 This would be a good idea to do so now if not we can proceed with the presentation. I see Lisa Krasna in the back, which is with public health in order. I'm actually on a trip with China now. So you've been with me? Yes, I've been with you. Public health, sir? I came from the Indian Department. May I come in here? It's good to be here. Is that Eric? Eric. That's with public health. Oh, I'm going to go to the studio. It's alright. I'm gone, just for a couple of seconds. So I am very, very delighted to have Dr. Obade Chano here with us today. We've been having ongoing discussions often on for about a year. And this is really a watershed in having this participation in our program, partly because we want to reach out to those on our campus who are actually in the field of doing public health. And he was trained as a physician and as a researcher. And his expertise is in cardiology. He has had lots of publications and experience in research. And a few years ago he traveled to China on the invitation from a professor there. And essentially fell in love with the culture, with people, with place, the public health issues that he felt a significant difference. And he has taken students and colleagues over to China to, especially if we rather have to look at heart disease. And today he's going to talk to us about these experiences and I hope we can follow up with him with additional questions and discussions. Thank you, Professor Obade Chano. I'm going to talk about the growing academic hypertension and heart disease in China and what the small organization that I belong to, which Professor Obade belongs to and some of you may know about, the China-California Heart Watch is trying to do in confronting this. So first of all I would like to start this with some questions. And I want you to, you don't have to tell me the answers to these questions but perhaps you could jot them down really quickly and then think about what your answers would be. Chinese farmers, the rural population of China, what percent of the world's population is it? 5%, 10%, what is it? And what is presently the most important cause of death in this sector of the world's population? And how rapidly is this cause of death increasing in China in terms of the number of deaths in terms of mortality? How rapidly is that increasing? There's a hint there that is increasing but how fast is it increasing compared to the United States. What source of support in terms of healthcare support is the most likely to solve the problem of heart disease in China? Private sector, Chinese government or what support? And how could a small organization best influence the potential source of support to do more about it? If you try to think about these questions you'll understand my logic in founding this small organization and working in China which is not only to directly do something and make a difference but perhaps to influence the powers of the beat to make even a bigger difference. Let's start with the first question. Rural Chinese people make up one-eighth of the world's population. More than there are people in the United States. 800 million people live in rural China. Western rural China in particular is poor and as I said as a response to one of the questions is in the sense of getting even poorer there's enormous inequality between rich and poor. There is a great neck urbanization with people rapidly moving from rural villages into little sized and large cities. And I'll show you an example of that, an amazing example of that in just a minute of a city in China that some of you I know I visited but you may not know the facts about its population increase. And there is no economic base in the private sector or even in the local government they could possibly meet the healthcare needs of this enormous population. The local economies are just too poor. They could not do it on their own. They have to get help from the outside. This is from 2006 so it's a few years old but it's statistics today are pretty much the same. There are 100 million rural Chinese that earn less than $1 income per day. We talk about the poverty in small countries like hate enormously poor and a fortunate population there's 10 times as many people in China that are that poor. If you're getting poorer between 2001 and 2006 the poorest 10% of households saw reduction in their income from $546 to $420. There's enormous inequality both between regions and between the rich and the poor in given regions. Urbanization is depleting labor in rural areas making it difficult for rural poor regions to attract investments. This table here shows the gross domestic product comparisons. It's flashing, you can give me upwards. 2005. China, I'm told the main thing is to look at the comparisons here. If you look at the eastern coast of China it's $3,528 GDP per year and if you look at the southern hinterland which includes Yunnan province it's three times smaller. So this is the kind of inequality between regions that you have in productivity and income. Urbanization, this is about Dali city. Who has been to this city? Dr. Wang has been there. Dali city is right in the middle of Dali state. This is Dali state or Dali prefecture. Dali city is right in the middle. It's in the southern part of Lake. This is our lake, our high. And in the year 1000 it was the 14th largest city in the world. It had 90,000 people. So in the year 1000 the city was very big. Dali was a big metropolis. It was a big metropolis. It was the capital of a small kingdom. And between 1000 and 1983 its population did not change. In 1983 its population was still about 90,000. It actually went down and then went back up a little to 90,000. So it reached its year 1000 population in 1983. Since 1983 what's happened in Dali city? This is what's happened. Its population has gone from about 100,000, 90,000 to about almost 600,000. It's increased more than five times in that short period of time. So where did all those people come from? They came from the countryside. They came from the villages. They came from the small towns in rural areas. Is this trend pretty much true for most of the larger cities in Yunnan? Dali is one of the fastest growing in population. The very large cities like Kunming is about now about 6 million. Not five to 6 million. They're also increasing in size, but not at this rate. And even the very large Shanghai and Beijing are also increasing. Do you know if this is the wrong for most of the Chinese cities? I've just seen that. People go back to the countryside because of the economic downturn. 