"Protect Medical Workers' Safety." Courtesy of Caixun.

“Protect Medical Workers’ Safety.” Courtesy of Caixun.

In the fall of 2009, I interned in the traumatology ward of Hangzhou Chinese Medicine Hospital in order to study sports medicine as part of my martial arts practice. I had hoped to see bone-setters at work, but the overwhelming majority of the patients were simply elderly people with bone spurs or degrading artificial hips that were giving them trouble. Unfortunately, the only thing that could be done for most of those patients was to give them herbal poultices and/or modern painkillers; I was told by the doctor whom I shadowed that back in the seventies and eighties – when the country was first beginning to develop – doctors saw a lot of car accidents and other industrial injuries. These days, however, all they got was old people with disintegrating bodies – great for China, but not so great for my ambitions of studying traditional bone-setting. Then, one day, a woman was rushed into our ER. She had been bitten by a poisonous snake while laboring in a field; she was still dressed in her work clothes and her hand had swollen up to twice its normal size. She had been driven into the city from her hometown, several hours away from our hospital. I asked why she hadn’t just gone to a more local facility and was told, “No one trusts rural clinics. They all think that you have to go to a big one in the city to get any kind of decent help.”

Many Chinese are extremely dissatisfied with the state of China’s healthcare system. The world has seen in the last couple of weeks just how frustrated some in China are over its healthcare situation, which causes many people to act under the same assumptions as the anecdotal snake-bitten farmer. China’s urban hospitals are constantly overwhelmed by patients who have traveled great distances, resulting in an even higher strain on the already insufficient system. The too-few doctors are being spread far too thin to be effective: according to the Wall Street Journal, in 2010 there were only 1.4 doctors per 1,000 Chinese, meaning that average appointments only last a few minutes. Chinese doctors are even notorious among expatriates for making shoddy diagnoses with potentially severe ramifications. China’s medical system has been broken for quite some time, in fact. Rising costs and under-trained professionals are just the tip of the iceberg.

During the Cultural Revolution, rural China relied on so-called “barefoot doctors” (chijiao yisheng), minimally trained medical workers whose expertise mostly covered basic hygiene, preventive healthcare, and family planning, since professionally trained doctors were rarely willing to work in remote areas. This system was highly effective in many areas but ceased in 1981 as part of China’s larger shift away from collective-based management. As a result of the shift from healthcare provided by collectives to privately managed healthcare, coverage in rural China dropped from 90% in 1981 to just 7% of all counties by 1999. Since 2002, government-funded rural health insurance in the form of collective medical schemes (CMS) that mimic the old barefoot doctor system in some ways has significantly increased rural coverage: by 2009, 94% of rural counties offered coverage under CMS. The amount of coverage provided under these schemes, however, is still relatively low: current premium subsidies are about ¥80 (roughly $13) per capita. The legacy of poor coverage since collectivism effectively ended and the current low coverage levels are some of the factors that drive rural Chinese to ignore their rural providers and travel to cities instead, which results in the overwhelming of urban infrastructure.

The rising costs of healthcare in China remain a huge obstacle even where coverage is available. By 2020, total healthcare expenditure is expected to hit $1 tn as China continues to modernize its infrastructure. A great part of this cost is due to the increasing ubiquity of Western medicines. Traditional Chinese medicine (TCM), which relies mostly on formulas composed of plants, animals, and minerals, all of which are collectively referred to as “herbs,” is still common and is generally less expensive than allopathic medicine since it does not rely on costly chemical processing and manufacturing. However, the use of allopathic drugs has shot up over the last couple of decades while the prevalence of traditionally trained TCM doctors has declined: as of 2007, there were only 270,000, half as many as in 1949, while the number of Western-trained doctors had increased by a factor of twenty to approximately 1.7 million. Currently, as much of 40% of China’s healthcare expenditure goes to medicine, compared to 10-12% for most Western countries. Part of this abnormally high cost, as has been revealed in the wake of the ongoing GlaxoSmithKline pharmaceutical scandal, is due to corruption and bribery aimed at increasing profits. Public hospitals are often encouraged to over-zealously prescribe medications to patients in order to gain more revenue; this, combined with the high prices, amounts to an extraordinarily high overall expenditure on medicine.

The high cost of medicine and lack of sufficient coverage, however, are only two of the problems confronting China’s healthcare. The recent hostility toward medical workers has exacerbated doctors’ resentment of the poor working conditions that the overcrowded hospitals have created. In addition to the widely-publicized fatal stabbing in eastern Zhejiang on Friday, October 25, there has been a rash of attacks at Chinese hospitals over the last few years: in 2010, there were more than 17,000 attacks spread across 70% of China’s hospitals.According to a 2013 survey of doctors by the Chinese Medical Doctor Association, 80% of the respondents said that they would not want their children to enter the medical industry, up from a 2009 survey in which 62.5% of respondents gave the same answer. The number of responding doctors which expressed this opinion has consistently increased each time the survey has been administered since 2002. Most of the doctors who responded also indicated that their salaries “didn’t match how much work they put into their jobs, and that tense doctor-patient relationships and enormous amounts of pressure at work are creating a negative attitude toward their jobs.”

Clearly, both patients and medical staff are extremely dissatisfied with the current state of China’s healthcare infrastructure. It will be absolutely necessary to continue to modernize and ramp up government spending in order to both make care more affordable and to decrease the individual workloads of doctors. This will be especially crucial in the coming years as China gets older and thus becomes more susceptible to chronic degenerative diseases. In addition to the rising risk of cancer and heart disease, which are now China’s top killersaccording to a new study, half of all adult Chinese may be pre-diabetic, meaning that many Chinese will likely depend even more heavily on the medical infrastructure in the near future than they do now. At its current levels of coverage and quality, the system just won’t cut it. It is often said of China that its main problem is “getting old before it gets rich”; getting sick before it gets rich may be more than the system can handle, and it may once again become the “Sick Man of Asia” but in a more literal sense than ever before.

Alexander Bowe has an MA in International Studies from the Korbel School and is currently a doctoral candidate in Political Science at Tsinghua University.

Preexisting Conditions: A Brief History of the Modern Chinese Healthcare System

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