Hello Fuzhou!
My second-to-last column. My last column, about my transition to residency, will appear in June; prepare your elegies now.

Stomach Cancer: Venturing Into the Belly of the Beast
By Zackary Sholem Berger

I've come to Fuzhou, a city of 5 or 6 million people in southern China, to help along some research into gastric cancer. Fujian Province, of which Fuzhou is the capital, records more cases of the cancer than anywhere else in the world.

Fuzhou isn't a bad city to call home for six weeks — the length of our stay — but it's not for tourists. The city rates just three pages in Lonely Planet China. And for an observant Jew coming to China around Passover, Fuzhou is even less hospitable, with the nearest Seder hundreds of miles away.

But any city, anywhere in the world, harbors innumerable, unexpected sights and sounds; any place, touristed or not, can become an interesting destination. I haven't fallen in love with Fuzhou, but for me it's certainly brought about a fascination with China, one that I hope will lead to understanding.

What's my work here like? An intelligent, energetic, talkative bunch of medical students, all women ("girls," they suggested I call them in Chinese), are abstracting the medical information from patients recently diagnosed with gastric cancer at Fujian Provincial Hospital. Sitting in the hospital's dusty, badly lit document room with its shelves full of manila patient folders, I'm making a database of this patient information. All the while, I'm being entertained by the side conversations of the medical students and bemused by the passing tableau of Chinese street life outside the window: a brass band on a flatbed truck, on the way to a funeral procession; the daily full-volume medley of patriotic marches from the loudspeaker of the high school next door.
Most worthwhile are the accidental discoveries. I have learned that Chinese university students aren't allowed to get married, and that Chinese doctors in various specialties learn on the job, rather than taking another post-doc after graduation (as is done with fellowships in the United States). To my new colleagues I provide, in return, strange facts of American life. I try to explain (in my halting Chinese) that my search for vegetarian restaurants does not mean I'm vegetarian, merely that I eat animals slaughtered according to rules stipulated by the Bible.

Whenever I take a detour on my way to work through the various hospital buildings, I am reminded that the difference between China and the United States is in large part just more people. While a hospital in the United States aims to be like hotel, a hospital in China can only look like a train station — masses of people waiting for their names to be called and tripping over each other's packages.

The bald data of the gastric cancer patients tell the same story over and over again: A man in his late 50s or early 60s, from Fuzhou or Changle (another city of Fujian Province, unluckily known as the world capital of gastric cancer), is diagnosed with advanced disease. This is awful, because gastric cancer caught early is much more treatable. Even worse is the repetition of this pattern. It means that no matter what statistical regularities pop up in these case series, Changle will remain the world's gastric-cancer capital for the foreseeable future.

This might lead to frustration. What's the point of small-scale clinical research when faced with an insurmountable problem? China's public health picture doesn't make matters much easier. For one thing, there's little to no health insurance here, so the health care you get depends on how much money you have in your pocket. If a sick person shows up at the door of a hospital where the costs are too much for her to pay, she will be treated there only until she's well enough to be transferred somewhere less expensive. Fujian Provincial Hospital is a top-of-the-line facility, and the poor go somewhere else. If the gastric cancer cases I'm reviewing here are disheartening, I can only imagine what it's like for poorer patients.

Any casual look around the Chinese streets leads to other sobering public health realizations. Cigarettes are everywhere. (At a banquet in my honor, a hospital vice president and I drank a toast to the defeat of Big Tobacco. In the name of all Americans, I apologized for our exporting the problem.) Bicycle riders go helmetless. As China undergoes a transition from an economy of scarcity, with lack of hygiene and widespread infectious disease the main public health problems, to an economy of abundance, new causes of death vault to the top of the list: heart disease, stroke and diabetes.

In short, it's a huge country with huge problems. From a health care perspective, you can't accomplish much of anything in six weeks. Sometimes, though, tangible accomplishment is not the goal. The aim of my visit is to make a brief first acquaintance with a country of a billion people, and, in particular, with Fujian Province, which has sent 300,000 immigrants to New York City over the past 25 years. When I walk the streets and see the people — fixing their bicycles in the open air; squatting on sidewalks, cleaning piles of scallions; polishing shoes, placing hot bowls of soup with noodles into huge ceramic jugs to keep them warm — I count myself lucky to have made the trip. I hope to do my best for Fujianese patients, whether they're in New York or in China.

Zackary Sholem Berger has now eaten in the best vegetarian restaurant in the world. Write doctor@forward.com, and he will tell you how to get there.

If I forget thee, Fuzhou
Things I want to remember about this trip to China. A to-be-modified list.

