Public health in the People's Republic of China

Since the founding of the People's Republic of China, the goal of healthcare programmes has been to provide care to every member of the population and to make maximum use of limited health-care personnel, equipment, and financial resources. The emphasis has been on preventive rather than curative medicine on the premise that preventive medicine is "active" while curative medicine is "passive." The public health system is overseen by the Ministry of Health and the modernization of the system is studied internationally.

The end of the famed barefoot doctor system based in the People's Communes and the increasing privatization of medicine, often poorly regulated, have made corruption and inefficiency in the delivery of health services serious problems. Mistaken political policies led to the starvation of millions during the Great Leap Forward; epidemic disease rebounded during the dislocations of the Cultural Revolution, which seriously harmed public health in China. The effective public health work in controlling epidemic disease during the early years of the PRC and, after reform began in 1978, the dramatic improvements in nutrition greatly improved the health and life expectancy of the Chinese people. The 2000 WHO World Health Report - Health systems: improving performance found that China's health care system before 1980 performed far better than countries at a comparable level of development, since 1980 ranks much lower than comparable countries.

Indicators of the status of China’s health sector can be found in the nation’s fertility rate of 1.8 children per woman (a 2005 estimate) and an under-five-years-of-age mortality rate of 37 per 1,000 live births (a 2003 estimate). In 2002 China had nearly 1.7 physicians per 1,000 persons and about 2.4 beds per 1,000 persons in 2000. Health expenditures on a purchasing power parity (PPP) basis were US$224 per capita in 2001, or 5.5 percent of gross domestic product (GDP). Some 37.2 percent of public expenditures were devoted to health care in China in 2001. However, about 80 percent of the health and medical care services are concentrated in cities, and timely medical care is not available to more than 100 million people in rural areas. To offset this imbalance, in 2005 China set out a five-year plan to invest 20 billion renminbi (RMB; US$2.4 billion) to rebuild the rural medical service system composed of village clinics and township- and county-level hospitals.

Traditional Chinese Medicine and Western Medicine
China has one of the longest recorded history of medicine records of any existing civilization. The methods and theories of traditional Chinese medicine have developed for over two thousand years. Western medical theory and practice came to China in the nineteenth and twentieth centuries, notably through the efforts of missionaries and the Rockefeller Foundation, which founded Peking Union Medical College. Today Chinese traditional medicine continues alongside western medicine and traditional physicians, who also receive some western medical training, are sometimes primary care givers in the clinics and pharmacies of rural China.

Although the practice of traditional Chinese medicine was strongly promoted by the Chinese leadership and remained a major component of health care, Western medicine was gaining increasing acceptance in the 1970s and 1980s. For example, the number of physicians and pharmacists trained in Western medicine reportedly increased by 225,000 from 1976 to 1981, and the number of physicians' assistants trained in Western medicine increased by about 50,000. In 1981 there were reportedly 516,000 senior physicians trained in Western medicine and 290,000 senior physicians trained in traditional Chinese medicine. The goal of China's medical professionals is to synthesize the best elements of traditional and Western approaches.

In practice, however, this combination has not always worked smoothly. In many respects, physicians trained in traditional medicine and those trained in Western medicine constitute separate groups with different interests. For instance, physicians trained in Western medicine have been somewhat reluctant to accept "unscientific" traditional practices, and traditional practitioners have sought to preserve authority in their own sphere. Although Chinese medical schools that provided training in Western medicine also provided some instruction in traditional medicine, relatively few physicians were regarded as competent in both areas in the mid-1980s.

The extent to which traditional and Western treatment methods were combined and integrated in the major hospitals varied greatly. Some hospitals and medical schools of purely traditional medicine were established. In most urban hospitals, the pattern seemed to be to establish separate departments for traditional and Western treatment. In the county hospitals, however, traditional medicine received greater emphasis.

Traditional medicine depends on herbal treatments, acupuncture, acupressure, moxibustion (the burning of herbs over acupuncture points), and "cupping" of skin with heated bamboo. Such approaches are believed to be most effective in treating minor and chronic diseases, in part because of milder side effects. Traditional treatments may be used for more serious conditions as well, particularly for such acute abdominal conditions as appendicitis, pancreatitis, and gallstones; sometimes traditional treatments are used in combination with Western treatments. A traditional method of orthopedic treatment, involving less immobilization than Western methods, continued to be widely used in the 1980s.

Primary support
After 1949 the Ministry of Public Health was responsible for all health-care activities and established and supervised all facets of health policy. Along with a system of national, provincial, and local facilities, the ministry regulated a network of industrial and state enterprise hospitals and other facilities covering the health needs of workers of those enterprises. In 1981 this additional network provided approximately 25 percent of the country's total health services.