10,000 in May, 30,000 in turn. The question is in the economic downturn, the worldwide recession, which we are now in, has that caused people to go back to the countryside? I think, once again, I'm not an economist. I think what happened was the people moved from the eastern manufacturing cities like Shenzhen and Guangzhou, Shanghai. They moved from those cities and they went back to their provinces. And then they went out and got jobs in local cities like here. So I don't think these cities are decreasing in population now because of that. They're still building and developing. It's not as fast as they were in, say, 2000 or 2001, 2002, but they're still building. And they need labor. A lot of these people work in construction. They need labor for the building. So in this setting of poverty, inequality, and breakneck organization, what is happening to heart disease in rural China? Let's take a look at what's happening in China in general. And let's compare it with the United States. What happens with the mortality from heart disease in the United States? Dr. Wang, you could probably take over from this and do a much better job than you could handle this very well. In between 1900 and about 1970, there was an increase in heart disease, mortality in the United States and death from heart disease. And then in about 1970 or so, it leveled off and its state leveled off. And some of the, I mean, there are all kinds of hypotheses as to why that happened. But I think the major ones involve healthcare improvements. Healthcare in terms of caring for people with heart disease, chronic care units, defibrillators, coronary bypass surgery, percutaneous interventions, and very importantly, preventive cardiology. Treatment of hypertension, treatment of hyperlipidemia, earlier diagnosis and treatment of diabetes. I think these are considered to be some of the factors which cause this to level off and not to continue increasing. Some people say, even if you didn't have any of this, it would have leveled off. But I really don't think so. I think our healthcare system did have an effect. I mean, with all of our defects in our healthcare system, I think it did have a positive effect in causing a leveling off of mortality in the United States from heart disease. Well, in China, in rural China, in particular, this business practically doesn't exist. When I go to villages, and I had one man, he walked three miles with chest pain. He came and he, to me, with the chest pain. We had an ECG machine, we had an ECG. He had an acute mild current in the fracture and then his ECG. And he did not, he refused to enter the hospital. Not because of money, because I would have paid for that for him. He didn't trust the hospital. He didn't trust the doctors. So his mild current fracture was treated with pain medications, the beta blockers and aspirin, which I gave him at home in bed rest. So no CCU, no defibrillator, no bypass surgery, okay, no PCI, and essentially, except for my advice to him to control his blood pressure and no preventive cardiology. So let's compare the U.S. with China. This is the U.S. and this is China. Okay? If nothing is done, the number of deaths in China, of course, this is number, not percentage. Okay, so you understand that. It couldn't be percentage. The number of deaths in China is going to continue to increase until about 2050. It's going to hit maybe 10 million deaths a year. Once again, going back to the poor country of Asia there's 10 million people. It's like there's a population of a small country dying a year. That's how many people will die from heart disease and stroke in China. In 2050, if nothing is done to address this problem. Why is heart disease, and it's increasing in China? My thoughts, number one reason is hypertension. Number two reason is hypertension. And number three reason is hypertension. Of course, there are other factors. Of course, there's hyperlipidemia. There's poor, high fatty foods, which are increasing. There's less activity, some degree of less activity. There's smoking. That's been going on since the 50s. I think uncontrolled high blood pressure, which is increasing in severity, which is increasing in prevalence, is the main reason for the increased incidence and mortality from heart disease. Have there been some studies that have looked at, for example, attributable risk in rural regions to say smoking versus hypertension and some of the other risk factors? Well, Yan Fangu, his cohort, which includes rural areas of Muka, M-U-C-A cohort, his hypertension is the strongest risk factor. Triple risk of hypertension is higher than the other risks in rural areas. Just to follow up on, I remember 10, 15 years ago, WHO was predicting lung cancer, essentially, the graph that you showed, skyrocketed in time. Is smoking as prevalent in the rural areas as one would expect in the big cities? It's very prevalent. It's prevalent among males, about 70% of adult males, and only maybe less than 10%, 5% of females. In some very remote regions, the women also smoke. They smoke pipes, but most of the women in rural China don't smoke. Is there a gender difference in hypertension, heart disease? Yes. Yes. It's more in high rate. This is prevalence of hypertension. These are different studies, so they're not exactly comparable and there's all types of biases involved, but if you look at the results of the different studies starting in 1959, the earliest studies in Chinese statistics of prevalence of hypertension in rural Chinese adults were as only about 5%, they didn't consider an important problem at all, going through the present where