Photo by Romain Pontida
China / Healthcare

The Bones of a Nation: Understanding Health and Society in China

I will never forget the feeling of anxiety that filled the waiting room of the hospital in Kunming, China. I remember the air smelling thick with cramped breath, cigarette smoke and iodoform. Families, friend groups, husbands and wives were all anxiously crammed together waiting to hear a word from one of the maybe five doctors shuffling in an out of the nervous mob. In the staircase off to the corner, older men in business clothes paced with bated breath, chain-smoking and occasionally checking to see if their number was on the board. Their loved ones were all either being operated on, x-rayed, or waiting to be attended to. In the courtyard, the elderly mulled and meandered while middle-aged people engaged in banter or involuntary small talk over cigarettes and instant noodles. Every once in a while, I would leave for fresh air, the spectacle of this arena-sized hospital and its buzzing chaos propped before me.

Pablo, my close friend from Barcelona studying with me in Kunming during my gap year, had recently broken his hand in three places training for an MMA tournament. He was, at that moment, being operated on by surgeons that could not even ask the usual and reassuring, “Are you comfortable?” in a language he could comprehend. I spent the following three hours during his surgery nudging my way through people trying to find a seat, eventually finding one only to surrender that seat to someone clearly much older and more deserving of it. Pablo’s tentative plan was to study Chinese at Yunnan Normal University until he could win enough fights and–supposedly–acquire enough fighting-clout in Kunming to transfer to a working visa as a professional trainer and fighter; a plan contingent on two working hands.

Those of us that arrive in China and know about its healthcare tend to think about being seriously injured while living there the same way anyone would about getting fired: we don’t. We knock on wood and pretend it only happens to other people. Today was not one of those serendipitous days. And since Pablo couldn’t speak a lick of Chinese, I had the responsibility of very nervously guiding him through the process of communicating with the nurses and the surgeon as well as getting him to the X-ray room and signing off on his medical bills as his only loved one.

The process of getting Pablo’s hand fixed was rather grim overall. When we arrived at the hospital, Pablo was immediately put in a bed and hooked up to antibiotic drip. The room was small, crowded, and dimly lit. The plaster on the walls was peeling off, and flies flew in and out of the open window next to his bed. The equipment looked maybe thirty years old with that stained, aged plastic look. There was only one doctor, and we waited for hours until he checked in on us. The night came, and I slept sitting upright in the chair next to his bed.

My two days on “Pablo patrol” were spent semi-aimlessly running around the hospital either collecting his X-rays or searching for the doctor or someone willing to listen to my god-awful Chinese. After the surgery, Pablo was given a lazily wrapped gauze cast still stained with his own blood. It looked like the kind of burrito that should come with many napkins. Pablo’s fingers protruding from the end of the cast were still so bloodied from the surgery that I had to demand the surgeon clean up and do it again. Finally, four days into our suggested seven-day stay at the hospital, we paid the bill hastily and left against the stern advice of the doctor and four clearly disgruntled nurses. A month after Pablo returned to Spain for a second opinion, he learned that the bone hadn’t been aligned properly during the surgery and that they had inserted the wrong implant for the wrong finger. He had to do the whole operation over, extending his recovery time by six months.

In all fairness, the attention to many of our problems was expedited by our naïve and somewhat helpless foreign appearance. Many people who could have brushed us aside went out of their way to make sure the system, as broken as it is, was not coming across as such. The aforementioned “disgruntled nurses” were an example of this; they appeared to take our concerns seriously even if there was no immediate solution. Much of their disgruntled-ness (and ours) came from culturally different views about patient-nurse and nurse-patient “dos” and “don’ts”—all of which we probably violated. This incident for us was one-and-done, but some of the individuals we met at the hospital have chronic illnesses and find themselves there frequently, often to no avail.

