Heralds of Health:The Yangming Crusaders

It is Lantern Festival, and the air is still rich in the ambience of the recent lunar new year holiday. Pesus Chou, professor of public health at Yangming University and the founder of the Yangming Crusaders, takes a group of more than 30 persons, lugging their medical equipment with them, on a flight through the cold winter winds to the island of Kinmen. County commissioner Chen Shui-tsai, though busy with the ongoing "homecoming for Xiamen relatives," nonetheless takes time out to meet with Dr. Chou, declaring "my deepest respect for Dr. Chou's decades of concern for this outlying little island of ours." Chen really appreciates the importance of Chou's visits: "If medical care is good, the county executive won't get the credit, but if it isn't, he will surely get the blame!"

Kinmen has always been shortchanged when it comes to medical care, and sending people over to Taiwan for treatment costs more than NT$300,000 per patient. The only real solution is to increase the quality of care in Kinmen itself. When Chen Shui-tsai says that even now the ratio of doctors to population in Kinmen, at 1:1500, lags far behind that in Taipei, at 1:500, you can imagine what it must have been like 20 years ago when Pesus Chou first brought her Yangming Crusaders to the "front lines" in Kinmen.

The Kinmen Matsu

In 1980, the wife of the then-Kinmen county commissioner visited Taiwan, and saw that county and city governments were promoting pap smears for women. So she asked Dr. Chou to come to Kinmen to provide pap smear tests. Recalling how hard it was back then, just she and four students in a lumbering old military transport plane, the always hearty Chou laughs and relates: "The thing we were most afraid of was landing on the wrong side. As we were coming in on our approach, a student said to me, 'We're OK. The sign says Recover the Mainland!, not Liberate Taiwan!'"

The second time that the Yangming Crusaders came to Kinmen was ten years ago. At that time, Dr. Cheng Tien-shun, now director of the county hospital but at that time a department chief in the Kinmen bureau of public health, came to Veterans General Hospital in Taipei for training. He asked around about the Crusaders, and finally got back in touch with them. The group was invited to come to Kinmen to do examinations for chronic illnesses. They have been coming ever since.

In 1992, Dr. Chou was named an honorary citizen of Kinmen County. Lin Fu-yung of the Kinmen environmental protection bureau, says: "This honor is reserved for people who have made a special contribution to the county." Access to Kinmen, a heavily militarized island, was long restricted, so this special provision was made for Dr. Chou so that she could come and go more easily. Lin adds that Chou has a special moniker in the county: "the Kinmen Matsu" (Matsu is the goddess of the sea and a special benefactor for the Kinmen faithful).

By 1990, the percentage of Kinmen's married women who had pap smears reached 63%, with a corresponding fall in the death rate from cervical cancer-all the way to zero, in fact. Says Lin: "It was Dr. Chou who introduced the idea of preventive medicine to Kinmen."

Hidden killers

Expanding beyond pap smears, the Crusaders have taken on the larger mission of preventing chronic illnesses. They discovered early on that the key to community preventive medicine is early detection and treatment.

Pesus Chou points for example to diabetes, the number-five killer in Taiwan, and to high blood pressure, at number ten. Both are also high risk factors for heart attacks and strokes. Early detection and treatment of these primary risk factors can prevent the secondary problems. That's the most effective and efficient approach.

From 1991 to 1995, tests by Yangming found 1,100 cases of diabetes in Kinmen; in many cases, the individuals had no idea they suffered from this disease.

Pesus Chou points out that diabetes victims are susceptible to retinal, kidney, heart, and cardiovascular problems. On this current excursion to Kinmen, the Crusaders give persons who already test positive for diabetes a battery of new tests: blood and urine analyses, blood pressure checks, electrocardiograms, ultra-sound tests, and retinal examinations. To complete their mission, the Crusaders have brought laser instruments along with them by air to perform immediate laser surgery on anyone with retina problems.

They will also conduct more tests for diabetes among residents over 40 in the Chinhu and Chinning areas of Kinmen.