it's as high as 35%. In our study at NUNON, it was 30% in middle aged elderly adults in Liaoning province in the northeast of China. It's for about 45% of adults in rural areas have hypertension. So there's a very rapid increase in prevalence of hypertension in countries like... So Bob, one other issue about that. So with an uncontrolled hypertension, a big issue, are you seeing proportionately more strokes versus coronary disease in rural China than, for example, in urban China where coronary disease seems to be going up and maybe stroke not quite as much because they're controlling blood pressure a little bit better in urban areas? Well, I'm not sure that's true, Nathan. I think strokes are... death from strokes, stroke mortality is still higher than coronary disease mortality everywhere in China. Stroke mortality is very high. It's one of the mysteries, really. The difference is so great that it makes a lot of sense. There might be differences in genetic differences. Yeah, much more than in estates. Stroke is a much bigger deal. Also in Japan, stroke mortality is high, which pans are all at least in the whole country, Korea also. In China, it's the only large country where there's an excess of stroke mortality over heart disease mortality. All over the city and countries. When I see more strokes, I see more strokes than heart attacks. Michael went with us. Remember, we didn't see any heart attack. But we see strokes. What was your definition of hypertension? It's a WHO definition. It's either a history of hypertension or a systolic blood pressure of at least 140, or a diastolic of at least 90. And do you see the prevalence of the degree of hypertension as it dropped off at the higher levels? Or do you see a kind of a continuous, I mean, a similarity of very high blood pressure versus just breaking up? I think, you mean compared to other places? I don't know. The question is that we see fewer people with very high blood pressure? Yeah, we see. Most of the people with hypertension have blood pressures in 240 systolic people, 140, 160, and diastolic between, say, 90 and 100, most of them. But we see also some with very high blood pressure. I see a lady with 260 over 140, and she just walked in and I measured it three times and it was that high. And she wanted to go home and she said, no, no, wait here. We have to give you some medicine. So you're giving her medicine, but how aggressively are you revaling or maybe secondary causes? Secondary hypertension versus primary hypertension. Secondary hypertension is a known cause, like needle artery stenosis or hypothyroidism. You know, in China, like everywhere else, most hypertension is essential hypertension. If we have young women, and we do a physical examination, we have young women, we've seen young women who seem very nervous, tachycardic, fast heart rate, and we'll check out somebody like that for hypothyroidism. We've seen some of those. In fact, some of them are so obvious that hypothyroidism actually treated them because it's not easy to get thyroid function tests. You have to send them far away, but we've actually treated them with tapasol or lithosol and adiablocker. But most of them are in one case of a coartation of the aorta in an adult. It's just very interesting how you want to get into it now. Because you're doing echocardiographs. Not in any particular sense, right? Yeah, but in some cases. We have echocardiographs in the end. So we're a small organization, China, California, Hardwatch, and what are we doing in China? Our mission is to, one, establish transnational education exchange to allow American students to study in developing areas of China, even on problems, research hypertension and heart disease in China, train rural healthcare workers, and get free clinical care. And I'm going to talk about each one of those in terms of our accomplishments. In education exchange, we have an intern program, which Michael Berniani, who's here, participated in. We are doing research. We have one publication in the period literature and international literature, which Ashkan Akashay is the primary author. He is a medical student at UCI. He and my colleagues in China, and Dr. Wang here, wrote this paper. It was published in the 2009. I'm going to show briefly something about that paper in the next 10 minutes. And we are teaching village doctors in training courses, which we hold now every year. And we have several clinical programs, but I think the most remarkable, especially for me, because I never expected to do this, and I am not a pediatric cardiologist, is our Grants for Kids program. Last year, we helped give 14 children a new chance of life, who never could have undergone surgeries or procedures if we hadn't been there to help them. This is Ashkan Akashay in Yunnan, and his paper was published in American Journal of Hypertension last year. Left in Turkino Mass of Blood Pressure and Untreated Hypertensives in rural Yunnan. Just briefly going through this in a formalistic type method, the methods that we used to do this was we randomly chose 10 villages, villages from different townships, and we randomly chose subjects, residents of those villages between the ages of 50 and 70 years from each village. We had a total of 490 men and women. Of those 490, 344 were available to participate. So the 490 were chosen from a list, but we didn't find all of them. Some of them had gone to the city to for a blue-blinded lame or some of them were too sick to come in and we did not consent. So we ended up with a sample size of 344 which individuals who participated between 50 and 70 equal numbers of men and women. We took histories for risk factors, smoking, alcohol use, medication use, and we measured blood pressure 3 times, measured height and weight to get body mass index. We did cardiac ultrasound using a small portable ultrasound machine in order to measure the interventricular septal wall thickness, that's the wall that separates the right and left ventricle and the left ventricular posterior wall, that's the opposite wall of the left ventricle and also the