A subscriber wrote: “So you need medical attention. Where would you rather be? In China or the U.S.?” This is my second blog on the topic and is devoted to the Western medicine practiced here. See last week’s blog for my thoughts on Traditional Chinese Medicine.
Given that even the most developed countries struggle with the challenge of providing adequate medical care to their citizens, how do you meet that enormous challenge in a country of 1.3 billion people who earn, on average, a mere $9,000 per year? Well, Chairman Mao found a way, and it worked undeniably well. Between the communists’ rise to power in 1949 and 1980 life expectancy in China rose a quarter of a century, the most dramatic increase ever recorded, according to US News & World Report.
They did so through the now-defunct cooperative medical system (CMS), a rural-based system that reflected the agrarian identity of China at the time. The CMS was a three-tiered system whose front line of care was what came to be known as Mao’s “barefoot doctors”, rural residents, mostly farmers, with some basic medical training. Communal health centers, funded by the communes they supported, and county-level hospitals made up the second and third tiers.
The system fell apart, however, when Deng Xiaoping opened China’s arms to the world and much of the economy was privatized and nudged into the currents of free market forces. But while the system looks much different today, the government has once again brought 95% of the population under the umbrella of health insurance. (As broadly noted in the current debate over health care reform in the U.S., 15.4% of the American population has no health insurance.)
So how do they do it? One could easily write a treatise on the topic but I have neither the time nor the expertise to do so, although I can say that the Chinese health insurance system is a hybrid of the single-payer systems found in Canada and the U.K. and the private insurance system found in the U.S. Like so many things here it is quintessentially Chinese.
And I can offer a few observations that I think must factor into the equation somewhere, somehow. Each, I believe, is just another facet of the Chinese deference to practicality and quest for balance in the face of the conflicting pressures inherent in the challenge of providing affordable but competent health care on such a massive scale.
My first observation is that there is an acceptance here that not all medical services require the same level of training and regulatory oversight. Nurses, pharmacists, and other medical practitioners appear to be far more empowered to handle routine medical needs than in the West. Not all medical procedures, after all, require the attention of a board-certified physician who has completed 7-8 years of schooling and apprenticeship and whose every move is scrutinized by legions of administrators and regulators. (All of whom add cost to the system.)
My second observation is that there is less sense of entitlement when it comes to both cosmetic imperfections and quality of life. While I admittedly don’t have the data to support it (This is a blog, not investigative journalism.) my sense is that they’re not doing double knee replacements on 70-year old men or removing unattractive but otherwise harmless birth defects or scarring. (The wealthy, of course, are different, but they’re different on their own dime.)
This undoubtedly comes from the decades of hardship endured by most Chinese but is, nonetheless, reflective of a cultural acceptance of the fact that much of what happens in life is beyond our immediate control. (Hence all of the cultural devotion to bringing about ‘good luck.’) You might call it the ‘life is hard, get over it’ perspective.
My third observation is that the citizens themselves – the would-be patients – bear a considerable portion of the burden for their own health care. While health insurance coverage is broad, it is relatively shallow, and hospitals, clinics, and pharmacies, like most businesses in China, operate on a strict cash-in-advance basis. The Chinese, as a result, actively save for their medical care. When one of our workers is hurt on the job, in fact, we send someone to the doctor with them, corporate cash in hand, to pay for their medical care. No credit, even for American multi-national corporations with long histories and good credit ratings.
And as you might expect in a culture where family bonds trump virtually all other obligations, this presumed self-reliance extends to the family as a whole. In most state-owned hospitals nurses and orderlies do not perform many of the housekeeping and basic care functions expected of them in Western hospitals. Family members, whose constant presence adds to the sense of over-crowding in most hospitals, are expected to empty bed pans, bathe the patient (assuming this does not involve serious medical risk), and provide food and drink, a simple expectation that greatly enhances the capacity of the hospital system and reduces the ongoing costs of operation. (There are always people for hire that will perform such chores in the event that there is no family available.)
Finally, whatever the root cause, virtually all of the Chinese I’ve discussed the matter with seem to have at least a rudimentary knowledge of disease, the body, and the basics of remaining healthy or recovering from a minor illness. And they accept personal responsibility for doing so to the extent they can.