Early in the morning on February 8 the Crusaders' test station at the county hospital is already overflowing with people. Why the rush? It turns out that the tests require an empty stomach, and these people are in a hurry to get the check-up over with so they can get on to breakfast.

Trust the Taiwan label

The testing process begins with registration, followed by measuring height and weight, filling out a questionnaire, checking blood pressure and pulse, taking a blood sample, and measuring bone density. A 73-year-old woman who has gotten up especially early for this explains: "They are from Taiwan proper, they must be smarter!"

Tung Li-yu, a 62-year-old wo-man from Lien'an Village, arrived at 7:00 a.m. "They come here every year, and so do I!" she says. She has high blood pressure, but keeps it under control with medication and exercise.

Lu Shu-chiung, a "community angel" for the Chinhu neighborhood, is here too. A lot of the older people are illiterate, or can't remember their ID numbers or telephone numbers very well, and Lu helps them one by one.

"The community angels are a new feature this year," explains Chou. These Florence Nightingales have been recruited with help from local authorities, and trained by Chou herself. Their work with the Crusaders marks the beginning of the localization of community preventive medicine.

Meanwhile, among the Crusaders themselves, there are some rookies, as well as some "old vets" who have been to Kinmen two or three times before.

Li Yi-jung, who is in Kinmen for the first time, says that her goal in joining the Crusaders was to get first-hand clinical experience earlier. "The stuff in school is too academic!" Chang Chih-chia agrees that the school curriculum is too heavy on theory, and offers few chances to interact with real patients, so he too can get some experience with the Crusaders. As Luis C.C. Hung, project manager at the Community Medicine Research Center at Yangming University, explains: "Students in medical school are naive, and they don't understand the real hardships people face. This kind of experience can be very instructive for them."

The Crusaders were founded by Chou single-handedly, yet she would rather not talk about their past or future.

After completing her degree at the graduate school of public health at National Taiwan University, Chou's first job was promoting general use of pap smears on behalf of the Cancer Society of the ROC.

In 1977, Chou entered what was then Yangming Medical College as a lecturer. That year Yangming accepted its first class of students on government scholarships, who would eventually have to practice medicine in remote areas. Students had no idea how to deal with the general public or local health agencies, so Chou got them involved in the work of the Cancer Society. The following year, her group was formally dubbed the Yangming Crusaders.

From the early days of doing cancer prevention, which brought them through all of the 309 townships in Taiwan's 21 cities and counties, to the group's more recent work on chronic illnesses and community preventive medicine in Luku, Puli, and Kinmen, Chou has been at the helm all the way. On the surface it seems she has not had any particular plan, but she has shown foresight, so that each step has been a natural progression.

Foolhardy

As her efforts increasingly come to the attention of society, Chou is gratified but characteristically self-effacing: "In fact, the Crusaders have been made up of fools, madmen, and people too dumb to know any better."

To inspire people to join in the Crusaders' mission, early on Chou invested virtually all of her time and energy into the group, discussing her ideals and dreams with students, often until the wee hours of the morning.

"The Crusaders became a spiritual symbol, a synonym for public service," says Chien I-chia, director of the Department of Community Psychiatry at the Pali Psychiatric Center, who was a member of the 7th Crusaders unit. Things were tougher back in the early days, with everyone having to get to the rendezvous on their own, rolling out their sleeping bags in town halls and paying their own way. To a certain extent they really were mad.

Chen Hsi-chung, who currently works in the psychiatry department at National Taiwan University, says: "The Crusaders really put a stamp on me, teaching me compassion for other people and an ability to live without frills." He joined the Crusaders in his first year in medical school, and upon graduating wrote a letter to Dr. Chou in which he told of the many opportunities he found through the Crusaders to widen his perspective and come into contact with a broader range of people: "It's not what I learned about pap smears, high blood pressure, and diabetes that was important, but what I learned about humility and gratitude."

Chang Chieh-hsin describes membership in the Crusaders as a "rite of passage" for med students. "It is a process of metamorphosis. Between the hardship of the tests you face and the joy of a mission well done, you develop a respect for life, commitment to society, and responsibility and initiative for yourself."