diameter of the ventricle of the left ventricle diastole. Using those three measurements one can use a formula to calculate the mass of the left ventricle which is a fairly accurate formula has been used in many epidemiological studies internationally. So in order to reduce variability I was very nervous that we weren't going to get good measurements. In order to calculate variability and reduce variability we did four measurements of each one of these so we had four separate left ventricular masses for each one of the 344 participants. This is me doing an ultrasound in a subject's home. We did some of these in the home, some of them in community centers, some of them in clinics. This is the small machine that we used to do the measurements on. This is a a picture, you can't see it very well, but this is the interseptal of the septal thickness. The lights are a little bit too bright here to see this. The septal thickness in this one was 1.8 centimeters, 18 millimeters. The posterior wall thickness was 16 millimeters, and the internal diameter of the left ventricle was 46 millimeters. Using those three measurements, you can calculate left ventricular mass and you use the formula called the DEVARU formula named after professor DEVARU who is a cardiologist at Cornell University and that's the formula. Everyone has to remember this, don't you? The professor is going to ask you next week, what's the DEVARU formula? Did you also get left atrial dimensions? I was curious. Yes, you did. I'm putting it on here, but we have to use that data. Yeah, that would be... Well, it's the next paper. Maybe someone wants to look at the left atrial dimensions and see how they're related to blood pressure. So we took the average of the blood pressure measurements, the average of the fluorescence of left ventricular mass and we calculated the left ventricular mass index which is left ventricular mass divided by the body surface area. This is just how we got down to 344. Okay. And in our results of the 344, 48 percent in men body mass index was 22.6 and 38 percent of smokers, most all of those were men. Now high cholesterol and diabetes we did not measure. We did not take blood specimens. We did self-reported. And in rural areas people never get tested. So basically we asked them, do you have high cholesterol and they would say yes or no. Now in many cases think they really don't know. So these data are a little bit questionable, frankly. There's a problem with them. It would have been nicer to do finger sticks or some kind of measurement but we didn't have that available when we started to study. Blood pressure, mean blood pressure was 130, diastolic blood pressure mean was 75 and mean left ventricular mass was 138 grams. And this is the relationship between systolic blood pressure and left ventricular mass. As the blood pressure increases, the left ventricular mass increases, this is a significant relationship of an R-squared of 0.22 and a slope of 0.4 for the systolic blood pressure. So remember slope is 0.4 whereas for the diastolic blood pressure slope is 0.7 there was a stronger relationship with diastolic blood pressure. So left ventricular mass the size of the left ventricle had a stronger relationship with diastolic than with systolic blood pressure. Which is kind of an interesting finding because it's not what we found in studies in the United States like the cardiac study, right Nathan? Yeah but I thought the electric R was higher for systolic. Yeah the R is higher but the slope is R is 0.2. R-squared is 0.2 and the R-squared is 0.18 so there's a little higher. But the slope here for the diastolic is 0.7 it's almost twice. So the relationship is a stronger steeper relationship. How much time do you spend with each subject? To do this 30 minutes to do the historical information about blood pressure and do the ultrasound and we do it in teams, we rotate so we'll have three teams, one team actually sometimes four teams we'll have one team doing intake in history and registration, consent one team is doing blood pressure then we have usually the medical student who doesn't speak Chinese the measure is hiding away and I one other student will be doing the ultrasound here and you've been able to get the undergraduate student Yes, we train them we train the students on the first two days when they arrive in Yunnan we train them to measure blood pressure and also we certify them and test them to make sure they're doing it accurately. Okay so this is just another way of looking at these data the relationship between blood pressure, a category normal, mild, moderate, severe hypertension, systolic and diastolic these relationships with left ventricular mass there's a constant increase in mass as you increase your category the severe hypertension being much higher than the normal particularly when you look at diastolic the mass is the highest severe diastolic hypertension it would be very interesting someday to plot the systolic versus diastolic on separate axes to see if there's any sort of J-shaped thing going on like with the diastolic Yes Okay and when we did multivariable analysis adjusting for age and body mass index and gender we also found the relationships significant relationships between left ventricular mass and blood pressure with a stronger relationship coefficient 0.7 as opposed to 0.38 for diastolic 0.7 for systolic 0.38 these are the beta coefficients in the multivariable analysis most of you know how this works multivariable analysis this is when you adjust for covariates you still see a strong relationship with diastolic so we concluded in our paper that the high prevalence of untreated hypertension there was a high percentage of problems in rural U-9 30% of our subjects had hypertension there was a strong relationship between blood pressure and left ventricular mass and the untreated diastolic blood pressure may have a greater effect on left ventricular mass all of the subjects that we studied were untreated if they were taking treatment for hypertension that was an inclusion criteria because there most people are