they won’t know what their options are if they are already infected.

While on the pilot mission, Chen also focused on education. “We didn’t just want to come to this region, give some shots and leave,” he says. “We wanted the knowledge of hepatitis B to be passed down through the generations.” Toward that goal, Chen helped design colorful cartoon posters to illustrate how the virus inflicts damage and how the shots prevent that. He also brought calendars for the children to take home to the parents, conveying the importance of being tested and then getting treatment or vaccination. Kids proudly sport teal-colored rubber bracelets that say “LIVERight” that they received after they bravely pulled up their sleeves and received their shots.

Len and Pu worked with local public health officials, school principals and health teachers to develop an education program that could reach 500,000 children across a wide geographic area. They developed surveys to test the students’ increase in knowledge. Linda Zhang, project manager for the Chinese Foundation for Hepatitis Prevention and Control in Beijing, was the local coordinator of the project. She says the teachers and students are grateful to Len and Pu. “Their lively, friendly teaching skills are really impressive,” she says. “And the local students and teachers have recognized the coordinators as their friends — even calling them overseas to invite them to come back to Qinghai for the Chinese New Year festival.” Len and Pu returned to the United States in November for the Qinghai schools’ winter break and headed back in March.

Hep B-free China?

So hopes hepatitis education in China will follow in the footsteps of the successful Clinton Foundation HIV/AIDS Initiative, launched in China by former U.S. President Bill Clinton in 2003. Len and Pu couldn’t help but notice the success of the HIV/AIDS initiative. “Everywhere we went, even the most rural areas, we saw HIV posters,” says Pu. “It was shocking. We didn’t see any for hepatitis B even though it is much more prevalent.”

Beginning with a hepatitis B summit targeting senior government leaders in Beijing in May 2009, So plans a similar attack. “We will unleash the Jade Ribbon ‘virus’ on China,” So says. “Maybe that’s what it takes to kill the hepatitis B virus.”

For now, the small volunteer effort is making a disproportionately large impact. All three volunteers shrug off the hardships of no heat, infrequent showers, mosquitoes and flies, endless hours in transit and sometimes questionable food.

“I knew before I arrived in Qinghai that this was an amazing project, but it wasn’t until I started visiting the schools and interacting with the students and teachers that I understood the importance of this endeavor,” says Pu.

That realization came when she was talking with the mother of a little girl who was vaccinated through the project. The woman told Pu that since her daughter was born after 2003 she was ineligible for the government’s newborn vaccination program. The family could not afford to vaccinate their child.

“With Stanford’s free vaccination program, she can be at ease that her daughter, along with so many other impoverished kids, can also be protected,” says Pu.

Chen looks back upon the first day after Sam So and everyone else from the United States left him alone in that foreign land. He recalls riding next to his driver, plugging along toward a school in a shiny black Volkswagen Santana sedan, dwarfed by the expansive horizon. The immensity of the landscape combined with the high altitude gave him the sense he could reach up and touch the clouds.

“I was really moved, almost to the point of tears,” he says. “It made me reflect on my decision to push ‘pause’ on my life as a college student in America to go there, and looking back, I realize it was totally worth it. I was doing something that would not only affect these students but every generation that comes after them. With only a year of college under my belt, it was an amazing opportunity to be a part of something so big.”


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Qinghai vaccine campaign photos

Photos by Jonathan Chen, Julie Len and Aaron Deemer
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