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We should be worried about China’s health – Chinese doctors speak out

After reading an article about the myriad problems facing China’s health system, I asked the doctors in my medical English class to briefly reflect on the system based on their own ideas and opinions. Of the 17, 15 doctors wrote that China’s system faced serious challenges. The following are excerpts from their papers that I think accurately reflect the challenges currently facing China’s health. I have not fact checked them, and in some cases I’m fairly certain they aren’t accurate, but that the doctors believe these statistics is revealing.

This one echoed many of the main points of the other doctors.

“For patients, medical services are too expensive. It is said that the average cost is about 500 yuan for a common cold in a mid-level hospital (the average income per day is about 80RMB in Beijing). About 70% of people living in the city get social insurance, which could cover 60% of the cost. For chronic diseases, the cost is even more. So people with diabetes or cerebral vascular disease, do not go to see the doctor and do not take the medicine regularly because they cannot afford the cost. What is worse, some people living in rural areas do not go to the village hospital when they are ill because they have to sell their house and go into debt to treat the disease. In order to raise China’s health level, the cost of medicine should be lowered.

For doctors, this job is no longer a good choice. 90% of doctors said that they are extremely tired. Most doctors have to work 60 hours per week (the average work week is 48). Additionally, being a doctor is a high pressure job which means that they have to focus almost every minute. 30% of doctors admit that they are depressed. In these years even the doctor’s personal safety is threatened. Several doctors were killed by their patients or their family members because of the unexpected therapeutic effects. However, the income for the doctor is low, which is not enough to raise a family. In this situation, some doctors choose to quit for an easier life and fewer students want to go to medical school.”

Red Envelopes and unnecessary prescriptions appeared in more than half of the papers –

“Although most doctors do their best to help patients, there are a few doctors who did some ugly behaviors such as accepting red envelopes, lacking responsibility, and so on.”

“The government does not pay enough money for the health-care system, so the hospital and doctors want patients to buy more drugs to get more money. Even some drugs are unnecessary. 75% of hospital’s income is from drug sales. World bank’s report on China’s health system found that less than 1% of drug prescriptions were reasonable in 2005.”

Concerns for safety came up in nearly half of the papers, this was partially because of the murder of a doctor in Harbin around the time of the assignment.

“…Under these circumstances doctors are worried about troublesome patients and their families. They only dare to make secure diagnosis and operations that insure success. If the risk of the operation reaches a certain degree, some doctors may avoid it. Therefore many patients who have difficult or rare diseases can’t get treatment.”

Government waste was also a major concern, and it surprised me that they were so forward with their discontent.

“The rich and officials waste medical resources. VIPs are very common in many large hospitals. They always do many unnecessary tests and waste the expert’s time.”

“Currently, China is an extremely unfair society. The possession of medical resources is extremely unfair too. It seems the Chinese government only serve themselves. It is reported that about 80% of the health care costs were consumed by 8.5 million governmental officers of the Chinese Communist Party. Despite a loud voice demanding an increase in spending on public health care, the government never wants to spend too much on medical care. It is not difficult to understand. The Chinese Government has a huge budget for spending on cars, banquets, travel, and economic development, but it cannot afford the health care of the large population.

Chinese health is a big problem, and I do not believe that the Chinese gov’t will change its policy on public health care in the near future.”

“Huge gaps in medical resources make many people prefer to seek treatment at prestigious hospitals, instead of at local health centers, for even minor complaints such as headaches and colds. In many large- and medium-scale cities of China, doctors see at least 50 patients a day. Emergency services are so overcrowded that the staff has set up beds in the corridor. People start lining up early in the morning to obtain appointments the following day.”

“Production and circulation of drugs in China is in full accordance with the operation of the market – to pursue profit maximization. This is a serious departure from the public welfare and health services. As of the end of 2005, China has more than 4,000 certified pharmaceutical manufacturing enterprises, as well as 120,000 of the pharmaceutical retail enterprises. In 2005, China’s State Food and Drug Administration approved 1,113 new drugs, while the U.S. FDA approved less than 100.” (This author later wondered whether the oversight was really sufficient).

