Source: NYT (9/30/18))
China’s Health Care Crisis: Lines Before Dawn, Violence and ‘No Trust’
By Siu-wee Lee
BEIJING — Well before dawn, nearly a hundred people stood in line outside one of the capital’s top hospitals.
They were hoping to get an appointment with a specialist, a chance for access to the best health care in the country. Scalpers hawked medical visits for a fee, ignoring repeated crackdowns by the government.
A Beijing resident in line was trying to get his father in to see a neurologist. A senior lawmaker from Liaoning, a northeastern province, needed a second opinion on her daughter’s blood disorder.
Mao Ning, who was helping her friend get an appointment with a dermatologist, arrived at 4 a.m. She was in the middle of the line.
“There’s no choice — everyone comes to Beijing,” Ms. Mao, 40, said. “I think this is an unscientific approach and is not in keeping with our national conditions. We shouldn’t have people do this, right? There should be a reasonable system.”
The long lines, a standard feature of hospital visits in China, are a symptom of a health care system in crisis.
An economic boom over the past three decades has transformed China from a poor farming nation to the world’s second-largest economy. The cradle-to-grave system of socialized medicine has improved life expectancy and lowered maternal mortality rates.
But the system cannot adequately support China’s population of more than one billion people. The major gaps and inequalities threaten to undermine China’s progress, social stability and financial health — creating a serious challenge for President Xi Jinping and the Communist Party.
Then, there are the scandals. In July, hundreds of thousands of children were found to have been injected with faulty vaccines. The news angered the public, rattling confidence in the government and amplifying frustration with the health care system.
While the wealthy have access to the best care in top hospitals with foreign doctors, most people are relegated to overcrowded hospitals. In the countryside, people must rely on village clinics, or travel hundreds of miles to find the closest facility.
The country does not have a functioning primary care system, the first line of defense for illness and injury. China has one general practitioner for every 6,666 people, compared with the international standard of one for every 1,500 to 2,000 people, according to the World Health Organization.
Instead of going to a doctor’s office or a community clinic, people rush to the hospitals to see specialists, even for fevers and headaches. This winter, flu-stricken patients camped out overnight with blankets in the corridors of several Beijing hospitals, according to state media.
Hospitals are understaffed and overwhelmed. Specialists are overworked, seeing as many as 200 patients a day.
And people are frustrated, with some resorting to violence. In China, attacks on doctors are so common that they have a name: “yi nao,” or “medical disturbance.”
In 2016, Mr. Xi unveiled the country’s first long-term blueprint to improve health care since the nation’s founding in 1949. Called Healthy China 2030, it pledged to bolster health innovation and make access to medical care more equal.
The deficiency in doctors has taken on more urgency as the Chinese government grapples with the mounting health problems of its vast population. Heart disease, strokes, diabetes and chronic lung disease account for 80 percent of deaths in China, according to a World Bank report in 2011.
Mao Qun’an, the spokesman for the National Health and Family Planning Commission, acknowledged that the hospitals could no longer meet the public’s needs.
“If you don’t get the grass roots right, then the medical problems in China cannot be solved,” Mr. Mao said. “So what we’re doing now is trying to return to the normal state.”
On some mornings, Dr. Huang Dazhi, a general practitioner in Shanghai, rides his motorbike to a nursing home, where he treats about 40 patients a week. During lunchtime, he sprints back to his clinic to stock up on their medication and then heads back to the nursing home.
Afterward, he makes house calls to three or four people. On other days, he goes to his clinic, where he sees about 70 patients. At night, he doles out advice about high-blood-pressure medications and colds to his patients, who call him on his mobile phone.
For all this, Dr. Huang is paid about $1,340 a month — roughly the same he was making starting out as a specialist in internal medicine 12 years ago.
“The social status of a general practitioner is not high enough,” Dr. Huang said, wearing a gray Nike T-shirt and jeans under his doctor’s coat. “It feels like there’s still a large gap when you compare us to specialists.”
In a country where pay is equated with respect, the public views family doctors as having a lower status and weaker credentials than specialists. Among nearly 18,000 doctors, only one-third thought that they were respected by the public, according to a 2017 survey by the Chinese Academy of Medical Sciences, Peking Union Medical College, Brigham and Women’s Hospital in Boston, Harvard Medical School, the Harvard T.H. Chan School of Public Health and the U.S. China Health Summit.
“There is no trust in the primary care system among the population because the good doctors don’t go there,” said Bernhard Schwartländer, a senior aide at the World Health Organization and its former representative to China. “They cannot make money.”
China once had a broad, if somewhat basic, primary health care system. “Barefoot doctors” roamed the countryside treating minor ailments. In the cities, people got their health care at clinics run by state-owned companies.