Health care was provided in both rural and urban areas through a three-tiered system. In rural areas the first tier was made up of barefoot doctors working out of village medical centers. They provided preventive and primary-care services, with an average of two doctors per 1,000 people. At the next level were the township health centers, which functioned primarily as out-patient clinics for about 10,000 to 30,000 people each. These centers had about ten to thirty beds each, and the most qualified members of the staff were assistant doctors. The two lower-level tiers made up the "rural collective health system" that provided most of the country's medical care. Only the most seriously ill patients were referred to the third and final tier, the county hospitals, which served 200,000 to 600,000 people each and were staffed by senior doctors who held degrees from 5-year medical schools. Health care in urban areas was provided by paramedical personnel assigned to factories and neighborhood health stations. If more professional care was necessary the patient was sent to a district hospital, and the most serious cases were handled by municipal hospitals. To ensure a higher level of care, a number of state enterprises and government agencies sent their employees directly to district or municipal hospitals, circumventing the paramedical, or barefoot doctor, stage.

1950s: The Decade of Construction
An emphasis on public health and preventive treatment characterized health policy from the beginning of the 1950s. At that time the party began to mobilize the population to engage in mass "patriotic health campaigns" aimed at improving the low level of environmental sanitation and hygiene and attacking certain diseases. One of the best examples of this approach was the mass assaults on the "four pests"&mdash;rats, sparrows, flies, and mosquitoes&mdash;and on schistosoma-carrying snails. Particular efforts were devoted in the health campaigns to improving water quality through such measures as deep-well construction and human-waste treatment. Only in the larger cities had human waste been centrally disposed. In the countryside, where "night soil" has always been collected and applied to the fields as fertilizer, it was a major source of disease. Since the 1950s, rudimentary treatments such as storage in pits, composting, and mixture with chemicals have been implemented. As a result of preventive efforts, such epidemic diseases as cholera, bubonic plague, typhoid fever, and scarlet fever have almost been eradicated. The mass mobilization approach proved particularly successful in the fight against syphilis, which was reportedly eliminated by the 1960s. The incidence of other infectious and parasitic diseases was reduced and controlled.

From the Great Leap Forward to the Cultural Revolution
Political turmoil and famine following the failure of the Great Leap Forward led to starvation of 20 million people in China. With recovery beginning in 1961, more moderate policies inaugurated by President Liu Shaoqi ended starvation and improved nutrition. The coming of the Cultural Revolution weakened epidemic control, a rebound in epidemic disease and malnutrition in some areas.

End of the Barefoot Doctor System and Consequences of the Privatization of Health Care
The barefoot doctor system was based in the people's communes. With the disappearance of the people's communes, the barefoot doctor system lost its base and funding. The decollectivization of agriculture resulted in a decreased desire on the part of the rural populations to support the collective welfare system, of which health care was a part. In 1984 surveys showed that only 40 to 45 percent of the rural population was covered by an organized cooperative medical system, as compared with 80 to 90 percent in 1979.

This shift entailed a number of important consequences for rural health care. The lack of financial resources for the cooperatives resulted in a decrease in the number of barefoot doctors, which meant that health education and primary and home care suffered and that in some villages sanitation and water supplies were checked less frequently. Also, the failure of the cooperative health-care system limited the funds available for continuing education for barefoot doctors, thereby hindering their ability to provide adequate preventive and curative services. The costs of medical treatment increased, deterring some patients from obtaining necessary medical attention. If the patients could not pay for services received, then the financial responsibility fell on the hospitals and commune health centers, in some cases creating large debts.

Consequently, in the post-Mao era of modernization, the rural areas were forced to adapt to a changing health-care environment. Many barefoot doctors went into private practice, operating on a fee-for-service basis and charging for medication. But soon farmers demanded better medical services as their incomes increased, bypassing the barefoot doctors and going straight to the commune health centers or county hospitals. A number of barefoot doctors left the medical profession after discovering that they could earn a better living from farming, and their services were not replaced. The leaders of brigades, through which local health care was administered, also found farming to be more lucrative than their salaried positions, and many of them left their jobs. Many of the cooperative medical programs collapsed. Farmers in some brigades established voluntary health-insurance programs but had difficulty organizing and administering them.

Their income for many basic medical services limited by regulations, Chinese grassroots health care providers supported themselves by charging for giving injections and selling medicines. This has led to a serious problem of disease spread through health care as patients received too many injections and injections by unsterilized needles. Corruption and disregard for the rights of patients have become serious problems in the Chinese health care system.

The Chinese economist Yang Fan wrote in 2001 that lip service being given to the old socialist health care system and deliberately ignoring and failing to regulate the actual private health care system is a serious failing of the Chinese health care system. "The old argument that "health is a kind of welfare to save lives and assist the injured" is so far removed from reality that things are really more like its opposite. The welfare health system supported by public funds essentially exists in name only. People have to pay for most medical services on their own.  Considering health to be still a "welfare activity" has for some time been a major obstacle to the development of proper physician - patient relationship and to the law applicable to that relationship."

Despite the decline of the public health care system during the first decade of the reform era, Chinese health improved sharply as a result of greatly improved nutrition, especially in rural areas, and the recovery of the epidemic control system, which had been neglected during the Cultural Revolution.