Storming the hospital – Violence as a first choice

I work in a large hospital, and sometimes there are “unfavorable outcomes”, which in hospital-speak translates as a death or life changing mistake. When we have an unfavorable outcome families typically gather in front of the administration offices and battle with the hospital’s security guards (we have a whole police office). These skirmishes have become increasingly common in China, and I’ve written about such an instance before (A fight at the hospital – Abortion in China), but it is a topic that deserves further discussion.

Let’s start with a recent example; a patient committed suicide by jumping out of his hospital room window as a result of being dissatisfied with his treatment, either because his disease was incurable, the pain was intolerable, or the bill was unaffordable (each person seemed to have heard something slightly different). The next day his family attempted to storm the offices of the hospital administrators in an effort to get compensation. This means literally forming an angry mob, and attempting to rush past the front desk and occupy someone’s office. Usually the police arrive first, and a brief brawl transpires. It can be pretty scary.

Something like this happens here about every 4-6 weeks, and each time I feel incredibly torn. These people are clearly in great emotional pain, but it is often unclear if there was actually any malpractice on the part of the hospital.

From talking with many of the administrators about these “events”, which isn’t easy, it seems that there is a single major underlying problem; the legal system would almost always favor the state-funded hospital, so lawsuits are rarely considered, and these violent mobs become the only viable way of seeking compensation. After the suicide, the patient’s family was seeking 100,000RMB in damage because the hospital did not stop him from killing himself (co-worker’s words, not mine, it is possible that the hospital was in someway at fault). This case would almost certainly be thrown out by the courts, but the angry mob approach may earn them some compensation. Occasionally these mobs are successful, which further encourages copycats.

Normally I would be tempted to side with the patients, they are disempowered by China’s flawed legal system. After one of my close friends was accused of malpractice, I realized just how difficult these cases can be. He is a well trained surgeon with years of experience, but one high risk operation did result in a patient losing vision in one eye. For the next week he could not come to work, out of fear that this family may try injure or even kill him. The doctor was completely devastated by the result of the surgery, as he had once prided himself on being the best in the department. It was a complication beyond his control, but he had no way of clearing his name.

With the current system there is no justice for the patients or the doctors. Without an impartial referee there is no real way to establish whether or not this was a case of malpractice, or something that happened as part of the normal risk of treatment. Doctors honestly dread giving bad news to patients, because it could be a matter of life and death for both parties (I’m embarrassed to say that at another large hospital, one oncologist writes patients’ diagnoses in English so they can’t lash out at him). At the same time patients worry that doctors are prescribing unnecessary medications (a topic that will be more completely addressed later) and treatments simply in an effort to increase their own profits (doctor pay is relatively low in China).

Without the law, there is no trust between the parties, and everyone suffers. Hopefully a more transparent system will be created so that China’s clinical gains in medicine are not overshadowed by patient experiences which leave family members contemplating violence as a first choice.

A visit from the Doctor – Nanjing 1891

Today I wanted to bring you something unique. This is from a diary written by a missionary who arrived in Nanjing at the end of Imperial China, and was integral in spreading western medicine in Eastern China.  I hope you’ll enjoy this moment from the past and reflect on how much China has and hasn’t changed.

August 1st, 1891 – One amusing experience was a call to the Fanti’s Yamen to treat a man who had cut his arm and fainted from loss of blood.

The Fanti is the treasurer and is a high official. The present one being a relative of the Emperor. A yamen is a palace which in Chinese style is composed of many rooms only one story high, separated by courts and connected by passageways and all surrounding a large central court which forms a beautiful garden of rare plants and flowers with grotesque stone work for which the Chinese are famous.

It being very hot we took chairs carried by 4 men which also was more dignified than riding donkeys.

