Free HPV vaccine, a gift for girls from a city

On the fourth floor of the Maternal and Child Health Hospital in Jungar Banner, Ordos, there is a long corridor from east to west, with several consulting rooms. You will feel that you are going through most of women's lives.

In the east is an HPV vaccination room, which is open to girls aged 13 to 18 years old and provides free bivalent HPV vaccine. There are enough vaccines. I have a refrigerator full of them. I don't need to make an appointment.

One afternoon in early July, I met Liu Yaxin, a junior high school graduate with a ponytail. Her father took her to get the third shot of vaccine. She was spending the summer when she was 16 years old. She was still confused. She asked her if she knew what the HPV virus was. She shook her head. The father beside her said that the baby was still small. It was the head teacher who sent a notice to the parents. He and his wife knew it was a good thing, so they led the child. The girls in Liu Yaxin's class have also been vaccinated.

Next to Liu Yaxin, who is also waiting for vaccination, is a 20-year-old female college student. She graduated from high school last year and was the first group of students in Zhungeer Banner to receive free HPV vaccine. After two injections last summer, she left home to go to Hohhot to go to college. Now let's make up for the last injection. In the university, girls already know what HPV is, and qualified people have been queuing up to make an appointment for HPV vaccine, and she is the first one to get it.

Further to the west, there are various red guide sheets on the door, which are respectively the B-ultrasound room, the department of gynaecology and health care, and the laboratory screening room for cervical cancer. These are women between 35 and 64 years old. Since 2011, this Maternal and Child Health Hospital has set up a permanent two cancer screening clinic (cervical cancer and breast cancer) with about 15 medical staff. In this season, more than 20 women come every day for free two cancer screening.

In the curtain enclosed examination room, every woman has to go to the examination table, and the doctor will check their breasts and vagina, and then carry out an HPV test - if the result is positive, it means that they are infected with HPV virus, and they need to continue to do HPV typing to find out what type of virus they are infected with, and perhaps further colposcopy and cervical biopsy are needed, To further analyze whether their cervical lesions have occurred and how deep the lesions are.

Such a test has been carried out in Zhungeer Banner for the tenth year, and the popularity has exceeded 70%. This means that when you walk on the street in Zhungeer Banner, most of the women who come face to face may have been screened for two cancers. Many of the people who came to the clinic at the beginning of July were counted one by one in the roster and called by doctors. They belonged to the last group of people who had not been examined.

What kind of disease are doctors waiting for?

In the whole cancer map, cervical cancer is a special kind of cancer - its cause is clear, and the persistent infection of HPV (full name "human papillomavirus") is a necessary cause of cervical cancer. More than 30 years ago, German scientist Harald zur Hausen detected HPV virus from cervical tumor tissue, confirmed the relationship between HPV virus and cervical cancer, and therefore won the 2008 Nobel Prize in Physiology/Medicine.

After that, people can confirm whether the patient is at risk of cancer by testing whether the HPV virus exists; There is also enough evidence to show that it takes many years from infection with HPV to development of cervical cancer, which gives humans the opportunity to carry out pre cancer diagnosis and treatment; Another advantage is that in 2006, the world's first HPV vaccine was launched. Early vaccination can protect women from the threat of cervical cancer for life.

All these factors add up to make cervical cancer the first cancer that can be eliminated by human beings. The World Health Organization wrote in the 2014 Guidelines for the Prevention and Treatment of Cervical Cancer: "The death of all (cervical cancer) patients is unnecessary."

But another reality is that death is still happening. In the past few years, about 300000 women around the world died of cervical cancer every year - only less than breast cancer and lung cancer. Moreover, the vast majority of deaths occur in underdeveloped countries and regions that have not yet established a cervical cancer prevention system. According to the research of the medical journal The Lancet, in 2018, more than one third of the world's cervical cancer disease burden was distributed in China and India. In many developed countries, the incidence of cervical cancer is declining, while in China, the incidence and mortality of cervical cancer are still rising.

Even in China, regional differences still exist. For example, the incidence of cervical cancer in cities is higher than that in rural areas, but the mortality of cervical cancer in rural areas is higher. Fifteen years ago, the Ministry of Health and the Ministry of Science and Technology of China carried out a national retrospective sampling survey of causes of death. If you spread out a map of China and compare it with it, you will see a long and high mortality zone of cervical cancer from south to north - from Hunan and Jiangxi all the way north, Inner Mongolia is at the northernmost end of this line. Ordos is one of the regions with the highest incidence of cervical cancer in Inner Mongolia.

