View from the Wall

Great Expectations


Four decades ago, the Cultural Revolution was at its peak. Destruction of the existing systems and thinking rushed across the nation of China. Rather than producing the intended clarity in ideology and practice, a broad emptiness was left behind. That decade proved, in retrospect, to be the focused tearing down of much of what had been established in the previous several millennia; it became an obvious fulcrum in Chinese history. Focused change–and more importantly, the acceptance of change–became the way forward. The revolution had begun.

Three decades ago, the entire picture had been redrawn. China was looking ahead onto a very foggy path. Mao was gone. There were many questions and few clear answers. The way of advance was not obvious. With time, however, and slowly at first, the leadership's resolve to step forward into the unknown grew more fervent. Each successful step forward strengthened the next. The desire and need for change began defining decisions and shaping policy. The real revolution was beginning to take shape.

Freedoms were increased, slowly but surely. "The New Socialist Economic Policies" (read: capitalism) year by year replaced the old socialist economic policies. Infrastructure was built, road by road, school by school, city by city. Each successive five-year plan, times six, refocused on the next essential transformational group of projects. China was being rebuilt, with increasing focus and clarity.

Looking back, it has been one of the most productive and positive times in the several millennia that China has been around. The narrow path through the fog is now a superhighway, and the way forward has become much more obvious. There are still a few obstacles lying in the roadway ahead, but the focus and intentionality have built much confidence and experience for navigation.

The embracing of change by the government as well as the culturethe Chinese people at all levelsis the driving force which has moved and will continue to move the history of the Middle Kingdom in a positive direction. Mao's embrace of revolution has, in a strange way, become the foundation of much of what is today transforming China in positive ways. Change is no longer a word which evokes fear and distrust in every Chinese heart. Instead, it has become the traveling companion, the guide, for charting the journey. Mao's successors, Deng Xiaoping and Jiang Zemin, by embracing change, very intentionally steered this fifth of the world consistently toward a brighter future and life.

I am a Western physician. China has been my home for two of these past three decades of change. I have watched with much encouragement (though it often was filtered through the discouragement of existing realities) as the impact of the country's embrace of change has taken effect. My expectation is that I will be even more encouraged over the next two decades. Much of the transformation I have seen and have come to further expect is in the area of my profession. I have been asked to describe here what direction medical care and other social services will take in China and what will drive that change.

It is the trend in medical/social services that I want to describe here, not the present reality. The trend, however, can only be accurately described by looking at past and present realities.

Twenty years ago, the best and most highly educated doctors in the provincial level hospitals where I worked, were, to be honest, vastly incompetent, highly corrupt, poorly educated, culturally controlled, without significant concern for the welfare of the patient and generally proud of what they saw as a great medical system. They had never seen anything else, and moving to lower level hospitals proved that their approach and education were far better. The level of health care delivery in the best hospitals in the province was literally 60 or 70 years behind the West. The system itself was built on a foundation of rust, termites and poor initial construction. Pride, politics, corruption and crippling cultural practices kept most patients from receiving much, if any, true medical care. I could fill books with sad examples of every aspect of what I have stated here, but space does not allow for that. I watched many people die, most unnecessarily, because fear, culture, corruption and a crippled system with nearly nonexistent standards of practice would not allow/accept my intervention. Where I intervened, and (literally) saved people's lives, I was then no longer welcome, even if I did so with the strongest discretion and care. As one moved "down" in the system (there were six levels of "doctor"with the lowest having a sixth to a ninth-grade education followed by less than a year of medical education), the realities of patient care became rapidly more dismal and dysfunctional.

Today, the trend is strongly positive. I could easily and extensively list and tell stories of present-day corruption, incompetence, continuing cultural issues, a lack of compassion and consideration for the patients and other issues which are abundant within the health care system in China. These things are real, and even, in many places, predominant. The access rural and poor people have to reasonable health care is still abysmal in most places. People with leprosy, HIV, disabilities, TB, and many other common illnesses are definitely not receiving anything near what the West would consider reasonable health services.

However, the real story is the highly positive trend that medical care and other social services are taking throughout China. That is all we have time for here.

I am proposing that there are six driving forces which have been, and are continuing, and should be expected to continue to effect positive change and transform the delivery of healthcare and other social services to the Chinese people. These are the following.

