1999 / 4月
Chang Chiung-fang /photos courtesy of Diago Chiu /tr. by Robert Taylor
The schoolchildren of Taipei County and City may not all remember his name, but many of them have had their kidneys "looked at" by him.
For the past 13 years Dr. Sheih Chung-pin, a consultant pediatrician at the Taipei Municipal Hospital for Women and Children, has been spending his spare time visiting the elementary schools of Greater Taipei as a volunteer to do ultrasound scans on pupils and teachers. This screening has alerted many children and adults to developing medical conditions, allowing them to seek early treatment. Hence many regard Sheih Chung-pin as their savior.
"Dr. Sheih is very old. For him to volunteer to give us check-ups is really marvelous." This is how Lin Tzu-chieh, a sixth-year pupil at Tunhua Elementary School, describes Dr. Sheih Chung-pin, a grey-haired, amiable man in his fifties.
In 1987 Dr. Sheih, a pediatrician at the Taipei Municipal Hospital for Women and Children, bought a portable ultrasound scanner with his own money and began visiting local schools to give the children kidney examinations.
Dr. Sheih says that kidney disease has long been one of the ten leading causes of death in Taiwan. "Both kidney transplant patients and dialysis patients have to endure considerable pain," he observes. In addition to this physical suffering, before the introduction of universal health insurance in Taiwan kidney disease was a tremendous financial burden for patients; now that dialysis is covered by National Health Insurance, it is a substantial item of the system's expenditure.
"Some kidney disorders can be prevented," says Sheih. He notes that some 20% of kidney failure cases have their origins in childhood, and early discovery and treatment can benefit many patients.
This is why Dr. Sheih decided to concentrate on preventive work, by screening elementary-school children for kidney disease.
Early detection, early treatment
In fact, since 1974 Taipei City Government's Bureau of Education has been providing annual physical check-ups for first to fourth-year elementary school pupils. They include examinations of the ears, nose, throat, teeth, heart and reproductive organs; vision and hearing tests; and a urinalysis.
The three most common methods used to screen for kidney disease are urinalysis, blood tests and ultrasound scanning. But blood tests are unlikely to reveal developing kidney problems in their early stages. Abnormalities do not generally show up in blood tests until the kidneys are severely damaged, with as little as only a quarter of kidney function remaining.
Urine tests also cannot usually detect structural abnormalities in the kidneys, because there are many reasons for a positive test. For instance, standing for long periods, strenuous exercise or fever may all give rise to protein in the urine. Hence in most cases where a child has a positive initial test, the follow-up examination does not reveal any problem. This is why Sheih Chung-pin decided to screen children by ultrasound.
Ultrasound, Sheih style
Ultrasound scans are generally done with the subject lying down, and a gel is spread on the area to be examined. The procedure is elaborate and time-consuming, and for this reason unsuitable for large-scale screening programs. But Sheih Chung-pin has simplified the procedure, not only making it quicker and more convenient, but also far less expensive.
Firstly he modified the examination posture: he has the children roll up the clothes from over their lower backs, and examines them standing up. He also puts diluted gel into a small container and dips the ultrasound scanner head into it before applying the head to the body, thus eliminating the need to spend time kneading and spreading the gel.
In line with the children's small stature, Dr. Sheih sits on a child's seat to do the scans, and examines the children in quick succession. In this way he can screen two to three thousand children a day without difficulty; on average he spends less than ten seconds on each child.
From the size, shape, position and outline of the kidney in the scanned image, along with variations in the renal pelvis and the kidney's position relative to neighboring organs, the highly experienced Dr. Sheih can quickly assess whether the child's kidneys are normal. "Today's instruments give good resolution, so it only takes a glance to see whether an organ is normal."
"It's all sticky!" is most children's reaction to the gel left on their bodies, but apart from this they experience no discomfort. Sheih Chung-pin points out that ultrasound is a form of "non-ionizing radiation." It can even be used on expectant mothers and their fetuses, so there are no safety concerns about its use on young children.