Yes, most of the men smoke and alcohol is often consumed, again by the men, in copious quantities. (Cultural norms are changing, particularly among young urbanites, but I have met very few women who smoke cigarettes or drink alcohol.) Still, every Chinese person knows to eat fruit with every meal (At the end of the meal – preferably 30 minutes later to be exact – to assist with digestion.) and the urban parks and numerous outdoor public exercise venues set aside by the government are generally brimming with people early in the morning regardless of age or physical limitations.
But, of course, even the healthiest lifestyles can’t preclude the onset of illness and if you’re the one it hasn’t spared, the quality of care available becomes of paramount importance.
For those who can afford it, there are private hospitals and clinics that provide world-class care and facilities. In the hospital where I had my surgery in Beijing every patient has a private room equipped with the latest in medical and personal electronics, the food is first rate – and served by the staff – and the doctors are all Western-educated and fluent in English. Priced accordingly, of course.
And there is, I’m certain, wide variation in the quality of facilities and care offered within the medical system that serves the bulk of the population. In the end, I’m really not qualified to assess the qualifications of Chinese medical care in general but I can tell you that when a fellow ex-patriate’s daughter fell off a kitchen counter and broke her neck the private hospital staffed with Western-trained doctors insisted she be admitted to a state-owned Chinese hospital because, as her parents were told, “That’s where the doctors with the most expertise in this type of injury are.” And, I’m happy to report, she fully recovered without a trace of the original injury.
There are, nonetheless, a few notable differences between what you may find here and what foreigners are accustomed to in their home countries. The first, of course, is the distinct possibility of over-crowding. The patient rooms tend to resemble the wards of old and beds are often placed wherever there is room. Privacy, as a result, is generally nonexistent, a reality reinforced by the constant presence of family members taking care of their loved ones.
And while the government is pushing reforms to address the problem, doctors and other medical professionals are notoriously underpaid, relying, in the past, on financial incentives provided by the pharmaceutical companies and gifts from their patients, leading some to conclude that patients were chronically over-medicated, and the poor, without the means to provide adequate gifts to their medical providers, were under-served.
Again, I am not an investigative journalist and offer no conclusive research on the topic. From everything I read, and all of the Chinese I speak with on the topic, however, my sense is that the government is actively taking steps to address this issue, although I can attest to the fact that gifts are still given by at least some patients. (I have yet, of course, to hear of any medical system that is deemed perfect by all of the citizens it serves.)
Perhaps the greatest difference, however, flows from the kind of practical perspective that you would expect to find in a society less concerned with legal rights and risks than the day-to-day realities of survival. After my own hernia surgery the surgeon asked extensive questions about my employment situation before providing his prescription for physical activity, ultimately suggesting that, “If you have to go to work, you have to go to work. If you can stay home and heal, that is, of course, best. Relax. Life is short.” Good advice, but a little less rigid than I would expect from a Western doctor understandably concerned with the threat of malpractice litigation.
All told I find the medical system here to be like many institutions in China – pragmatic. You can’t sue the state-owned hospital for a gajillion yuan if there is a mistake made in your care, but somehow I suspect that the average Chinese has access to more medical care, TCM or Western, than the citizens of many countries at comparable levels of economic development. Infant mortality, in fact, fell from 50 per thousand in 1980 to just 15.2 per thousand today, still above the U.S. at 5.9, but below Mexico at 16.3.
So, to answer the subscriber’s original question regarding where I’d rather receive medical care, the answer, of course, is neither locale. I’d rather not need it. I do believe, however, that I am living a healthier lifestyle here in China and I have no fear about becoming ill or injured here. Wherever I happen to be I am confident that I will get good care with less paperwork. I may not be able to sue for malpractice, but I’m personally okay with that. Life is full of risks. We can’t mitigate them out of existence even if we try.
In the true spirit of yin yang theory, we just have to find the natural balance, as the Chinese so often seem to do, between what we hope to gain and what we stand to lose.
Copyright © 2013 Glassmaker in China
Notice: The views expressed in this post are strictly those of the writer acting in a personal capacity. They are not in any way endorsed or sanctioned by his employer or any other individual with which he may be personally or professionally affiliated.