Standing with a section of dissected stomach in the pathology laboratories of the Fujian Tumour Hospital, while smiling for the Fuzhou television news cameras. Later in that same photo op, looking wise and pathologist-y while looking through a microscope at what was, to be completely factual, slides of perfectly normal thyroid. Being asked six times what my opinion of Fujian is. (Uninformed? Naive? "Please get some traffic laws enforced, and quickly too"?)

Strolling round the eerily empty grounds of one of Fuzhou's several gated communities, to which we were invited by a gastroenterologist at the Fujian Provincial Hospital. His house was huge by Chinese standards, and beautiful. A park in the center of the compound is surrounded by statues of Mozart, Schubert, et al. "What do the farmers do whose farms used to be here?" "They work in the development."

Industry Enterprise of Nanputuo Temple Xiamen, Vegetarian Dept. A/k/a the best vegetarian restaurant I have ever eaten at.

The abovementioned Nanputuo Temple, the first Buddhist temple I have ever set foot in. "Zey davenen! [They're davening!]" said Blanca as she watched worshipers with their candles. "Nisht genoy davenen, zey tuen tefile. [Not exactly davening, they're praying.]", I managed to come up with.

Blanca's kindergarten class at four forty-five, pickup time: thirty sets of hands grabbing at the wooden barrier separating them from their parents, while my daughter sits cool as a cucumber in the middle of the room, in her chair. "Oh, hi, Dad," she might as well be saying. "Here you are, then."

Vegetarian restaurants: a taxonomy.
Or: La la la la la! I can't understand you!

There are several kinds of vegetarian restaurants, and each have their place in the world: the restaurants based on the theory that vegetarian cuisine must imitate meat; the homestyle places; and those which manage to break free of the limitating modifier "vegetarian" to sublime deliciousness.

The first vegetarian restaurant we acquainted ourselves with here in Fujian province was of the first type (Fake Meat), and very tasty. We chose it as the site of the farewell banquet we threw last night for our Chinese friends and colleagues.

According to the textbooks, Chinese friendship is fueled by favors. In my brief time here, I've learned that this is true -- but it's not just cold quid-pro-quo'ing. Having to perform favors to keep the wheels of society going means that one is always on the lookout for favors to perform. Sort of like observing the mitzvot. Last night at the banquet we threw I experienced a marvelous balancing of emotions: satisfaction that we could treat our friends, and warmth at the hospitality and welcoming nature of the Chinese that had occasioned this treat of ours. Or maybe the warmth came from the not-bad Chinese beer, and the many times I said "ganbei." (Everyone pretended to understand my toasts -- courtesy of the Oxford concise Chinese-English dictionary and an American soupcon of linguistic chutzpah.)

We took a taxi back to our apartment complex, and the three of us walked around the circular driveway connecting the buildings. In a large, empty room in the middle building, whose windows looked out onto the driveway, we saw a solitary man playing the recorder. His music was beautiful, though I couldn't identify it as anything more specific than "Chinese."

The security guard and the doormen were chatting outside. I managed to ask them, in Chinese, "Does he play every night?", and they said no, just a couple of times a week.

"Is he a musician?" I asked.

They both laughed. "Sorry! We can't understand you! Ting bu dong!" No! I wanted to shout. Give me another chance, please! I can make this sentence work! I can change around the tones!

I have some experience with speaking languages other than English, my native tongue, and I can tell you that Mandarin Chinese has been the one which (in my brief time here) has demonstrated the most frustrating variation in how (or whether) I'm understood by the person I'm talking to. I performed an unintended experiment a few days ago on a street in Fuzhou, going into several establishments and asking, "Excuse me, please, where's the internet cafe?" Of five people I asked, three responded, one looked at me without saying anything at all, and one, a young woman working at a salon, shrieked, covered her face with her hands, and ran inside. Is it my Mandarin, or is it the fact that I'm six-foot-two and blonde?

I tried to ask the women my question again about the recordist, but the great wall of incomprehension was down for the night. I got to understand a bit; that's a tantalizing symbol of my entire trip.

The second type of vegetarian restaurant is typified in my mind by Veg City Diner, in New York (rest in peace!), now replaced by Curly's Vegetarian Diner. In other words, it's been a great trip to China, but it's going to be time to go home soon.

The third type of vegetarian restaurants include the best I've ever eaten in. Ladies and gentlemen, I have been to the mountaintop: the best establishment I've ever slurped a noodle at is right here in Fujian. More information to come.

Passover in Fuzhou: discoveries and reacquaintances

Fish breaded with matzah crumbs, fried in peanut oil. Yum!
Fish soup.
Fish.
And more fish.
The chocolate macaroons, carried across two continents and a great ocean, from The Sweet Life on Hester Street.
Salted peanuts.
kheroyses (charoset) made with dried fruit from said candy store, doused in red wine, and left to sit. More wine than fruit. Also yum.