However, this is the story of the past. At the end of the corridor on the fourth floor of the Maternal and Child Health Hospital in Zhungeer Banner, there is a notice board for experts to sit down. It is a doctor named Duan Xianzhi. Her medical experience of more than 40 years is recorded in dense text.

The story of Ordos fighting against cervical cancer probably began with her.

Free HPV vaccination for girls Photography | Lin Songguo

The starting point of all this was in 2005, when two doctors who were interested in the prevention and treatment of cervical cancer met.

In the autumn of 2005, in the Cancer Hospital of the Chinese Academy of Medical Sciences, preventive medicine expert Qiao Youlin received the news from a colleague that a gynecologist from Inner Mongolia wanted to meet him. This doctor is Duan Xianzhi. He studied in the tumor hospital many years ago, and later did cervical cancer prevention and treatment alone in Inner Mongolia. "He traveled many places, saw the suffering of the people in Inner Mongolia, and took many detours.". Shortly afterwards, at the Ordos Resident Office in Beijing, the two met and had a meal.

In that year, Qiao Youlin, 50, was one of the most authoritative experts in the field of cervical cancer prevention and treatment in China. He graduated from Johns Hopkins University School of Public Health, which is one of the world's top medical schools. After graduation, he initially worked at the National Cancer Institute of the United States. In 1997, the Cancer Hospital of the Chinese Academy of Medical Sciences went to the United States to recruit. Qiao Youlin was called back to serve the country. The next year, he began to do research on prevention and treatment of cervical cancer in China. When Duan Xianzhi found him, he had established demonstration sites for cervical cancer prevention and treatment in Xiangyuan County, Shanxi Province and Shenzhen, and began to train grassroots doctors.

In an article, he recorded his feelings at that time: "I once conducted cervical cancer screening for many rural women in grass-roots units such as Xiangyuan and Yangcheng in Shanxi Province. I saw the eyes of women suffering from cervical cancer who were unlucky enough to be cured and survive, and also saw the helplessness of rural women because they were poor and had no money to cure diseases. These scenes deeply hurt my heart."

Duan Xianzhi, 53, was director of obstetrics and gynecology at the People's Hospital of Inner Mongolia Autonomous Region. Different from Qiao Youlin's elite medical education, Duan Xianzhi was born in the countryside of Jungar Banner, Ordos, and is the only girl in the village who has attended high school and university. After graduating from university, she started from the most basic level hospital, from Zhungeer Banner to Ordos City, and then to the capital of the autonomous region. Every step was not easy. After 30 years of medical practice, she met tens of thousands of bottom women. She has the most personal feelings about their plight.

When she was in her twenties, she worked as an obstetrician and gynecologist in Zhungeer County Hospital. In her village, many women were diagnosed with cervical cancer. Once, one of her relatives went to the county hospital to visit her relatives. She asked the other party to have an examination by the way. The other party said, "What are you looking for? I don't feel anything." The result was cervical cancer. But it was found early, and there was still treatment, and she survived. Another relative was not so lucky. He also found cancer by accident. He was in advanced stage and had received radiotherapy and chemotherapy, but it was too late. He died less than half a year later.

Another time, when she went back to the village to visit her relatives, she heard that a neighbor had died of illness. After asking, she learned that the old lady had been menopause for many years and began to bleed again, which was a typical symptom of cervical cancer. Instead of going to the hospital for treatment, the old lady stayed at home until the end of her life.

In Ordos in the 1980s, cervical cancer was still considered a cancer that must die. Duan Xianzhi remembered that at that time, there were few patients who went to the hospital to see doctors, and most of them were in the late stage, and there was no good treatment. The hospital would do some lymph node cleaning, or radiotherapy and chemotherapy for them, but they were basically palliative, which was difficult to cure thoroughly.

But after that, as a grass-roots doctor, Duan Xianzhi began to experience the renewal of medical technology.