China’s “barefoot doctor” system was one of the Communist revolution’s most notable successes. In 1965, Chairman Mao, troubled by the lack of health care in the countryside, envisioned an army of people who spent half their time farming (many worked in the fields without shoes) and half their time treating patients. They weren’t doctors, but rather a sort of health care SWAT team. The authorities gave them a short training period — several months to a year — and a bag of limited medicine and equipment.
Average life expectancy in China increased to 63 years in 1970 from 44 in 1960, according to Theodore H. Tulchinsky and Elena A. Varavikova, authors of “The New Public Health,” a book about global medical care. The maternal mortality rate in rural China fell to 41.3 per 100,000 people from 150 per 100,000 before 1949, according to a 2008 article published by the World Health Organization. In the same period, the infant mortality rate fell to 18.6 per 1,000 from 200.
But the public was fed up that it could not get medical treatment whenever or wherever it wanted. People needed a referral to see a specialist in a hospital.
In the mid-1980s, the government lifted the barriers, allowing people to be treated in hospitals. At the same time, China began an economic overhaul that led to the dismantling of the entire system. Government subsidies were cut drastically, and hospitals had to come up with ways to generate profits.
As hospitals started investing in high-tech machines and expanded to meet their new financial needs, medical students were drawn to them. Many believed that being a specialist would guarantee them an “iron rice bowl,” a job that was secure with an extensive safety net that included housing and a pension.
Dr. Huang initially followed the more lucrative path. After graduating from medical school in 2006, he started working as an internist in a hospital in Shanghai.
But he kept seeing patients with simple aftercare needs like removing stitches, changing catheters and switching medication. “These things really should not be done by us specialists,” he said.
When Dr. Huang saw a newspaper article about general practitioners, he decided to enroll in a training program in 2007. He was inspired by his aunt, a “barefoot doctor” in Mingguang, a city in Anhui Province, one of the poorest regions in China.
As a boy, he had followed his aunt as she went to people’s homes to deliver babies and give injections. “After becoming a doctor, I’ve realized that the people’s needs for ‘barefoot doctors’ is still very much in demand,” he said.
Corruption and Backlash
In March, a doctor was killed by his patient’s husband. In November 2016, a man attacked a doctor after an argument over his daughter’s treatment. The month before, a father stabbed a pediatrician 15 times after his daughter died shortly after her birth. The doctor did not survive.
Dr. Zhao Lizhong, an emergency room doctor in Beijing, was sitting at a computer and writing a patient’s diagnosis when Lu Fu’ke plunged a knife into his neck in April 2012. Around him, patients screamed.
Hours earlier, Mr. Lu had stabbed Dr. Xing Zhimin, who had treated him for rhinitis, in the Peking University People’s Hospital and fled. Police officers arrested him in his hometown, Zhuozhou in the northern province of Hebei, later that month. Mr. Lu was sentenced to 13 years in jail.
“We know that this kind of thing can happen at any time,” Dr. Zhao said.
The root of the violence is all the same: a mistrust of the medical system.
It goes back to the market reforms under Deng Xiaoping in the 1980s. After the government cut back subsidies to hospitals, doctors were forced to find ways to make money. Many accepted kickbacks from drug companies and gifts from patients.
In a survey of more than 570 residents in Beijing, Shanghai and Guangzhou conducted in 2013 by Cheris Chan, a sociology professor at the University of Hong Kong, more than half said they and members of their family gave “red envelopes” as cash gifts to doctors for surgery during 2000-12.
Dr. Yu Ying, who worked as an emergency room doctor at Peking Union Hospital, one of China’s top hospitals, said she was once a valiant defender of her profession. On her widely followed account on Weibo, China’s version of Twitter, she pushed back against critics who called doctors “white-eyed wolves.”
“After I discovered the truth, I really had to give myself a slap in the face,” she said.
Dr. Yu said she had heard accounts from outpatient doctors who accepted thousands of dollars in kickbacks from drug companies — “cash that was bundled into plastic bags.”
“In the entire system, the majority of doctors accept red envelopes and kickbacks,” she said.
The corruption is endemic. GlaxoSmithKline paid a $500 million fine in 2014, the highest ever in China at the time, for giving kickbacks to doctors and hospitals that prescribed its medicines. Eli Lilly, Pfizer and other global drug giants have settled with regulators over similar behavior.
It all makes for a violent mix.
Many hospitals are taking measures to protect their workers. In the southern city of Guangzhou, the Zhongshan Hospital has hired taekwondo experts to teach doctors self-defense techniques. Hospitals in the eastern city of Jinan are paying private security companies for protection. Last year, the government pledged to station an adequate number of police officers in emergency departments, where most doctor-patient violence occurs.