The city-dwelling blue collar worker is at least afforded close proximity to hospitals. Rural Chinese are left with doubly underequipped village clinics and are often forced to travel hundreds of miles into cities to visit large enough hospitals with specialists trained in Western medicine. A villager, arriving in Beijing—for example—after boarding a ten-hour train from one of the many provincial towns, will find hospitals that are understaffed and overbooked, with doctors seeing upwards of two hundred patients a day. The international average doctor-citizen ratio is one to 1,500-1,200, while in China it is one to 6,666. And these doctors are severely underpaid. Most make less than $1,000 a month—strikingly low considering their scarcity—leaving little incentive for the brightest minds to pursue a career in medicine. The way that Chinese society undervalues its physicians within its social strata, combined with the population boom of the last fifty-plus years, renders many of these problems cyclical.

Moreover, scandals within the healthcare sector repeatedly undermine people’s trust in the overall system. In 2015, fifteen percent of 12,600 surveyed doctors in China reported having experienced physical assaults from patients in the previous year. Violence enacted on doctors by patients or their family members has become so common that it has obtained its own phrase, “yi nao,” meaning “medical disturbance.” This metric illustrates the erosion of trust between practicing physicians and Chinese patients and the festering wound that is access to quality healthcare in China.

In truth, the history of healthcare in China has not always been so odious and was, for years, at least optimistic. Some Chinese still remember the “barefoot doctors” at the dawn of the Cultural Revolution, initiated by the Chinese Ministry of Health and distributed locally in the fifties. The barefoot scheme was designed to reform health education, equip the Chinese with practical skills, and provide care for the rural poor. And it worked, drastically decreasing easily preventable deaths. Mao’s army of village doctors helped China increase its life expectancy from 44 to 63 in the sixties. The infant mortality rate fell from 200 to 18.6 per 1,000.

However, during this period, the Chinese government restricted villagers from receiving care directly from large hospitals in order to avoid congestion; people needed to first get referrals in order to see a skilled city-doctor. In the mid-1980s, policy changes relaxed this restriction in response to a population desiring freedom of choice. The central government simultaneously cut hospital subsidies. And as the need for skilled physicians in big hospitals increased with more customers, doctors saw their incomes plummet with new spending cuts. Entering the 21st century, China has struggled to update many of these policies and has fallen behind its peer nations. With an economy sitting at the second largest in the world, China’s health services are ranked at 81 out of 188 countries according to UN development data. Xi’s intentions of updating some of these old systems will hopefully bear fruit in the coming years, though, at this stage, China’s healthcare problems are more grass-roots than any proposed solutions.

Today, healthcare in China is mainly dominated by the state. Xi Jinping’s 2016 goal for “Healthy China: 2030” focuses on distinctly governmental solutions. Second and third priorities (respectively) on his list are innovation and scientific development, mainly envisioning government policy leading health markets and a deeper incorporation of Western medicine. “Fairness and justice,” as Xi’s fourth and final area of focus, seems to be angled at re-establishing the people’s trust in the government as a whole when it comes to healthcare. A prioritization of healthcare could fare well for the Chinese people if it takes the shape of government funding for updating outmoded technology. But a government-led health economy may ironically threaten the momentum of free-market innovation itself.

In recent years, deep structural issues in the Chinese healthcare model have caused a rise in domestic technology startups and their internationally-sourced venture-capitalists hustling to make a dent in the archaic system from a grass-roots approach. These startups are lean and efficient, able to address what the government is too slow to while tapping into a market of 1.4 billion people with the highest rates of cancer and diabetes in the world. VoxelCloud, AliCare, Medical Xpress, Medistar and The Care Voice are just a few of a growing number of startups utilizing big data, artificial intelligence, and mobile platforms to fill in China’s healthcare gaps. With the rapid growth in the tech-sector in health, it would make sense for Xi to open up to freer markets and foreign venture capital.

It seems strange to me that the Chinese government can justify spending trillions of dollars on infrastructure in other countries while many of their less developed cities struggle to provide their citizens with even basic care. This issue naturally springs from the high-speed growth mentality that the Chinese government has adopted over the past ten years. If the Maoist conception of modern China saw its birth with the Cultural Revolution in the 1960s and 70s, then in the 21st century China is approaching its teenage years: puberty is settling in with all its awkward, sporadic growth and subsequent growing pains. As we all know, some things take longer than others, while others-like public healthcare (and facial hair)-get left behind. However, the health of its people are the fortifying bones of any developed nation. As China gears towards adulthood, it will need to address some of these health issues more seriously in order to stand on two legs in the coming decades.