In 1985, when she was 33 years old, she went to Beijing for further study and learned new knowledge like a sponge. First, she went to the Cancer Hospital of the Chinese Academy of Medical Sciences to learn how to treat tumors. There, she saw the colposcope for the first time. Speaking of this, she was full of enthusiasm, with round eyes and a smile: "I am not curious enough. How can I have such a thing? I can also zoom in." Later, she went to the Union Medical College Hospital to learn about chemotherapy and radiotherapy of hydatidiform mole, and finally went to the Maternity Hospital to learn about obstetrics, I returned to Inner Mongolia with all my skills.

Over the next ten years, her concept gradually changed - compared with passive treatment of diagnosed cervical cancer, active screening in the general population may help more people.

At the end of June this year, I met Duan Xianzhi in Yizhuang District of Beijing Tongren Hospital. She is 68 years old and has reached the retirement age, but she is still working. She has seven operations a day and has to return to Ordos for medical treatment at intervals. At the age of 58, she was transferred from Inner Mongolia to Beijing and learned to drive to and from work within three weeks.

On the day of the meeting, she got off the operating table, took off her mask and hat, exposed her curly hair, smiled kindly, and spoke with a strong Inner Mongolian accent about the change of her ideas at that time. She quoted an old saying: "If you are ill, you will be treated. If you are ill, we doctors will be treated. What is the treatment? Just prevention. I thought, why can't I be a doctor? "

Before going to find Qiao Youlin, she had started screening in Inner Mongolia alone. In 2003, the Obstetrics and Gynecology Department of the People's Hospital of Inner Mongolia Autonomous Region where she worked bought an instrument that can do liquid based thin-layer cell detection (that is, now the common "TCT detection"). It was the most advanced cervical cancer screening technology at that time, and the detection rate of cervical cancer cells was nearly 100%. She began to call the doctors who were familiar with her at the grass-roots maternal and child health care hospital, and began the first step of screening.

In Wushen Banner in the west of Ordos, Jin Hua, the former president of Wushen Maternal and Child Health Hospital, recalled to People that in early 2005, she received a phone call from Duan Xianzhi asking her to organize local women to participate in cervical cancer screening. Jinhua once went to the Obstetrics and Gynecology Department of the People's Hospital of Inner Mongolia Autonomous Region for cesarean section, so she met Duan Xianzhi. In May of that year, Duan Xianzhi took six doctors to Wushen Banner and began screening while training local medical staff.

This screening was good, 400 people came, 4 cancers and 28 precancerous lesions were detected - this is a very high detection rate.

In the same year, Duan Xianzhi met Qiao Youlin and told him about Inner Mongolia, asking him to help Inner Mongolia. Qiao Youlin understood her efforts, and won 3 million euros of Italian sponsorship for Inner Mongolia, sent equipment, and held many learning classes. Cervical cancer screening requires funds. Take TCT as an example, patients pay 160 yuan at their own expense. With scientific research projects, which means money, they began to give free physical examinations to women in Inner Mongolia.

In Wushen Banner, women receive cervical cancer screening   Photograph provided by respondents

Today, looking back at the history of cervical cancer screening in Ordos, one key factor that can not be ignored is that such a private project has won the trust and support of the government - which means not only money and people, but also the guarantee of government orders and smooth implementation.

2005 was the first turning point. When Duan Xianzhi was doing two cancer screening in Wushen Banner, the director of the Ordos Municipal Health Bureau made a special trip to inspect. The director thought that they had done a good job and that they were "doing practical things for the people", and that this should be carried out in the whole city. By 2010, with the support of the director, Ordos began to carry out free two cancer screening in the whole city, and all the expenses came from government expenditure.

Wang Shuyun, chief of the Maternal and Child Health Department of the Ordos Health Commission, told us that Ordos had carried out two cancer screening for five years from 2010 to 2015, but there was no hard task at that time, specifying how much each flag and county should complete, which was more like a purely voluntary project benefiting the people.

However, Qiao Youlin, a public health expert, knows that this is far from enough - the control of any disease needs to cover enough people, which is known as "mass immunization" in the new era of coronation. According to the recommendation of the World Health Organization, the coverage rate of cervical cancer screening should reach 70%. "If this number is not reached, the control of the disease is insignificant.".

In 2014, Qiao Youlin and Duan Xianzhi began hard lobbying to persuade the Ordos government to do a two cancer screening project for the whole population.