not treated now when we finished the study we saw 50 points you mean you didn't treat them? of course we treated them we did the survey and then immediately we put them on medication and also gave them appropriate advice on life about the lifestyle of modification but all of the participants when we saw them were not receiving treatment for the blood all the participants had high blood pressure none of them were receiving treatment so we believed that untreated diastolic blood pressure may have a greater effect and the reason they weren't receiving it was because they hadn't seen anybody or that they had no contact most of them didn't know they had no contact with healthcare no one measured their blood pressure they didn't know some of them had been taking medication and they just stopped because they didn't know they had to continue to take it there's also an unfortunate tendency of some physicians see physicians in China are fee-for-service providers they're not paid by the state and even no doctors are fee-for-service providers so there's a temptation in another factory they get a percentage on medications when they prescribe medications they get a cut on that so there's a tendency to get expensive medications because they get more money so rather than give high-procure fives out which is very cheap they'll give an ARB which is expensive but once they give one prescription for two weeks then the farmer can't buy it anymore so it's finished it doesn't take medication for the last two weeks when you say you gave recommendations about lifestyle changes mostly reducing self-intake mostly reducing self-intake but also smoking cessation reducing alcohol intake most of the men also drinking is primarily also a male vice did you find the next I'm thinking the training of physicians there is kind of like a negative consequence for them if they do what would be better I'm going to talk about training physicians just a couple of minutes that's our second program we're going to talk about well let me just the third program the student internship program these were one of our groups of student interns some of these Daisy Shen these are UCI students Ben Zakariah some of you may know these are UCI students this was one group of student interns last year Carol Thompson is a nurse from Hogue Hospital she volunteered to help us and Dr. Poon Kimble Poon is a cardiologist from Los Angeles who volunteered county director at SCI wonderful lady very dedicated to her her citizens she's the director of Yangbi County near Dali City and this is Mr. Lee her assistant this is Dr. Poon examining a little girl and this is one of our students Alina Khan a Columbia student examining a child this is Anastasia Colasola she's Russian but she lives in England and she's the young girl who recently brought to me because she is working on this project for her university looking at distance from the village distance from the city and this is another one of our students who has a child of eyes in Arizona when we leave a township at the end of the internship I have our students write a report in English and then translate it into Chinese and this is the report from one of our villages which we give to the local health department and we tell them how many people have high blood pressure how many have severe high blood pressure how many are treated how many are not treated our hypertension training seminar is getting back to Dr. Chun's question we started these in 2008 the first training seminar was in Kunming Professor Law was on the faculty this is another faculty member Joy Beckman who was a cardiac nurse at the Harvard UCLA Medical Center Joy is a Chinese born American or American born Chinese born I guess CVS she was born in China but now she lives in America and she's training village doctors here to measure each other's blood pressure this lady in the fancy costume is a honey this was our training seminar in Kunming in 2008 in April 2008 we trained 160 village doctors in 2009 we had two training two trainings one in Zhongdian in Northwestern Inan we trained 40 village doctors and one in Longling in Southwestern we trained 130 village doctors and in 2010 April we're going to have three in April and we hope to reach at least 300 village doctors and we tend to we want to repeat that in October so we have two sessions three two different times three training seminars each time one in 2010 will be in Pu'an which is another state another prefecture we invite renowned international and national lecturers does anyone recognize this if you're Chinese you might recognize this he is Hu Daiyi he's been most famous cardiologist in China he lectured at the first Kunming seminar and he's attending our internship mission in April and we also have local faculty who trained from Kunming who trained our village doctors some of these local faculty are doctors at Kunming Medical College some of them are missionary doctors this is Dr. Lu Cheng who is a he's a professor at Singapore University but he is a missionary doctor now working with a Christian group and he's an excellent teacher he trains village doctors as his work there he helps us train village doctors using very innovative methods of training very simple methods that they can understand how to diagnose and treat hypertension this is practical training how to measure blood pressure taking an exam giving the exams before the session and after the session to see what improvement we can see and then we award certificates and this is our graduating class now you have questions this is a good time oh just the conflicts with the financial conflicts training the village doctors well you have to understand the village doctors are farmers and they are not rich, they are poor they are a little bit better off than the other farmers but not much so we have to understand their financial needs and what we are trying to train them to do is most important thing is hypertension is a long term disease you have to treat it for a long time so that means when you find a patient with hypertension a patient for life every time