Now the wine is used up, so this Shabbos it's pineapple beer and lychee-nut beer. Will report on consequences.

Two weeks in Fuzhou

My primary thought about being in China right now is: "What am I going to cook for Pesach?" (Answer: Fish soup. The fish are beautiful here, and the produce fresh and bright-tasting. Do I know how to fillet? Not yet. Can I ask for fillet at the store? Already tried that: after fifteen minutes of back-and-forth, I got a fish sans head but otherwise unaltered. So bring me the fish knife, squire!)

My secondary thought is this: I expected totaliarianism to be more . . . evident somehow. A Soviet grayness to everything, a hesitancy to speak about certain matters. It is true that the medical students I have the pleasure of spending time with did at first decline to criticize the government in public. But tonight we went out together, and they asked me what I thought of Chinese democracy. After a few minutes of pursuing the topic, I got the impresssion that they just don't care. It's all politics, one of them said. Would it matter if they believed the horror stories I'm telling them about their government's oppression? Or is economic life in China (for a certain class) just too much improved for the accusations of the disaffected to make much difference?

Tang meets WCW
Not quite Lolita in Teheran.

Somehow, exchanging poetry is even more interesting than typing information on cases of gastric cancer into a database.

As with every conversation with this group of Chinese students (all women), we talked this way.

1. I try to say something in Chinese, after looking up all the words I need in the dictionary. (Preparation time: 15 minutes per sentence.)

2. My interlocutors look blankly at me. Then one of two things happen:

a. "Oh!" The shock of realization, and they repeat the phrase with proper intonation. Or:

b. They grab the dictionary so they can figure out themselves what I'm trying to say.

3. Repeat.

This time we were talking about poetry. (The last time we were talking, I tried to use the phrase "vegetarian restaurant," and one of them asked politely why I needed access to a library. Tones matter, ladies and gentlemen. Don't try speaking Chinese without a high tolerance for non sequiturs.)

"What is the difference between 'poetry' and 'poems'?" they inquire.

Um -- poetry is "writing poems," the art of poem-writing, I responded lamely.

They had favored me with handwritten copies of two poems from the Tang Dynasty. (I'm now in love with Tang.) In return, I gave them a scrawled copy of William Carlos Williams' poem about the red wheelbarrow.

While trying to explain the poem, it became obvious how little I understand it. What is the meaning of "so much depends/upon"? Don't the white chickens (why white?) lend a comic air to the whole image? (A student asked if Williams meant to eat the chickens. Shades of the Koch parody.)

I asked them to bring me a modern Chinese poem. They agreed, but one said, "I don't like modern poetry. It's not beautiful. And it doesn't rhyme."

I suppose it's nice to know that some misconceptions are universal.

Preparing for a Chinese Seder

In thinking about our Fuzhou Passover, I've been trying to avoid the cliche of China-in-bondage. But the facts keep rearing their ugly dragon heads. Did you know, for instance, that Chinese university students are not allowed to marry? Or that the recent unrest in Guangdong province, in which police shot and killed protesters, hasn't even been heard of by the medical students I've talked to here in next-door Fujian?

Kosher Chinese
More conversations with Chinese medical students.

[My wife, my daughter, and I had eaten at a vegetarian restaurant recommended by the students I'm working with. The students asked me about my dietary habits, and why I wanted to eat at such a restaurant. This conversation, like all others we've been having, is a linguistic smashup between my wretched beginner's Mandarin and their serviceable, though distinctively Chinese, variety of English. Also agreed upon in this conversation: Americans are friendly though their president is incompetent.]

Students' Q: How long have you been a vegetarian?

A: I'm not. I'm kosher.

[Here follows my basic explanation, with much pointing at dictionary entries. The Oxford English-Chinese dictionary's entry for "kosher" means nothing, apparently, to these educated, native speakers of the target language.]

Q: You don't eat shrimp? Or oysters?

A: No.

Q: What a pity! They are so tasty!

A: [shrugs]

Q: Wait! Fish are also living, but you eat them?

A: It's in the Bible.

Q: Oh, the Bible. [This with the same tone that one might say: "Oh, the Articles of Confederation."] We're Buddhist! We eat anything!

A: If you like, you can look up 'kosher" on the Internet. If you care.

Q: We don't care.

Fuzhou Sojourn

Another Western blogger in Fuzhou! Figure the odds.

On Sunday

On Saturday, we rested. On Sunday, we scaled a mountain called Gu San, or Drum Mountain. I carried my daughter uphill - at thirty-five pounds, she was some baggage. The hill rates a matter-of-fact three lines in Lonely Planet which does not capture the spectacle of hundreds of Fujianese, old and young, slackers and Army types, climbing the hill for pure recreation. This time they had the added attraction of giants walking among them -- me and my wife -- and their movie-star daughter. I am not kidding abou the reception she got. People crowded to touch her, women offered to carry her up the mountain, old men touched her face. But even this paled before the stir she has caused at her day care, where against my wife's vociferous protests she is given more than the oher kids, before they are.