On arriving we were shown into a reception room with much ceremony and etiquette though being foreigners and being they being used to foreign ways relaxed the strictness to half foreign style. We answered to our names ages and residence and whether married and how many children we had. Then we were shown to the room where the injured man lay. I will not give details of the treatment suffice to say a gaping wound in the arm had to be sewed up as it was nearly dark. I had to do it hurriedly as I could not trust them to bring a light as they would hold it right over the ether and cause an explosion. Then on going to give the man a drink of water they filled a cup with my antiseptic solution of corrosive solvent and only for my assistant would have given him a dose sufficient to be a thorough quietus. The wound was filled with flour to stop blood. After all was over they wished us to stay all night and give us a foreign supper as good as could be gotten in the Astor House Shanghai. As usual in a Chinese house there was a perfect crowd of servants and people to stare at us and as we would not drink wine they gave us foreign soda water and as each cork popped this crowd jumped as if in serious danger.

They gave us a fine bed with Chinese pillows which we would vote at home to be hard and only a roll to hurt the back of the neck but tiredness with experience in roughing it will soon to sleep anywhere.

Next morning we were shown the yamen.

In it they rooms of foreign furniture such as a piano billiard table etc.

Was called to prescribe for Fanti himself. Our entertainers were jolly fellows and all dissipated (here meaning: Overindulging in sensual pleasures) as all Chinese officials are.

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Going to the hospital in China – A few tips for medical emergencies in the middle kingdom

As one of the very few expat bloggers working in a Chinese hospital I feel it is my responsibility to share some tips on going to the ER in China, as well as a bonus helping of awful hospital experiences. Hopefully, you’ll never need to use these.

Bring someone with you

Chinese hospitals are not designed for the patient’s convenience, so even if you have excellent language skills, odds are that you will need someone to assist you while you are there. For foreign teachers I would strongly recommend bringing a co-worker or someone from the foreign affairs office since they will generally be able to use the school’s clout on your behalf.

As I mentioned in yesterday’s post, I saw a doctor, and then was sent to collect the prescription myself. Had I been in too much pain to move, I would have had to wait for one of the nurses to help me (and they are almost always busy or “busy”). Going with a friend will greatly speed up the process.

Hospitals also do not typically provide food for their patients, so you will need to arrange meals for yourself.

Example: On a trip to Hunan province, my friends and I ended up staying in a rural guesthouse. Around 3am it was clear that two of my friends had food poisoning (one of them is now my wife). By the time the hospital in town was open, both of them had vomited at least 5 times. My wife threw up out the window on the way to the hospital, again in the bushes out front, and in 3 or 4 random sinks in random offices, our other friend wasn’t faring much better.

Over the next 6 hours they both received 4 IV’s and a couple injections. I had to leave the ER to go to the pharmacy at least 6 times. I’m not sure how they would have been treated if I had not been there to help.

Bring cash

While a trip to the hospital isn’t nearly as expensive as it is in the US, few hospitals outside of China’s major cities are going to allow you to pay with a bank card, and none will provide service prior to payment (at least for ER treatment). I would suggest a minimum of 800rmb, but the treatment I received in yesterday’s case was only 25rmb.

Rough price guide

  • Seeing a Dr. 5-10rmb, seeing a specialist 15+rmb
  • staying overnight in a “common” room ~15-20rmb, staying in a VIP room ~800+rmb
  • Most surgeries are less than 1,000rmb
  • IV’s and injections ~30-40rmb

You are getting an IV

China has one of, if not the highest, rates of IV prescription. Nearly 80% of the time you go to the hospital you will be prescribed one. For anything related to vomiting or diarrhea you can expect them to hang one or two bags of saline which will help re-hydrate you, and bags of very strong antibiotics for virtually any infection.

While this isn’t considered to be a very good practice, when you are sick enough to go to the ER, it’s probably worth accepting their treatment.

Don’t expect comfort

I’ve heard that when women are waiting to give birth, the doctor will come by their bed, lift up the sheets, and give a pelvic exam without saying a single word to the patient. I have even heard of a woman getting slapped for screaming too loudly while giving birth, and that’s at one of the top hospitals in China.

Generally speaking “patient experience” is not a consideration, but you can be your own advocate. If they want to give you an x-ray without a lead vest, ask for one. If they try to use a needle that you did not personally see them remove from the packaging, ask for a new one. While they might think of you as the demanding foreigner, your health is worth the bad reputation.