they come back for a visit you make money every time you prescribe in medicine you are going to make money but if you prescribe in medicine which is so expensive that they can't take the medicine they are not going to come back so we try to say this is the right way for your villagers, for your patients and that also can work out well for you we do a little calculation to show you and we think it has some effect we are hoping it has some effect now there are healthcare reforms on the table in China I don't have the date on that now which are going to discourage prescribing expensive medications for problems like hypertension there are reforms that the Chinese government is now beginning to enact so basically given your focus on generics which I think have a very important treatment to have some of the manufacturers of the generic drugs that have been interested in perhaps partnering I love to do that that makes a lot of sense to have a manufacturer who wants to for example ARBs they are going generic in China next year or this year so we would like to get maybe a local company once again on the EDL on the essential drug list in China it would be a big great for them it would make sense for them perhaps to help us but I only have so much time in my day I can't do it so you have to do that application we are actually Jason Ehring who has who is very involved with the generic drug market in China right he is on our board in medicine so most of the medicine is it western medicine or is it like medicine in China first of all there is western medicine and then there is Chinese medicine in traditional Chinese medicine we don't describe traditional Chinese medicine I there are I just want to give you another talk some of them have some degree of effectiveness particularly the way they are used in the country traditional Chinese medicine they are not effective at all and almost everyone I see who is on traditional Chinese medicine are more virtuous than I although I know there are some of them particularly Danshan Danshan has been shown to be effective but I don't describe it now the western medicines are manufactured in China international multinational corporations like but they are manufactured in China do they have a large supply from how do the villagers access yes they are all on this essential drug list there are large supplies and they are available to the local doctors and to the pharmacists in local pharmacies so what you are saying isn't the issue it is mainly trying to get the people to screen and educate their doctors I am curious what kind of formal education they have they have three months very good question they have three months of treatment three months of training after high school so we all have to be literate in Mandarin theoretically although I met quite a few who are really not literate in Mandarin surprising but there are some but they are supposed to be literate in Mandarin they are both graduated from high school and then they have three months of training after that some of them have a little more training maybe six or nine months of training and during that training they receive little or no training about chronic diseases like hypertension yes with the people going on to the provinces and we train them what kind of follow through do you have after you have trained them because you are just saying that you did mention this is a long term treatment ok that is another project maybe you could volunteer and stuff like that what I have been wanting to do I almost did it last year but we just have too many things to do is we would do the training seminar before the training seminar I would go into say three or four villages where I knew there was a good chance that that doctor was going to come to the training seminar I would go in and measure 30 blood pressures in that village and then a few months after the seminar we go back to the same village and measure 30 blood pressures and see if the blood pressure went down or not but we just have it other than pre and post exams which are not very good follow up we have not done that type of even the medium term follow up but it is certainly an excellent idea we really kind of need a grant for that or if there is some way to even survey the doctors who participated in these training courses like one year later asking them what they are doing I will tell you they are doing good things we are not going to tell you I didn't pay any attention to you they are going to tell us the best way is to go in and see how the blood pressure is changing I would give this internet access I would give this internet access non-existent in many places I mean in some town centers in town centers usually there is one computer in the administrative office or two maybe in very large towns there may be an internet bar in the villages there is no computer access those doctors don't have computer access do you think over the next 10 years you might need to change these positions no well I don't know hard to say in 10 years internet is spreading there but not rapidly certainly couldn't do it now let me talk about our last program here our clinical care program I am just going to talk about the children because we do also do clinical care for adults Yunnan province has about 50,000 children with congenital heart disease and that's based on one study done by a professor at Kuiming Medical College she's a surgeon she did a prevalence survey a large part of the province and just extrapolated from her prevalence survey that's about how many kids have congenital heart disease in Yunnan province 50,000 the local hospitals I think there are four or five in Kuiming and one or two in Dali do about 2,000 procedures either surgical or non-surgical procedures to correct congenital heart defects so you can see that the numbers don't match up you take a long time of 2,000 a year to reach 50,000 the kids keep being born so obviously what's happening to the others in United States we don't see older children or adults with uncorrected congenital heart disease we see them rarely because they're