An Improving Context. More people-favoring politics/policy, a constantly more positive socio-economic setting, developing insurance systems, increasing access, better education, better infrastructure (clinics, hospitals, equipment, roads, communications, etc.) and so on are all indirectly having a positive impact on how effectively the government can deliver health services.

Fighting Corruption. Though it is still a major detriment to the function of the health system, year after year we observe both a growing governmental opposition to these practices as well as a growing group of healthcare workers who simply reject this foundation within the system. Where ten years ago corruption of various approaches was nearly impossible for a patient to avoid in a simple visit to the doctor, today it is becoming increasingly common to find entire hospitals where (often because the director has decided to follow his heart and care for the people instead of only for the financial greed of the staff) corruption is becoming a thing of the past.

Rapidly Growing Competence. Twenty years ago there was little incentive to do a better job, to be a more effective physician. Today there are many medical education institutions, hospital directors, and individual healthcare workers who seem to have gained a strong desire to do their job well. The rate at which many physicians have caught up to the knowledge level of the West, and the (slower, but sure) rate at which this competence in diagnosing and caring for patients is becoming more commonly practiced is overwhelming. Whereas twenty years ago one was hard put to find a physician who even knew how to diagnose well, today, especially among the younger doctors, a hunger for better understanding and practice is becoming the norm at higher levels and filtering down into lower levels very quickly.

Increasing Compassion and Caring in the Culture. I call this the Wen Jiabao Effect. There is surely a continued need for growth here, but twenty years ago it was a rare thing to find a doctor who cared much whether the patient lived or died. Medicine was just a job and cultural thinking placed little value on the life of someone outside one's circle of relationships. If the patient suffered or died, nobody cared. I often saw people die simply to protect the "face" of the departmental director or some other person on the staff. Today, I could quickly name several dozen doctors in our area who sincerely care about their patients and go out of their way to do things the system would deem unnecessary in order to bring better care, more comfort and simply improved medical practice to patients they have no relationship with. There is clearly a growing consideration of others taking place. I see Wen Jiabao modeling this sincere caring for the little people. I see our provincial director of the Bureau of Health, for the first time of which I am aware, being someone who is willing to step out and use his position to truly impact a position which regularly stands up for the health care needs of the people, especially the poor and disenfranchised. We saw the response of the people to the needs and hurting created by the Sichuan earthquake. We are witnessing a change in the culture which is quite clear. It is quickly becoming more acceptable and practiced to have compassion and consideration for others, even when one does not have any relationship with them.

A Movement from Communism toward Capitalism. When there is a dollar to be made, people will begin to deliver a service. Access to reasonable healthcare is definitely increasing as the system becomes more capitalist. Of course, there are many negatives to this as well. Exploitation and mercenary practices will always increase where capitalist medical systems are in place. However, the other end of the spectrum is also very much happening. A surgeon friend of mine, at my urging, finally left his hospital, tired of delivering substandard care, cheating people and having to bow down to the hierarchy there. He started a private surgery clinic which provides higher quality, lower cost specific surgeries to those who need them. The local hospitals were nearly shut down by his move. Their response was to begin providing higher quality, lower cost surgeries. This trend is going on in many aspects of the system. Free commerce is driving improvement in a broad array of delivering what the people need.

A More Free-to-Serve and Increasingly Inspired and Empowered Church. Certainly, as freedoms have increased and believers have become empowered, the Spirit has moved many to become involved in caring for those who would otherwise go without. Medical practitioners are coming to Christ, and those who already know him are becoming bolder and being led by the Spirit into a broad array of service ministries. Most of them are simply becoming models of the sort of values that doctors must have in order to be both professionally excellent and sincerely compassionate and loving toward those for whom they care.

There are many examples and other influences which I have no space to present. The trends, however, are clearly very encouraging. The government, the culture, and therefore the healthcare system, have embraced positive change. The upward trend will continue. The Chinese people have enjoyed increased access to health care and social services over the past three decades, and they may look forward with great expectations to even more rapid improvements over the next decade.

Image credit: Hospital Entrance by Michael Coghlan, on Flickr

Paul Lee

Paul Lee is a long-time worker in China. View Full Bio