This pair of partners have very different personalities - Qiao Youlin is outgoing and talkative, has professional background, and is an elite scholar; Duan Xianzhi is more introverted and clumsy in expression, but her advantage is that she is a local obstetrician and gynecologist, and has been doing practical things for many years, which is naturally trustworthy. She understands the local culture and logic, and has accumulated contacts. Therefore, they divided their work: Duan Xianzhi went to ask the officials who could make decisions in Ordos. When they made an appointment, Qiao Youlin told them.

In June this year, when we met Qiao Youlin in the office of the Chinese Academy of Medical Sciences, he still clearly remembered how he "made an impassioned statement" in front of the officials: "We used advanced HPV nucleic acid detection, that is, to take a secretion, which is not troublesome; the cost is also low. A woman can do a screening for five years for 50 yuan. Residents and taxpayers have made contributions to the city. Now we spend 10 yuan a year for her, which is not much. "

Such lobbying has been carried out many times. In 2016, the Ordos government finally made up its mind to fully cover the two cancer screening. All permanent residents of the city can enjoy free two cancer screening - not the registered population, but all people who have lived for more than six months can enjoy this service.

When talking about this, Qiao Youlin mentioned some specific people, women who work in restaurants, cleaners, scavengers, and vagrants. Because public health is not only a science, but also a cause related to fairness. The more people in poverty, the more they need these concerns.

For decades, Qiao Youlin has conducted cervical cancer pilot projects in dozens of cities in China. Ordos is the first city to respond to his suggestions and start comprehensive screening for two cancers. He said that scientists and doctors could not clap together if it could be done. At that time, Ordos did have a group of enlightened and caring officials.

For example, the director of the Ordos Health and Family Planning Commission at that time (the institutions were not merged at that time), surnamed He, was a female. In 2010, she expressed interest in Duan Xianzhi's two cancer screening in Zhungeer Banner. For another example, the deputy director of the Health and Family Planning Commission at that time, surnamed Wang, was a male, but had a public health background and professional background, and later came to the municipal government as the deputy secretary general. Once these officials understand and agree with the significance of this matter, it will become easier to rely on their promotion at the top.

In 2016, Ordos officially launched such a project to provide free two cancer screening for women aged 35 to 64 years from 2016 to 2020. At the end of the five years, the screening rate must reach 60%.

This is a real government action - the government has issued an implementation plan, set up a technical expert group, and issued a technical guidance plan, with a special fund of 6 million yuan every year. Wang Shuyun, from the Maternal and Child Health Department of the Ordos Health Commission, remembered that in those five years, they assigned screening tasks to each flag and county every year and had to assess them every year. Once it was found that this flag and county might not be completed in that year, the Municipal Health Commission would go down to urge.

By the end of the five-year period last year, 200000 women had been screened in Ordos, and the screening rate had reached 59.6%, basically achieving the goal.

How difficult will it be to screen nearly 60% of women of the right age in a city like Ordos?

In July this year, when I arrived in Ordos, I really felt the vastness - it took more than five hours to drive from Wushen Banner in the west to Zhungeer Banner in the east. There are few people and cars driving in the grassland and forest, only the road extends straight ahead. And because of the high altitude, the sky and clouds are close to each other, which makes the world more vast. Passing through the pastoral area, there are sporadic families on the roadside. They seldom live together, and they are all far apart.

The first difficulty of two cancer screening is distance. It is unrealistic to let everyone take the initiative to go to the Maternal and Child Health Care Hospital in Qixian County for screening. Ga Rige, vice president of Wushen Banner Maternal and Child Health Hospital, said that every slack season (for example, when herdsmen finish shearing their wool in June, they will have a rest time), they will go to the countryside with equipment. Some remote villages and towns need to drive three or four hours to arrive. They can't go back and forth in a day, and sometimes sleep in an ambulance. Even so, some herdsmen still need 70 kilometers to travel from their homes to towns, and it takes more than an hour to ride motorcycles.

Both Duan Xianzhi and Qiao Youlin, as well as grass-roots doctors who perform screening work, know that screening for two cancers is not only about the disease itself, but also about poverty, lack of information, women's shame on their bodies, and the stereotypes surrounding them.