Trust your doctors

Most of the doctors in China are better than the hospitals they serve, so even though the hospital may look awful you can probably trust your doctor. This is especially true when you need treatment for an infection, vomiting or diarrhea, since these are common diseases and of the local variety, your doctor has probably seen them hundreds of times. Also a dead foreigner is the last thing any hospital wants, and they are more likely to send you on to the next hospital than treat a disease they don’t know how to handle.

That being said, it is best to go to the highest level hospital you can quickly reach, and avoid clinics when possible. I have been told that clinics employ the doctors that hospitals won’t. Also only agree to having a surgery if it absolutely cannot be postponed. While it would be cheaper in China, it’s not worth the risk.

Example: In the dead of winter on a trip to Zhongdian, Yunnan my friend woke up in the middle of the night and began vomiting blood. We both knew it was altitude sickness, but the hospital wouldn’t open for another 10 hours. The hospital was unheated, and the IV bottles had to be warmed over the space heater to keep them from freezing.

When they tried to find a bed for her, it was like something out of the worst version of Goldilocks. The first bed was too bloody, the second bed had too many urine stains, and luckily the third bed was just right. After 3 IV’s and a few hours on oxygen, she was able to get on the bus and make it back down the mountain.

The Future of TCM is Western Medicine

If you are new to Traditional Chinese Medicine I suggest reading my other posts on the topic first (1, 2, 3, 4)

For many Westerners “Traditional Chinese Medicine” brings to mind an image something like this

However this is not what TCM looks like in most of China. At the hospital where I work there is a TCM department, their patients are mostly elderly and have been referred for pain management, not yin and yang disharmony. TCM is shifting from local practitioners who collected their own herbs to massive TCM pharmaceutical companies, the entire system is changing. I thought today we should wrap up our look at TCM by discussing its possible future.

Medications

It may surprise many of my western readers to learn that Chinese herbal medicines usually look nothing like that picture above. Now most cures come in the form of a pill, a powder, or a pre-mixed tonic; gone are the days of an individualized prescription.

As TCM pharmaceutical companies strive to package the herbs in a more palatable form, they are slowly moving away from whole herbs to isolated active ingredients. This is exactly what happened in Western Medicine almost 200 years ago.

The major difference that remains is the approach the two systems take to dosage, as western medicine is typically a once daily pill. TCM prescriptions however still require multiple doses (highest I’ve seen is 6/day), but this is changing as Chinese society becomes more focused on convenience.

TCM herbal cures today

Diagnostics

For decades TCM has insisted that modern scientific methods could not be used to evaluate the efficacy of TCM cures, because their diagnostic approaches were completely different. For example it is not uncommon for similar symptoms, which may be diagnosed as one disease in modern medicine, while it could be seen as distinctly different problems in TCM.

However recent labeling requirements by the drug regulators in the US and the EU require scientific studies that show these are effective in treating the ailments described. In the interest of profits many TCM pharm. companies have dropped their previous reservations about these tests in an effort to reach new markets.

Being able to claim that herbal cures are effective by western standards implies that the TCM diagnostic system is not necessary. If you show that a certain herb is effective in combating bacterial infections, means that the root cause was never an excess of “heat”.

I think in the next few decades, TCM’s role will shift away from diagnostic work, but will continue to produce medications that are based on traditional ideals.

Acupuncture

This is one aspect of TCM that will remain in-use and keep its distinct identity (partially because of its popularity abroad at the moment). However as the TCM diagnostic system declines, acupuncture will shift from being used to re-calibrate the system, and become used largely for subjective treatments (pain management, nausea reduction…).

Currently my hospital is experimenting with the clinical use of herbs and acupuncture for similar purposes, and are having some good results.

Interesting note for scientific minded people, acupuncture methods are tested against sham acupuncture (needles in non-meridian points) to help control the placebo effect.

I am hopeful for the future inclusion of traditional knowledge in modern medicine. TCM is a treasure trove of cures that were discovered over thousands of years of experimentation, and soon the useful bits will be absorbed into modern medicine to benefit all people, without the false promises and scams that currently affect TCM.

