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China Health Care
Since the founding of the People's Republic, the goal of health
programs 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 health-care system has dramatically improved the
health of the people, as reflected by the remarkable increase in
average life expectancy from about thirty-two years in 1950 to
sixty-nine years in 1985.
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-level, 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.
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"--rats, sparrows, flies, and
mosquitoes--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, plague, typhoid, 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. Relaxation of
certain sanitation and antiepidemic programs since the 1960s,
however, may have resulted in some increased incidence of disease.
In the early 1980s, continuing deficiencies in human-waste
treatment were indicated by the persistence of such diseases as
hookworm and schistosomiasis. Tuberculosis, a major health hazard
in 1949, remained a problem to some extent in the 1980s, as did
hepatitis, malaria, and dysentery. In the late 1980s, the need for
health education and improved sanitation was still apparent, but it
was more difficult to carry out the health-care campaigns because
of the breakdown of the brigade system. By the mid-1980s, China
recognized the acquired immune deficiency syndrome (AIDS) virus as
a serious health threat but remained relatively unaffected by the
deadly disease. As of mid-1987 there was confirmation of only two
deaths of Chinese citizens 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. Additionally, it was announced that China was
experimenting with the use of traditional medicine to treat AIDS.
In the mid-1980s the leading causes of death in China were
similar to those in the industrialized world: cancer,
cerebrovascular disease, and heart disease. Some of the more
prevalent forms of fatal cancers included cancer of the stomach,
esophagus, liver, lung, and colon-rectum. The frequency of these
diseases was greater for men than for women, and lung cancer
mortality was much greater in higher income areas. The degree of
risk for the different kinds of cancers varied widely by region.
For example, nasopharyngeal cancer was found primarily in south
China, while the incidence of esophageal cancer was higher in the
north.
To address concerns over health, the Chinese greatly increased
the number and quality of health-care personnel, although in 1986
serious shortages still existed. In 1949 only 33,000 nurses and
363,000 physicians were practicing; by 1985 the numbers had risen
dramatically to 637,000 nurses and 1.4 million physicians. Some
436,000 physicians' assistants were trained in Western medicine and
had 2 years of medical education after junior high school. Official
Chinese statistics also reported that the number of paramedics
increased from about 485,400 in 1975 to more than 853,400 in 1982.
The number of students in medical and pharmaceutical colleges in
China rose from about 100,000 in 1975 to approximately 160,000 in
1982.
Efforts were made to improve and expand medical facilities. The
number of hospital beds increased from 1.7 million in 1976 to 2.2
million in 1984, or to 2 beds per 1,000 compared with 4.5 beds per
1,000 in 1981 in the United States. The number of hospitals
increased from 63,000 in 1976 to 67,000 in 1984, and the number of
specialized hospitals and scientific research institutions doubled
during the same period.
The availability and quality of health care varied widely from
city to countryside. According to 1982 census data, in rural areas
the crude death rate was 1.6 per 1,000 higher than in urban areas,
and life expectancy was about 4 years lower. The number of senior
physicians per 1,000 population was about 10 times greater in urban
areas than in rural ones; state expenditure on medical care was
more than -Y26 per capita in urban areas and less than -Y3 per
capita in rural areas. There were also about twice as many hospital
beds in urban areas as in rural areas. These are aggregate figures,
however, and certain rural areas had much better medical care and
nutritional levels than others.
In 1987 economic reforms were causing a fundamental
transformation of the rural health-care system. 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.
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.
Although health care in China developed in very positive ways
by the mid-1980s, it exacerbated the problem of overpopulation. In
1987 China was faced with a population four times that of the
United States and over three times that of the Soviet Union.
Efforts to distribute the population over a larger portion of the
country had failed: only the minority nationalities seemed able to
thrive in the mountainous or desert-covered frontiers. Birth
control programs implemented in the 1970s succeeded in reducing the
birth rate, but estimates in the mid-1980s projected that China's
population will surpass the 1.2 billion mark by the turn of the
century, putting still greater pressure on the land and resources
of the nation.
* * *
A thorough, scholarly study of China's geography is Zhao
Songqiao's Physical Geography of China, which contains a
number of detailed maps and charts, as well as interesting
photographs and Landsat images. The China Handbook Editorial
Committee's China Handbook Series: Geography provides a less
technical overview of the physical environment and includes brief
summaries of the topography, climate, and administrative divisions
of China's provinces, autonomous regions, and special
municipalities.
A good overview of China's population is provided in a series
of articles found in China's Economy Looks Toward the Year 2000,
Volume 1: The Four Modernizations, a collection of papers
published by the United States Congress Joint Economic Committee.
It opens with a general assessment of population policies and
problems and continues with articles on the 1982 census results,
family planning, the labor force, and material poverty. An article
written by H. Yuan Tien, entitled "China: Demographic Billionaire,"
in Population Bulletin also provides a good demographic
overview.
China's One-Child Family Policy, edited by Elisabeth Croll,
Delia Davin, and Penny Kane, is an excellent analysis of the
radical policy first announced in 1979. The work discusses the
origins, problems, and prospects of the one-child policy. Tien's
"Redirection of the Chinese Family" provides a concise overview of
the one-child policy and its implications. (For further information
and complete citations,
see
Bibliography.)
Data as of July 1987
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