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:: By Amber Lee Mason

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Investigations ::

Lessons from rural Chinese health care

The floors are dirty, the beds narrow, the furniture chipped and worn. The bathroom is a grungy closet. But what might appear to Western eyes as untenable environs for medical care are just fine for this rural clinic, a center for tropoblastic disease—a condition in which embryonic tissue grows abnormally—located in the poor southeastern provence of Anhui.

“It’s a really different perspective,” says Arthur Haney, the Catherine Lindsay Dobson professor and chair of obstetrics & gynecology. “They had a strategy that they were going to put money into things that made a difference in outcome”—like sterilized surgical instruments, not amenities. So while some incidental housekeeping may have suffered, the patients’ health was well guarded.

Clicking to the next slide during a Thursday evening lecture at the Gleacher Center, Haney, who specializes in endocrinology and infertility, continues to explain the ins and outs of rural Chinese health care, as he sees it. He’s quick to point out that he’s no China expert and insists throughout the talk that he’s not an “authoritative voice,” deferring on some matters to citizens of the People’s Republic of China dotting the audience. But with 35 years of experience in medicine and several trips to the PRC—including three months on a State Department scientific exchange—Haney has had a chance to pick up a few lessons for the West.

Measures, he found, that can “make a major impact on [public health] aren’t necessarily that expensive or sophisticated.” By carefully allocating resources, the PRC concentrates funds and expertise where they’ll make the greatest difference, a legacy of the Maoist system. From 1949 to 1976, when Mao Zedong died, China democratized health care, Haney says, with “barefoot doctors”—rural professionals who provided access to government-funded, low-level care in the countryside, where 85 percent of the population lived. During that same period neonatal deaths dropped to 15 percent of their previous levels and life expectancy doubled to 70 years.

Small, spartan clinics still serve China’s rural population—some 70 percent of 1.3 billion people—referring patients to higher-level care as necessary. These infirmaries, like the tropoblasty clinic, are frugal with their resources. The theory, Haney says, is that “nobody ever died because they didn’t have perfect pain care during delivery.”

Just as no-frills medicine targets the care that makes the most difference, a no-frills health-care system targets the patients who matter most. A minor in his prime who suffers a broken leg will generally be treated, Haney says, with more enthusiasm than an older patient with chronic complaints.

The country’s HPV program exemplifies its big-picture care. A sexually transmitted disease, human papilloma virus sometimes causes cervical cancer. A Pap smear can catch HPV in its early stages, and women in the U.S. are urged to have one every year, spending hundreds of millions of dollars on the tests. In rural China, however, women generally get a single Pap at age 35. Because monogamy is the norm, Haney explains, if a woman doesn’t have HPV by 35, she’s unlikely to contract it later in life. And because HPV often takes a decade or more to cause cancer, 35 is generally early enough for effective treatment. This system, Haney concedes, leads to a slightly higher incidence of cervical cancer but maximizes cost-effectiveness while keeping death rates low.

Other cultural factors help control costs. Family members, for example, often provide food and do laundry for a hospitalized relative. If a blood transfusion is necessary in an Anhui clinic, the family replaces every pint.

Likewise, expensive technology is adopted selectively. Esophageal cancer rates in China are astronomical because of heavy pollution, packaged foods, and smoking, so advanced treatment is often available. But the Chinese avoid pricey technology when the same results can be achieved with a cheaper method. In the case of a man suffering from prostate cancer, doctors treated him through inexpensive surgical castration, not a costly series of testosterone-suppressing drugs. “He felt perfectly comfortable,” Haney says, that he was getting the right level of care.

Ancient remedies also augment care when Western technology is neither available nor cost-effective. Before the modern period doctors, responsible for maintaining health, were paid when patients were well, not when they fell ill, Haney notes. Drawing on that tradition, herbal medicines and acupuncture are widely popular, comparatively cheap, and effective ways to maintain health and manage chronic pain. “A good acupuncturist,” he says, “is worth his weight in gold.”

Things, of course, are changing in China. The breakdown of the central state has reduced guaranteed social services. Growing personal wealth is fueling demand for individualized care. And as rural families are divided by workers streaming into the cities, the sick and the elderly are less able to rely on them for care.

More and more, Haney says, China faces many of the problems taxing the U.S. health-care system: costs rising faster than wages, increasing income disparities, and unequal levels of coverage. Development has shifted the main cause of death from infections, now easily treatable, to degenerative chronic diseases, which are more expensive to manage.

The West, however, could take cues from Chinese medicine, Haney suggests. The United States might better use its limited resources by providing a safety net for the uninsured, adopting policies that benefit the nation as a whole, and focusing on cost-effective treatments. Not every medical lesson, however, may translate. When it comes to judging the individual’s worth versus the society’s needs, he concedes, “our [values] are simply different from theirs.”