Over the past 13 years, Sheih Chung-pin's voluntary screening program has identified several thousand children with abnormal kidneys. Yang Mei-hua's eldest daughter is one of them.
Yang Mei-hua recounts how seven years ago, when Dr. Sheih examined the children at her daughter's school, he discovered that one of her daughter's kidneys was smaller than the other. Yang was told by the school to take her to a hospital for a follow-up examination.
This examination showed that the ureter from the child's smaller kidney passed too directly through the wall of her bladder, so that it was not closed by the pressure in the bladder. This meant that urine could flow back into the kidney, causing the kidney to atrophy. After an operation to reimplant the ureter into the bladder wall, the condition stopped deteriorating. The child is now in her second year at junior high school, and goes back to hospital for a check-up every six months.
"All these years I've never had the chance to say how grateful I am," says Yang Mei-hua, who finds Sheih Chung-pin's philanthropic spirit both admirable and moving.
When Yang Yung-fu's daughter was examined by Dr. Sheih in her fourth year of elementary school, she was found to have hydronephrosis (distension of the renal pelvis, which collects urine from the kidney and passes it to the ureter). After treatment she made a full recovery. Yang, who is head guidance counselor at Tunhua Elementary, says: "Both as a member of staff here and as a parent, I'm very grateful to him!" This year Tunhua Elementary had a special certificate of thanks made for Sheih Chung-pin. The teachers also tell the children to be like Dr. Sheih and to be grateful to him. However, says Yang Yung-fu, "All that isn't enough to express a fraction of the gratitude we feel for Dr. Sheih."
The modest doctor
Although there are no safety concerns with ultrasound scanning, for Dr. Sheih to carry out screening at a school always requires a letter to the school from the Bureau of Education, and the agreement of parents.
Before going to a school, Dr. Sheih first contacts the school's nurse to arrange a time. This is why all the school nurses are familiar with this "modest" doctor.
Apart from a few more remote schools, Sheih Chung-pin has carried out examinations at the majority of schools in Taipei City and County. He has visited many more than once, and some even invite him unprompted.
"This is the third time already!" says Wang Shu-fen, who has been Tunhua Elementary's school nurse for 17 years. She says that when Sheih Chung-pin went to Tunhua Elementary to examine the children shortly before the winter holiday, it was his third visit in ten years. Wang says that every time Dr. Sheih comes to the school, as well as examining the children's kidneys he also does abdominal scans for teachers. "But he's very modest-he always says he's not an expert, he's just taking a quick look for us."
Nonetheless, this "quick look" has benefited quite a number of teachers.
Nurse Hsieh Hsiu-li of Huachiang Elementary School recalls how Dr. Sheih once discovered a lump in the liver of a 30-year-old male teacher at the school. It was later confirmed as malignant and removed.
Other examples include stage one cancers in the kidneys of teachers at Wuhsing Elementary and Mucha Shihchien Elementary; a malignant tumor in the reproductive organs of a teacher at Chengyi Elementary; and cancer of the bladder in a teacher at Wensheng Elementary. These were all discovered early by Sheih, so that the prognosis for their treatment was good.
"Teachers are older, so in fact there's a greater likelihood of discovering tumors and other disorders in them than in the children," says Sheih Chung-pin.
Kidney disease in Taiwan
Dr. Sheih's 13 uninterrupted years of dedicated voluntary work has yielded other valuable results too.
Over the years he has screened around a million children. Statistically, the results show that the rate of kidney abnormalities in Taiwanese schoolchildren is around five per thousand. Conditions include solitary kidney, hydronephrosis, unequally sized kidneys, renal cysts, kidney stones and misplaced kidneys.
"Most doctors wouldn't see more than ten or 20 patients with only one kidney in a lifetime, but I've seen any number of them." In his many years of screening schoolchildren, Dr. Sheih has found a case of solitary kidney (with a fully developed kidney on only one side of the body) in about every 1,000 to 1,500 children, which is similar to the rates reported in other countries.