Gariger remembered that in the first few years, they went to the farming and pastoral areas to have an examination. They had to work hard to summon people to check the breast first, which was relatively acceptable to everyone. But when they heard that the cervical examination "had to take off their pants," everyone ran away, so they left without checking. ". Duan Xianzhi has investigated the reasons why local women do not want to participate in cervical cancer screening. The reasons in order are: they do not know the benefits of examination, they feel uncomfortable doing gynecological examination, they have psychological burden after finding out the disease, they do not want to check because they have no symptoms, and they would rather not check if they find out that cervical cancer can not be cured, and they are afraid of being cheated. One percent of the people gave the reason that the husband did not allow it.

In order to allow everyone to screen, some banners and counties send rice and oil to female residents. Garige's method is to give lectures, which are more than ten or twenty times a year. He is Mongolian, cheerful and good at talking, and also understands the pastoral culture. Every time he goes down with his Han colleagues, he gives lectures in Mongolian, and his colleagues speak Chinese again. He turned on the computer and showed me a PPT with hundreds of pages entitled "For the Health of Sisters". After years of training, he has mastered the skills of speaking to grassroots women.

He often doesn't talk about cervical cancer at the beginning. From young people getting married and having children to prenatal screening and genetic diseases, the middle naturally turns to cervical cancer. Why do people get cancer? We can't say that "there is unlimited malignant proliferation of cells". If we can't understand it, we can say that the cells have become bad and disobedient.

The female cervix, he compared it to a doughnut. The cervix is diseased, that is, "the doughnut is not well preserved and moldy". There are not many PPT words, and they are all pictures that can be understood at a glance. In order to make everyone believe, they also interviewed some patients who had been diagnosed, broadcast the interview video to everyone, and shook their stubborn shame and opinions little by little, so that they could go to the examination bed at ease.

In such a large-scale screening process, you will see the vast majority of women, their lives, situations, emotions and the fate they are encountering.

What impressed the medical staff most was that at the beginning of the screening, a large number of infected people and cancer patients were detected - in Zhungeer Banner, the initial HPV positive rate even reached 23%. Almost everyone can give examples of people around them - because many people are screened for the first time in their lives, all infected patients quickly emerge.

After a long time, people will gradually understand that the environment in Ordos at that time - early marriage, pregnancy and fertility of women in pastoral areas are high-risk factors for HPV infection. Drought and sandstorm in the grassland, coal mines on the surface and underground, natural gas and rare earth will weaken their immunity, make it difficult to remove the virus, and start to pathological changes after a long time.

In the early years of farming and pastoral areas, women often lived a poor and busy life. Their daily life was to raise livestock and children, and they had to do something every season. Like every woman, they also experience physical pain: pregnancy, childbirth, abortion, uterine prolapse, ovarian cysts... But the HPV infection is secret, it is widely spread through sexual behavior, but the two high-risk subtypes (HPV-16 and HPV-18) that are most likely to lead to cancer will not have obvious symptoms for a long time after infection. With the development of the disease, The lower body began to bleed, and they finally found out, but at that time it was often cancerous.

In 2005, Duan Xianzhi was screened for the first time in Wushen Banner. A staff member of Wushen Banner Women's Federation called Tuan Yue helped to summon patients. Duan Xianzhi greeted her at that time. Now that she is here, check it. At that time, the inspection was carried out at one's own expense, with 160 yuan per person and more than 1000 yuan per month's salary for the regiment. He divorced and raised two children alone, which was a small amount. After several days of conflict, she felt that she was in good health, but she was not at ease. Finally, she decided to check. One rainy day, she rode a motorcycle to the health care hospital. Two months later, she received a phone call and knew that she had cervical cancer. She was only 36 that year.

In the following years, she performed one operation after another - first, conization of the cervix was not enough, then the entire uterus was removed, but the cancer cells were still growing, and finally the ovaries and fallopian tubes were removed, "scraped clean, all gone, all gone", and the cancer cells disappeared. In July, I saw Tuan Yue in Wushen Banner. She is over 50 years old, has wrinkles on her face, and has become a grandmother. Over the past decade, she has never had any physical problems. In order to exercise, she walks to and from work every day. She said that her physical indicators are good enough, even better than many peers.

She is the head of the nursing department of Wushen Banner Maternal and Child Health Hospital, and she is also very impressed with a patient. It was the summer of 2013, and free two cancer screening had begun. There was a public toilet in front of the health care hospital, and a 63 year old cleaning woman was responsible for sanitation. There were few people in the sky, so I called the cleaning woman to check. When I looked under the light, the old lady's cervix was black and blue. She took a cotton ball to clean the secretion, and blood oozed at the touch. Qi Qige was experienced and knew that it was urgent. He called the old lady's daughter directly and asked her to take her mother to the superior hospital for inspection. Later, it was found that the old man had precancerous lesions. Because she was old, her ovaries and uterus were completely removed, and she recovered well. Now she has retired.