usually almost all corrected when they're small or they die if they can't be corrected or we either don't survive or they're correct but in China they don't get corrected and they live into adulthood miserable lives suffering all their lives or they die at an early age and the parents can do nothing and the problem is knowledge one and two money the local medical community doesn't have the knowledge to do the screening and diagnosis and even if they can screen and diagnose there's nothing they can do about it because the families don't have the money so we started a program for children in 2008 and in 2008 we supported a successful surgical or percutaneous intervention treatment of five children that was the beginning and our goal at the beginning of 2009 was to double that number to 10 that was our stated goal we stated it at our fundraiser not too far from here Irvine Valley College we're going to try to do 10 in 2009 with the help of generous help of equipment donations from AGA Corporation which makes medical devices to fix the children's hearts and Sotocyte Corporation makes ultrasound and collaborations with Chinese foundations like the Red Cross Foundation at the Wash-off Foundation we didn't do 10, we did 14 children and this is one of the things we had zero mortality in 2009 in zero serious morbidity all the kids went home and were followed up six months later and they're all doing well and I want to show you a picture of each one of these kids in two years I'm going to be there so many kids that I'm going to have to click this for an hour so still we have thousands of kids that need help this is the fundraising part of the talk but you know I'm not expecting any money just to show you why do we ask the $2,000 from the students family we plan to expand this and this year we hope to do 25 to 30 kids we hope to help we've already done three one is a little girl with cleft palate who had severe heart disease she had patent doctoric arteriosus ventricle supple defect and atrial supple defect we've corrected all three defects we have an effective medication to treat her pulmonary artery high blood pressure, hypertension it's another type of hypertension she's now getting discharged from the hospital in Chengdu she's going home in a couple of days back to Kunming and she has cleft lip, cleft palate six months we're going to refer her to an oral surgeon who will also do a charitable charitable funded surgery to give her a beautiful smile and all the boys will love her we have two other little children who while last month in January underwent procedures at Kunming's St. John's cardiology hospital St. John's heart disease hospital it's nothing to do with religion it's the name of the hospital St. John's heart disease hospital in Kunming that's what we do with the percutaneous procedures the surgery is we do either again on hospital in Kunming at the Chengdu Military Hospital because we know the doctors there and one of those two hospitals are these Chinese doctors through the fall Chinese doctors through the fall Chinese doctors that's it thank you very much this should be on here applause there are different procedures but I wanted to give sort of a ballpark cost for the cardiac repair in other words related to what we fund that's a good question to do a percutaneous procedure simple surgical supplement effect closure 20,000 R&B 3,000 dollars between 15,000 and 20,000 so it's about 2 to 3,000 dollars to do surgery like a little girl in Chengdu that's much more expensive now what we've done is we kind of multiply our ability to help these kids because now we have support from other foundations like the little girl in Chengdu Chinese health from the hardware students have to pay for her we have the Kua Sha Foundation which is a large foundation in Beijing the way they work is they match a child with a donor so they have a child that needs help and they go out and hunt for a donor a wealthy person in China and they found a donor for the civil girl so they paid for the surgery but we work with them and some of those groups are matching donations that I'm actually trying to count they'll make because another organization is called the Children's Hope Foundation they're a Christian based foundation they used to be based in US but now they're totally in China and what they do is every time we find a child that needs help they give us I think 7,000 R&B 7,000 that's a good part of them it can be almost half they give 7,000 to support that kid's surgery and then you support the balance yeah we support it yeah yes do you choose them? which kids with the general heart defects get treatment? how do we choose them? we have two types of screen what is medical? I have to approve them otherwise I approve whether or not we're going to support we may recommend it but I will approve whether they're going to support and what is medical screening? I have to feel that if there's a good chance that this child's heart can be fixed and that there's not a high mortality I told you about the child who went to Beijing for surgery and came back and died two weeks later I don't want that ever to happen again I mean it probably will eventually but I want to reduce the possibility of that happening because it would have been better just not to try than how that happened the second one is an economic one the family hasn't shown us proof of poverty their documents they have to produce Pin Kun Jung Min and Shou Yun Jung Min these are proof of income and proof of poverty which they they can they have to produce now of course families may cheat they may get a friend to sign off on these documents but we can't do anything about that we don't go beyond asking for those documents I did some a preliminary study and a lot of minority people in China are illiterate so when you ask them to produce documents like that do you have assistance? many are illiterate so how can they produce documents the local governments are always involved so we don't we never the local government is always involved so the local we communicate with the local government the