Note: I am basing these conclusions on discussions I’ve had with employees of my hospital’s TCM department, as well as discussions I’ve had with students and co-workers about their views on these products, which were largely negative.

Eating Everything – TCM and Chinese Cuisine

“In Guangxi we eat everything with 4 legs but tables and chairs, everything in the ocean but submarines, and anything in the sky but airplanes,” a giddy student told me when I asked about local dishes. It turned out that this was much closer to the truth than I had imagined at the time.

In my four years here in China, I have been introduced to a variety of foods: roast dog, snake soup, chicken ovaries, duck stomach, goose intestines, a variety of fowl flippers, and pig arteries, brain, and even urethra (my previous post on dog meat). I’ve seen so many animals served up that I doubt that there is even a Chinese word for kosher.

Behind many of these strange dishes are concepts from TCM. It’s actually hard to get through a trip to a Chinese barbecue without being told that X is good for your health.

Many local cuisines feature flavors and spices that attempt to ward off illnesses caused by the climate. According to TCM theories, Sichuan is very damp, so the overload of chilies is to prevent “damp” related illnesses.

Another example is dog meat, which is considered to be very “yang” or “hot” (this usually implies it is good for male virility). So dog meat tends to be a winter food to protect your body from “cold” illnesses. As a result I have been told by countless students, that if I have a cold (actually a “hot” illness) eating dog could aggravate the symptoms, and possibly kill me.

As I mentioned yesterday, many other TCM beliefs are based on sympathetic magic. The powers of many rare or powerful animals are absorbed through their organs, or by drinking special alcoholic tonics that have been improved with real bits of animal.

In Jonathan Watts’ book “When A Billion Chinese Jump” (which I will be reviewing soon), he points out the wider ecological impact of China’s culinary pursuits. Perhaps the most disturbing is his account of a tiger farm, where the park’s restaurant serves up “secret” dishes prepared with tiger meat for 500RMB. Watts also reported last year that the Beijing zoo had been selling various wild animal dishes too. For now he said the most common Chinese reaction to seeing a new animal is “how does it taste?”

He also notes that pangolins, which used to be common in my former home of Guangxi, are now exceptionally rare due to poaching. Because of the high prices that often come with TCM treatments, their populations have also declined in Malaysia and Indonesia. TCM claims that their flesh improves blood circulation (so does aspirin).

Watts says that the Chinese gov’t is willing to protect TCM at the cost of China’s biodiversity. Considering the governments condemnation of religion as anti-science, this seems a bit hypocritical.

In many cases though this is a false choice, TCM and China’s animals do not have to be at odds. The best case for this is bear bile.

In China TCM pharmaceutical companies currently run bear farms. These practices have not only been exposed as being disgustingly barbaric, but threaten the popularity of TCM as Chinese people are slowly becoming more opposed to animal abuse.

The problem is that bear bile actually does contain a chemical that has some health benefits (ursodeoxycholic acid). TCM treatments insist on whole bear bile. To collect this, thousands of Asiatic black bears are kept in cages so small they cannot move, and in some cases have permanent catheters inserted directly into their gall bladders to allow easier collection. Current estimates place total production at over 7,000kg/year even though there is only demand for 500kg. This has led to it being added to an increasing number of TCM based products that are completely inconsistent with tradition.

This savagery however is entirely unnecessary because this active ingredient can be synthesized. If TCM practitioners would accept this as the valid substitute that it is, we could stop the suffering of these animals.

The problem is that the gov’t media portrays this option as an assault on culture, instead of acknowledging that modern medicine has actually endorsed an active ingredient from TCM.

If you are interested in learning more about bear farming, and the efforts being made to stop this practice, please visit Animals Asia 

An example that I was surprised not to see in Watts’ book was shark fin soup. Widely believed to be an excellent booster of Qi, but actually contains no additional nutrition beyond vegetable stew. You can learn more about this destructive practice here

Tomorrow we’ll be looking at the future of TCM