Passing the torch

"The hardest part is finding people. When it's not summer or winter vacation, I can't even say for sure who the Crusaders are," says Chou. Yet, each year for the past 20, the group has come together without a hitch, building a record of achievement and a certain renown in the process.

Over the years, surveys by the Crusaders have resulted in the publication of more than 100 papers. Some members have even published their first papers while still university students. For example, Yang Nan-ping, a former "commander" for the Crusaders and now an orthopedist at Provincial Taoyuan Hospital, published "Awareness of, Attitudes about, and Behavior towards Pap Smears for Cervical Cancer among Primary School Teachers" in an international journal in his fifth year at university. The production of academic studies "was a completely unexpected byproduct," says Chou happily.

In fact, the way Chou describes things, it has all been smooth sailing, no matter how difficult the actual work or how glorious the achievements. Step-by-step, this small campus-based group has done things that government and private enterprises would find enviable.

For the first ten years, the Crusaders focused on cancer prevention. In the most recent decade, efforts have been concentrated on community preventive medicine, with systematic examinations and follow-up surveys being done for chronic illnesses in Luku, Puli, and Kinmen. In 1998, the Yangming Crusaders also created a "human rights education team." Every summer they hold a "human rights education camp" for middle school students, instilling "right to health" conceptions-about the dangers of smoking, drinking, drugs, betelnuts, riding motorcycles without a helmet, and so on-into the younger generation.

For many years, the Crusaders were an informal body, managed by word of mouth. It was only in the 19th year, after a member was killed in an automobile accident, that the group formally registered as a campus organization. It is now the most famous "club" at the university.

Yet, given the improved medical environment, there are those who wonder if the Crusaders are still needed. Others doubt whether the group could continue to function without Chou's leadership.

In fact, the mission of the Crusaders has always evolved to fit changing times. Anyway, says Chou, the point of founding the group was not to pile up publications and accolades, but to educate future public health workers. "Education is not in what is said, but in the intangibles."

Seemingly tireless, Chou is, in the words of her good friend Bo Yang, "a devoted old mother hen." She is still as enthusiastic as she was 20 years ago. As she explains, each year is like starting over, with a group of new people. Maybe this is the reason both why the Crusaders stay alive and why Chou never seems to get any older.

Migratory birds

Back in Kinmen, as there is a break in the action for this two-week, 22-person excursion, Yang Ming-hsun, a fourth-year med student who is also a team leader, affirms that this year's trip has been another important experience for the students. But what do the folks in Kinmen have to say?

"The 'migratory-bird' style of the Crusaders still leaves a little something to be desired," says county executive Chen Shui-tsai. Arguing that Kinmen is very suited to research in community health care, and that such studies are good for the residents as well, he suggests that Chou move the Community Medicine Research Center to Kinmen.

Chou admits, "Community health care only works if it is sustained over the long term." That is precisely why she has begun the "community angels" program. "The angels will work shoulder to shoulder with the Crusaders," she explains. They will continue work left undone by the Crusaders, and be "health managers" for their neighborhoods, educating people, reminding those with chronic conditions to seek appropriate medical attention, to take their medications, and so forth. As Chou says: "We will pass the baton to them."

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Professors and students overcame all obstacles to airlift heavy medical equipment to Kinmen, and then to take it by boat to Little Kinmen islet. They may just be, as they claim, a bit mad.

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Founder and leader Pesus Chou says that she has never had any long-term plan; she has just taken things as they come and been lucky.

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The Crusaders have made the round of Taiwan's cities and counties, starting out providing pap smears and later taking on chronic illnesses. (courtesy of Pesus Chou)

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This year the focus of examinations is on people over 40. Items checked include blood pressure, pulse, blood, and bone density.

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It only takes a few minutes to check bone density using advanced ultrasound gear. The people of Kinmen have great faith in the Crusaders.

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Members of the Crusaders pose for a commemorative photo outside the Kinmen county hospital. At front, from right to left: Chen Shui-hu, director of the Kinmen County bureau of health, Pesus Chou, Luis C.C. Hung, and Chen Tien-shun, director of the county hospital.