These are the stories of surviving in danger, but not everyone is so lucky. Qiqige still remembers another patient, a Mongolian female in the pastoral area, who came to Qiqige for screening after shearing her wool in June of one year. Her lower body was already in pain and bleeding. TCT results showed that she was a high-level lesion and must be operated immediately. More than a month later, she went to Yulin, Shaanxi Province, which borders Wushen Banner, for conization.

After surgery, 20% of patients with cervical cancer may relapse, so re examination is very important. The third month after the operation, Qiqige called back and asked the other party to go for a review on time. The other party said that there were too many things at home to attend to, so he would go back later. In the sixth month, Qiqige called again. She urged again before the other party went. By the time she called for the third time, the other person was already in hospital - because the reexamination was not timely, the cancer cells had metastasized, and it was too late. It is only one year from diagnosis to death. She died at the age of 39, which is quite young.

This is the most powerless place, and also the collective trouble of doctors - how to extend the tentacles to the most marginal and difficult to reach corners. Kang Li is a gynecologist in Zhungeer Maternal and Child Health Care Hospital. She has worked in this hospital for 20 years, because the screening in Zhungeer Banner has been carried out for 10 years, and the infection rate and cancer rate are decreasing. However, she has received two special patients: they came from remote villages, suffered from mental illness naturally or postnatal, and were occasionally sent by their relatives for screening, Once checked, it is already cervical cancer or precancerous lesions.

In Kang Li's opinion, they are the most incapable of self-protection. In the rural environment, they may live prematurely, have multiple sexual partners passively, and their health conditions need to be improved. These are all high-risk factors for HPV infection. They are the people most in need of care.

How to protect such the most vulnerable groups earlier and let similar things not happen again is another topic that Ordos will face next.

Therefore, by 2019, Qiao Youlin felt it was time to put the vaccine on the agenda.

In the international medical community, there is a consensus that the cervical cancer prevention system is divided into three levels. The third level is treatment, the second level is screening, and the first level is the dream of all doctors and scientists, the jewel in the crown, that is, injecting HPV vaccine, which is a way to eliminate cervical cancer once and for all.

In fact, as early as 2011, Qiao Youlin put forward the plan of "screening mothers and vaccinating children" in Jungar Banner. He planned to screen 2000 mothers and inject their children with HPV vaccine. At that time, 2000 people had been selected in the whole Banner, registered files, and 10000 vaccines from the United States had arrived at the customs. But at that time, this was too advanced, There is no HPV vaccine on the market in China. Due to various concerns, those vaccines could not enter the country, which has been a pity for Qiao Youlin and Duan Xianzhi.

In the following years, they did not give up lobbying for vaccines. Sometimes on Women's Day, Duan Xianzhi goes back to Ordos to give a health lecture. There are officials sitting on the stage. Whenever she has the opportunity, she talks about three-level prevention, how good the vaccine is, and how many countries in the world have started to inject.

In 2019, Qiao Youlin and Duan Xianzhi decided to raise the issue of vaccines again, and sent this idea to a vice mayor of Ordos. Compared with eight years ago, officials' acceptance of this matter is significantly higher. Shortly afterwards, Qiao Youlin and Duan Xianzhi led the way and introduced the director of the Ordos Municipal Health Commission to foreign vaccine manufacturers. They met in Beijing and had a negotiation.

Wang Shuyun is the head of the Maternal and Child Health Department of the Ordos Municipal Health Commission. She was also present at the negotiation. She recalled to us that during the negotiation, the manufacturer was very active. There were three doses of bivalent HPV vaccine, and the full price was close to 1800 yuan. The manufacturer only charged 580 yuan for one dose. This is a discount that exceeds their expectations. Therefore, the Ordos Municipal Government quickly decided to vaccinate HPV vaccine free of charge in the whole city, and the government took all the expenses. The matter was also quickly passed the resolution of the Ordos National People's Congress.