1990s to present
Western style medical facilities with international staffs are available in Beijing, Shanghai, Guangzhou and a few other large cities. Many other hospitals in major Chinese cities have so-called V.I.P. wards or gaogan bingfang 高干病房. These feature reasonably up-to-date medical technology and physicians who are both knowledgeable and skilled. Most V.I.P. wards also provide medical services to foreigners and have English-speaking doctors and nurses. Physicians and hospitals have sometimes refused to supply American patients with complete copies of their Chinese hospital medical records, including laboratory test results, scans, and x-rays.

Despite the introduction of western style medical facilities, the PRC has several emerging public health problems, which include problems as a result of pollution, a progressing HIV-AIDS epidemic, millions of cigarette smokers, and the increase in obesity among the population. The HIV epidemic, in addition to the usual routes of infection, was exacerbated in the past by unsanitary practices used in the collection of blood in rural areas. The problem with tobacco is complicated by the concentration of most cigarette sales in a government controlled monopoly. The government, dependent on tobacco revenue, seems hesitant in its response and may even encourage it as seen from government websites. Hepatitis B is endemic in mainland China, with about 10% of the population contracting the disease. Some hepatitis researchers link hepatitis infections to a lower ratio of female births. If this link is confirmed, this would partially explain China's gender imbalance. A program initiated in 2002 will attempt over the next 5 years to vaccinate all newborns in mainland China.

Strains of avian flu outbreaks in recent years among local poultry and birds, along with a number of its citizens, have caused great concern for China and other countries. While the virus is currently mainly animal-human transmissible (with only two well documented cases of human-human have been to the present known of to scientists), experts expect an avian flu pandemic that would affect the region should the virus morph to be human-human transmissible.

A more recent outbreak is the pig-human transmission of the Streptococcus suis bacteria in 2005, which has led to 38 deaths in and around Sichuan province, an unusually high number. Although the bacteria exists in other pig rearing countries, the pig-human transmission has only been reported in China.

As of 2004, in more undeveloped areas it is advised to only drink bottled water as cholera, among other diseases, is spread through the water supply.

Sex education, contraception, and womens health
Sex education lags in China due to cultural conservatism. Combined with migration of young unmarried women to the cities, lack of knowledge of contraception has resulted in increasing numbers of abortions by young women.

Hepatitis B and SARS in China
In 2007 health officials announced that China had some 130 million hepatitis B virus carriers. Although not identified until later, China’s first case of a new, highly contagious disease, severe acute respiratory syndrome (SARS), occurred in Guangdong in November 2002, and within three months the Ministry of Health reported 300 SARS cases and five deaths in the province. By May 2003, some 8,000 cases of SARS had been reported worldwide; about 66 percent of the cases and 349 deaths occurred in China alone. By early summer 2003, the SARS epidemic had ceased. A vaccine was developed and first-round testing on human volunteers completed in 2004.

The 2002 SARS in China demonstrated at once the decline of the PRC epidemic reporting system, the deadly consequences of secrecy on health matters and, on the positive side, the ability of the Chinese central government to command a massive mobilization of resources once its attention is focused on one particular issue. In 2002, the pneumonia-like SARS surfaced in Guangdong province, resulting in 348 deaths. Despite the suppression of news regarding the outbreak during the early stages of the epidemic, the outbreak was soon contained and cases of SARS failed to emerge. . Obsessive secrecy seriously delayed the isolation of SARS by Chinese scientists. On 18 May, 2004, the World Health Organization announced the PRC free of further cases of SARS.

HIV/AIDS in China
China, similar to other nations with migrant and socially mobile populations, has experienced increased incidences of human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS). By the mid-1980s, some Chinese physicians recognized HIV and AIDS as a serious health threat but considered it to be a "foreign problem". As of mid-1987 only two Chinese citizens had died from AIDS and monitoring of foreigners had begun. Following a 1987 regional World Health Organization meeting, the Chinese government announced it would join the global fight against AIDS, which would involve quarantine inspection of people entering China from abroad, medical supervision of people vulnerable to AIDS, and establishment of AIDS laboratories in coastal cities. Within China, the rapid increase in venereal disease, prostitution and drug addiction, internal migration since the 1980s and poorly supervised plasma collection practices, especially by the Henan provincial authorities, created conditions for a serious outbreak of HIV in the early 1990s.

As of 2005 about 1 million Chinese have been infected with HIV, leading to about 150,000 AIDS deaths. Projections are for about 10 million cases by 2010 if nothing is done. Effective preventive measures have become a priority at the highest levels of the government, but progress is slow. A promising pilot program exists in Gejiu partially funded by international donors.

Nutrition
In the 2000–2002 period, China had one of the highest per capita caloric intakes in Asia, second only to South Korea and higher than countries such as Japan, Malaysia, and Indonesia.

China has problems in certain western provinces in iodine deficiency.

Hygiene
By 2002, 92 percent of the urban population and 68 percent of the rural population had access to an improved water supply, and 69 percent of the urban population and 29 percent of the rural population had access to improved sanitation facilities.