Improving heart healthcare in rural Chinese villages
University of Liverpool
New research co-led by the University of Liverpool offers valuable insights to improve healthcare for elderly residents in rural Chinese villages who are at risk of life-threatening heart conditions.
A clinical trial conducted by Liverpool Centre for Cardiovascular Science (LCCS) researchers, working in close collaboration with healthcare experts in Nanjing, China, demonstrates that a telemedicine-based, village doctor-led care model significantly enhanced the management of atrial fibrillation (AF). AF is a common heart condition linked to a higher risk of stroke, dementia, heart failure, and death – with 1 in 3 adults at risk of developing it.
In China’s rural areas, where around 500 million people live, many elderly residents (age 65+) struggle with limited healthcare access. Village doctors play a crucial role as primary healthcare providers but often lack specialised training in managing chronic diseases. Telemedicine, which uses technology to provide medical care remotely, offers a promising solution.
The MIRACLE-AF trial was a randomised clinical study conducted in Jiangdu County, Jiangsu Province in the east of China. A total of 30 village clinics were randomly assigned to either the intervention group (telemedicine-based integrated care) or the control group (usual care). The study enrolled 1,039 rural residents aged 65 years or older diagnosed with AF.
Care given to the intervention group was based on the AF Better Care (ABC) pathway, which is a holistic management approach to AF developed and validated by LCCS researchers and recommended in international guidelines. The ABC pathway focuses on three core approaches: ‘A’, avoid stroke by appropriately using blood clot prevention therapy; ‘B’, better patient centred symptom management; and ‘C’, cardiovascular and comorbidity risk factor management.
The telemedicine-based model utilised in the MIRACLE-AF trial provided village doctors with real-time expert consultation and support, continuous education and training, quality control monitoring to ensure adherence to evidence-based guidelines, and a centralised data repository for patient tracking and management. By integrating these digital health tools, village doctors were empowered to provide higher-quality AF care, resulting in better patient outcomes.
Key findings from the trial include the rate of major cardiovascular events, including cardiovascular death, stroke, or heart failure was lower in the telemedicine-based group than in the usual care group. Importantly, at 12 months, adherence to integrated AF care, based on the ABC pathway, was significantly higher in the telemedicine-based group compared to the usual care group.
Professor Gregory Lip, Price-Evans Chair of Cardiovascular Medicine, NIHR Senior Investigator and Director of Liverpool Centre for Cardiovascular Science, University of Liverpool said: “This study demonstrates the effectiveness of a telemedicine-based, village doctor-led approach in bridging the gap in AF management in rural China. By leveraging technology and local healthcare providers, we can ensure that even the most underserved populations receive high-quality, evidence-based care. Significantly, we can even also promote the ABC pathway more widely as an effective approach to AF management and care, sometimes called an ‘Easy as ABC’ approach.
“The success of the MIRACLE-AF trial paves the way for the broader implementation of telemedicine solutions to address other chronic diseases in rural populations. We are hopeful that similar models can be adapted to different healthcare settings, improving health outcomes for millions of rural residents worldwide.”
The ABC pathway is also being tested in a clinical trial in Europe, as part of the Horizon Europe funded AFFIRMO project, co-led by LCCS: www.affirmo.eu.
The paper, ‘Telemedicine-based integrated management of atrial fibrillation in village clinics: a cluster randomized trial’ was published in Nature Medicine (DOI: 10.1038/s41591-025-03511-2).
Journal
Nature Medicine
Method of Research
Randomized controlled/clinical trial
Subject of Research
People
Article Title
Telemedicine-based integrated management of atrial fibrillation in village clinics: a cluster randomized trial
Article Publication Date
21-Feb-2025
Dr. Bethune, The Doctor Who Helped the New China: Part 2
BETHUNE IN CHINA. THE MAKING OF A HERO (1938–1939)
In October 1937, Bethune, now 48 years of age, recognized that the Sino-Japanese conflict in the most populous country in the world was to be a momentous event and he was able to convince the Canadian Communist Party and the China Aid Council based in New York to send him to China to organize medical care for Mao Tsé-Tung’s Eight Route Army, one of the main military forces of the Communist party of China. In early January 1938, he traveled from Vancouver to Hong Kong with Jane Ewen, a Canadian nurse from Winnipeg. It took them a further three months to travel by train, by horse and on foot under daily Japanese attacks to reach Yenan in northern China , where Mao’s headquarters were located.