Of course, this is also based on the actual situation of Ordos - Ordos has a small population, with a permanent population of more than 2 million, and all girls in junior and senior high schools add up to only 50000. If all of them are vaccinated, it will cost 30 million yuan; But at the same time, Ordos is rich in mineral resources, and its financial revenue has always ranked first in Inner Mongolia Autonomous Region.

Everything went smoothly here, but then it got stuck in a key place - the cost of vaccination needs to be transferred from the Municipal Finance Bureau, and the money is still not available. In fact, the Finance Bureau can afford this money, but the most fundamental reason is that we need to find the basis from the policy - why is this money spent here? Is there a precedent for HPV vaccination in other cities? Since Beijing, Shanghai, Guangzhou and Shenzhen have not done it, is it appropriate for us to be the first?

Once these questions are asked, the vaccination will be postponed. After that, Qiao Youlin told many stories in interviews with the media——

At that time, Duan Xianzhi told him that there was a female vice captain in charge of culture, education and health in Zhungeer Banner named Zhang Yinyin, who could talk to her. Zhang Yinyin has worked in Zhungeer Banner for many years, and she is familiar with the whole cervical cancer screening work. In the spring of 2020, they went to see Zhang Yinyin. After hearing this, Zhang Yinyin did not hesitate, but quickly agreed to give free vaccinations to junior high school students aged 13-15 according to international practice. However, Zhang Yinyin finally decided to give full coverage to all junior high school and high school girls, reaching the age of 18, "I didn't play before because I didn't know that we owe them something. I can manage high school, and I also played for them." She thought that 18 year old girls would soon go to college, or enter the society, and get vaccinated, so they no longer have any worries.

When meeting us, Qiao Youlin repeatedly sighed about Zhang Yinyin's responsibility. She was chivalrous and "willing to die". As an official, he admired her for doing good deeds, even if there might be some risks.

Shortly after that, Zhang Yinyin was transferred from Zhungeer Banner and now works in another post. After Zhungeer Banner took the lead in vaccinating against HPV, some media learned her story from Qiao Youlin and wanted to interview her. She didn't want to ask for credit, but all refused. In July this year, we met Zhang Yinyin in Ordos. She is not tall and has short hair. We talked in her car for more than half an hour.

She said that the foundation of vaccine preparation was the hard work of Duan Xianzhi and Qiao Youlin in Jungar Banner for many years. She would listen to every lecture of Duan Xianzhi as long as she had time, so she also understood the importance of cervical cancer prevention and treatment and the benefits of vaccine. She was willing to support this work. Another condition is that Zhungeer Banner was just doing a popular practical project at that time. She was in charge of health and education, and just made vaccination for students into a "healthy on campus" activity. This does not need to be coordinated with other departments, and she has greater autonomy. But the most important thing is: "It depends on whether you want to do it. If you want to do it, I think it can be done.".

Another way to understand her may be that she is also the mother of a daughter. Her daughter is already a graduate student. In the first year of her daughter's college admission, Zhang Yinyin asked her to take a self funded tetravalent cervical cancer vaccine. As a woman and a mother, she has already understood the benefits of vaccines.

On August 1 last year, Zhungeer Banner started the vaccination of HPV vaccine. The preparatory work was very low-key. No media was invited and no information was published on the Internet in advance. Only the team of Qiao Youlin and Duan Xianzhi, as well as some necessary medical staff, were present. Qiao Youlin said that he was worried that the matter would be stopped the night before.

But in the end, the injection went on smoothly. That was the first dose of free HPV vaccine in Zhungeer Banner, and also the first dose of free HPV vaccine in China. Everyone is very happy.

Qiao Youlin took a group photo with the first vaccinated girl. It has been 15 years since he and Duan Xianzhi first went to Ordos for cervical cancer screening. It has been 10 years since the first mention of vaccine. They have waited too long for this moment.

In today's Ordos, a three-tier prevention system for cervical cancer has been established. The doctors in the Maternal and Child Health Care Centers of all banners and counties are the nearest line of defense to ordinary women. They are like capillaries all over the city.

There was only one doctor named Cao Xiaoyan in the department of gynecology of Wushen Banner Maternal and Child Health Hospital. One day when I was in her consulting room, I saw an ideal and harmonious relationship between doctors and patients. Cao Xiaoyan is familiar with the symptoms and medical history of many people. She is trained to ask personal questions, but at the same time, she makes them feel respected and cared for. She also knows that many people are in a poor financial situation and will feel distressed to spend a little money, so she basically does not charge inspection fees. If a patient sends her her own jelly, she will accept it. However, some people kept red envelopes to frighten her and the little nurse half to death, which was not allowed.