As well as establishing the incidence of kidney abnormalities in Taiwan, Sheih Chung-pin's screening program has also shown that renal cysts are more common among children than was previously thought. This is because there are rarely symptoms, so that many cases remained undiscovered.
Sheih says that adults with polycystic kidney disease need to be careful to avoid high blood pressure and urinary tract infections, otherwise they risk early kidney failure.
Also, the early detection and treatment of many kidney conditions can prevent their becoming worse or reduce the risk of complications. For instance, early treatment of obstructive disorders of the urinary tract can prevent impairment of kidney function; people with unequally sized kidneys are at higher risk of high blood pressure, and discovering the condition early enables them to be advised to monitor their blood pressure; and because in people with only one kidney the load on that kidney is greater, they have to take care to limit the amount of protein and salt in their diet so as to avoid chronic kidney failure.
In the earliest stages of pregnancy, the development of the urinary system is intimately related with that of the genital organs. Hence Dr. Sheih's renal examinations have also revealed many disorders of the reproductive system. For instance, solitary kidney is often associated with double uterus and double vagina, often with obstruction of the vagina on the side without a kidney. Sheih Chung-pin has discovered over 50 such cases, the largest single group among the 200-plus cases so far reported worldwide.
The Hippocratic oath
For many years Dr. Sheih has tailored the timing of his clinics and other work to the rhythm of elementary-school children's lives. "Other people don't like to work on Saturdays, but I'm just the opposite-I try to arrange as much of my work at the hospital on Saturdays as I can." Sheih Chung-pin says that one reason why he holds his referral clinics at the hospital on Wednesday and Saturday afternoons is that elementary schools do not have classes on these two afternoons, so children can go for follow-up examinations at these times.
However, doing ultrasound scans on two to three thousand children a day continuously for over a decade has been a great physical strain on Sheih.
When asked why he is willing to spend so much time and effort, grey-haired Dr. Sheih simply answers shyly: "During medical training every physician reads Hippocrates' aphorism 'Your first concern is the condition of your patients.'" All he is doing today, he says, is his duty as a doctor.
The physical strain he can cope with, but the red tape he finds more wearing. Although Dr. Sheih provides his examinations free of charge, he still has to get the authorization of the Taipei City and County bureaus of health and education, and the agreement of the schools and of the children's parents. In the early days he employed a nurse as an assistant, but later, to save on expenses, he took on all the work himself.
Chiang Chia-lu of Taipei City Government's Bureau of Education, which has overall responsibility for health checks for the city's schoolchildren, says that Sheih Chung-pin writes to them every year, and because his examinations are of benefit to the children, the bureau welcomes them. But due to budgetary considerations, it has not so far been able to include ultrasound kidney scans among its own routine health checks.
Let's all do it together!
Sheih Chung-pin plans to retire soon. When he does, will he continue screening schoolchildren? "If I have the opportunity, I hope I can do more and go on with it longer," he says. He very much hopes that after he retires he can concentrate on screening work, and over three to five years expand his program throughout Taiwan. But this would require a source of funding. "At the moment, that doesn't look very likely." On questions such as the complexity of the government bureaucracy and how funding is allocated, the old doctor is unwilling to comment very much, but his frustration is obvious.
Be that as it may, Dr. Sheih's kidney scanning work over the last 13 years has not only built up a mass of valuable medical data, but can also serve as a model for others to follow. If other kidney specialists are willing to take on the task, Dr. Sheih welcomes them: "Let's all do it together!"
Kidney disease is one of the ten leading causes of death in Taiwan. But 20% of kidney failure cases have their origins in childhood, and early treatment can help many patients.
When doing his voluntary ultrasound screening sessions at elementary schools, Sheih Chung-pin sits on a child's chair and examines the children standing up. In this way he can examine over 2,000 children in a morning. (courtesy of Sheih Chung-pin)
During his many years of kidney screening work in elementary schools Dr. Sheih has amassed much data and written many reports, which have contributed greatly to basic research into kidney disease in Taiwan.
Children today grow taller and heavier than in the past, but if they do not have regular check-ups, health problems may easily go unnoticed.