China's health transitions
Authors: Rachel Leow
Journal: The Lancet (2014)

I've had two serious medical encounters in my life, a decade and an ocean apart. The first was in 2003. I'd just moved from Malaysia to the UK for school, and was visited by a bout of stomach cramps I chose to ignore. 2 days later, half-comatose in an ambulance, I scrawled something on a form to get immediate, unconditional health care. It took a whole day to be diagnosed (appendicitis) and sent for surgery. Because of the long wait, my appendix ruptured in surgery. The incision on my abdomen was only partly stitched, resulting in a strange, guitar-shaped scar, and I had 4 days of fevered, postoperative infection. But I recovered, and was discharged without a single invoice. The National Health Service's founding principle held true throughout my botched appendicectomy: free at the point of delivery. The second emergency took place in 2013. In the intervening decade, I'd soldiered through graduate school and moved to the USA for a postdoctoral fellowship. A skiing accident left me concussed with memory loss and a brain haemorrhage. I had two emergency room visits, several brain scans, and months of surveillance. Back in Boston, I was seen by world-class specialists and research pioneers in neurology. And basking in the warm aegis of Harvard University's health insurance, I paid not a single cent for this treatment. But I did receive the bills, so I know exactly what state of penury I would be in if not for Harvard. The disparity between these two experiences gave me cause for reflection. It was clear to me, sitting on my sofa looking through 5-figure medical bills, that the USA provides health care only to the wealthy or blithely employed. There is a consensus in many other countries that to consign national health to loosely regulated for-profit insurance companies has disastrous social consequences. The USA seems to disagree. Its squabbles over health-care reform are part psychological warfare: Republican strategists encourage pundits to play on some Americans' ideological antipathies by using phrases like "government takeover" to describe any move to increase the role of the state in the provision of health care. Screams of "socialised medicine" invariably follow, which suffice to stymie, if not extinguish, any effective redress of inequalities in access to health care in the country. Is an increased state role in health-care provision really so terrible? The history of health care in China, as illuminated by the essays in Medical Transitions in Twentieth Century China, proves instructive. There are many reasons to compare Chinese and US health-care histories: not least because they've been deeply connected through decades of comity and mutual exchange in the fields of medical education and research. This connection is exemplified by the remarkable work of the Rockefeller Foundation's China Medical Board, whose centenary this volume marks. But another reason to compare them is that China's past and present provide the USA with important lessons in the politics of health-care provision. For me, a major takeaway from the book is that China's health-care provision was arguably at its best not in the early decades of the 20th century, when the new republican government soaked up western practices of health and hygiene, nor in its later decades, when the traumatised post-Mao government fled from the excesses of the Cultural Revolution into the arms of capitalist reform. Rather, in certain respects, health care flourished under Mao. Many of the essays in Medical Transitions in Twentieth Century China offer compelling evidence for the importance of state intervention in health care. Within a year of taking power in 1949, the Chinese Communist Party (CCP) tackled smallpox, plague, and cholera in Beijing, as Daqing Zhang documents in this collection. Mao's mass mobilisation campaigns are often associated with the tragic excesses of the Great Leap Forward or the violence of the Red Guards. But, as Miriam Gross and Kawai Fan argue, the control of schistosomiasis in China could not have taken place but for one such campaign, orchestrated by Mao in his relentless crusade against the snails which carried the disease. Official data show that the number of government hospitals burgeoned by nearly 140% between 1949 and 1960. Mao also installed a system of communes—the Cooperative Medical System—that provided a provincial and local structure of free basic health care, as well as the system of barefoot doctors, which, as Xiaoping Fang outlines, penetrated deep into China's rural areas. One should not overstate the accomplishments of Mao-era medicine. The case of China offers important insight into the limitations of public health when its priorities are dictated by the whims of one man. The schistosomiasis campaign, for example, thrived because Mao took a personal interest in it, and public support for it waxed and waned with Mao's popularity. And, of course, Mao killed many more people than his medicine saved. Lincoln Chen and Ling Chen's compelling chapter narrates how more Chinese people died from famine in the 20th century than from all wars and epidemics put together. In the longer term, the CCP left an ambiguous public health legacy. For example, sociology and psychology were banned in universities by 1957 as "bourgeois" sciences, and this, Veronica