On arrival in Yenan, he met Mao, who had heard of Bethune’s heroics in Spain and wanted him to duplicate these efforts in China. Bethune’s plan was to establish mobile surgical units and travelling blood banks, and he assured Mao that he could reduce casualty mortality rates by 75%. Soon after, he was made Commander of all Chinese medical forces. The fact that Bethune was a card-carrying communist with credentials from the Communist Party of Canada was instrumental for him to get accepted by Mao and the Eight Route Army.
He resumed performing surgery after two years without having done any operating (Figure 19), and he not only treated war wounds but also took time to deal with civilian illnesses as well. He renovated existing primitive hospital facilities and opened a ‘model hospital’ in a Buddhist temple on September 15, 1938. Unfortunately, the hospital was destroyed by the Japanese forces three weeks later. The hospital was eventually relocated in Shijiazhuang and renamed the Bethune International Peace Hospital. The hospital still exists today and has become a 2000-bed ultramodern facility.
Recognizing that his Chinese colleagues were completely untrained but dedicated, intelligent, anxious to save and aspiring to be of aid to suffering mankind, he gave them daily courses on basic anatomy, physiology and how to treat minor wounds. He understood that more doctors and nurses were needed, and he took young peasants, whom he called “barefoot doctors, docteurs aux pieds nus” and graduated them in one year for doctors and six months for nurses. In a letter to Dr Louis Davidson, a well-known New York thoracic surgeon, which was reprinted in the Baltimore Evening Sun on January 13, 1940, Bethune wrote the following :
The work I am trying to do is to take peasants (boys) and young workers and make doctors out of them. They can read and write and most have a knowledge of arithmetic. None of my doctors has ever been to college or universities, and none has ever been in a modern hospital (most of them have never been in any hospital), much less a medical school. With this material, I must make doctors and nurses out of them- six months for nurses and one year for doctors-. We have 2,300 wounded in hospitals all the time. These hospitals are merely the dirty, one-story mud-and-stone houses of out-of-the-way villages set in deep valleys, over hung by mountains, some of which are 10,000 feet high.
After the war, barefoot doctors became very important in the Chinese health care system because they could provide medical services in rural communities. At one point, there were more than one million barefoot doctors in China, but they no longer exist, having been gradually replaced by ‘administrators’. Bethune laid the groundwork for a medical school, now located in Changchun, Jilin province, and wrote an English medical textbook that was later translated in Chinese. In modern China, the Jilin University medical school founded by Bethune is one of the few to be recognized as an Advanced Institute by the Central Government. This is where, one of the authors of this manuscript (JD) spent a sabbatical year in 2008–2009.
He designed operating equipment, which included a collapsible operating table, antiseptics and sterile gauzes that could be packed in wood boxes and brought to the battlefields on the backs of three mules. Most, if not all, of the surgical instruments that he used were made by local carpenters and blacksmiths. The operating unit included Bethune, two Chinese doctors, one interpreter that Bethune had trained as an anesthetist, a cook and two orderlies. Bethune’s stamina, his ability to improvise, and the speed and relative roughness with which he operated (so frequently criticized in his Montreal days) now became indispensable assets . He would often be warned ahead of time that a major battle was to take place and he would move his unit and equipment near the battlefield. His slogan was: “Doctors go to the wounded; do not wait for the wounded to come to you”.
He took soldiers as brothers and treated villagers as his relatives. When soldiers heard that Bethune would be at the front to take care of the wounded, they chanted: “Attack, attack, Bethune is with us”.
On October 28, 1939, he cut his finger with an osteotome while doing an open reduction of a fractured tibia, and some days later, he operated bare-handed on a soldier whose scalp injury was infected. Interestingly, Bethune did most of his operating in China bare-handed, not only because surgical gloves were unavailable but also because he preferred it that way. On November 11, he wrote the following:
I came back from the front yesterday. There was no good of my being there. I couldn’t get out of bed or operate… I think that I have septicemia or typhus fever
Soon after, an abscess of his finger developed, followed by upper limb gangrene, and sepsis. Bethune, who was conscious to the end, and who had refused to have his arm amputated, died on November 12, 1939, only 18 months after his historical meeting with Mao. Of note, Bethune had given some time before his personal supply of sulfamides to wounded soldiers.
A long procession of comrades and soldiers carried his body for four days along icy mountain paths to a place of relative safety in Shansi where he was buried in a United States flag because no Union Jack flag could be found. In 1952, his remains were taken to the Revolutionary Martyr’s Cemetery in the suburbs of Shijiazhuang, located approximately 300 km from Beijing. Across the street from the cemetery is the Bethune International Peace Hospital, where a memorial hall inside the hospital attracts thousands of visitors every year.