Mr. Mao, the spokesman for the health ministry, said that while the figures for attacks on medical personnel looked alarming, they needed to be put in context. Chinese patients sought medical help eight billion times in 2016, a number that is equivalent to the world’s population, according to Mr. Mao. There were roughly 50,000 medical-related disputes in that period, a tiny fraction of the total number of health visits.
“Therefore, our judgment is the doctor-patient relationship in reality isn’t tense,” Mr. Mao said.
If Beijing hopes to overhaul health care, it needs to persuade a skeptical public to stop going to the hospital for the sniffles.
To help change the culture, China is pushing each household to sign a contract with a family doctor by 2020 and subsidizing patients’ visits. General practitioners will also have the authority to make appointments directly with top specialists, rather than leaving patients to make their own at hospitals.
Such measures would make it easier for patients to transfer to top hospitals without a wait, while potentially giving them more personalized care from a doctor who knows their history. It could also cut down on costs, since it is cheaper under government insurance to see a family doctor.
After the government’s directive, Dr. Yang Lan has signed up more than 200 patients, and monitors their health for about $1,220 a month. From her office in the Xinhua community health center, a run-down place with elderly patients milling about in the corridors, she keeps track of her patients with an Excel sheet on her computer. She said she had memorized their medical history and addresses.
Dr. Yang, 31, said her practice was largely free of grumpy patients and, as a result, “yi nao.” She sees 50 to 60 patients in a workday of about seven and a half hours. In the United States, a family doctor has 83 “patient encounters” in a 45-hour workweek, according to a 2017 survey by the American Academy of Family Physicians. That’s about 16 patients in a nine-hour workday.
The patients get something, too — a doctor who has time for them. Every three months, Dr. Yang has a face-to-face meeting with her patients, either during a house call or at her clinic. She’s available to dispense round-the-clock advice to her patients on WeChat, a popular messaging app in China. A patient is generally kept in the waiting room for a brief period and, if necessary, gets to talk with her for at least 15 minutes.
On a hot summer day, an elderly woman with white hair walked into Dr. Yang’s clinic. She has cardiovascular disease, and Dr. Yang told her to watch what she ate. Next, a man with diabetes dropped in. “Hey, you got a haircut!” Dr. Yang exclaimed. At one point, four retirees swarmed Dr. Yang’s room, talking over one another.
“I think she’s really warm and considerate,” said Cai Zhenghua, the patient with diabetes. He used to seek treatment at a hospital, he said, adding, “The time spent interacting with doctors here is much longer.”
The government aims to increase the number of general practitioners to two or three, and eventually five, for every 10,000 people, from 1.5 now. But to even have a chance of reaching its goals, China needs to train thousands of doctors who have no inkling of how a primary care system should function and little interest in leaving their cushy jobs in the public hospitals.
It is forcing hospital specialists to staff the community clinics every week and paying those doctors subsidies to do so. It is also trying to improve the bedside manner of doctors with government-backed training programs.
In Shanghai, Du Zhaohui, then the head of the Weifang community health service center, introduced a test that uses mock patients to evaluate the care and skills of general practitioners. The doctors have 15 minutes to examine “patients.” The teachers use a checklist to grade the doctors on things like making “appropriate eye contact” and “responding appropriately to a patient’s emotions.”
At a recent test, one doctor, wearing crystal-studded Birkenstock sandals, examined a patient who had insufficient blood flow to the brain by swinging a tiny silver hammer, the equipment that is used for testing reflexes.
“That isn’t the right way,” Li Yaling, head of the center’s science and education department, said with a sigh. She said the doctor was probably too nervous and should have used a cotton swab to stroke the soles of the patient’s feet instead.
Dr. Zhu Shanzhu, a teacher in the program, said one of the main problems was that doctors did too few physical examinations in the community clinics. Many of them lean toward prescribing medicine instead. Clinical reasoning, too, is poor, she said.
In 2000, Dr. Zhu designed a course to train general practitioners in Shanghai’s Zhongshan Hospital, at the request of its director. Her first course was free. No one showed up.
Nearly two decades later, Dr. Zhu, 71, says that training is still insufficient and doctors do not spend enough time studying the latest research and techniques in their field.
“If there’s more money, the good people will come,” she said. “And a high economic status will elevate the social status.”
The government has pledged to increase the salaries of family doctors. But Dr. Zhu isn’t optimistic.
“All these ministries need to coordinate among themselves,” she said. “Our country’s affairs, you know, they aren’t easy.”
Follow Sui-Lee Wee on Twitter: @suilee.
Research was contributed by Zhang Tiantian, Zoe Mou, Qi Xu, Tang Yucheng, Amy Cheng and Elsie Chen.