Cao Xiaoyan was originally a doctor in the township health center, but was transferred to Wushen Banner Maternal and Child Health Care Hospital a few years ago. The growth process she has experienced is the epitome of this systematic training of doctors——

Before arriving at the health center in 2015, Cao Xiaoyan only saw some basic gynecological diseases in the villages and towns and did physical examinations. In 2016, the city began to carry out two cancer screening projects. She was sent to Beijing to attend a special training class for colposcopy. Each maternity and child health care hospital sent two people. In the First Hospital of Peking University, she received a closed training for 21 days. The teacher was strict and would not let them go shopping. She would call a video at any time to check and ask them to work hard. After returning from Beijing, she has gained some knowledge and confidence.

In the following five years, she screened 10000 women of suitable age in Wushen Banner. Last year, she found more than 30 precancerous lesions alone, which means that as long as these 30 patients are treated promptly, they will not be worried about their lives. She stopped them on the way to death.

When the vaccine was launched in Ordos this year, someone from the Municipal Health Commission proposed that the five-year cycle of screening had just ended. Should we stop it and spend all the six million yuan of the annual funds on vaccines in the future? Duan Xianzhi was a little worried. This is absolutely not possible. Cervical cancer screening must not stop.

She explained the reason to us - the first batch of children who were vaccinated were 18 years old. After about 15 years, they would reach the age of high incidence of cervical cancer, but the incidence of the disease has become very small. Girls younger than them would also be protected by the vaccine. But in the next 15 years, adult women who cannot be protected by vaccines still need cervical cancer screening to block the road to cancer.

For this reason, cervical cancer screening cannot be stopped temporarily, and the Ordos Municipal Government has also adopted Duan Xianzhi's suggestion. The system will continue to run.

Wang Shuyun, from the Maternal and Child Health Department of the Ordos Health Commission, said that the most difficult screening now is for women living in remote areas, especially Mongolian women in pastoral areas. They are considering how to further delegate screening, such as to villages or communities, to make screening services more accessible. In Rwanda, Africa, the medical staff in the village completed the screening and vaccination of cervical cancer, and now this country has basically eliminated cervical cancer. Of course, it is difficult to test technology and personnel.

After the Ordos vaccine was launched, Qiao Youlin, 66, continued to fly around the country and continue to talk about the good quality of cervical cancer vaccine. He always believed that remote areas were the most important. Only if these areas were well done, the elimination of cervical cancer could become possible. When we contacted him in June this year, he was flying to Qinghai. Last year, at the National Two Sessions, he also wrote a proposal on the introduction of HPV vaccine into planned immunization, which was submitted through the director of the Beijing Municipal Health Insurance Bureau.

Qiao Youlin said that the story of Ordos and cervical cancer shows a truth - in such a huge country, the whole country is marching forward and free HPV vaccination may be difficult to achieve in the short term, but regions with conditions and willingness can do it first.

For example, at present, throughout the country, Ordos and Xiamen have already vaccinated girls with HPV vaccine for free, Shenzhen is promoting it, and two other provinces have also shown interest in it, namely Guangdong and Hainan.

All their efforts in Ordos over the years are like dropping a stone on the calm water. "If no one does it all the time, the water will not be turbulent. But as long as someone can throw a stone, or someone dares to jump, the wave will roll up."

The battle between human beings and cervical cancer has indeed become a wave. Last winter, the World Health Organization released a Global Strategy for Accelerating the Elimination of Cervical Cancer, which includes: 90% of girls should be vaccinated against HPV before the age of 15 by 2030. China is one of 194 countries that have made commitments. This is also the first time that the World Health Organization has announced to eliminate a cancer.

In Ordos, there is still much to do. In late July, the doctors of Qiao Youlin, Duan Xianzhi and Zhungeer Maternal and Child Health Hospital prepared to go to the countryside again with equipment. In the vast agricultural and pastoral areas where it is most difficult to reach, there are still some women who have not completed cervical cancer screening. This time, they are going to stay there and go to four more villages and towns to work at full capacity for 30 days. There are also 3000 women waiting for screening.

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