My first day at work

My ever-helpful and indefatigable liaison picks me up at the door of my apartment building to take me to the hospital. Since we are late, he explains, we'll go on his motorcycle. I wear a helmet. I think I might die on the busy Fuzhou streets. We arrive safely.

I am welcomed by two distinguished professors and two gastrointestinal fellows. To put this in perspective, remember what sort of treatment the United States reserves for foreign-medical graduates. Then keep in mind that I haven't even graduated from medical school yet (I do so when I return, on May 11th). So you'll understand why I feel vaguely guilty about the friendliness, generosity, and eagerness to please that I have been received with by every Chinese person -- really! -- since our arrival. One of the professors comments that he knows I'm from Israel, since I'm wearing something on my head.

I get a tour of the hospital, which is large and well-equipped. The campus is attractively landscaped, with many patients, relatives, doctors, and nurses bustling about between buildings. The nurses wear peaked pink caps. I draw many stares, and I try to return them in a friendly way rather than by staring down at my shoes.

Later I have a chance to sit and talk with the fellows, who, like their medical counterparts in the United States, seem relaxed, hyper-trained, and underutilized. To repeat the theme: they are friendly and engaging, and really quite thrilled at my fumbling Mandarin. They're patient enough to wait while I keep looking up necessary words.

I am shown to the medical-records room, with sober shelves of manila patient records, and introduced to the medical students that I'll be working with. They will abstract medical records and I will enter the information into a computer. Medical school is five years long in China, but as in Europe and other countries (unlike the U.S. model) it's a course of study that starts at the beginning of university. They ask me questions about China. I ask them if they can criticize the government, and they say not in public. They would rather not talk about politics out in the open, but say they do so among themselves in their dorm.

At the end of a week in Fuzhou

On arriving at the airport I found someone holding a sign at the gate with my name on it -- a first indication of my undeserved status of "foreign expert" which can bring all sorts of special treatment that I am not complaiing about at all. We were driven through the hills of Fujian in the middle of the night; the first song we heard on the car stereo was "Hotel California." We arrived at our fabulous apartment in the middle of downtown Fuzhou. Our apartment has balconies onto which one can step out and view the quite unexceptional downtown of a midsized Chinese metropolis, topped most of the day by a grayish haze. The following typically Chinese characteristics (I think) of this apartment are worth mentioning. Nothing like the mound of paper goods (napkins, paper towels, and the like) which the typical American apartment is outfitted with; we have a small number of pink and green rags. No oven! On the other hand, no oven I will have to kasher for Passover.

The apartment building is part of a luxury complex, and there are security guards hanging out outside at all hours -- tall gentlemen loafing at their ease on the plastic chairs ouside. After the first time they see us, the don't need to ask anything about us. We're the foreigners: a six-foot-two-inch tall blond guy with a head covering, his almost-as-tall wife, and their daughter whose blond hair and white skin have already come close to causing innumerable traffic accidents, not to mention the definitely non-hypothetical spectacle of grown men and women gasping in awe and stooping to touch her cheeks. On my way to work, I meet the stares of many curious passersby.

Before I talk about my work, I should explain why I'm here. I'm participating in a collaboration between NYU and the Fujian Board of Health on the topic of gastric cancer, which is quite prevalent in southern China. Why the high prevalence? That's the research question. It certainly has something to do with diet and environment, but the NYU researchers I'm working with are particularly interested in the bacterium Helicobacter pylori, made famous this year by the Nobel Prize for Medcine -- and whether the interacting genetic polymorphisms (diversity) of people and H. pylori might explain the high prevalence of gastric cancer both in Fujian and in Fujianese immigrants, who make up most of the Chinese immigrant pool to New York.

My goal here is to help with the basic, epidemiological analysis of data collected by chart review. How many gastric cancer cases have there been in Fuzhou (or two particular hospitals in this city) over the past few years, of what types (i.e., found where in the stomach), and with what risk factors have they been associated? I have found out that medical care in China, at least in some sectors, is very much pay-for-service. The Fuzhou hospital I am working at now (about which more below) treats mostly middle-class and wealthy Fujianese. Poorer patients go elsewhere, and this bias in the distribution of gastric-cancer cases I'll be analyzing obviously means something to our results. From a broader perspective, this schizophrenia of the Chinese health-care system -- government funding of all hospitals combined with vast inequalities of treatment -- was examined in a recent article in the New England Journal of Medicine.

Greetings from Fuzhou!

Where I can't see blogs (or Blogger blogs). I hope I can post, though.