Pearson argues, still hampers public and medical attitudes towards mental health in China. And as Carol Benedict's chapter shows, China ignored a growing international consensus in the 1950s on the harmful impact of tobacco on health. Instead of educating the public on this matter, the CCP nationalised the tobacco industry, encouraged cigarette consumption, and benefited from its lucrative sales. Still, beneath this bleak picture, there were also crucial advances during this period of state intervention into health care. Life expectancy almost doubled, infant mortality plummeted, and many contagious diseases were contained. But from the 1980s, economic reforms enacted under Deng Xiaoping began to shift China towards more American models of privatised health care. A minor quibble I have with the book is that this crucial theme is not more clearly synthesised from the many chapters which comment on it. By contrast, the book provides an impressive account of the important foundational continuities between the Nationalist and Communist health regimes. Under Deng, China's state-owned health-care system was largely dismantled; centralised investment in health care and other public services was drastically curtailed. Deng's economic reforms had a lasting impact on the health-care system. In her analysis of tuberculosis control in Shanghai, Rachel Core highlights how financial burdens fell increasingly on the patient as China moved towards an out-of-pocket health-care system. The urban–rural divide in Chinese health-care provision also became more unequal than in the past; Tina Phillips Johnson and Yi-Li Wu focus on this issue by discussing how, in 2004, maternal and infant deaths were three times higher in rural than in urban areas. Some of these inequalities have been narrowing in recent years. Since the late 1990s, China has recognised and begun to reverse the harms caused by privatisation of the health sector. It has, if you will, begun to resocialise medicine. Today, the government's stated intention is affordable, equitable health care for all by 2020, and aims to achieve that by redistributing resources to poorer areas, financing community health centres for basic primary health care, controlling pharmaceutical prices, improving the efficiency of public hospitals, and lowering health insurance premiums, among other initiatives. In this respect, China might now offer a model for the USA's health-care reforms: political will is yielding results, and Bridie Andrews in the book's final section paints an overall optimistic picture for China's medical future. This is a bit of a reversal. In a fascinating contribution, Xi Gao explores how throughout the 20th century, it was China who was drawing on health models from the USA, as well as from Europe, Japan, and, under Mao, the Soviet Union. The Soviet model proved particularly transformative. China embraced not only the Soviet Union's technical expertise, but also its principle of "medicine in the service of the people". Societies organise their health-care systems not primarily on the basis of expertise, but on an essentially moral call of what a state ought to do for its citizens. When that call has been made, decisions about what models of health care to implement can proceed. Policy makers might choose more state-supported welfare models, or they might design private health systems which are regulated so that they do actually function in the service of the people. In the USA, the screams of "socialised medicine" are so much noise around an essential confusion over health-care model and social principle. As China's medical transitions show so well, models have frequently been, and will continue to be, negotiable. Principles should not. Medical Transitions in Twentieth Century China provides rich insights into how one country has dealt with perhaps the most central issue for any human society: the health and wellbeing of its citizens. Yet the book sheds light on more than simply China's own medical transitions, and should appeal to anyone interested more broadly in the modern history of health. For as its essays highlight through the lens of China's recent past, the world of the 20th century was profoundly global. It was a world of shared technological and medical advances, shared experiences of war, and, particularly in the later decades of the century, shared challenges of diseases such as HIV and severe acute respiratory syndrome. What distinguishes one national story from another are the choices each has made in responding to these global challenges, and what answers each has given to the fundamental question of how best to care for each other. As my personal experience of health-care systems suggests, those choices ripple through every level of society, right down to the individual sitting on a sofa in Boston ruminating over that terrifying ream of medical bills. The central difference between my medical experiences in the USA and the UK was not financial, since in both cases I paid nothing. It boils down instead to that moral call, to the choice society made about me. In the UK, I am a person who lives and flourishes under a state that cares as a matter of principle about my health. In the USA, I am a consumer who lives and flourishes at the grace—and profit—of an insurance company. Even despite that scar on my abdomen, I know which one I'd rather live in.