local government knows this and they help with that if the families don't remember that you turned down in the last year several applicants for these type of work about five three of them for medical reasons they were just too complicated I just didn't want to take a chance at and two of them because they didn't have they admitted their incomes were high and they were in a range where I thought it would be they probably could raise the money so I referred them to local how closely do you follow through their procedures and what kind of commitment is there how closely do you follow the procedures I mean after the procedures done well before, during and after as far as like do you determine which hospital they go to which doctor they see for their treatment and then afterwards how long is the commitment of the organization well I have to approve in order to approve the grant I have to know which hospital they're going to if I don't like the hospital I think it's not a good hospital I wouldn't approve the grant and they can go to any hospital they want but then they're going to have to find their own life so that's number one in terms of follow-up afterwards the hospitals have been doing that and they do that with six month follow-up visits now there are some of them that don't do the six month follow-up visits and that's troublesome for me I don't know what happens when they go back to the village we have had no reports of problems but there could be problems that we don't know about and once again that's because we're small and we just don't have the funding now I've recently hired a nurse and I'm hoping that she's a young woman she's 26 years old and I'm hoping she will we can get her to go to some of these places like the cost of follow-up care if there's a complication or something like that is there a commitment for that to the families? we don't have any, we don't make a commitment but if we have if there's a problem we've always covered it we had one child, didn't have surgery it was on medication and did poorly and we had to take, recover the cost of that child being admitted to an intensive care unit when you're home yes I know you didn't mean to show this slide but I think two years ago in the US the Institute of Medicine recommended that the food and drug administrations start regulating salt in American diet in FDA said we have too many problems we won't follow up on this and I just what is the equivalent do you have support for the educational component of prevention to talk to people about salt intake and is there support from the Chinese government agencies that we have no support for the Chinese government to do that, we do advise people about reducing salt intake but as you probably know advice about dietary changes you know, it goes in one ear and out the other ear and I don't think they we tell everybody who is smoking to stop smoking and when I do that I tell them you have to stop smoking you have high blood pressure because you're smoking and everybody, all the guys in the room laugh they're addicted, they know they can't stop smoking that's the salt data China this is from the industry salt production in China it's surpassed the United States yes what kind of conditions do you work with like do you have an infrastructure in place do you have toilets running water is that way yeah we have I personally own an apartment which I lease for zero money to the China California hard watch as a clinic we have a living room set up as a clinic we have the sleeping area slept as residents for the students when the students come, like if you come to do an internship you're a practicum, stay there and we also use it as an office space we have rented a similar residence or facility in Bali city we're opening up a satellite clinic in Bali city I want to hire a doctor to run the satellite so we have that what else we have an ultrasound machine two of them we have ECG machine we have other simple medical equipment that's it, that's all we have what is the estimated cash out of the volunteer going into this program how much would it cost you to volunteer yeah fly food I would volunteer if you are willing to stay at our residence in Kunming it's free we offer that to volunteers there's plenty of places to stay if you don't want to stay at the residence you have to pay for your own apartment and that will be a few hundred dollars a month and food maybe also maybe two hundred dollars a month for food airfare airfare airfare, no we don't cover airfare are you a physician no I'm not because if you're a physician we really want to get the air to help us then we pay we've done that to a couple of people not that we don't want you not that we don't want you it's a long journey but there's a donation and the airfare that essentially everyone has to pay or it's a different thing student interpreters or during practice they have to pay their own expenses and they also request a donation which is on the website volunteers with medical experience doctors nurses we don't pay your airfare you don't have to give a donation you know just as long as you're acceptable and we need we'll take that if you're a pediatric cardiologist if you have any special skills or often adult cardiologists we'll also pay the airfare up to twelve hundred dollars since you are a 501 to receive these folks can write us off their taxes yes I'm looking at the intentions on the website I notice the donations vary depends on the length of the internship the two week internship is fourteen hundred the three week is two thousand the five week is twenty five hundred but the five week is filled up we don't have any more places in June and July we have places in May, August, September and October June and July is filled with those of us that say may want to do this as a practical site I'm in a magic program is it possible to change the duration of our internship? yes yes yes I already talked to I just talked to me about it we'll arrange something if you're in a practical world we'll arrange a reasonable we'll make it reasonable thank you so much thank you